'Don't Sit in the Back Row'

Matthew W. Parker, MD, FACCMatthew W. Parker, MD, FACC, Early Career Imaging Section Editor, discusses career development in the field of cardiovascular imaging in this interview with Susan Wiegers, MD, FACC, FASE, past president of the American Society of Echocardiography (ASE) and current professor of medicine at the Lewis Katz School of Medicine at Temple University, where she is senior associate dean of Faculty Affairs and senior associate dean of Graduate Medical Education.

Dr. Wiegers, let's start with your own career path. You have obviously been successful as a director of an echocardiography laboratory, president of a national society and now a senior position in the dean's office at an academic medical center. How did you get your start in cardiovascular imaging?

I was actually a physics major in college, with plans for graduate school in astrophysics, when I decided to go into medicine. Changing to medicine made my senior year easier, replacing senior-level quantum mechanics with freshman-level biology! In medical school, I was naturally attracted to cardiology because of the link to physics. When I was at the University of Rochester, Navin Nanda, MD, FACC, was doing some of the early work with two-dimensional echocardiography (you have to understand this was the 1980s, and when he said he was showing you the left atrium, you thought "yeah, right, that fuzzy blob is the left atrium"). The combination of physics at work and application of echocardiography to patient care, especially in the acute setting, was really exciting to me. I then worked for two years as an emergency room physician and medical director of a nursing home. I completed my cardiology fellowship at Boston University and dedicated an additional year of training to advanced echocardiography with Arthur E. Weyman, MD, at Massachusetts General Hospital.

What was your first job after training?

I was faculty at Boston City Hospital for a couple of years before moving to Philadelphia. In Philadelphia, I first took a part-time job at the University of Pennsylvania and kind of rapidly accelerated to interim director of echocardiography when the previous director of echocardiography left. From there, I became associate director of echocardiography, along with Martin St. John Sutton, MBBS, FACC. When he stepped down from that role, I became the director. I always saw patients in clinic and attended in the coronary care unit in addition to echo (or otherwise you would be a radiologist and not a cardiologist).

What was the biggest shock as an attending that you didn't learn in fellowship training?

Nervousness or uncertainty when the preceptor is no longer watching over your shoulder is common among new attendings, but I think working in an emergency room prior to fellowship had already taught me to be decisive. The real shock for me was financial. When I went from a part-time position to interim director of echocardiography, I knew I deserved a raise, so I asked for one. They responded by asking what I thought I deserved and I gave them a number. They agreed right away. Looking back, I should have asked for five times that! The only way to know what your time and expertise is worth is to ask your colleagues around the country. Young professionals may not realize that a large number for them, personally, may be a small number to their employer, considering what they are doing for the institution.

If you could go back in time, what would you say to your early-career self?

I probably could have been promoted faster had I traveled to more meetings, given more talks and spent less time with my family. At the time, that was a source of anxiety. Now, looking back from my current vantage point, I worked out a good balance. That is, I have achieved a lot in my career and have a happy family, as well. I would tell myself, "It is going to work out."

What non-medical skills have been most important for success?

In general, it is very important to identify your own weaknesses and then do something about them. For me personally, here are two examples:

First, I started out pretty naïve about finances. It is great that most doctors are not "in it for the money," but doctors need to be able to talk to the managers, accountants and professionals who pay the bills and keep the lights on. Read the book Accounting for Dummies. Ask lots of questions about profit and loss statements, accounting reports and business spreadsheets, so that you know what is being measured and reported. Do not assume it is someone else's problem. The great part about this is it helps you make your argument when you need to upgrade equipment or buy new technology, because you will be able to talk about what it means in hard numbers. The bottom line for doctors is "what is best for the patient," but you need to be able to help the C-Suite see it your way.

The other skill is public speaking. I wrote about this in a President's Page for the Journal of the American Society of Echocardiography. An estimated one in three people are held back in their careers because of discomfort with public speaking. It is a skill, like running a code. The first time you run a code, you are terrified, and even after that, you have a physiologic reaction. But once you learn how and have some practice, you can be intellectually engaged without being tachycardic. I learned how to speak in front of people in my high school debating club, where I broke down in tears in the middle of a prepared speech, but then got better over time. If you are not comfortable speaking in front of people, take a course to learn how and find an opportunity to practice.

Finally, for all early career physicians, my advice is to be purposely visible. Go to your department meetings or practice meetings. Sit in the front row – not in the back row! – and ask questions. Show that you are engaged.

What do you think will be the biggest development in cardiovascular imaging in the next ten years?

The biggest development will be deep machine learning. I talked about this during my ASE Edler Lecture this past June. Driverless cars are a reality, with Uber cars in Pittsburgh that drive themselves but have a driver just for show – this will eventually be the paradigm for diagnostic imaging. I used to collect erroneous computer-generated EKG readings for laughs, but now the computer reads the EKGs and we sign them. To illustrate this point, I asked the audience at the Edler lecture how many measured the PR interval on the last EKG they read. No one raised a hand. An echocardiogram is more complex than an EKG, to be sure, but the speed of computers will cross that gap someday soon. That is not to say this is good or bad, but it will happen. And it will change our work significantly.

The Medicare and CHIP Reauthorization Act (MACRA) and the transition from volume to value will also change our work significantly. What suggestions to you have for early career cardiovascular imagers dealing with this change in payment models?

The most important thing is to know the rules. However, you cannot realistically go on the Medicare website and read the MACRA rules because the website is gobbledygook. The ACC, ASE and all of the imaging subspecialty societies have policy papers that translate the material for physicians in imaging. Read these! Staying up-to-date on multimodality imaging of mitral regurgitation comes naturally, but policy article may take more of a concerted effort to seek out and read. Just like understanding the finances, you need to understand the rules if you want to keep doing what you enjoy.

Finally, how has your career turned out differently than you envisioned?

"Back in the day," I aspired to be a chair of medicine. However, the duties of a chair of medicine at most institutions have changed and the parts of the role I really wanted (i.e. faculty affairs and graduate education) have moved to the dean's office for faculty affairs. I wanted to be president of the ASE since early on, and I planned for it. These types of things take work and involve service on committees and engaging and asking questions at society meetings.

Also, around age 55, my husband left academic practice and went into industry, where he learned a whole world of new things, which prompted a re-tooling of my own career. In part, I realized I could recognize, for example, a quadricuspid aortic valve but had seen that on echo so many times that it was not exciting anymore, so I wanted new challenges. The change in career focus has been worth it!