December 13, 2017 | Thomas M. Munger, MD, FACC
Education

In an interview conducted by Vaibhav R. Vaidya, MBBS, Fellow in Training (FIT) at Mayo Clinic, Thomas M. Munger, MD, FACC, chair of Heart Rhythm Division of Cardiovascular Diseases at Mayo Clinic, discusses the challenges and joys of administration, and gives advice to budding cardiac electrophysiologists. He also explains changes to the health care legislative landscape and shares his thoughts on social media.

You run a large academic cardiac electrophysiology program. Can you share how you initially got involved in administration?

I administered the cardiology residency program at Mayo Clinic 20 years ago. It was the early days of the internet and we were developing an internet-based curriculum. I had done a lot of computer programming in the 1970s when I was in high school and college; that experience, coupled with the ability to start organizing an actual online curriculum for the residents, piqued my interest as far as seeking additional administrative responsibilities. Administration is not something anyone is typically trained to do in medical school.

In the early 2000s, I was education vice chair under the instruction of David Hayes, MD, FACC. Douglas Packer, MD, FACC, and Stephen Hammill, MD, FACC, who were in charge of Mayo Heart Rhythm, mentored me further by assigning me to direct internal clinical operations. I also joined a Centers for Medicare and Medicaid Services panel on coding for four years, along with the Heart Rhythm Society health care policy, ethics and coding work groups. During this time, I worked at the local and national level on efforts to optimize national supply chain with agreements that would enhance value at the buyer's (hospital and patient) level. I have always had interest in our own health care system, to enhance consumer value and quality of the services we deliver to patients every day.

What are the challenges and joys of such an immense administrative responsibility?

Administration has a lot of different pieces. It is like running a restaurant. You have payroll; staff to hire, educate, manage, mentor and promote; marketing, quality initiatives, supply and financial stewardship; research and innovation to foster; collaboration within and outside the larger institution; and legacies to document and celebrate. I find myself now like a person in Home Depot, trying to decide which components I need to acquire to build the best system.

What advice do you have for FITs who may be considering a future in administration?

I go into meetings now and am surrounded by many people who have acquired Juris Doctor, Master of Public Health or Master of Business Administration degrees as part of their medical curriculum. This will be critical in the future and you will get a head start on everyone else if you incorporate this into your formal education. For most people my age, we have learned it on the fly and acquired street experience. But for the next generation, having a concentration in one of these other programs would get you up to speed quickly and differentiate you in this regard.

Like every other aspect of medicine, having a mentor who can teach you the language and show you different aspects of the job early on in your career is helpful. For me, Stephen Hammill, MD, FACC, was the key person who helped me along. He had lot of experience with the Heart Rhythm Society, serving as president and administrator for our group for over two decades. Being able to work closely with someone like Hammill early in your career is important.

What advice do you have for general cardiology fellows considering a career in cardiac electrophysiology? Is it a good time to get into the field? What are your thoughts on job opportunities in cardiac electrophysiology?

This is another good question about the manpower and womanpower needs in electrophysiology. For health care in general, there are two big humps in demographics; there are a lot of physicians in the Baby Boomer group, a smaller group of Gen X'ers and then a large group of Millennials. There are going to be a lot of retirements occurring over the next five to 15 years as Baby Boomers move out of the workforce. Those jobs are going to have to be replaced and I do not see them going away at all.

Cardiac electrophysiology has continued to grow since I went into it in the late 1980s. With new indications, discoveries and ways of doing things, it is going to continue accelerating over the next few decades. I do not see any change in the need for the clinical electrophysiologist going forward. Could you be doing something different in 2034 compared to now? Definitely. Nothing like that stays the same. What I do now, compared to 1980, is very different: the diagnostic tools, therapies, workups and interventions have nearly all changed. I would be optimistic about it. Do not plan on electrophysiology fellowship based on the job market, because if it is your passion, you are going to find jobs in it that will evolve and provide career satisfaction over time.

The health care legislative landscape continues to evolve and change. How will the Medicare Access and CHIP Reauthorization Act (MACRA) impact the practice of cardiology and electrophysiology?

Earlier this year, I went to ACC's Cardiovascular Summit – a three-day course organized by the ACC on health care legislative landscape – and it was excellent. If any of you want to get more information on this topic, this ACC course brings you up to speed quickly.

The Affordable Care Act, also known as Obamacare, is an insurance program for patients. MACRA is a way for the government to actually look at the value of what they are paying for and try to improve the quality of outcomes in a cost-efficient manner. Mayo has always been a supporter of this. In 2009, our former CEO Denis A. Cortese, MD, wrote an article in The New England Journal of Medicine about the value in health care, which is what MACRA is trying to enhance.

Health care has traditionally been an opaque market over the last 50 years. We have insurance companies, government payers, patients, providers and hospitals, many of which do not talk to each other. It has been difficult to bring a lot of market forces to bear. MACRA moves away from a fee-based payment model to an outcome-based payment model, where efficiency and good outcomes are rewarded. Those that are not being efficient are not rewarded. This should help create more of a market-based system, where ultimately you are driving down costs and helping more patients. It was passed bipartisan, one of the few pieces of legislation to get more than 90 votes in the Senate in the last several years. I am hopeful that this will remain a part of whatever the insurance plan ends up being passed in Congress.

Should FITs be aware of these changes in health care legislation? What do they need to know?

It is imperative that FITs learn about health care legislative landscape. Starting this year, hospitals and health care organizations are required to report to the government on their outcomes, costs and quality measures. They are starting out small, but it will grow dramatically over the next three years. Medicare and the government will use that data as a benchmarking method to decide who is going to get bonus payments over the next few years and who will get reductions in their reimbursement.

Thus, it is important to know which outcome measures are being reported at your institution. Not all of them are the same, so you can ask locally which ones are you are held to and which ones you have to report. Also, understand that it will not just be outcomes that are reported like it has been in the past; they will be looking critically at the cost your organization charges for different services. Know that the data is actively being collected now and it will expand over the next couple of years.

Finally, what are your thoughts on social media in medicine?

Social media is clearly generational. You see a lot more people on Facebook, Twitter, LinkedIn, Snapchat, We Chat and all other modalities in the under 40 years old demographic. That being said, there are still plenty of older folks who are using these platforms. I think it is going to be important for education and providing feedback to patients. I have asked several times if we could use social media the way Lowe's, Amazon or any of the other commercial entities use it as a way of imparting information to the consumer that does not necessarily involve a human on the other side. There are opportunities to use social media as an educational tool for both physicians and patients, but it just may take a while to catch on. When Amazon went into their business model back in the 1990s, it did not catch on initially. Everyone would say: "Gee, this is great. But why aren't people embracing it?" It took a generation before the big migration from brick and mortar stores to internet-based consumerism occurred. I think the same thing will happen with medicine, but it will take a decade. Or two!