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Identifying excellence in contemporary cardiology practice: transparency, professionalism and the role of the professional society
  1. Simon Ray1,
  2. Richmond Jeremy2,
  3. Rick Nishimura3,
  4. Iain A Simpson4
  1. 1Department of Cardiology, University Hospitals of South Manchester, Manchester, UK
  2. 2Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
  3. 3Department of Cardiology, Mayo Clinic, Rochester, Minnesota, USA
  4. 4Wessex Cardiac Unit, Southampton University Hospital, Southampton, UK
  1. Correspondence to Professor Simon Ray, Vice President for Clinical Standards Division, British Cardiovascular Society, 9 Fitzroy Square, London WIT 5HW; Simon.ray{at}uhsm.nhs.uk

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A recent article in the British Medical Journal raised important questions about professional transparency, the collection and use of outcome data and the respective roles of professional societies, commissioners of care, regulators and politicians.1 Professional societies have traditionally been viewed both internally and externally as existing largely for the benefit of their members in providing a forum for education and scientific exchange as well as focus for interaction with other professional organisations and with various regulatory bodies.2 This perception has evolved with the increasing involvement of large international societies in the development of guidelines for the delivery of cardiology care. The mission statement of the European Society of Cardiology is to reduce the burden of cardiovascular disease in Europe, that of the American College of Cardiology to transform cardiovascular care and improve heart health and that of the British Cardiovascular Society to promote excellence in cardiovascular care. These are sweeping and ambitious aims and extend much further than the provision of education and the writing of practice guidelines, essential as these activities are. Regulators are becoming more interested in the continuing competence of medical staff. In the UK medical revalidation is just beginning with the explicit aim of assuring patients and the public, employers and other healthcare professionals that licensed doctors are up to date and fit to practice.3 Revalidation is about defining acceptable practice, not excellence, and the expectation is that the vast majority of doctors will pass muster. In the US physicians must complete Maintenance of Competence (MOC) over a 10-year cycle including self-evaluation of medical knowledge and practice performance and an exam.4 Modern medical professionalism extends beyond competence and mandates that doctors keep the needs of patients paramount and view their service through their patients’ eyes. All patients deserve good doctors but what makes a good cardiologist and what is the role of the professional society in identifying and promoting excellence in clinical practice as well as patient experience? The educational, clinical and regulatory frameworks differ from country to country but there are common themes emerging that transcend national boundaries.

Most patients assume that the doctor treating them is both well trained and up to date. With substantial input from professional societies many countries have now developed curricula for training in cardiology that require the acquisition and demonstration of a set of knowledge, skills and behaviours before qualification and certification as a specialist can be recognised. Such curricula if appropriately applied and assessed are a reasonable assurance that a specialist is competent to practice on completion of training but do they fulfil the patients’ holistic expectation of a ‘good cardiologist’ and can they demonstrate this continuing competence over a professional lifetime? Professional societies are the only bodies with sufficient depth of knowledge to define specialty specific process and outcome measures and to identify the boundaries of acceptable practice. They are also uniquely placed to engage with their members and patient groups to improve standards of clinical care. In this respect cardiac surgery has lead the way, with publication of outcomes and the development of a process to identify outliers. This has not been an easy path and, as has been acknowledged by the Society for Cardiothoracic Surgery of Great Britain and Ireland, there is an implicit tension between the status of a professional society as a membership organisation and a role as an advocate for the primacy of the patient in all aspects of care.2 However it may be overcome if there is complete transparency about aims and ideals and a clearly demonstrable commitment to raise standards. This does require a significant change in the way both the leadership of a society and its members view the organisation and for some it is likely to be a difficult transition. It also requires that patient groups play a much bigger role than is traditional in the setting of professional standards. So if professional societies are to assume this role what can they do to equip their members with the resources to develop and demonstrate a high quality of practice—what it is to be a good cardiologist?

