Jan 19, 2016 | Jeremy Nicolarsen, MD
Career Development

Careers in adult congenital heart disease (ACHD) are on the rise. In the first of this three part interview series, we’ll look at ACHD care in a large health system – a much less common but growing practice model. In this installment, we’ll hear from Alison Meadows, MD, PhD, director of the Adult Congenital Heart Disease Program for Northern California Kaiser Permanente. Meadows received a PhD in Engineering from the University of Pennsylvania and taught in the School of Engineering before matriculating at University of Pennsylvania School of Medicine. After residency and fellowship, Meadows was on faculty at Boston Children’s Hospital for two years, followed by three years at University of California San Francisco (UCSF), before taking her current position.

Training in ACHD

How did you train for a career in ACHD?

I completed a pediatrics residency at Children’s Hospital of Philadelphia followed by pediatric cardiology at Boston Children’s and a two-year fellowship in cardiac magnetic resonance imaging (MRI) and ACHD at Boston Children’s Hospital/Brigham and Women’s Hospital.

Do you have any suggestions for ACHD training?

There are multiple paths to becoming an ACHD specialist; this is what makes our field such a broad and deep field. We have people with different expertise coming together to care for these patients. Allowing physicians to approach ACHD from either pediatrics or internal medicine will maintain this diversity and allow optimal care of the ACHD patient.

What experiences enhanced your training and what did you wish you had learned when you had the opportunity?

I wish I had done a combined internal medicine and pediatrics (Med-Peds) residency. The biggest hole in my training was internal medicine. I have now learned adult medicine, but I did it the hard way. I am glad I did a pediatric cardiology fellowship. My in-depth training in congenital cardiac anatomy and physiology has been invaluable in my understanding of ACHD. Also, my pediatric cardiology training allows me to stay connected to the pediatric world. It is imperative that we, as ACHD providers, stay in touch with what is going on in the pediatric congenital heart disease. The field is changing so rapidly. The patients we see now will be different than those we see in 10 or 20 years. Their history will be different. To be prepared to care for these future ACHD patients, we need to stay in touch with that world.

Mentorship

How did you find your mentor(s) in ACHD?

I have been incredibly lucky! I have had such great mentors. My PhD mentor, John S. Leigh PhD, was a biophysicist who did nuclear MR and molecular imaging. As I was trying to find my “question”, I realized I wanted to do something in a slightly different field. I was interested in cardiac MRI and computational modeling of the cardiovascular system. This was not his expertise, but he was excited to help me regardless. He did not try to fit me into a hole he needed to fill, rather, he encouraged me to find my own way. When I finished my PhD, he recognized my love for medicine and encouraged me to go to medical school.

My ACHD mentor, Michael Landzberg MD,  welcomed me into his program. He valued my congenital training. He supported my interest in this “adult” field, even when others were skeptical about my long term acceptance given my pediatric background. He has been a fabulous role model and continues to be a great mentor!

What makes a good mentor?

Great mentors recognize what the mentee has to offer, encourage them to build upon their strengths and foster their unique contribution to the field. A great mentor recognizes that their role is to help the mentee shine and contribute something more, something different to the field.

Careers in ACHD

What does a typical workweek look like for you?

We are clinically quite busy! We actively care for more than 1,100 ACHD patients. The patients in our clinic are primarily those with moderate to severely complex lesions. Our team consists of two ACHD cardiologists, a nurse case manager, a nurse practitioner, a senior administrator and a sonographer. Each of our patients has a local adult (or pediatric) cardiologist that co-follows the patients with us. We do our own complex imaging (MRI, CT, echocardiography, TEE). We have a busy inpatient service; heart failure, arrhythmias, peripartum, non cardiac surgery. We have a surgical service; one of the Stanford congenital surgeons is contracted with us to do our simple CHD surgeries. For the more complex specialty services, including complex CHD surgery, congenital cath interventions, and complex electrophysiology interventions, we collaborate with Stanford and UCSF.

