Oct 21, 2015 | John J. Lazarus, MD, PhD, and Devraj Sukul, MD
Career Development

Brahmajee Nallamothu, MD, FACC, is a professor of medicine in the Division of Cardiovascular Medicine at the University of Michigan. He is a practicing interventional cardiologist and clinical investigator, focusing on improving the delivery and quality of cardiovascular care. He has received research funding from the Agency for Healthcare Research and Quality (AHRQ), Veterans Administration, and the National Institutes of Health. Recently, he served on the Institute of Medicine (IOM) committee that published a seminal report on strategies to improve cardiac arrest survival.

1. How did you become interested in interventional cardiology and clinical investigation? What continues to motivate you in these two components of your career?
   
   I love both these parts of my career, and yet they raise different challenges, require different skill sets and have led me toward different satisfactions during my career. I became interested in interventional cardiology because of my interests in ST-elevation myocardial infarction and acute coronary syndromes, as well as interventional coronary procedures. It was a natural fit from day one. I still continue to find great joy in being in the cath lab. It provides me with the ability to profoundly affect lives, one patient at a time. In this regard, I don't think my path in interventional cardiology is much different from others.
   
   My research career was a more winding road. Early on in my training, I struggled to find the right partnerships to ignite an interest in research. Very accidently, I was able to find great mentorship during the end of my internal medicine residency, and this set me off to pursue a health care policy fellowship through AHRQ.
   
   A big reason for my luck was that I was waiting for my wife to finish up her training (she's a dermatologist), and I didn't have immediate pressures to apply for fellowship. This turned out to be the singular most important decision I made in my professional life. For two years I had a chance to deeply engage with amazing teachers and build up diverse skill sets in research. I learned how to ask and answer impactful questions – and importantly, I learned to write.
   
   I continue to be motivated by the great challenges that lay ahead for medicine, especially as we move into the digital era. We are awash with data and information. How we change this information into usable knowledge and clinical wisdom is unknown, but clinical outcomes research is poised to answer these questions.
2. How did you become involved in the research of the care of cardiac arrest patients?
   
   I can actually remember the exact moment. I was on the critical care unit service in the hospital, and we had a complex patient who suffered an in-hospital cardiac arrest that didn't go well. That afternoon I was in the cafeteria and came upon Ben Abella's classic Journal of the American Medical Association (JAMA) paper from 2005 on the quality of resuscitation care for in-hospital cardiac arrest while skimming through the journal.
   
   The funny thing about that paper was that it was one of two papers published that week in JAMA on resuscitation care. The other one focused on out-of-hospital cardiac arrest. In a broad sense, quality of resuscitation care reported in the two papers was actually worse by some measures in the hospital. This sparked my interest since it seemed counterintuitive to me. I ran some ideas by one of our superstar cardiology fellows: Paul Chan, MD. Paul has gone on to be a national leader in this space and written seminal papers on the topic. I've been so privileged to work with him and to tackle some fundamental questions on this critical topic.
3. Could you tell us about your experience on the IOM committee that recently published the report Strategies to Improve Cardiac Arrest Survival: A Time to Act?
   • While working on this multidisciplinary committee, what perspectives from other disciplines intrigued or surprised you regarding the care of these complex patients?
     
     I loved working on the IOM committee – so many smart and dedicated people from different disciplines and professions. It was clear to me from these interactions that cardiac arrest has been primarily in the space of emergency medicine physicians. This isn't entirely surprising, but it did make me wonder if this is why less attention has been paid to post-cardiac arrest care until recently. Although I found everyone interesting in the committee, the opinion of Ralph Sacco, MD, MS, past president of the American Heart Association and a neurologist – I found to be extremely valuable for my thought process. The ultimate outcome of cardiac arrest continues to depend heavily upon neurological outcomes and so hearing Ralph's views were so instructive.
   • How do you see the role of cardiologists changing for the care of these patients in the future?
     
     We had a number of cardiologists on the committee, and I believe the roles of cardiologists will only grow in the future for this condition. But I believe it will primarily grow as part of multidisciplinary teams that include critical care physicians, neurologists and other healthcare providers. For example, one of the great debates in resuscitation care right now is the role of the cath lab for revascularization. The potential expansion of hemodynamic support devices in these patients could also expand our role as cardiologists. Finally, we will also continue to have an important role in secondary prevention among patients with ventricular arrhythmias. It is a very exciting time to be in this field.
   • Do you see these patients as a specific group that requires specialty care from cardiac intensivists? If so, what is your advice to cardiology fellows in becoming comfortable with the care of these patients?
     
