Passing the torch: Challenges ahead

My term as President of the Society for Cardiovascular Angiography and Interventions is drawing to a close. As I write this last President's Page, our scientific Sessions are just a few weeks away, and my successor, Dr. Bonnie Weiner, is preparing for me to pass the torch into her capable hands. Trying to decide what to write, I considered devoting this Page to a review of what the Society has accomplished in the past year. However, I decided against that, figuring those who actually choose to read this page have probably also read those I've written in the previous 11 months, visited www.scai.org to see the latest information about Society activities, and read the Society's newsletter. Therefore, you already know the past year has been busy, with many accomplishments in each of the Society's key mission areas—education, advocacy, and promotion of quality care. You also know that I have tried to focus on the overarching theme of quality, and that I've been assisted at every step by many superbly talented SCAI members as well as a very capable staff. Although this Page is my final one as President, it seems more fitting to focus on the challenges ahead rather than those met in the past, but of course, there is some overlap. Many of the concerns we face in delivering the highest quality care tend to reoccur as drugs, techniques, and technologies evolve and as agencies, such as the Centers for Medicare and Medicaid Services (CMS), struggle in an attempt to manage and finance our health care systems. In this Page, I will highlight what I consider to be the biggest challenges facing our profession, and our Society, in the near future. From the day we start our training as interventionalists until the day we “hang up the lead,” we face the challenge of staying current in this dynamic field of medicine. It is a challenge all health care professionals face, but for interventionalists it seems there are new therapies, technologies, and techniques coming at every turn. It is our responsibility as physicians to learn them, become proficient in them, and deliver them appropriately and expertly to our patients. Right now, for example, we know that percutaneous valve therapies are on the horizon as well as several percutaneous delivery methods for gene therapy and several new drugs. For our Society, the challenge—although perhaps it is really an opportunity—is to promptly develop and deliver objective, unbiased education so that our members are poised to provide such treatments with the highest quality, especially in an era when pay-for-performance is looming. As those who read my earlier President's Pages know, I believe the best way to adapt to the forthcoming “pay-for-performance” initiatives is to view these as “pay-for-quality” initiatives [1, 2]. Rather than view these as a threat, these could be viewed as an incentive to get on board with quality improvement and to achieve the highest benchmarks of quality one possibly can. Fortunately, your Society is ready to help. Examples of SCAI's readiness include the innovative and well-received educational programs we developed and offered in the breakthrough technologies of carotid artery stenting and cardiovascular CT imaging. These programs, which have been cited for both their excellence and relevance, are evidence that your Society is one of the best vehicles for education and training. I expect that, in the next few years, SCAI will continue to be a leading provider for training in devices, drugs, and other innovations. Interestingly, the second major challenge I foresee derives, in part, from the first. Working in a field as dynamic as interventional cardiology means facing the controversies that inevitably will arise. Consider, for example, the widespread reporting, and some might even say outcry, about one of the most oft-used tools of our trade—drug-eluting stents (DES). Who would have predicted that a device, welcomed with such enthusiasm just a few years ago, would come under such intense scrutiny? In such situations, the challenge for our profession, and for SCAI, is to speak with clarity and from a position of both authority and credibility when discord and sound-bite rhetoric are overwhelming good clinical sense. I believe that is exactly what SCAI did in responding to this issue. Instead of dodging the issue or being swayed by the controversy itself, SCAI took a deep breath, gathered the best minds and available data, and examined the evidence carefully. We then spoke clearly and forcefully, first to the Food and Drug Administration when we were invited to speak during its advisory hearings, and shortly thereafter to members and the public with a practical, focused Clinical Alert that can be used as a guide for physicians until more data about DES and late-stent thrombosis are available [3]. And, importantly, the Society developed and disseminated its recommendations swiftly, thereby providing members with needed input on patient care as quickly as possible. I view this as one of SCAI's more important jobs—to be the voice of the profession when new advances are announced; when worrisome data make headlines; and when the patients we treat are being swamped by dramatized reports in the news. It is also SCAI's responsibility to take a stand on issues that can affect quality-of-care. For example, the Society developed an Expert Consensus document on the controversial topic of percutaneous coronary intervention without on-site surgical backup [4]. SCAI's Board of Trustees voted unanimously to develop and publish that document because there was a gap between the guideline recommendations and what was actually occurring in hospitals throughout the world. We felt it was important to fill that void with a thoughtful document that provided recommendations aimed at quality. Being proactive and taking stands such as this one, even if doing so is controversial, is among the challenges facing SCAI in the future. Similarly, it will fall to the leaders in our profession and our Society to speak loudly and clearly in the anticipated debates about health policy. For those of us who practice in the United States, SCAI has an essential role in monitoring the health care arena, keeping our membership informed, and appropriately representing the best interests of our patients and our profession. In many cases, that means helping us as individual practitioners understand the complex and seemingly circuitous developments in government. Now and in the future, as our elected and appointed officials debate how to reform Medicare, fix the flawed formula that CMS uses to set payment rates, collect and use benchmarking data for quality, insure the uninsured, and so on, you can trust SCAI to educate both government officials and our members. However, SCAI can only do so much; you must also act. We will advise you when to contact your elected officials and what you might say, but it remains your job to act. SCAI can and will be your advocate, but each of us must be willing to lend our voices to that of the Society. Although I could list more, one of the greatest challenges is that of preparing the next generation of interventionalists to take over our field and maintain its momentum. In the 30 years that the Society has existed, the specialty of invasive/interventional cardiology has seen amazing progress. There is every reason to expect this trajectory will continue. Our current fellows-in-training and early-career interventionalists must be supported, encouraged, and integrated into leadership positions both in our profession and within SCAI. In recent years, SCAI has taken major steps toward renewing itself by growing its membership base and by fostering programs specially designed for fellows, such as the C3 Summit and the SCAI Interventional Cardiology Fellows Course, and by establishing the Interventional Career Development Committee. This committee's purpose is to encourage the active involvement of young physicians in SCAI and to connect them with mentors. This is one of the most important things the existing members and “old guard” can do—help to foster the careers of those who will succeed us. While there are substantial challenges facing our profession and SCAI, I strongly feel that we will meet these challenges much as we have done for the past 30 years. During the past year, I have had the honor of meeting and getting to know many of SCAI's members. I have continually been struck by how talented, creative, and committed we all are to our common goal of high-quality patient care. In addition, our Society, now more than three decades old, is robust and rock-solid, its ranks growing and its path clear. As long as we, the members, continue to support its mission with our time, expertise, enthusiasm, and effort, the Society will ably represent us, deliver the education and training opportunities we need, and support us in the optimal care of our patients. Norm Linsky, our executive director, refers to the presidency as being in “the Big Chair.” Perhaps naively, I thought I knew what that meant a year ago, but now I truly understand why he calls it the Big Chair. Sitting in the Big Chair is a huge responsibility and a great privilege. It is something I will remember forever. Please know that it has been an honor to serve as SCAI's President and to work alongside so many of you focused on achieving SCAI's mission. I offer my best wishes to Dr. Weiner during her year in the Big Chair, and thank SCAI's many volunteers and staff for their unwavering support and assistance throughout my term.