Ralph Brindis, president of the American College of Cardiology (ACC) 2010–2011, is a clinical professor of Medicine at the University of California, San Francisco, USA. In this interview with Cardiovascular News, he spoke about his career, greatest influences, the National Cardiovascular Registry and his efforts as a swimmer for the University of San Francisco Master’s Swim team.
Can you describe your journey into medicine and cardiology?
I am the first member of my family to pursue a career in medicine. My father, uncles and both grandfathers were involved in various aspects of the leather business. This include the tanning of leather, shoe manufacturing, radio and camera cases, parachute pads and roller skate straps. My father did not sell his leather business until he was convinced that I actually was going to graduate from a medical school!
My interest in medicine began in high school when I participated in a summer National Science Foundation programme in Biochemistry at the Loomis School in Connecticut. This incredibly stimulating summer included college level biochemistry coursework and opportunities to perform animal research projects. Mine was “Molecular Control of Fetal Lung Ontogeny” which taught me substantial techniques used in rat research. This led to a self-directed animal research project in my senior year in high school. While at the Massachusetts Institute of Technology (MIT) I spent two of my undergraduate years at the MIT Clinical Research Center where Dr Robert Lees had created a lipid research programme including an inpatient lipid metabolic patient ward.
I learned research techniques in immuno-electrophoresis and had contact with patients with significant lipoprotein abnormalities. While initially unsuccessfully applying to medical school, I obtained a Master’s Degree in Public Health at University of California, Los Angeles (UCLA) in biochemistry and environmental sciences while pursuing additional research involving lipoproteins and fatty acids. The following year I worked as a research assistant at the Wadsworth Veterans Affairs (VA) in thyroid research. I would drive over to the UCLA delivery room and pick up fresh human placentas placing them in a bucket of dry ice and then riding back with them between my legs on my motorcycle to the VA. Fortunately I never had a motorcycle accident as I suspect a placenta on the ground besides me would have been quite confusing to the emergency technicians on the scene. Emory Medical School eventually accepted me where all aspects of medicine, both the classroom work and particularly the clinical rotations, were incredibly stimulating for me. I loved surgery, paediatrics, and internal medicine but also enjoyed all rotations including psychiatry, obstetrics and gynaecology and anaesthesiology. Cardiology was the favourite, however, with incredible mentors such as Willis Hurst, Bruce Logue, Nanette Wenger and a host of other Emory Cardiology stars. I graduated Summa Cum Laude and then moved west to University of California, San Francisco (UCSF) for my internal medicine residency, chief residency, and then my cardiology fellowship.
Who have been your greatest influences?
I have been incredibly blessed with so many mentors. My father and mother head the list in terms of their encouragement but also promoting high expectations of their son. My wife Claire has been a true mentor and personal coach particularly during the years of my involvement with the ACC on the national stage. In terms of clinical mentors, Kanu Chatterjee, Mel Cheitlin, Nora Goldschlager, Bill Parmley, and a Kaiser colleague Bill Raskoff head the list. ACC mentors include Michael Wolk, Pam Douglas, Doug Weaver, Fred Bove, John Rumsfeld, Jack Lewin and the late Jim Dove but there are really are so many others that have given me great advice and counsel.
Which innovation in the cardiovascular field shaped your career the most?
The validation of cardiovascular outcomes sciences and the science of cardiovascular quality as true disciplines has had the major impact in my personal professional growth and recognition on the national stage. The final acceptance that one “must measure it to manage it” along with the push for transparency in cardiovascular care has led to a tremendous boon for careers in cardiovascular research particularly in our need to understand comparative effectiveness in the present era of Health Care Reform and the push to “bend the healthcare cost curve”.
As president of the American College of Cardiology, what have your biggest projects and achievements been?
