March 8, 2016 | Travis Taylor, MD
Chapter Engagement

Edward T.A. Fry, MD, FACC, is the current president of ACC Indiana Chapter and Raymond E. Dusman Jr., MD, FACC,is an electrophysiologist who serves as the president-elect of ACC Indiana Chapter and as the chief physician executive for the Parkview Health system.

The Business of Medicine

Taylor: You were elected as the president of the ACC Indiana Chapter from 2013 until April of this year, which has been a time of tremendous change in medicine. How will the business of medicine evolve over the next 10 years?

Fry: In 2015, we had the repeal of the sustainable growth rate and institution ofits replacement – the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) – which changes the payment model from incentivizing volume to incentivizing value.

Taylor:  How do you think payment models will evolve over the next few years?

Dusman:  Payment model innovation will clearly emphasize outcomes as an endpoint—not simply completion of testing, treatment, etc. We already see this firmly in both government and commercial plans. Also, we will see a shift of risk from payers to providers and patients – already evident in the rising deductibles of current health plans.

Taylor:  Several Republican candidates are campaigning on promises to repeal the Affordable Care Act (ACA). Do you think this is a possibility if a Republican is elected president or is the process already in place to maintain this system for the foreseeable future?

Fry: I think this is only political rhetoric. The change that we are going to see from volume to value is here to stay. Furthermore, I believe that health care is a right for everyone and I think that most of us got into medicine because that is what we believed. I am in favor of tweaking ACA, as there are some policies that disincentivize innovation, such as the tax on medical devices.

Taylor:  Are many of us going to participate in accountable care organizations (ACOs)?  It seems like end-of-life discussions will be more difficult in ACOs, as the patient’s perception may be that the doctor would rather make money than offer what the physician knows to be a therapy of marginal benefit, but the patient thinks is a worthwhile endeavor.  How is end-of-life care going to be affected by ACOs?

Fry: Many people don’t realize it, but ACOs were actually started by private industry. It gives you a real incentive to keep patients out of the hospital. I could imagine that it may make certain decisions more difficult, but it’s really all about shared decision making. Doctors need to take the time to explain the goals of care, risks and benefits of pursuing certain therapies at the end of life.

The Practice of Medicine

Taylor: I saw on ‘Health Grades’ that you have been rated 4.8/5 stars by your patients. How much attention should cardiologists give to their ratings on these sites? 

Fry: People will look for outside objective measures. We do that for everything else that we do in our lives, whether it be travel or buying any consumer product. I think health care will be the same. I think one of the problems with those kinds of sites is when we move to team-based care, you want to know more about how has your team performed as opposed to how have you as an individual performed. The individual rating may be more applicable to primary care doctors as you are really rating your “quarterback,” but when you get into specialty care, you are really concerned about the team, and obviously cardiology is team driven whether it is structural heart disease, advanced imaging or heart failure.

That being said, whether it’s ‘Health Grades’ or ‘Angie’s List’ or whatever, this is now being incorporated into Medicare. The bottom line is measuring performance by the ultimate end user, which is the patient, is important, but I think it is equally important that performance is measured on a team basis, especially in cardiology.

Taylor:  What innovation has benefited patients the most over your career?

Dusman:  In the area of electrophysiology – I have been most impressed by the advances in arrhythmia ablation with improved outcomes and safety, as well as the progress of implantable devices, especially implantable cardioverter defibrillator therapy, yielding smaller devices, flexibility of programming and greater ease of implantation. In other areas within cardiology, the improvement of chronic cardiac conditions, outcomes and quality of life with lifestyle change and innovations within medical management, coronary interventions and now valvular interventions have been particularly impressive.

Career Advice

Taylor: What should FITs who are starting their career search look for when evaluating potential jobs? 

Fry: Culture is number  one, two and three and by culture, I mean “fit”. You need to have a compatible set of values with whatever job environment you are going to be in, whether that is in academics, private practice or integrated practice. Some of that is a gut feel, but some of that has objectivity to it. What sorts of things do they do to demonstrate that they are patient-centric, professionally supportive, that they believe in team-based care and shared success?  I believe that if you just simply chase the highest paying job, you’ll be unhappy.