     I see the role of cardiac intensivists as expanding in many ways over the next few years – and resuscitation care and cardiac arrest is just one example. I absolutely think that cardiology fellows need to be comfortable caring for these high-risk patients. As emergency medical systems and pre-hospital care grows, I believe more of these patients will arrive to hospitals in a salvageable state and require complex interventions and specialized care.
   • Do you think there are good examples of systems with high quality cardiac arrest care? What are the challenges to applying these successes more universally?
     
     One of the key points that the IOM report emphasized was geographic variation in outcomes of resuscitation care across the U.S. We have some systems, like in Seattle, WA, that have outstanding rates of survival for "shockable" rhythms, while other regions of the country struggle. This is partly explained by pre-hospital care, including bystander and high-performance cardiopulmonary resuscitation. I believe the challenges to improving care are substantial but addressable through a greater focus on implementation science that identifies unique barriers to establishing better emergency medical systems in under-performing areas. I also think many of these challenges will be addressed by innovative technologies.
4. What advice would you give to cardiology fellows interested in an academic career, specifically in clinical outcomes research?
   
   I would give three pieces of advice: First, do it because you love it. It is hard to balance this type of career, and it isn't for everyone. Second, find a great role model and mentor to show you the way. Don't discount this part of the equation. This also means that you should try to find a great team to work with along side your mentor. The most impactful (and fun) research being done today is by teams of investigators, rather than individuals.
   
   Finally, I think that fellows most interested in research need to spend at least a year of time dedicated to developing these skill sets away from clinical work. It isn't easy to do high-quality research. I wouldn't let a fellow perform an angioplasty without proper training. Similarly, I would caution fellows to move toward a research career without the proper set of tools. This is critical.
5. In your experience as a mentor and mentee, what are some important characteristics of a productive and effective mentor-mentee relationship?
   
   The mentor-mentee relationship is critical to a productive research career. I can't emphasize this enough, and early on in my career I never appreciated this relationship fully. I took it for granted because I was lucky – I had wonderful mentors. I give full credit to them for helping me to develop my career both on the clinical and research sides.
   
   The reason it is easy to discount this relationship is because the best mentors seem to do it so naturally (just like the great bedside clinicians). It can be tough to realize all that they do for you. The further I go along I think the key characteristic that I've found in my best mentors has been an amazing generosity of spirit. These individuals are as excited about my career achievements as they are about their own. They take my challenges and advancements personally. This isn't something that is always common, but it is something fellows should actively seek. For this reason, the best mentors often have active research teams of fellows and research associates that aggregate around them.
6. Finally, what advice would you give cardiology fellows as we try to strike a balance between our personal and professional lives?
   
   Your life will evolve over time, and it is only natural. When I first started out in training I wasn't married and didn't have kids. Working on the weekends or late at night wasn't hard to do (and was actually fun when I was in the middle of an exciting project). That changes quickly as you get older and the hardest thing to do is constantly prioritize your obligations to your family and your colleagues. Your partner's and kids' priorities quickly become more important than your own. So it takes maturity to set limits on what you will and won't take on (e.g., I don't do peripheral or structural heart work in the cath lab). It also requires a great environment with colleagues who are supportive because no one can accomplish much alone. That said, this will be a constant challenge no matter what you do, and I'd recommend you continually re-evaluate yourself and your career path through feedback loops with family, mentors and close friends. Don't get so busy with the hard day-to-day tasks that you lose sight of your overall life goals. I love Gretchen Rubin's famous quote: "The days are long, but the years are short." Things pass by sooner than you can imagine.

This article was authored by John J. Lazarus, MD, PhD, and Devraj Sukul, MD, fellows in training (FIT) at the University of Michigan.

The 'Conversations With Cardiologists' feature of the FIT newsletter, ACC On-Call, highlights prominent cardiologists throughout the country and shares their invaluable insight on cardiology and sage advice for FITs. If you know of a cardiologist you'd like join the conversation, please let us know at fellowsintraining@acc.org.