Three Lessons Learned From a Hybrid Clinical Practice

When I first graduated from my advanced heart failure and transplant cardiology fellowship, I took my first attending position with the advanced heart failure department at an academic institution. It was a position where I had found much of what I sought in an attending position – a faculty position at a quaternary cardiac center with an LVAD and cardiac transplant center, the ability to participate in research, and teaching responsibilities with trainees.

After two years, I moved to a different city where I assumed a position with Mount Sinai Hospital in New York City in a hybrid capacity: I would, as part of the faculty of the advanced heart failure department, round on the advanced heart failure, LVAD and cardiac transplant patients and rotate through the LVAD/transplant clinics. In addition, I would also assume the role of Director of Heart Failure at Mount Sinai Queens Hospital and oversee the development of a heart failure program at an affiliate hospital.

I was initially wary of the transition and the impact it may have on an academic career as this practice model was different from the traditional models I had trained in and had been accustomed to. However, I ended up gaining much more than I could have imagined.

Below are some lessons learned from my time as an advanced heart failure cardiologist working in a hybrid practice:

1. I learned firsthand the impact of health disparities.

By working in Queens, rounding in the inpatient service and seeing patients in the clinic for heart failure patients, I saw firsthand the barriers they faced to receiving appropriate medical care – whether it was lack of insurance, inability to follow up due to transportation, language barriers, lack of stable housing, or inability to obtain medical therapy. It impacted my practice habits enormously, as it made me more aware of the issues that can arise that can affect patient adherence and helped me appreciate even more the importance of multidisciplinary approach to patient care, including social work, nursing care, rehabilitation services, nutrition educators, other medical and surgical specialties.

2. I learned leadership skills.

Tasked with the development of a heart failure program, I quickly started to learn leadership skills, including development of protocols, evaluation of heart failure metrics and standardization of care, and initiating or participating in multidisciplinary meetings to improve outcomes. In addition, such a position afforded me autonomy to launch quality initiatives or improvement projects that I had interest in.

3. I learned that practicing advanced heart failure is a two-way street.

When I first started in my current position, my concern was I would have less opportunity to maintain my advanced heart failure training. In such a hybrid position, not only was I able to continue to round on advanced heart failure/LVAD and cardiac transplant patients, but I was also able to bring advanced heart failure care to a population that previously did not have access to heart failure care. Queens is very famously known as one of the most culturally diverse boroughs in the world. With this came exposure to advanced medical conditions of patients who had emigrated from regions around the world that at times were unable to access medical care. Seeing these patients in a collaborative manner with my colleagues allowed patients to be evaluated for complex coronary or structural interventions, electrophysiologic procedures, and advanced heart failure therapies, such as LVAD and cardiac transplant. For me, delivering such care to an undeserved population was as important as my time on the advanced heart failure services.

Though I had reservations about a hybrid clinic practice, I gained a perspective on patient care that I would not have achieved otherwise. I truly learned to appreciate the economic and psychosocial barriers that a patient may have to access appropriate medical and learned to hone leadership skills to not only build a heart failure program, but to help close the disparity gap as much as possible.

This article was authored by Preethi Pirlamarla, MD, an advanced heart failure and transplant cardiologist at Mount Sinai Hospital and Director of Heart Failure at Mount Sinai Queens Hospital. Twitter: @PPirlamarla_MD

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