James Blankenship (Department of Cardiology, Geisinger Medical Center, USA) is the 2015–2016 president of the Society for Cardiac Angiography and Interventions (SCAI) and has been involved with designing and implementing the society’s new strategic plan. He talks to Cardiovascular News about the plan and how climbing Kilimanjaro with his three children was a good reminder of what matters most in life.
Why did you choose medicine as a career and why, in particular, did you choose to specialise in interventional cardiology?
Throughout high school and college (university), I was interested in ecological sciences. One summer while at college, I dissected the guts out of armyworm caterpillars and used them to perform cytochrome C oxidase assays. That taste of research made me turn toward something more meaningful than understanding the inhibition of cytochrome C oxidase! Therefore, helping people seemed much more interesting. Fortunately, I realised that I had been taking the same courses as those of the pre-med major students; so, I signed up for the medical college admission test (MCAT) and was admitted.
During my residency, the cardiology department served the best food at their morning conference—which meant I kept coming back to the department after my cardiology rotation. Pretty soon, I knew a lot about cardiology and the cardiologists knew me—and surprisingly, they offered me a fellowship. That was at the University of Michigan, and I learned angioplasty from Drs William O’Neill, Eric Topol, and Eric Bates. They were my career mentors in interventional cardiology; they got me started on research in this area, and they have inspired me with their integrity and passion over the years.
During your career, what has been the most important development in interventional cardiology and what has been the biggest disappointment?
The stent has been an important development. Interventionists who started their career after 1995 have no idea of what life in the cath lab was like before the arrival of the stent. Prior to 1995, we frequently made frantic trips from the cath lab to the surgery suite because a percutaneous transluminal angioplasty procedure ended with an occluded artery. This was after inflating a perfusion balloon in the artery for 30–60 minutes in the hope—usually with little real chance of success—that it would seal a type D dissection. Or you would spend your night worrying that the small dissection in the proximal left anterior descending would occlude suddenly at four in the morning.
However, transcatheter aortic valve implantation (TAVI) threatens to overtake the stent as the “most important development” in interventional cardiology.
In terms of disappointment, I think that has to be drug-eluting stents. Early reports suggested that they would eliminate restenosis after percutaneous coronary intervention (PCI) but that did not turn out to be the case.
Of the research you have been involved with, what do you think has had the biggest impact on clinical practice?
The development of our ST-segment elevation myocardial infarction (STEMI) PCI programme has had the biggest impact on our clinical practice. While not “research” in the typical sense, it did lead to several journal articles and demonstrated that clinical practice can generate data worthy of publication. Like many other institutions, we found that our STEMI PCI programme halved STEMI mortality, decreased length of stay, and decreased post-myocardial infarction complications at our practice.
At the moment, research has taken a distant back seat to clinical work and to the administrative duties of serving as director of our hospital’s cardiology department. However, I still help fellows with their research projects and write up results of some of our quality improvement projects.
As 2015–2016 president of SCAI, what do you hope to achieve during your presidency?
The implementation of SCAI’s new strategic plan, which we started work on in 2014 and which was approved by our board of trustees in October 2015. We will be unveiling the full plan at the 2016 SCAI annual scientific sessions (4–7 May, Orlando, USA).
The new plan re-affirms SCAI’s traditional strengths: education, quality, and advocacy. We will introduce new programmes in all of those areas. The plan also emphasises a new area—research. Dr Kenneth Rosenfield, SCAI’s president-elect, has a passion for research and will lead us in developing interventional research. Two other over-arching concepts that permeate the new plan are efforts to engage and encourage early career interventionists and fellows, and to increase our international presence through international educational programmes and membership.
What do you think, as a society, SCAI offers the interventional cardiologist?
SCAI is the voice of the interventional cardiovascular profession and the home for interventional cardiologists. We are only society in the USA that focuses solely on serving interventionalists and their patients and the only worldwide interventional cardiovascular society.
Also, SCAI members say that what they value most about SCAI are our educational offerings, particularly the annual scientific sessions. Members value the relatively intimate settings where they can engage world-renowned interventionalists close-up.
Another unique and popular feature of SCAI is our inclusiveness. In the last eight months, we have appointed more than 150 members to committees, workgroups, writing groups, and advocacy teams. Committee membership is open and it is still possible to walk into a committee meeting at the annual scientific sessions and participate.
What will be the focus of the 2016 meeting?
This year’s programme will focus on bringing evidence to clinical practice. Most of the sessions will present the latest evidence and use real cases to discuss how to translate evidence into clinical practice.
This will be in the theme of all the tracks. A full-day coronary track will focus on “CHIP”—complex high-risk interventional procedures. These sessions will show how evidence for proper patient selection, technique and outcomes for complex procedures leads to success in real cases. Our peripheral tracks and structural heart tracks will also be looking at translating evidence into clinical practice. Additionally, a programme on congenital heart disease interventions is nested within the structural programme.
Finally our quality track, which is unique to SCAI, will focus on the important elements for certification, education, and operational aspects of the cath lab, as well as reimbursement and occupational hazards.