My partner and I alternate duties week by week. One is the outpatient provider with three full and two half-days of clinic per week, while the other covers the inpatient service, takes consults from other centers across our region, and does cardiac MRI (10-12 per week).  

When I was looking for a partner, I hoped to recruit someone with adult cardiology training. Combining pediatric- and adult-trained providers in a program gives the program depth. Each shares a different expertise.

What do you enjoy about working in a large health maintenance organization (HMO)?

It is just a joy to go to work! There are no egos. People value what you have to offer and enjoy helping you in return. They are excited when you can do research, but that is not required. Your job is to provide the best patient care that you can. 

Do you maintain exposure to academic medicine?

I have appointments at Stanford and UCSF, so I can stay connected to the academic world. There is a lot of support for doing clinical research (we have an active division of research with abundant internal funding), but it is not expected.

Program Development

What made you choose to start an ACHD program?

I saw it as a huge opportunity. My joy in my career comes from caring for patients. I love clinical medicine, and enjoy it more than doing  research. But of course, I still wanted to do something special and contribute something important in the field. The opportunity to build a program was perfect for me.

When physicians come from academics, they think an academic institution is the only place they will be happy. They feel that stepping out of academics is taking a step down. But that is not the reality at all. Non-academic careers can offer great satisfaction.

How and where is your program housed?

Our program is based in an adult hospital and serves as the ACHD hub for Northern California Kaiser Permanente.

What’s been the biggest challenge in growing your program?

As I was starting this program, I recognized that I had never done this before. I am a good ACHD doctor, but I had never started a program! I needed someone to give me some guidance. I worked one hour per week for six months with a wonderful “coach” – Bonny Clarke MCC, MPH. She previously ran the physician leadership program for Northern California Kasier Permanente . She was my third great mentor and was an equally important part of my career development.

She taught me to “let go” of the need to do everything for every one of my patients. This was the biggest challenge for me, but she was right! If there are 13,000 ACHD patients in the Northern California Kaiser system, and the population is growing, I am not going to be able to care for all of them. If my vision is to create a “system” to provide the best long-term care for these patients, I will need to recruit help. So I developed a “champion” program. I have an adult cardiologist in each sub-region who has been chosen to be my “point person”. They manage the simple ACHD patients with guidance and help co-manage the more complex patients. These champions have been chosen because they either have some ACHD training or are young and smart and willing to learn new things. We provide an educational program for them (monthly webinars, one-to-one communication) and they are all growing as ACHD providers. They not only get to know the patients (and are available if a patient becomes acutely ill), but they serve as a local resource for the other cardiologists. As the ACHD population grows, this will be the only way to really provide adequate care. We have to empower and educate our colleagues to help provide care for these patients.

What’s the most important thing for an ACHD program to be successful?

In a program like ours, we have responsibility for all aspects of these patients’ care. We need to make sure they have the services they need, whether it is within our organization or referred out to other specialty centers. We need to be in constant communication with other providers who are involved in the care of these patients. This is fairly easy in an integrated system such as Kaiser Permanente.

Future of ACHD Care

What does the future of ACHD look like?

The types of patients will change over time as surgical interventions and management are evolving. The typical patients we see will reach adulthood healthier, but the sicker patients who previously did not make it to our clinics will start to reach adulthood. At some point, we will have an ACHD population that is more stable and the numbers will plateau (probably in a few decades). Adult cardiologists will have more involvement in the management of these patients as they will have more basic training in congenital anatomy and physiology. They will be responsible for patients with simple diseases and ACHD specialists will take care of the most complex diseases.

How will ACHD be practiced in the future?

The model of care is moving toward health systems. It is the future of medicine. Yes, academic centers will always be critical to the care of these patients and the advancement of our knowledge of how to best care for these patients, but much of the care will be provided through hospital systems like Kaiser Permanente.

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This article was authored by Jeremy Nicolarsen, MD, a fellow in training at University of Colorado Hospital and Children’s Hospital Colorado in Aurora, CO.