I think opportunity to grow should be next, meaning opportunities to develop professionally, to be innovative, to explore new therapies and technologies, and bring those things into the group. The environment that you are going to work in needs to be compatible with your work-life balance, and your personal and professional goals. If you are not happy, but you are getting paid a lot of money, you will be miserable. If you are happy, but you are not getting paid much, you will still be happy.

Taylor: What advice do you have for cardiologists who are starting their career and are quickly going to go from living paycheck to paycheck to the top 1 percent of earners?

Fry: It’s almost like draft day in the National Football League. Your eyes can certainly be bigger than your stomach. I think it’s important to realize that nobody knows where things will be in five or 10 years. As the saying goes, past experience does not guarantee future performance. You have to be conservative in your saving and your spending, and be thankful for what you are doing. You have to live within your means and be realistic. The bigger issue is that people that are coming out of training today are saddled with a lot of debt. The first and foremost thing is to do everything you can to get out of debt. Once you do that then you are in a much healthier position and you are much less vulnerable to problems in the future.

Work-Life Balance

Taylor: You seem to have a very happy family life.  How have you been able to keep a favorable work-life balance?

Fry: Pick a good partner. That is key. It is a partnership. Part of that is your value system.  No doubt about it, being a cardiovascular professional is a huge time commitment, but you have to recognize where your priorities lie. There is nothing more important than being there for my kids or with my wife. My wife is the one who makes the most sacrifices. She compensates for that by having her own interests and friends and is very independent. We both have areas of professional interest and satisfaction. That is important as well. Not everyone is going to have a husband, a wife, a partner or kids, so there are other ways that you can have personal satisfaction.  Number one is enjoying what you do.  Number 2 is thinking that you are making a difference in other people’s lives.  Number 3 is prioritizing your non-professional responsibilities and interests. For some people that will be their faith, their hobbies or their family. If you are thinking about work 24/7, you will probably not be very effective in your job, because your job is being able to relate to people. If you can’t relate to your family or friends around you, you probably won’t be very good at your primary responsibility.

The Importance of Active Engagement With the ACC

Taylor: What do you see as your mission when you become the president of the ACC Indiana Chapter?

Dusman: The state chapters connect members to the national efforts of the ACC. As with any professional organization, the members are the real key to organizational success. I believe part of my role as president of the Chapter will be to provide the communication necessary in both directions, engaging state members to individually and collectively drive change and improvement efforts, while aligning to national imperatives. At the center of our efforts are the patient and community members – their cardiovascular health and well-being is entrusted to our professional expertise. To accomplish the outcomes desired by all stakeholders – patients, providers, payers and communities – a team effort in collaboration is paramount. With the increased voice and professional contribution of our cardiovascular team members, our Chapter can truly be leaders in the team work necessary for success. On this basis, the future is bright and exciting for all of us, our patients and our communities.

Taylor: Why should younger faculty or FITs become involved with the ACC?

Dusman: As our professional organization, the ACC provides the infrastructure and support to integrate all aspects of the cardiovascular world, bringing scientific discovery to the bedside, developing information technology solutions, such as the NCDR to improve how we care for our patients, and engaging patients through online resources such as CardioSmart. Changing practice patterns and patient habits is very difficult, requiring purposeful effort and champions. As future leaders and champions of these efforts, involvement by younger faculty or FITs is critical to our current and future success. To be effective, you need to be engaged. Fortunately the ACC emphasizes the importance of diverse input in achieving current and future success. The timing and opportunities now for younger members in the ACC could not be better.

Taylor: How has the ACC changed the practice of medicine in the past few years?

Dusman: Several aspects come to mind, including driving research and innovation; driving educational efforts to lessen the translation time from scientific discovery to bedside improvement; and developing national databases to allow comparative analysis and provide tools for practitioners to improve process and outcomes.

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This article was authored by Travis Taylor, MD, a fellow in training (FIT) at St. Vincent’s Hospital in Indianapolis, IN.