AHA/ACC Issue Updated Guidance on Maintaining Ethics and Professionalism in Cardiovascular Care

May 11, 2021—The American Heart Association (AHA) and the American College of Cardiology (ACC) announced the publication of a report on medical ethics and professionalism that addresses important and timely topics in cardiovascular medicine, including diversity, equity, inclusion, and belonging; racial, ethnic, and gender inequities; conflicts of interest; clinician well-being; data privacy; social justice; and modern health care delivery systems.

The report is based on the proceedings of the joint 2020 Consensus Conference on Professionalism and Ethics. Ivor J. Benjamin, MD, and C. Michael Valentine, MD, served as cochairs of the conference. Dr. Benjamin et al published the report online in Circulation and Journal of the American College of Cardiology.

Other organizations had the opportunity to review and provide feedback on the report, including the Heart Failure Society of America, the Preventive Cardiology Nurses Association, the American College of Preventive Medicine, the American Association for Thoracic Surgery, the American College of Physicians, and industry.

According to the AHA and ACC announcement, the Consensus Conference Report presents a road map to achieving equity, inclusion, and belonging among cardiovascular professionals that calls for continual assessment of the professional culture and climate, focused on improving diversity and achieving effective allyship. The report proposes continuous trainings to address individual, structural, and systemic racism, sexism, homophobia, classism, and ableism. The new report updates previous guidance the groups issued in 2004.

The announcement noted that the report’s writing committee is a diverse group of cardiologists, internists, and associated health care professionals and laypersons, organized into five task forces, each of which addressed a specific set of related topics: conflicts of interest; diversity, equity, inclusion, and belonging; clinician well-being; patient autonomy, privacy, and social justice in health care; and modern health care delivery.

Recommendations for championing equity in patient care also include an annual review of practice records to assess for differences in patient treatment by race, ethnicity, zip code, and primary language. The report suggests each health care setting conduct an annual review to ask, “How is racism operating here?” This review would examine structures, policies, and norms and identify opportunities for intervention and improvement.

The AHA and ACC reiterated their endorsement of the Principles of Professionalism published in 2002 in the Physician Charter on Medical Professionalism. Both organizations also reaffirmed their commitment to social justice in the new recommendations.

The societies stated that the report calls for a foundation of training in allyship and antiracism as part of medical school course requirements and experiences: a required course on social justice, race, and racism as part of the first-year curriculum; school programs and professional organizations supporting students, trainees, and members in allyship and antiracism action; and facilitating immersion and partnership with surrounding communities.

A section of the report is focused on the need for psychosocial support of the cardiovascular workforce, recommending that health care organizations prioritize regular assessment of clinicians’ well-being and engagement.

The ACC/AHA announcement advised that additional recommendations address the well-being of trainees and call for preventive and responsive mental health resources in postgraduate training programs. The resources should include an ombudsman program that allows for both confidential reporting of mistreatment and access to support. There is specific attention given to identifying “disruptive” or abusive behavior among medical teams and recommendations to ensure these behaviors are addressed regularly through professional training. Early career professionals and fellows in training were involved in this process.

As outlined by the AHA and ACC, the report details additional opportunities to:

• Improve efficiency of health information technology, such as electronic health records, and reduce the administrative burden
• Identify and assist clinicians who experience mental health conditions, alcoholism, or substance abuse, the prevalence of which is 2% to 14% among clinicians
• Emphasize patient autonomy using shared decision-making and patient-centered care that is supportive of the individual patient’s values
• Additional privacy protections for patient data used in research
• Guidance on maintaining integrity as new ways of delivering care emerge (eg, telemedicine, team-based care approaches, physician-owned specialty centers)
• Routine audits of electronic health records to promote optimal patient care and ethical medical practice
• Expand and make mandatory the reporting of intellectual or associational interests in addition to relationships with industry

“As much as 80% of a person’s health is determined by the social and economic conditions of their environment,” stated Dr. Benjamin in the AHA and ACC announcement. “To achieve social justice and mitigate health disparities, we must go to the margins and shift our discussions to be inclusive of populations such as rural and marginalized groups from the perspective of health equity lens for all.”

Dr. Benjamin continued, “The delivery of cardiovascular care is evolving rapidly. Through this evolution, our professional obligations to patient-centered care must remain steadfast. How we engage and employ staff, receive payment, and provide and document patient care requires maintaining standards that are beyond reproach. We must maintain and promote integrity in all we do to protect public trust in science and medicine. Individuals and professional communities must take responsibility for evaluating and maintaining standards of care, while promoting an environment of diversity, equity, inclusion, and excellence for all.”

Dr. Valentine, MD, added, “We have seen the COVID-19 pandemic challenge the physical and economic health of the entire country, coupled with a series of national tragedies that have awakened the call for social justice. There is no better time than now to review, evaluate, and take a fresh perspective on medical ethics and professionalism. We hope this report will provide cardiovascular professionals and health systems with the recommendations and tools they need to address conflicts of interest, racial, ethnic, and gender inequities and improve diversity, inclusion, and wellness among our workforce. The majority of our members are now employed and must be engaged as the leaders for change in cardiovascular care.”

At the ACC’s 70th annual scientific session held virtually, the report’s details and recommendations were presented and discussed in a May 15 session titled, “Diversity and Equity: The Means to Expand Inclusion and Belonging.”

Beginning May 11, the AHA’s six-episode podcast series, “HeartBEATS from Lifelong Learning Professionalism & Ethics,” is being released weekly.

The podcast seeks to amplify the report’s details, dialogue, and actionable steps for cardiovascular and health care professionals, researchers, and educators. The podcast series and roundtable discussion will explore perspectives that support robust ethical personal and professional behaviors and organizational actions and policies within the context of the current health care and scientific environment, as outlined in the Consensus Conference Report.

The AHA’s recorded webinar, “Ethics and Professionalism: A Common Ground of Understanding” will be available on demand as of May 28.