A Plea to My Colleagues in the Cardiovascular Space: It’s Time to Lock Arms

There have been few stories quite as impressive as that of cardiology.  Within half a century, and through the work of passionate individuals with singular purpose and unrelenting energy, we have pioneered and promoted the utility of aspirin and statins in primary and secondary prevention, the use of rapid mechanical reperfusion for acute myocardial infarction, myriad mechanical and pharmaceutical therapies for heart failure, and minimally-invasive therapies for structural heart disease.All of these achievements, and more, have been the envy of other specialties.

When I graduated fellowship just short of 10 years ago, there was so much positive energy. We were well on our way to curing many of the diseases that ail humans, including the “big ones” heart attack and stroke, and all working together proudly side by side; general cardiologists, heart failure specialists, electrophysiologists, and interventionalists were all cardiologists at their core, tackling the same diseases from different angles. Rapidly, our advances rolled out, reaching patients all over the country regardless of insurance status, income level, or other barrier. And it worked.  Incidence of myocardial infarction declined, survival with heart failure improved, and life expectancy soared. “More was more” and the sky was the limit.

But times changed. Inevitably, the financial constraints of our healthcare system were reached. It turns out not everyone can get everything, and we as a society have to make some tough choices. What is truly necessary, what is the bare minimum, and what is appropriate care for an individual patient? What is too much, what is harmful, and what does not add enough incremental value per unit cost? These were the new questions, and cardiology was under attack. We are, after all, the top inpatient reimbursement segment in all of medicine, and so the spotlight was, and remains, first and foremost on us. Whereas “more is more” was the old way, “less is more” is the new mantra.

At risk is not just the future of our specialty, but the potential for continued advances and population-wide improvement in health and wellbeing; even worse, we risk going backward, with deterioration of some of our major advances, if we are not careful.  For we do not truly know the active ingredients or the full recipe of our prior successes; unraveling some of the components might overshoot the mark, leading to deleterious effects that may not be felt for decades.

But what I’m really concerned about is not that this risk is now present, or that we need to do our share to control cost, but how we as individuals or groups are reacting to it. Rather than sticking together, protecting what we’ve accomplished side by side, we seem to remain indifferent to each other’s plight. When stents for stable angina were under attack, only the interventional voice was heard. When outpatient same-day imaging was scrutinized, only the non-invasive voice was heard. When defibrillator implantation was questioned across the nation, only the electrophysiology voice was heard. And when the device companies were challenged by new taxes that ultimately affect our entire field through innovation, only their voices were heard. What we have all lost is a basic understanding that we are in this together; we sink or swim as a team.  If we were willing to soar together, why are we not willing to hunker down together, regroup, and re-emerge with one strong voice?    

My friends, it is time to lock arms. There is too much at stake to do otherwise. From an advocacy perspective at the very least, there should no longer be interventional, heart failure, electrophysiology, and non-invasive cardiologists. There is simply the cardiologist, and we need to think and act as one to make sure we preserve our flexibility, autonomy, and ability to move the cardiovascular care needle in positive directions.  

To do this, we will need to put aside any differences we may have between us, including any nuanced practice differences, as we are surely far more similar than we are dissimilar. Of course electrophysiologists are passionate about devices, interventionalists are passionate about stents, and non-invasive cardiologists are passionate about imaging. And it is the nature of those who use tools to truly believe in the power of those tools, more than the power of someone else’s tools. I may not believe in the magic of stress tests as much as my non-invasive colleague, and he or she may not believe in the wonder of stents as much as I do, but we both believe in cardiology more than any other specialty. And the reality is that we use each other’s tools all the time. 

So, let’s start finding ways to protect what is most important to us, the autonomy to decide when to and how to treat our patients, the ability to innovate and perform practice-changing research, and the goal of eliminating or reducing the burden of heart disease, while also trying to cut costs in a way we can all agree upon. Let’s do it as a team, each taking a bit of a hit that is fair and balanced across each of our subspecialties, without pointing fingers at each other. You may say that this is the job of leadership and the professional societies. I would agree, and I and others have been doing our share. But, leadership reflects membership as much or more than membership reflects leadership. Indeed, it all starts on the front lines. And ours must be a formidable one.  

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Dr Srihari S. Naidu is Director of the Cardiac Catheterization Laboratory, Interventional Cardiology Fellowship Program, and Hypertrophic Cardiomyopathy Treatment Center at Winthrop University Hospital, and Associate Professor of Medicine at SUNY – Stony Brook School of Medicine. He is a Trustee of the Society for Cardiovascular Angiography and Interventions (SCAI) and Member of the American College of Cardiology (ACC) Interventional Leadership Council. He can be reached at ssnaidu@winthrop.org