Advocate for our patients, advocate for our profession

Imagine yourself as a young interventional cardiologist, a year or two out of fellowship, just appointed to the Economics of Health Care Delivery Committee of a major medical Society. It is the young cardiologist's first committee meeting. Members are arguing about how the Society should cope with rapid changes in the health care system. Suddenly a senior member of the Society proclaims “Remember our patients. We need to focus on how to improve care of our patients”. The young cardiologist is very impressed and decides that here is a cause worthy of his time and energy. The year was 1989, the society was the American College of Cardiology (ACC), the elder statesman was Adolph Hutter Jr MD (then president-elect of the ACC), and the young cardiologist was one of the authors (JCB). That incident inspired my view of advocacy throughout his career, and Dr Hutter's words continue to remind my of why we should all be advocates. Advocacy is a major activity and goal of SCAI, and SCAI devotes enormous resources to advocacy. But what does advocacy mean in healthcare, and specifically for SCAI? The word “advocacy” comes from Medieval Latin ad (“to”) + vocare (“to call”). The literal meaning is “to summon to one's aid”, and a common definition is “to support or urge by argument; recommend publicly”. The natural next question is “When used in the medical profession, what is advocacy supporting, and to what purpose?” The medical literature on advocacy describes 3 general types of advocacy. The first is advocacy for specific patients or groups of patients 1, 2. Examples are patients who lack insurance or the resources to obtain medical care, such as children or the elderly. Patients with diseases that are perceived as needing additional resources, such as AIDS or breast cancer, are included here. The medical literature robustly debates the ethical obligation of individual physicians to advocate for their patients and whether such advocacy skills should be taught during medical school and post-graduate training 3-5. A second type of healthcare advocacy, also for patients, is for making high quality services available to patients. Examples in this category include patient-centered decision making (promoting autonomy of patients), efforts to ensure appropriate availability and use of services, and efforts to improve the quality of care provided to all patients. All physicians have an ethical responsibility to advocate for patients in this way. Many would purport that physicians and other cardiovascular professionals are uniquely qualified to provide this type of advocacy, given our knowledge of clinical issues and the healthcare system, and our direct interactions with patients and families. The third type of healthcare advocacy is not for patients, but for other stakeholders, such as medical professionals. This type of advocacy typically falls to professional medical societies rather than individual physicians. While medical societies have been accused of “differing from trade unions only in their sanctimoniousness” 6, professional societies generally balance advocating for patients and advocating for members 7-13. Advocacy for physicians and other medical professionals can be viewed as indirect advocacy for patients, since challenges that healthcare providers face may translate into poorer care for patients 12. This perspective has become more common, or at least more often verbalized, as the medical profession and its practitioners undergo rapid transitions that severely stress clinicians 10, 14. In this context, the need for advocacy for medical professionals, and perhaps for their patients, has become more apparent 14. SCAI has a long tradition of advocacy for members. In 2001 SCAI, under the leadership of Dr. Joe Babb, formed the Advocacy and Government Relations Committee, initially chaired by a past president, Dr. Carl Tommaso 15. The challenges identified then were strikingly similar to those we face today. SCAI's first advocacy committee focused on regulators in Wisconsin and Massachusetts with no medical knowledge writing policies that would dictate how interventional care was provided, a 23% decrease in Medicare-allowed charges for interventional procedures over the previous 4 years, and federal regulation of cardiac cath labs. Advocacy goals in 2001 were fair reimbursement for cardiologists, influencing federal and state regulation of interventional cardiology practice, facilitating FDA approval of new drugs and devices, and improving relations with legislators. SCAI's advocacy efforts over the past decade have reflected the evolving need for a society focused on interventional cardiology to advocate for both patients and professionals 16, 17. Patient advocacy has been directed towards supporting the needs of individual patient groups (e.g., pediatric patients who often have no or limited insurance coverage, or patients who would benefit from new technologies such as TAVR) and ensuring that policies do not restrict patients’ access to medically necessary care. Even greater advocacy efforts, often unrecognized as advocacy, have been directed toward improving outcomes and delivery of care for patients 18. This concept produced the “real value equation” proposed by Duffy in which the value of a medical service is defined in part by the perceived value of the service to the patient 19. At present, SCAI's Advocacy and Government Relations Committee is chaired by Dr. Peter Duffy, assisted by co-chair Dr. Osvaldo “Steve” Gigliotti, SCAI Senior Director Wayne Powell and 26 SCAI members. The committee's mission is “to educate members, ourselves, and key stakeholders (legislators and their staff, government agencies, patients, and the general public) about policies and positions that directly and indirectly affect all aspects of interventional cardiology and to advocate for those positions as directed by the Executive Committee of SCAI.” The committee meets by telephone monthly and face-to-face at the annual SCAI scientific sessions. The pervasiveness of patient advocacy throughout SCAI is represented by the fact that at least 15 of SCAI's 30 committees work to improve the quality of patient care. For example, Drs Mike Jaff and Kenny Rosenfield of the SCAI Peripheral Vascular Disease (PVD) Committee recently led a coalition of societies that convinced CMS's coverage advisory committee to recommend coverage of PVD procedures. The Structural Heart Disease Committee is leading SCAI's advocacy efforts for appropriate approval of, payment for, and training in new structural heart procedures. SCAI's Quality Improvement Committee is evaluating and influencing the development of new quality measures for evaluating and compensating SCAI members. The SecondsCount Editorial Board manages the SecondsCount.org website that provides information about cardiac diseases and treatment to over a million people each year. SCAI is updating its Strategic Plan 20. Advocacy for both patients and professionals will play a prominent role. With the addition of non-physician cardiovascular professionals to SCAI, we are learning about a new set of concerns and challenges they face. SCAI will be adding these issues to our portfolio of advocacy issues as we move forward. If you have other ideas or want to volunteer, contact Wayne Powell ([email protected])mailto: or Jim Blankenship (570-854-3712, cell) or [email protected]