Chris’s Corner: It Runs in the Family...
By Sandra Lewis, MD, and Lisa Rosenbaum, MD
Editor’s Note: Sandra Lewis, MD, and her daughter, Lisa Rosenbaum, MD, are likely one of the few mother-daughter cardiologist pairs in existence. Dr. Lewis has been in practice for the last 30 years, and currently practices cardiology at Northwest Cardiovascular Institute in Portland, Oregon; Dr. Rosenbaum is now in her second year as a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania, having recently completed her clinical cardiology fellowship at NYPH Weill Cornell. Having undergone training 30 years apart, each doctor has a unique perspective on the field of cardiology. I invited them to share some of their experiences in this edition of Chris’s Corner.
This is our first visit to Chris’s Corner, so let’s start with a bit of introduction, and a little glimpse into our daily dialogue.
We are two generations of cardiologists in a family with 10 physicians just in the immediate family. Despite living 3,000 miles apart, we keep in pretty close communication. This morning began with a typical email chain. There was no “Hello!” or “How’s the weather?” Instead, there was a link to yet another article blaming money-hungry physicians for all the woes of the world, including childhood obesity, lack of end-of-life discussions, and overspending on American health care.
When we both have the time to move beyond the subject line, our emails deal with such things as statin guidelines, medication adherence, the role of the specialist in the evolving delivery systems, appropriate use, and—once in a while—shopping or a new hairstyle.
Our training was separated by 30 years. Our perspectives are from East Coast academia and West Coast private practice. Our visions of “the cardiologist” reflect the amazing changes in cardiovascular medicine in approaches to both disease knowledge and cardiology practice. Sub-sub specialized cardiology seems foreign to one of us, and completely normal to the other.
We share a love of cardiology, a deep joy in taking care of patients, and distrust about easy answers.
Sandra Lewis, MD: More senior cardiologists have seen amazing changes in the practice of cardiology. At the risk of sounding like I walked in the snow four miles every day, both directions uphill, I’ll tell you some memories from my fellowship: watching Scott Mitchell and Craig Miller cool a patient for aortic repair in an ice-filled canoe; John Simpson bringing in balloons he made in his garage shop for the day’s angioplasty; and Mike Bristow teaching fellows to use beta-blockers in heart failure, but needing years to convince anyone to sponsor a large multicenter trial.
We had farm animals living on the roof of the hospital, producing anti-thymus globulin from injected human thymus to treat rejection in the transplant patients. Echo, electrophysiology, heart failure, interventional cardiology, and imaging were all in their infancy and part of the comprehensive cardiology training.
Each new finding pushed our abilities to improve our patients’ outcomes, but much of the regulation and direction we now work with were still in the future. Evidence-based medicine? Well, it was a goal but not quantified. Appropriate use? Not part of our vocabulary. The training and the excitement of the learning and building in many ways shape the cardiology training of this generation.
I have continued to learn and grow through the 30 years since my fellowship, but none of that growth has been more meaningful than going through fellowship again with my daughter. Together we are able to challenge each other’s assumptions and perspectives. It is safe to share our uncertainties, stimulating to question the status quo, and invigorating to engage in debate: Why do we push diet and exercise when it doesn’t work? What really is “shared decision making?” What about adherence, statins, and stents? Do work hours allow for adequate learning? The best things happen in the hospital in the wee hours.
Lisa Rosenbaum, MD: Though I could not admire the way my mother approaches clinical care more, I have chosen a very different path. At the University of Pennsylvania, my broad research interest is in behavioral economics—more specifically, how emotions inform decisions and behaviors related to cardiovascular health. I am also a writer, and spend much of my time thinking about how to communicate science to the public in a way that is both honest and emotionally compelling.
Perhaps it is because of my mother’s experiences—and getting the sense of the people and the stories behind the evidence—that my own interests have really converged upon trying to understand the barriers to disseminating this evidence into practice. We have this incredible arsenal of medications to treat cardiovascular disease, yet it’s hard to get our patients to take them.
For instance, the age-adjusted rate of cardiovascular disease death has fallen about 40% in the last 30 years, a success due in large part to knowledge wrought by rigorous clinical trials. And yet, the dominant cultural narrative increasingly focuses, in an overly simplistic way, on cardiologists behaving badly. We all want to improve the quality of the care we deliver, but when externally-imposed and untested measures are implemented, it can lead to unintended consequences and further distraction from the kind of doctors we want to be.
Despite these challenges, the passion I have for cardiology, the awe I have about what the field has done for our population, and the sense that we can still do better have only intensified. This partly stems from my own clinical experience and fascination with behavioral economics, but most of it, I am sure, is because I carry not just my own observations, but those of my mother’s. For that, I feel incredibly lucky.
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