No cardiologist keeps up to date with current developments simply by a process of osmosis. Increasingly there is an expectation that Continuous Professional Development (CPD) should cover the breadth of clinical practice rather than simply focussing on an area of specialism.3 Professional societies have an important role in the provision of CPD across the breadth of the curriculum and in developing methods by which their members may demonstrate not just attendance at a session or the reading of an online resource but that they have completed a formative assessment of their knowledge in a particular area. In Australia and New Zealand the new educational CPD program for cardiologists will include formative assessment as a requirement. Societies also have a role in the development of new forms of CPD that break away from the traditional format of didactic lectures to focus on interactive discussion of difficult or challenging cases that illustrate particular points and in the development of simulator based learning. Up to now the expectations of patients have played little if any role in influencing CPD requirements or the methods by which CPD is delivered and assessed. This is changing and professional societies have a responsibility to ensure that CPD is developed and conducted with the interests of patients in mind so that the focus is on enabling their members to practice in a holistic manner to a high standard. To this end the American College of Cardiology is developing modules for MOC that enable cardiologists to demonstrate knowledge directly related to their own patients and putting together quality improvement projects that make a direct difference to patient care. They are reinforcing this by teaching quality improvement techniques such as Lean and Six Sigma so that physicians can implement change in their practice in an effective manner. There is also an important role for the development of non-technical team work skills as illustrated by the highly successful ‘Carry on in the cath lab’ session developed by the British Cardiovascular Society in association with Barts and the London Trust, focusing on team working, task management, situation awareness and decision making.5

Transparency of outcome data is essential where this can be provided. The ideal model is for data to be collected prospectively on a regional or national template that allows subsequent cleaning, analysis and benchmarking so that risk stratified and benchmarked outcomes can be provided for individual operators or teams. In the UK such data is already collected through a number of national cardiac audits covering most aspects of acute and chronic cardiology care, a resource unavailable in most other countries.6 Similarly, the Cardiac Society of Australia and New Zealand has initiated a Cardiac Procedures Registry to document interventional outcomes and promote quality care in both public and private practice settings. Individual data is easier to provide for procedure related specialties but important information can be obtained about the function of clinical teams for areas such as heart failure. There is of course a cost to setting up these structures but it is dwarfed by the money spent on the services themselves and the positive impact on outcomes of publishing data is well demonstrated by the improvement in UK cardiac surgical results.7 So a culture of transparency requires the active engagement of professional societies to set standards and the bounds of safe and acceptable practice and of those who commission and fund healthcare to provide the political will and infrastructure to support the collection and analysis of high quality data such that it has the trust of both doctors and patients. Developing that trust will also require transparency in the way data is collected, handled and published so that it is demonstrably accurate and it is clear that analysis is both independent and objective. In itself, providing good quality, comparative outcome data can be a powerful driver to quality improvement but it is essential that methodologically robust and proportionate mechanisms are developed to support those cardiologists whose results may appear to be less good than expected.

Identifying and dealing with underperformance is a difficult area and one with which many doctors are uneasy. By setting standards and defining the boundaries of good practice Professional Societies may help individuals to aspire to excellence and avoid poor practice but they are not the regulators. However they are uniquely placed to work with other bodies including regulators in investigating circumstances where performance is below expectations and in co-ordinating any clinical retraining required to restore an individual to competent practice.

Some areas do not lend themselves to audit of hard clinical outcomes and a different approach is required. Quality improvement programs provided by professional societies are well developed in echocardiography and other imaging modalities. Completion of these processes demonstrates that a department has appropriate equipment, facilities, clinical expertise and governance procedures to provide a good service to patients. Intrinsic to these programs is the requirement that the cardiologists involved are themselves appropriately trained and with appropriate on going experience. Measures of patient experience are not well developed in cardiology practice. There is increasing recognition that a single point in time assessment will carry less value than regular, repeated feedback. Professional societies have an important role in the development and validation of appropriate measures of patient experience and in the incorporation of these measures into quality improvement programs that become part of routine practice. Cardiologists should recognise that measuring patient experience is more than just a cosmetic exercise but a central part of clinical care and that the results of validated measures of a cardiologist's interaction with patients should be published as part of transparency of outcomes.

So a good cardiologist puts patients first, is competent, up to date with contemporary knowledge, transparent about outcomes, welcomes constructive feedback from patients and colleagues and acts on it. Professional Societies have a responsibility to provide their members with the resources to achieve these aims, to promote effective stakeholder involvement, transparency of process and fair and objective assessment to agreed standards. After all, every patient deserves a good cardiologist.

References

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Footnotes

  • Contributors SR and IAS developed the idea for this article. All authors contributed to the text and approved the final version. SGR acts as guarantor.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.