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Clinical Excellence in Cardiology Clinical Excellence in Cardiology Roy C. Ziegelstein, MD* A recent study identified 7 domains of clinical excellence on the basis of interviews with “clinically excellent” physicians at academic institutions in the United States: (1) commu- nication and interpersonal skills, (2) professionalism and humanism, (3) diagnostic acu- men, (4) skillful negotiation of the health care system, (5) knowledge, (6) taking a scholarly approach to clinical practice, and (7) having passion for clinical medicine. What constitutes clinical excellence in cardiology has not previously been defined. The author discusses clinical excellence in cardiology using the framework of these 7 domains and also considers the additional domain of clinical experience. Specific aspects of the domains of clinical excellence that are of greatest relevance to cardiology are highlighted. In conclusion, this discussion characterizes what constitutes clinical excellence in cardiology and should stimulate additional discussion of the topic and an examination of how the domains of clinical excellence in cardiology are related to specific patient outcomes. © 2011 Elsevier Inc. All rights reserved. (Am J Cardiol 2011;108:607–611) On the basis of interviews with 24 academic physicians and clinical excellence has not been clearly demonstrated. deemed “clinically excellent,” Christmas et al1 identified 7 For example, the compliance of hospitals with performance domains of clinical excellence relevant to all disciplines in measures is not associated with improved heart failure out- medicine: (1) communication and interpersonal skills, (2) comes.10,11 The speed with which an interventional cardi- professionalism and humanism, (3) diagnostic acumen, (4) ologist achieves reperfusion of the culprit vessel, the so- skillful negotiation of the health care system, (5) knowl- called door-to-balloon time, is an important performance edge, (6) taking a scholarly approach to clinical practice, measure in the treatment of patients with acute ST-segment and (7) having passion for clinical medicine. What follows elevation myocardial infarctions. However, a recent study is a discussion of clinical excellence in cardiology that of 8,771 patients with ST-segment elevation myocardial identifies aspects within each of the 7 domains that are of infarctions who underwent primary percutaneous coronary particular relevance to this specialty. intervention showed that although median door-to-balloon time decreased, and the percentage of patients with door- Is Clinical Excellence in Cardiology Different from to-balloon times Ͻ90 minutes increased from 2003 to 2008, Clinical Excellence in Other Specialties? in-hospital mortality did not change during that time period, even after controlling for baseline characteristics.12 In no other field of medicine has there been so much Excellence in clinical cardiology may differ from clinical work on performance measures and guidelines, with numer- excellence in other specialties because the things cardiolo- ous statements published by the American Heart Associa- gists do are different from the things other physicians do. tion and the American College of Cardiology. Performance Like other specialists, cardiologists use their medical measures in cardiology have been created for the treatment 2 knowledge and skill to improve the health of their patients, of acute cardiac conditions in the inpatient setting and for but cardiologists also “have the tools to alter the course of outpatient management of coronary artery disease, heart 13 3–5 the disease.” Cardiologists perform or supervise a variety failure, and atrial fibrillation. Compliance with these per- of invasive and noninvasive procedures not generally per- formance measures has been monitored in the inpatient formed by other specialists. Differences in scope of practice setting (i.e., with the National Cardiovascular Data Regis- and the plethora of guidelines and consensus statements in tries6 and Get With the Guidelines7,8) and outpatient arenas 9 the field of cardiology create a different context for clinical (Practice Innovation and Clinical Excellence ). Despite the excellence in this specialty. The 7 domains of clinical ex- effort that has gone into developing guidelines and consen- cellence previously described1 are discussed individually sus statements in cardiology, the link between compliance with this special context in mind. Communication and Interpersonal Skills Department of Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, Maryland. Man- Communication and interpersonal skills are critical to uscript received February 2, 2011; revised manuscript received and ac- many aspects of the patient-physician interaction in cardi- cepted March 29, 