The ACC National Cardiovascular Registry (NCDR) and also our foray into cardiovascular Appropriate Use Criteria have been personal highlights over the past decade in my work for the College. I have been actively involved in the NCDR since 1997 serving as the chair of the NCDR Management Board and also as chief medical officer. The NCDR has now grown into six registries: CathPCI, ACTION-GWTG for acute coronary syndromes, CARE for carotid stenting and endarterectomy, our ICD registry, IMPACT evaluating congenital heart disease catheterisation procedures, and now our ambulatory PINNACLE registry in physicians’ offices. The NCDR is being utilised in 2,500 US hospitals, contains over 11 million patient records, represents a US$23 million/year investment for the ACC, and has over 70 ACC staff at Heart House actively involved in its operations. It also utilises over 150 of our nation’s outcomes cardiovascular researchers as dedicated volunteers among our NCDR steering and research and publication committees. It has now generated over 100 manuscripts guiding our clinical community in quality assessment, disparities, post-market device and drug surveillance, and appropriateness, generating evidence for our clinical practice guidelines committees, offering avenues for ABIM recertification and much more.
ACC’s creation over the past five years of Appropriate Use Criteria (AUC) covering cardiovascular imaging and also coronary artery disease revascularisation offers clinicians, payers and patients guidance based on common clinical scenarios as to the appropriateness of use of both testing and revascularisation strategies. These AUC documents have been incorporated into care algorithms in an electronic decision support tool called FOCUS. The ACC now proudly can offer true guidance for performing the right test, to the right person and at the right time. AUC hopefully will address issues misuse, underuse and overuse of testing and procedures typically related to issues surrounding frequency of testing.
What is your opinion on the US healthcare reform?
The passage of the Affordable Care Act (ACA) was truly a monumental achievement by our US legislature this past year. Clearly this bill is far from perfect with many deficiencies that the College is actively pursuing to rectify such as the revamping of the Independent Payment Advisory Board, promoting actual healthcare delivery reform, tort reform, and importantly payment reform. The ACA has however made great strides towards achieving universal coverage.
What is the most interesting paper you have come across recently?
Many of the scientific advances in cardiovascular disease come to mind but a manuscript that has occupied a substantial amount of my time and focus recently has been a manuscript appearing in JAMA in January this year from the NCDR ICD Registry on the US prevalence of implantable cardioverter defibrillator (ICD) implantation for primary prevention of sudden cardiac death not meeting either Medicare coverage and reimbursement policy or our clinical practice guidelines recommendations surrounding ICDs. It is with great pride that the ACC and Heart Rhythm Society have created and now manage our national ICD registry which has already collected 750,000 ICD implant records. Our ICD research and publication committee oversees key manuscript publications. The committee offers insights into competency of ICD implanters related to training backgrounds in terms of complication rates, issues surrounding racial and socioeconomic disparities in implantations and now this landmark article surrounding ICD appropriateness. I acknowledge some of the challenges and potential flaws of this JAMA report but the range of inappropriate use in the USA from essentially 0% to 60% in our nation’s hospitals clearly indicates substantial opportunities for improvement.
Tell us about one of your most memorable clinical cases.
Two patients come to mind. They demonstrate both the intellectual stimulation that medicine and cardiology affords us and also humility that permeates the practice of clinical medicine. Just recently I saw a patient with compensated systemic lupus erythematosus who had been previously managed by Valentin Fuster who had recommended a porcine aortic valve replacement (AVR) and a mitral valve replacement (MVR) for significant aortic stenosis and mitral regurgitation in 2003. She had done remarkably well since that time until recently when she noted progressively marked exertional fatigue. She was noted to have postural symptoms and exertional lightheadedness. Evaluation elsewhere demonstrated a normal SPECT MPI study, a transthoracic echo showing normal left ventricular function with a modest AVR systolic gradient but the mitral valve was not well visualised or adequately interrogated. A routine exercise treadmill test demonstrated a 40 millimetre HG blood pressure drop with near syncope in early exercise with a peak heart rate of 105. She had been prescribed Florinef with no benefit and in fact was admitted for symptoms of congestive heart failure with a BNP of 1000. My subjective assessment was a possible left ventricle inflow obstruction possibly secondary to pannus ingrowth of the mitral valve. On exam indeed there was a diastolic rumble and a TEE confirmed a 24mm mean gradient across the MVR with a calculated MVA of 0.4cm!! She is now being scheduled for repeat MVR.
