08:55pm Monday 18 November 2019

Changing Environment Poses New Challenges for Interventionalists

Back then most of us were primarily coronary interventionalists. Drug-eluting stents (DES) were newly approved, and the idea of 60- to 90-minute door-to-balloon times was still a distant goal. Peripheral interventions were only beginning to interest us, and only busy cath labs might have had a single person performing valvuloplasty and early ASD closure.

PCI volume was increasing annually, as were advances in scientific discovery and drug/device development. We envisioned helping an increasing number of patients in ways our specialty’s founders could not have imagined.

Today, the tools we use have improved, enabling us to treat more complex disease, but the decision making has become more complicated. The challenging global economy is draining money away from healthcare and medical research. Coding and billing issues are becoming as important to our livelihood as the technical aspects of performing successful interventions. Doctors are making headlines for all the wrong reasons, amid allegations of conflict of interest and inappropriate interventions.

In less than a decade, the bright future we forecasted changed dramatically, altering the professional landscape for all of us. These changes can be both dizzying and frightening. It helps to examine some of the trends that will influence our careers at least over the next few years.

Hospital-Owned and -Affiliated Employment

When I started my career, most cardiologists were self-employed, often small business owners. Changes in reimbursement and fears over further erosion of physician income have pressured most independent cardiologists to seek financial relationships with their hospital networks.

I predict more than 80 percent of cardiologists will be affiliated with a hospital by year’s end. This may be contrary to our natural tendencies toward independent thinking and quick decision making, but it doesn’t have to result in conflict. In fact, working in partnership with a hospital network may help us accomplish bigger goals, such as system-wide improvements in access and quality of care.

Tip: Get to know hospital administrators, and have patience when working with them. They need us as much as we need them.

Declining PCI Volume and Reimbursements

Every year we get paid less despite providing increasing levels of care. PCI volumes are static or declining due to a combination of factors, including better preventive care, reduced restenosis, and increasing interest in medical management of chronic stable angina.


Tip: Distinguish yourself from your peers in your community through patient outreach, excellent customer service, and unique services such as transradial, structural, or peripheral procedures.


Tip: Support our profession by participating in the societies that represent us, such as SCAI and ACC. Only through organization and cooperation can we influence policymakers and funders to support our positions.

Conflicts Over Appropriateness of PCI

Angioplasty has come full circle in the eyes of the public and some of our colleagues. What recently was hailed as the mainstay treatment for coronary artery disease is now assailed by some as expensive, overused, and potentially dangerous. Our judgment is being called into question by a small but vocal number of colleagues and by the media.

Meanwhile, we have better technology and data to guide our decision making than ever before. Noninvasive assessment of coronary ischemia continues to improve; angiographic image quality is vastly superior to the days of film; and advanced techniques such as FFR, IVUS, and OCT allow us to make better-informed decisions about which patients will benefi t from intervention.


Tip: Accept that the future will bring more scrutiny of what we do, how we do it, and how much it costs. Have strong justifi cation for each procedure you perform, and document it. In borderline cases, use additional imaging or functional studies to provide rationale for treatment strategies.

Internationalization of Cardiology

Historically, many advances in Interventional Cardiology have been conceptualized and developed in the United States and Europe, but research and technology investments are shifting as U.S. healthcare expenditures plateau or decline and as the incidence of cardiovascular disease grows globally.


Tip: Seek opportunities to draw on the experiences of colleagues in Asia, Latin America, and Australia.


Many of my senior colleagues grumble about the passing of “the good old days.” Having never seen them firsthand, I’m not sure exactly what I’m missing, but I do know that change is inevitable. The experience may be upsetting, but it also represents an opportunity to improve ourselves and our profession. One thing I know: there will always be room for thoughtful, compassionate doctors who perform procedures well and take good care of patients.


Dr. Tu is the director of the cardiac catheterization laboratory at Louisville Cardiology Group, Baptist Hospital East, in Louisville, KY. He is the co-chair of SCAI’s Interventional Career Development Committee, a SCAI-ELM Fellow, and the founder of World Health Initiative, a charitable organization.

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