2011. ology, as they are in other disciplines. These skills are Dr. Ziegelstein was supported by the Miller Family Scholar Program of particularly relevant to behavioral counseling in preventive the Johns Hopkins Center for Innovative Medicine, Baltimore, Maryland, and is an inaugural member of the Miller-Coulson Academy of Clinical cardiology. One of the main roles of the cardiologist is to Excellence at Johns Hopkins, made possible through the support and advise patients to adopt behaviors that promote heart health generosity of the Miller-Coulson family. and to avoid others that do not in a way that is clear, useful, *Corresponding author: Tel: 410-550-0523; fax: 410-550-1094. and respectful. Unfortunately, cardiologists may be lacking E-mail address: [email protected] (R.C. Ziegelstein). in their interpersonal skills and often demonstrate only mod- 0002-9149/11/$ – see front matter © 2011 Elsevier Inc. All rights reserved. www.ajconline.org doi:10.1016/j.amjcard.2011.03.095 608 The American Journal of Cardiology (www.ajconline.org) erate interest in educational interventions that pertain to image coming to mind. Cardiologists with great diagnostic cardiovascular risk reduction.14 Hayes et al14 concluded that acumen are those who demonstrate superb skill at integrat- “cardiologists demonstrate areas of weakness in core com- ing information from the history and physical examination petencies as reflected by the American Board of Medical and solving the clinical puzzles that confront them. They are Specialists that involve patient care and interpersonal com- the individuals whom other cardiologists turn to with diag- munication skills.” Particularly disappointing is the finding nostic dilemmas or when they just do not know what to do. that cardiologists often lack knowledge, interest, and com- The report on clinical excellence by Christmas et al1 sug- mitment to communicating with patients about smoking gests that an important part of diagnostic acumen is being cessation.15 Indeed, many cardiologists do not consider “right.” Almost all cardiologists can think of someone themselves the most appropriate individuals to communi- whom they routinely turn to for help and who always seems cate with patients about quitting. Clinical excellence in to be “right.” For many, Ken Baughman was that person. cardiology is dependent on communication and interper- sonal skills in all patient encounters, something that is Skillful Negotiation of the Health Care System perhaps most evident when making recommendations to reduce cardiovascular risk. Like other specialists, cardiologists must have an under- standing of the health care system to deliver appropriate Professionalism and Humanism care to their patients. Health insurance benefits, medication costs, and disability determinations are all important to the As is true of other specialties, professionalism and hu- care of patients with cardiovascular disease. Skillful nego- manism are critical aspects of clinical excellence in cardi- tiation of the health care system is a particularly critical ology and central to the public trust in cardiologists. How- aspect of clinical excellence in cardiology to demonstrate ever, the benefits that clinicians in this specialty derive from when treating older patients with heart failure and multiple having “the tools to alter the course of the disease”13 are co-morbidities, especially near the end of life. Although accompanied by unique threats to professionalism that may heart failure guidelines recommend that patients with the be posed by purveyors of those tools. The pharmaceutical most advanced stage of heart failure be considered for and device-manufacturing industries are major sponsors of hospice care,21 patients with heart failure are rarely referred research in cardiovascular disease and spend large sums of to hospice. Only about 1 of every 10 patients in hospice has money promoting their products to cardiologists. In 2005, a primary diagnosis of heart failure.22 Compared to other 73% of medical device funding targeted cardiovascular dis- subspecialists who regularly deal with patients at the end of ease,16 and stories about how relations with industry may life, cardiologists appear to have little skill in negotiating affect the practice of cardiologists and erode the public trust the health care system to the advantage of their patients. are now common in the lay press. In a recent national survey Cardiologists are less likely than oncologists or primary of physicians, most respondents surveyed reported physi- care physicians to report having working relations with cian-industry relations, and cardiologists led the way.17 In a hospice.23 This may be because cardiologists may have recent poll conducted by Consumer Reports, Ͼ3 in 4 indi-
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