The humbling case occurred when I was a medical resident running the medical trauma room at San Francisco General Hospital. A 21-year-old female was brought in by ambulance in full asystolic cardiac arrest with ongoing CPR documented for over 45 minutes. After running a long Code Blue drill I pronounced her dead. While giving my regrets to the family, the ED nurse beckoned me out of the waiting room to inform me the patient had taken a breath. After another 20 minutes of resuscitation we finally encountered Osborn waves pathognomonic of hypothermia. Her core temperature was taken and found to be 72 degrees Fahrenheit. I had not thought of hypothermia as it was a warm day outside but a later history divulged that her “friends” after injecting her with heroin had put her in a bathtub of ice when she became unresponsive before seeking medical care!! Her actually EKG with the Osborn waves is reproduced in the Lange textbook series. Unfortunately although the patient attained consciousness, she eventually succumbed to multiple complications include DIC and staph pneumonia.
What are your current areas of research?
Most of my present writings have been in the arena of cardiovascular outcomes research, appropriate use criteria and cardiovascular advocacy.
What advice would you give to young cardiologists?
Despite the present turmoil related to healthcare reform and acute changes in cardiovascular care delivery models, the future for the young cardiovascular specialist is incredibly bright. There is a projected workforce shortage and our aging US population with the retirement age boomer generation tells me there will be terrific job opportunities in the immediate future. The explosion of cardiovascular technology, innovation and new drugs makes this an exciting time to be practicing cardiovascular medicine.
Outside of medicine, what other interests do you have?
I have been a member of the University of San Francisco Master’s Swim team now for over 20 years with my favourite swimming stroke being the 200-yard Butterfly. This event is the only way I can ever win “points for the team” as few people are stupid enough to enter this event. This is a source of some personal pride as for years I more resembled a pithed frog trying to swim the butterfly before developing enough coordination not to drown during the event. I also enjoy drinking fine wines, playing mediocre golf and interacting with my two grandchildren, Violet and Elias.
September 1980 Certified, Internal Medicine
November 1983 Certified, Cardiology
November 1999 Certified, Interventional Cardiology
January 1985 Fellow of the American College of Cardiology
1981–1983 Cardiology Fellowship, UCSF School of Medicine, Moffitt , San Francisco
1980–1981 Chief Medical Resident, UCSF VA Hospital, San Francisco
1977–1980 Internal Medicine Internship and Residency, UCSF Moffitt Hospital
1973–1977 Emory University Medical School, Atlanta, Georgia. Doctor of Medicine. Graduated Summa Cum Laude – First in class
1971–1972 UCLA School of Public Health, Division of Environmental Health,Nutrition Biochemistry, Los Angeles. Masters of Public Health in Nutrition/Biochemistry
1966–1971 Massachusetts Institute of Technology, Cambridge, Massachusetts. Bachelor of Science in Biology
1962–1966 The Peddie School, Hightstown New Jersey
1998–Present Clinical professor of Medicine, UCSF School of Medicine
2009–Present Affiliated faculty, Philip R Lee Institute for Health Policy Studies
1992–1998 Associate clinical professor of Medicine, UCSF School of Medicine
1985–1992 Assistant clinical professor of Medicine, UCSF School of Medicine
1983–1985 Clinical instructor in Medicine, UCSF School of Medicine
2003–Present Regional senior advisor for Cardiovascular Diseases, Northern California Kaiser Permanente
2003–Present Staff cardiologist, Oakland Kaiser Permanente Medical Center
2000–Present Staff cardiologist, Summit Medical Center, Oakland, California
American College of Cardiology (President, 2010–2011)
Society of Cardiovascular Angiography and Intervention
California Chapter, American College of Cardiology
American Heart Association
Alameda County Medical Society
California Medical Association
The California Academy of Medicine