Crisis
Spencer B. King, III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions*
The economic crisis that the world is currently going through reminds me of the often-used root of the Chinese symbol for "crisis." It is the symbol for "danger" plus the symbol for "opportunity" or "resourcefulness." Far be it for me to claim understanding of economic opportunities in a markedly depressed economy. Nor do I fail to see the enormous hardship that is resulting from this condition. I am told that 70% of the American economy is consumer spending, that is, buying "stuff." George Carlin had a wonderful bit about the need for bigger and bigger houses in order to have some place for our "stuff." And, much of the world depends on selling us "stuff" to keep their economies afloat. In medicine, we are more fortunate than most since much of what we do is not completely discretionary. Nonetheless, medicine is clearly taking its lumps, and hospitals and physicians are suffering.
So there is plenty of "danger," but where is the "opportunity"? The fact that health care costs in the U.S. far exceed any other country was an interesting statistic as long as the bills were being paid. Now there is an imperative to control costs. This is where "opportunity" becomes the operative word. Not until gas prices hit $4.00 a gallon did I consider dumping my beloved 18-year-old, 8-cylinder car for a hybrid. Now that prices have moderated I still enjoy the 49 miles/gallon city driving compared to the previous 19. Will the crisis in medical financing lead to improved "mileage" for our health care efforts? The new administration is looking to prevention as a means to improve this efficiency, and such efforts are laudable. But, how do improved prevention methods impact those of us engaged in interventional medicine? It should be obvious that prevention is now morphing into "medical intervention" whether it is defined as primary or secondary after one of our interventions. It is also clear that much of the medical intervention is being applied by interventional cardiologists.
Science and technology have been at the heart of interventional cardiovascular medicine and must also drive medical intervention. Through clinical research, we have created an extensive evidence base that is currently being enforced through various mechanisms, but does one-size evidence fit all? It would be ludicrous to put a stent in every patient with angina without clear evidence of what the treatment was to accomplish. On the other hand, it is an excepted core measure to put every patient on some statin no matter what dose or effect is achieved. The suggestion that everyone with an abnormal C-reactive protein needs massive statin therapy is the one-size-fits-all concept that, along with direct-to-consumer advertising, drives medical costs. Medicine must be personalized in order to be effective and cost-effective. As shown in the second generation stent trials, future events will be driven by progression of disease, not failure of the stent. Through active medical management, the chance of recurrent events and poorly reimbursed costs can be reduced. Attention to therapies appropriate to each patient's problems, including selection for or against intervention, will be increasingly scrutinized. Genetic identification of which patients will benefit from which therapies, and which patients will not, is increasingly possible for many conditions. In order to apply these valuable cost-effective methods, which will enable treatment of the right patients, a form of universal health coverage will be necessary. Denying insurance to genetically susceptible people must not be allowed if the power of genetics is to be added to our armamentarium.
The imperative of controlling costs will certainly lead to uncomfortable decisions, but the era of "every therapy for everyone" is over. The opportunity for medicine is to harness the power of technology, medical informatics, genetics and personalized prevention, and therapy for the best outcome for our patients. I do not think that the "danger" in this crisis is the extinction of the cardiologist or the interventionalist, because we are best suited to apply personalized approaches that produce the optimal cost-effective therapy for our patients. It will be crucial to document those results through research in order to mobilize the allies needed to achieve these goals. Hopefully the economy will improve in the coming years. In the meantime, it will be a tragedy if we do not take advantage of the current crisis to build a better system of health care.
* Address correspondence to: Spencer B. King III, MD, MACC, Editor-in-Chief, JACC: Cardiovascular Interventions, Saint Joseph's Heart and Vascular Institute, 5665 Peachtree Dunwoody Road, NE, Atlanta, Georgia 30342 (Email: sbking{at}sjha.org).
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