ACC President Mary Norine Walsh, MD, FACC: ACC.18 Opening Showcase Speech

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My father is going to be 90 years old on May 7. He is alive because of the extraordinary advances in the treatment of cardiovascular disease.

He remains alive due to the constant care and love of my mother. But he is also alive because I was his advocate.

Dad started running when he was 50 years old. He is a trend-setter in our family. A trend some of us later followed. My older brother Jay became a runner at age 40 and I at age 50.

Dad is a voracious reader and the year he turned 50 he read The Complete Book of Running by Jim Fixx. His first run was after a long day of work at his office. While driving home, he pulled the car over at a local park and ran around on the grass in his dress shoes. He later got himself some running shoes and he was soon running a few miles every day no matter what the weather.

And in 1978, seeing a person running down the street was very unusual. There weren’t races to train for or running clubs or expensive clothes to buy just to run in. Dad was frequently stopped by police officers who wanted to know why he was running and where he was going.

So the day he told me he hadn’t run for two weeks, he got my attention. This was 15 years ago now. He was 75 years old. He’d run almost daily for 25 years. His “GERD had been acting up while he was running,” he said.

Well, I did what all of you would have done, I arranged for him to see a trusted colleague who scheduled a stress test. A stress test that turned out to be normal. Now I know many of you want to know how many METS he went and what flavor of stress test he had but suffice it to say that in a good lab with good cardiologists overseeing things, he had a negative stress test.

But his symptoms persisted. I am embarrassed to say that at one point, during a Thanksgiving weekend visit, I actually told my dad that he was just getting used to his new hypertension meds and that he’d be feeling better soon. He didn’t restart his running and after about a month of this he woke up one morning and asked my mother to drive him to the hospital because he as in pain. This from a man who had never been hospitalized in his life. In the ER his EKG was normal, his cardiac markers negative and he was admitted to the medicine service.

Remember that negative stress test? Well, the medicine docs did what most medicines docs would do: they ordered tests to figure out what was wrong. My dad had a RUQ ultrasound, an upper GI endoscopy, a HIDAA scan and a barium swallow. All of which were unrevealing. On a sunny Friday morning in December, I called Dad in his hospital room to see how he was feeling. He told me that he was fine, but that he was to call the nurse if he had chest pain so that the nurse could get an EKG. “And I know how to get the chest pain,” he told me. ‘I’ll just eat breakfast and then walk in place at the side of my bed.”

I know. I then did what all of you would have done. I called my trusted colleague, the cardiologist, who had not yet been consulted on Dad’s case, and I asked him to please take my dad to the cath lab. And he did. Here is the opening shot from his angiogram. Well, one like it anyway. Pretty tight left main, huh? You’ll not be surprised to hear that the next step was a balloon pump and coronary bypass surgery later that morning. That was 15 years ago.

That day and ever since then, my brothers and sisters have asked what would have happened to our dad if I hadn’t stepped in to agitate the system. How would he have fared? My answer has always been, “Everyone needs an advocate.”

Everyone needs an advocate.

We all serve as advocates every day. In many areas of our lives, but some of the most important ways we advocate is as health care professionals, members of a cardiovascular team and as members of the American College of Cardiology. Some of our efforts as advocates are more visible than others.

Heather Ross, PhD, DNP, ANP-BC, is an advocate. She is a nurse practitioner and a professor at Arizona State University.

But she is also an advocate for change in health care as she mounts her campaign for the US House District 6 in Arizona.

My friend and Indiana ACC Governor-Elect, Don Westerhausen, MD, FACC, is an advocate. Don is campaigning for public office, too.

He is running to represent his district in the Indiana state legislature. One of the issues he is most passionate about is affordable health care and the impact of health care costs on the poor and vulnerable.

These members of the College have made their roles as advocates for health care very visible and very public. But most advocates aren’t so visible.

I want to show you three ways we can and do advocate every day.

One: We can be quality leaders both nationally and at our own institutions. It is rough out there in healthcare today. Shrinking margins and a focus on the bottom line can often pit hospital administrators against physicians and nurses as they attempt to cut costs. But healthcare is not only about the bottom line. When we work in dyad leadership teams with our administrative partners it is incumbent on us to keep the focus on quality and patient safety. We are lucky in cardiology. We have reams of quality data to back us up.

We have more randomized controlled trials and guidelines than any other field of medicine and our registries, including the NCDR suite of registries allow us to track real world data that we can use in quality improvement. Keeping an eye on quality and patient safety is our job. We can advocate for quality by using data to innovate.

