January 18, 2017 | Rick A. Nishimura, MD, MACC
Education

In an interview with Sherry-Ann Brown, MD, PhD, and Megha Prasad, MD, Fellows in Training (FITs) at Mayo Clinic, Rick A. Nishimura, MD, MACC, Judd and Mary Morris Leighton Professor of Medicine at Mayo Clinic, discusses his achievements, mentorship, the future of cardiology and physician burnout.

Sherry-Ann Brown/Megha Prasad: You have been recognized as a Master of the ACC. What has this journey been like for you, and what advice do you have for FITs to become more involved with the ACC with the hopes of reaching that status?

Rick A. Nishimura: I have been very fortunate in terms of my involvement with the ACC. It has, indeed, been a great journey and the opportunity to work with a society such as the College has been tremendous. I started as a young member of one of the peripheral education committees. By demonstrating enthusiasm and energy, the committee chairs, as well as the ACC staff, recognized that I was very eager to contribute to the College. From there, I was fortunate to be given the opportunity to chair a number of sequential education committees and then subsequently information technology committees. By focusing my clinical research in the area of valvular heart disease, I was selected as a member of the Valvular Heart Disease Writing Committee and subsequently, again through hard work and demonstrated enthusiasm and commitment, had the privilege of participating as the committee chair. Thus, it is important that FITs and young faculty, when given the opportunity, demonstrate commitment and enthusiasm to College activities. This can now start at your chapter level, and there are also Sections and Councils that you can start to voluntarily participate in. You will find that the participation itself is very rewarding. One of the most enjoyable features of the College is the ability to meet and network with cardiologists from all over the country and, now, from all over the world.

SAB/MP: What are you most excited about in the field of cardiovascular medicine and, specifically, cardiovascular education over the next decade?

RN: Cardiovascular medicine is undergoing a dramatic change. There is definitely a knowledge explosion now with expanding science, technology, diagnostics and treatment. We are accumulating data knowledge exponentially. Thus, it is really impossible for a single cardiologist to be able to retain all of the knowledge necessary to keep up as a competent cardiologist. Thus, we will need to create a "knowledge management system", in which our highly recognized and vetted ACC/American Heart Association guidelines are parsed, stored and retrieved in "byte-sized chunks of knowledge". This will allow one to access information that they need about a particular patient at the point-of-care, when it is needed the most.

It will be important to have this vetted, reliable, but clinically applicable discrete knowledge incorporating all new science when managing patients in the future. However, it is also important that the "core competencies" be the foundation of all cardiovascular practitioners. The ACC has created these core competencies so all are able to understand what they need to know and, using the tools from the ACC and other institutions, know where their own gaps in knowledge lie. Finally, it is incredibly important for the FITs and new faculty to fully develop the capabilities of "clinical decision-making" for optimal patient care.

SAB/MP: Given your clinical interests in invasive hemodynamics and hypertrophic cardiomyopathy, what advances in these fields are you most excited about? What advice would you give to fellows interested in these areas?

RN: Structural heart disease is now emerging as one of the key specialty areas in cardiovascular medicine. We now have the knowledge of the natural history of diseases such as valvular heart disease, myocardial disease and pericardial disease. Diagnostic modalities are getting better and better, and much more sophisticated. Outcomes from interventions are improving, thus lowering the threshold for intervention before the onset of myocardial problems. Finally, catheter-based therapy for all of structural heart disease is emerging. In a person who is interested in structural heart disease, it is important not only to be able to perform diagnostics and therapeutic procedures but to understand the underlying pathophysiology of the disease and to be able to interpret complex hemodynamics that will accompany these complex patients. Programs aimed at training experts in structural heart disease will be necessary for the future.

SAB/MP: What innovations do you think should be brought to cardiovascular training in the next year, and what is the best way to continue to incorporate technology into education?

RN: Fortunately, the ACC has developed the COCATS training statements that define core competencies and milestones. FITs now have a roadmap to pursue so they can become the most competent cardiologists upon graduation. With all the training that will be needed for all emerging areas, it will be necessary to derive a "competency-based program", in which training is done to achieve a level of competency and not necessarily a set time duration (for instance, instead of a certain number of months training for Level 2 in the Cardiac Catheterization Laboratory, training can be completed once a fellow shows competences defined by the core competencies; such as the performance of the procedure, the understanding of complications, the ability to communicate with patient and families, the interpretation of the procedure, as well as knowing the indications for the procedure). However, as stated above, it is also of great importance for our fellows to understand basic pathophysiology principles, be able to perform a proper history and physical examination, and then apply all the knowledge into clinical decision-making that will end up being the best for the patient. We cannot let technology take the place of "thinking".

SAB/MP: Looking back over time, what did you do as a fellow that you would recommend to current and future FITs? Any regrets?

RN: Though it sounds corny, I do believe the best approach to training is to decide what area you're passionate about. This will be a career that you will do for the rest of your life. You want to be able to pick the area, pursue it with enthusiasm and have the ability to wake up every morning thinking that you are going to have a great time in your practice or academic setting. It is important to pick the right mentor and continually ask for sage advice regarding direction and future accomplishments. One needs to set out specific goals to be achieved during specific periods of time. This will include specific research projects and the currency for academic centers are still publications.

SAB/MP: Which accomplishments are you proudest of?

RN: Developing the expertise for excellent patient care, as well as the research in hemodynamics and valvular heart disease have been rewarding. However, the areas that have been most satisfying are those involving education. At Mayo Clinic, it has been such a pleasure to take a group of young FITs through hemodynamics and clinical decision-making. The courses we teach around the country, including Board Reviews and Maintenance of Certification Sessions, are particularly rewarding, as they truly help the attendees understand their knowledge gaps and what is needed to continue to practice excellent medicine. One of our proudest accomplishments that we did together with Patrick T. O'Gara, MD, MACC, past president of the ACC; David R. Holmes Jr., MD, MACC, past president of the ACC; Elizabeth Klodas, MD, FACC; and Carole Warnes, MD, FACC,was the development of a "Emerging Faculty Program", in which we have taken the young superstars of the future in education and brought them to the Heart House for intensive instruction in cardiovascular education. This young faculty have now "emerged" as the current leaders of the College.

SAB/MP: Physician burnout is an increasing concern in this next generation of physicians? What has changed, if anything, and how do you recommend preventing burnout and addressing this important issue in the next generation of FITs?

RN: Burnout is certainly an increasing problem in all fields of medicine. It is difficult to juggle the increasing demands of the profession with family and personal life. However, there are certain things to remember:

• Family always comes first. You will never regret the time you spent with your significant other and/or children.
• Your future satisfaction will be dependent upon your love and enthusiasm for what you are doing. Thus, it is important, as stated above, that you pick an area that you really enjoy working in. It is also important to remember that one of the major factors for "burnout" is loss of autonomy and control. When looking for positions and jobs, this concept is very important to remember when negotiating contracts. It is also critically important to take time out for one's self and develop outside interests and regular physical activities.
• What is most difficult is to prioritize, which might require "saying no" to a number of requests, no matter how attractive they may be. I also sit down with mentees and have them list 1) things they are doing that they want to continue to do, 2) things they are doing that they will not want to continue to do, and 3) things they are not doing that they would like to do. By writing down these three columns, one has a better chance of adjusting priorities accordingly.