What You’ll Learn

An experienced cardiologist reflects on what inspires him–technological innovation and new drugs that help patients who couldn’t be helped before–as well as the challenges of non-compliant patients and denials by insurance companies. He reveals his ability to work more efficiently and synthesize data is the most significant advantage he’s gained since the early years of his career.

Interviewee: I’ve been in practice for 20 years now. For the last 12 years, I’ve been with a private hospital-based multi-specialty group in rural North Carolina, and I’m in the cardiology division, non-interventionalist.

VIVO: IWhen were you most recently inspired in healthcare? 

Interviewee: When the patients have a good outcome, it’s inspiring. Either their heart failure is improved or we assess their coronary disease and intervene and they’re doing well.

VIVO: Can you tell me something new in your field that has inspired your work, whether that’s technology or a procedure or anything that’s been new to you?

Interviewee: The ability to do certain interventional procedures like TAVRs and Watchman devices to help the patients that couldn’t be helped before. Along with some of the newer drugs that are coming out like Entresto and SGLT2 inhibitors to help with heart failure and outcomes.

VIVO: What would you say is the most persistent challenge that you experience?

Interviewee: Patient non-compliance. We try to get them on the right drugs and do the right things and it’s very difficult to do that. The very close second is dealing with insurance companies because they’re the main hindrance in trying to get these things done.

VIVO: What wisdom have you gained from being a cardiologist?

Interviewee: Helping take care of people with heart disease.

VIVO: Has that changed your perspective on life at all or how you live your life?

Interviewee: Yeah, I definitely try to stay in shape and gain weight and eat and those types of things. You don’t want to have the same outcomes as a lot of your patients.

VIVO: Looking at the field of cardiology, what do you think it will look like in 10 years?

Interviewee: Hopefully improved technology, improved medications to improve outcomes. There’s less disease. And less acute issues like heart attacks and cardiac death.

VIVO: Is there any specific medicine or anything within the realm of what you mentioned that you hope absolutely exists within 10 years?

Interviewee: I hope it’s easier to get PCSK9 inhibitors‚Äîthose are really potent medications to decrease cholesterol‚Äîso it becomes more standard therapy than it is now.

VIVO: What do you think is not being said in the field of cardiology that needs to be said either to patients, to cardiologists, to others?

Interviewee: I would say to the payers that if you want to improve the health of your patients and outcomes and decrease costs, stop hindering my ability to get the medications that do it.

VIVO: Why did you became a cardiologist?

Interviewee: I was interested in the problems, cardiac stuff and helping people with chronic diseases like heart failure and coronary disease.

VIVO: Has it been what you expected?

Interviewee: Some of it has, but some of it hasn’t.

VIVO: Anything specific come to mind?

Interviewee: Dealing with all the hierarchy in the hospital system. Trying to get things done within our own practice where you have to deal with multiple administrators that don’t understand anything. And then the payers that decide they don’t want to cover a certain drug or pay for a certain drug or certain therapy, even though the patient has very good indications to have that done‚Äîany class one indication to do something and the insurance company denies it. Which will actually save them money because they’ll decrease outcomes like heart attacks and death. Death is cheap for the insurance companies, but bad outcomes like heart attacks and strokes are not.

VIVO: How many patients do you see in a day?

Interviewee: Usually 20 to 22.

VIVO: If you had to break it down into how many patients you see that are more high risk to moderate risk to low risk, what would that makeup be on average of the patients you see?

Interviewee: Probably 20% low risk, 40% moderate, 40% high.

VIVO: Can you tell me about your process for how you determine which treatment is right for each patient?

Interviewee: It depends on their cardiac disease and evidence-based data. Then you determine what treatment you want to put them on.

VIVO: Can you share any examples of a recent clinical decision you made?

Interviewee: Heart failure—beta blockers, renin-angiotensin blockers, SGLT-2 inhibitors, Entresto, mineralocorticoid receptor antagonist, statins, aspirin, platelet coronary disease. Those are the standard things you go through to put patients on for their treatment.

VIVO: What differences do you notice in the way you approach your day compared to those cardiologists that are within their first couple years of their practice?

Interviewee: I can process a lot faster and move through the system. I’ve been doing this a long time, so synthesizing the data fairly quickly and being efficient in clinic and hospital are probably the biggest differences.

VIVO: And how important is that efficiency to you?

Interviewee: It’s everything. If you’re not efficient, I wouldn’t be able to do this interview with you because I’d still be doing charting at work.

VIVO: What unique challenges or advantages do you experience based on your rural location?

Interviewee: The advantage is that there’s really no competition, at least from other cardiologists. We’re it‚Äîyou don’t have to worry about that aspect of it. But the challenges are transportation and low socioeconomic status. A lot of people can’t afford their medicines, so it’s difficult to get them the treatment they need.

VIVO: Does being in that setting influence any of your clinical decisions or your patient interactions?

Interviewee: Every single day. Patients can’t show up, they can’t get a ride, can’t get their medicines because they don’t have enough money to deal with their co-pays. We have to work around those things and it takes a lot of time and effort.

VIVO: You mentioned a couple of these things earlier, but I want to dive a little more into the impact of your work on personal habits of your own. Can you tell me a little bit about in your day-to-day, how you manage stress?

Interviewee: I go to the gym. Pretty much every day I’m trying to exercise or do something before I come home to bridge that gap of the stress and aggravation of work and take it out in a run or on the bike or lifting weights.

VIVO: Can you think of any recent or long time ago, any significant lifestyle changes you made as a result of your career?

Interviewee: Starting to go to the gym and work out.

VIVO: How do you manage work-life balance?

Interviewee: You do what you got to do at work and then you try to live the rest of the time that you’re off. Burnout is flowing around a lot, but at the same time, the administrators want you to work at your maximum potential, 110%‚Äîand it’s not a joke. You try to do what you can for the patients and try to see as many as you can. The problem is there’s more work than people and it is what it is.

VIVO: What misconceptions do you think people have about heart health?

Interviewee: Unless you’re having a heart attack, they don’t understand that certain behaviors and non-compliance with their medications does put them at risk for a heart attack until it happens and they have an outcome, then all of a sudden they’ll wise up a little bit. But if it doesn’t cause any pain or cause any symptoms, a lot of times they do not want to do what you ask them to do.

VIVO: Do you have any strategies that you found work well for you for how you communicate pretty complex information effectively to patients?

Interviewee: I tell them what their diseases are and you read the room about how in-depth you want to get and the types of language‚Äîit’s more of an art than a science. Give them the information they need in a way that they want it or can comprehend it so they take the medicine or do the activity you need them to do to keep themselves healthy.

VIVO: In wrapping up, I’m curious if there’s a single most important piece of advice you would give to patients with any type of cardiac disease?

Interviewee: You’re going to the doctor to get advice to help yourself. Listen to it.

Participant Profile

• Male Cardiologist in rural North Carolina
• 20 years experience practicing cardiology (12 years in current setting)
• Works in a private hospital-based multi-specialty group
• Non-interventional cardiologist
• Sees 20-22 patients daily with patient mix of 40% high risk, 40% moderate risk, 20% low risk
• Faces challenges with patient non-compliance and insurance restrictions
• Values efficiency and exercise as a stress management tool