At our place, we recently did a deep dive into the literature on hepatitis C positive cardiac donors and made the decision after looking at our own data that we should consider such donors as options after discussion with our patients awaiting transplant. Each year about a thousand donor hearts aren’t transplanted because of donor hepatitis C infection. But as you know, there are now several new, highly effective drugs that have been shown to clear hepatitis C close to 100 percent of the time. In the last month, we have transplanted X patients who were gravely ill with hepatitis C positive donor hearts.’ These patients had few other options. Our experienced team of physicians, nurses, pharmacologists and others used quality data, both external and internal, to take a risk and advocate for patients who had few other options.

A second way we can advocate is to advocate for and support each other. The practice of medicine today can feel like death by a thousand cuts.

Shortened office visits, mandatory web-based training modules, reporting requirements and an EHR inbox that never closes can leave us feeling depleted and defeated. Last Wednesday our EHR went down for a few hours and we had to scramble.

We went old school and took histories and recorded findings on paper. No access to past medical history or records made it difficult to evaluate and treat patients, but what was equally bad was the dread we all felt about the amount of catch up work that lay ahead after the system came back online.

Doctors are burned out. Cardiologists are right there in the middle of the pack.

And nurses are burned out, too.

We cardiologists are not happy at work.

And we don’t seek help for burnout.

We have to help each other. We must focus not on the triple aim, but the quadruple aim. The well being of doctors, nurses and all members of the care team needs to be a primary concern of our health systems, our institutions, our practices and even our patients. And it starts with us. We must advocate for the health and wellbeing of our colleagues.

The College’s Task Force on Diversity has made us aware that among the many reasons to strive for a diverse workforce improving team care and preventing burnout are prime among them.

So do your part to improve diversity in our profession. Whether it’s improving the pipeline to cardiology, encouraging recruitment, helping with retention or fostering leadership, your active engagement can make a difference. The College has made diversity a part of its strategy and so can you.

We need to offer bystander support when it is needed. Recognizing a stressed colleague and offering to help, challenging a situation that involves harassment, racism or any kind of demeaning behavior toward a colleague, trainee, administrator or other team member can diffuse the situation. Modeling bystander support to our students, residents and fellows can help change culture and support the quadruple aim. Advocate for each other.

Susie is one of our medical assistants. She has taken to writing daily inspirational slogans on the dry erase board in our clinic area. Last week I asked her why she’d started doing this and she replied that felt she needed to do something to support the team in light of all of the bad news in the world today. Susie is an advocate for her team.

A third, and most obvious way we advocate, is for our patients. Our dear patients. Many of them are catastrophically ill when we first meet them, and even if they’re not, they are often frightened. Frightened to hear what we might tell them, frightened of a new diagnosis or treatment, frightened of the path ahead. We ae used to being advocates for our patients. We fight for their lives. Here are some of my patients and the fantastic team I work with every day.

But beyond our clinical care of our patients, we are on a new playing field of advocating for them. Never have we been so restricted by external forces with regard to how we diagnose and treat disease. We have had some huge advocacy wins for our patients recently. Some long-fought battles appear to be won. Soon, physician assistants, nurse practitioners, and clinical nurse specialists will be able to supervise cardiac, intensive cardiac, and pulmonary rehabilitation programs due to passage of the CV Rehab Bill, and the Children’s Health Insurance Program, or CHIP, is safe for at least a few more years. These wins are big, but the daily skirmish continues in our advocacy for our patients.

Prior authorization and other insurance restrictions are not just daily hassles in our practices that contribute to our burnout, they are clear threats to the wellbeing of our patients. Filling out the endless prior authorization forms, e-requests, and taking the time to talk to an insurance physician for a ‘peer-to-peer’ discussion of an imaging or other diagnostic test is important advocacy that we do every day. In addition to advocating for the best care for our patients, we are also unflagging in our support of our own evidence-based guidelines and appropriate use criteria. Every time we take on the system in this way we are advocating for a better care for our patients and a superior health care system.

Our ACC cores values now explicitly call out that we be patient-centered. We are the future of cardiovascular healthcare and the protectors of our patients. When we return to work on Tuesday morning, enriched by the new science and technology, practice development, and networking at this fantastic meeting, let’s continue to advocate. When barriers to care are erected, let’s surmount them.

Let’s not take no for an answer.

Let’s take care of each other.

Let’s advocate.

Oh, and on May 7, remember to wish my dad a happy birthday.

Keywords: ACC Publications, ACC Scientific Session Newspaper, ACC Annual Scientific Session, Leadership, ACC History

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