This year we will also pay tribute to female interventional cardiologists who have served as role models for younger colleagues and influenced our specialty.
In summary, SCAI 2016 will be the best SCAI annual meeting yet! Our quest in bringing our colleagues and recognising our emerging leaders and luminaries will be evident by our incredible faculty for this year’s meeting.
You helped to coordinate and direct the “ProvenPCI” programme. What is the goal of the programme and what has it achieved so far?
ProvenCare PCI is a Geisinger Health System programme that started in 2007 to improve the quality and efficiency of interventional coronary procedures. Our interventional team has identified 33 best practice elements that we commit to accomplishing before, during, and after every PCI. Most are guideline-based or evidence-based. For each element, we either do it or document a legitimate reason for not doing it. Currently, we complete 96% of the best practice elements. These are tracked, reported, updated annually, and constantly subjected to quality improvement programmes in an effort to hit 100%.
The final component is contracting with insurance companies to increase routine payment for PCI in return for not charging for PCI complications. We save money by performing excellent, evidence-based PCI that minimises complications, and we share the savings with the insurer.
What advice would you give an interventional cardiologist who is just starting out in their career?
Become an excellent interventionist—find and cultivate a mentor. Also, be humble enough to recognise that everyone has something to teach you.
Study your mistakes and those of your colleagues so that you do not repeat them. You should also study other interventionalists as they work and visit other cath labs to see how they do things. Furthermore, systematically study your outcomes and identify opportunities for improvement—position yourself to be the go-to person in your lab for new techniques and devices.
Engage in professional society work: attend annual meetings of your society and leverage your contacts. Ask the president to appoint you to committees in which you are interested (and be persistent about getting an appointment).
Once engaged in the society, you should follow these rules: always be polite to society staff; answer emails promptly, and engage in email conversations. Show up at committee meetings and conference calls; let staff know if you cannot attend. Volunteer for assignments, particularly the ones nobody wants. If given an assignment, be sure to deliver on time. Network, collaborate, and get to know everyone!
What has been your most memorable case and why?
My first major cath lab disaster occurred in 1988. A routine post-myocardial infarction, post-tissue plasminogen activator catheterisation resulted in sudden paralysis below the 10th thoracic vertebrae and the patient died.
Autopsy showed cholesterol embolisation to the anterior spinal artery of Adamkiewicz. I felt terrible about the case and attempted to expunge a sense of guilt by organising a research study to look at the incidence of catheter-induced cholesterol embolisation after tissue plasminogen activator. Incidentally, as a profession, we could do a much better job of supporting our colleagues after cath lab disasters. A few words of sympathy and support mean the world to a colleague who has just suffered a catastrophe in the lab.
Last year, you climbed Kilimanjaro. How do you think that experience will influence you?
The best part was doing it with my three grown children. The experience highlights two points. At your funeral, your kids will not talk about how many cases you did as an interventionalist but will talk about what you did together—such as climbing a mountain. Therefore, take time for your family. Second, stay in shape. Our profession has lots of occupational hazards and requires stamina—being physically fit will prolong your career (and allow you to do fun stuff after work).
Outside of medicine, what are your hobbies and interests?
Frogs and dancing! But those are not interesting. For me, the only thing worth mentioning is my religious faith. In my view, we worship a god—whether that god is fame, fortune, family or a deity. I believe that there are historical data to support the Christian faith and, therefore, I follow it. I also believe that even if you do not think that the Bible is the “word of God”, it is a good handbook for daily living. It teaches mercy (being kind when it is not “deserved”), grace (ie. giving what is good when it is not “deserved”), love, and the importance of faith. In my view, those are principles we should all practice toward family, friends, and colleagues.
Director, Department of Cardiology and Cardiac Cath Labs and Board certified interventional cardiologist Geisinger Medical Center, Geisinger Health System, Danville, USA
2012–2014: Masters in Health Care Management from Harvard School of Public Health
1984–1987: Cardiology fellowship, University of Michigan Hospitals, Ann Arbor, USA, including nuclear cardiology and interventional cardiology training
1983–198: Emergency physician, Foote Memorial Hospital, Jackson, USA; Flight physician, Borgess Inflight Medical Service, Kalamazoo, USA
1980–1983: Internal Medicine internship and residency, University of Michigan Hospitals, Ann Arbor, USA
1976–1980: MD, Cornell University Medical College, New York City, USA
2015–2016: President, SCAI
2014–present: Member, American College of Cardiology Interventional Section Leadershp Council
2014–2015:Co-Chair SCAI strategic planning workgroup
2014–2016: Technical Advisory Panel for ACC/SCAI Appropriate Use Criteria for PCI in Stable Ischemic Heart Disease
2011:Technical Advisory Panel for ACC/SCAI Appropriate Use Criteria for Cardiac Catheterization
2015: Climbed Kilimanjaro (19,300 feet)
2011: “Master of the American College of Cardiology” designation by American College of Cardiology