Step 1: Visit other programs in the same "class"

I reached out to program leaders at high volume, successful community structural programs across the U.S. I'd met early in my career. This led to visits with Mir Wail Hashimi, MD, FACC, in Mobile, AL, who helped build a high-volume program within a private practice model. I met with the president of the Arkansas Heart Hospital, Drew Jackson, who helped craft a high-quality and cost-efficient structural program in a nonteaching community integrated hospital. These visits to two completely different programs gifted me with some practical ideas I employed as I started my own journey.

Seek out a well-established program and leaders in the same type of setting for your own potential program to serve as a model, whether it's an integrated community hospital or a private practice, etc. Every model comes with its own predefined challenges. If you work in a private practice setting at three hospitals, it may be inherently more challenging to gain alignment with any particular hospital administration.

Step 2: Learn the geography of your practice

KDMC is in a very rural area in eastern Kentucky. I knew that despite the low population density, it's the only tertiary center capable of doing structural procedures in about a 100-mile radius. I also knew the health system had at least half a million patients in its catchment area and there was a very low penetration of valvular heart disease therapies. Many of our patients drive up to two hours, even from other states, including western West Virginia and southern Ohio, as well as southeastern Kentucky.

I also studied the neighboring programs to better understand their catchment areas and services offered. I wanted to ensure that I would partner with these programs to help all patients in the area – not waste time competing with them.

Step 3: Understand your patient population

When I heard of the paucity of tertiary care centers over such a broad swath of land, I recognized the need for a strong structural program in the area to improve access to care. However, one thing I did not recognize was the lack of connectivity overall in Appalachia. This is one of the areas that's being referred to when politicians and policy makers talk about improving broadband access. (See the cover story for more on digital equity.) When I first moved here in 2019, I was shocked to see how many people still use flip phones and don't have access to the internet. Now I totally understand when I ask a patient for their phone number and learn they do not have a phone. Notably, this lack of access to basic health information makes patient education very difficult.

I have relied heavily on resources on ACC's CardioSmart.org website and YouTube videos to help my patients understand their valvular heart disease process as well as the options available for treatment. I have also devised different analogies and diagrams to explain these concepts to patients. Many are familiar with farming or engine mechanics, so we try to use those examples when explaining the pathophysiology of mitral regurgitation, for instance. Shared decision-making is my personal mantra. I do my best to ensure patients and their families have all the information they need to make a well-informed decision between medical therapy, surgery and percutaneous therapy.

Step 4: Understand the internal politics

Relationships within the home institution are the main reason structural programs are either incredibly successful or fail to grow. These relationships include how cardiologists interact with each other and the cardiac surgeons. What do the cardiac surgeons think of the field of structural heart disease? Are they supportive or skeptical? Are the cardiologists more aggressive with early diagnosis and referral or do they tend to refer patients later in the disease process? Are there any opportunities for education on ACC/AHA guidelines? Relationships between physicians and hospital administration is equally vital. How accessible are the administrators? Do they meet regularly with physicians?

Step 5: Get to know your industry partners

Industry can be vital in your quest to grow your program. Device manufacturers have additional resources at their disposal, both monetary and educational, to help you grow as a clinician and a leader. They can connect you with other leaders in the field from around the country and can also support educational events locally to raise awareness about structural heart disease. They have a wealth of resources to help educate your patients and referring providers.

However, try not to be biased. If you trained with a particular device but there is more than one option on the market, consider ensuring your program has access to both products. This can help protect your program in case of a supply chain issue, but also demonstrates you are willing to grow and that your top concern is offering the best care with the latest devices. And you want to model good behavior for the rest of your program – selecting one particular device every time without taking into account individual patient characteristics can potentially send the wrong message to your colleagues.

Step 6: Align your vision with your organization's vision

You may be the smartest person in the room and the best proceduralist in the country, but if your organization's administration is not supportive of starting a particular procedure, it's unlikely you'll get to do it (at least at that facility). Whether you work at one hospital or several around town, take a moment to make sure your goals are consistent with those of the health care system(s) at which you practice. No alignment = no achievements.

On the flip side, with good alignment, the possibilities are endless. In business, I believe that creating opportunities for win-win-win-win situations is the key to success. Patients win, providers win, health care systems win, industry wins. Maximize these opportunities and growth will ensue.