Cardiologist Tariq Ahmad, MD, Assistant Professor of Medicine at Yale, interviews his former mentor, Christopher O’Connor, MD, Chief Executive Officer for Inova Heart and Vascular Institute and former Chief of Cardiology at Duke, on what it means to be a good leader in medicine. Read or listen to their conversation.
Tariq Ahmad: Hello and welcome to NEJM Catalyst. My name is Tariq Ahmad. I am an Assistant Professor of Medicine at Yale. I’m a heart failure cardiologist and I’m about almost 2 years into my first job. I finished cardiology and heart failure and cardiac research training at Duke where I was for 5 years, and there I had the honor of working under Dr. Christopher O’Connor, who was my Chief of Cardiology. I consider him a close mentor.
Dr. O’Connor is one of the leaders of academic medicine in the United States. He was at Duke for more than 31 years, where he did his residency. He was a Chief Resident. He did his fellowship in cardiology and rose through the ranks from being Chief of Heart Failure to Chief of Cardiology, Head of the Heart Center, and he was instrumental in bringing Duke up to a top 5 U.S. News and World Report cardiac center. Then he switched career paths and became CEO at Inova Heart and Vascular Institute. I was inspired to interview him based on a recent podcast by Dr. Lee [and Jeffrey Balser], who was exploring the question of what it takes to successfully lead academic medical centers, and I have the honor of being able to ask him a few questions about that. Dr. O’Connor, welcome.
Christopher O’Connor: Thank you. Thank you, Tariq, and thanks for having me on.
Ahmad: Dr. O’Connor, my first question for you is, you are one of the best leaders I have come across, and I’ve always been curious as to what makes someone a good leader in medicine. Can you tell us a little bit more about how you were identified as a good leader early on in your training? Is this something you developed? Is it something that you worked on, and how did you get better at being a leader?
O’Connor: I think leadership is something that’s learned and acquired, and there’s probably some inherited components to great leadership if you look at leadership across history. But I think one of the things we realize in medicine is that (a) we don’t receive much leadership training and (b) it is a skill set that can be improved upon and acquired.
I would say that in my specific case, I was very fortunate to have trained under great leaders as a house officer, particularly as a Chief Resident under Dr. Joseph Greenfield, Dr. Robert Califf, Dr. Bill Anlyan. These were leaders who — even Dr. [Eugene] Stead when I was very young in training — these were established great leaders in medicine and I was fortunate to have had some time underneath them.
Ahmad: Dr. O’Connor, you really excelled as an academic cardiologist. You led very important trials in heart failure. You basically were a triple threat in the true sense of the word, and then you led a highly academic medical center, Duke, where they published some of the key papers in heart failure and cardiology that followed all across the world. Can you tell us a little bit about how those qualifications and characteristics are important these days as large academic centers are becoming heart and vascular centers? Are those skill sets still going to be as important? What are the different things that are pulling at you when you’re leading academic medical centers nowadays as compared to when you were coming up?
O’Connor: It’s a great question: how do we continue to maintain a culture of academic medicine that is innovative, productive, thoughtful, and commitment to the goals that academic centers aspire to? I think it’s really important we understand the ecosystem of medicine now. And what’s happened now, contrasted to when I was going through, is that the economics have changed drastically and the discretionary monies that were available to departments and divisions are no longer there because health systems no longer have the margins that they used to have, and because of this, there’s been enormous pressure on faculty to do more clinical and more justification of their salaries, complete justification via research, complete coverage by research grants, or complete coverage by clinical activities. I think this has really been the struggle in where there needs to be more work funds to keep the culture that we value so much.
Ahmad: I want to get a little bit into what you said. I did my internship and residency at Brigham and Women’s and fellowship at Duke, and now I’m at Yale and I can see how important leadership at the top is in helping develop faculty members. In one of the prior podcasts [with Jeffrey Balser], it’s said that you can understand how academic centers are moving based on following the money. How important is it to have people be chiefs of cardiology and directors of heart and vascular centers, see eye to eye or be the same person, and what different responsibility do these two people have, and how can they work together in making sure that the system provides really good clinical care but also does research and retains faculty, which is not completely going to feed the bottom line in the short term?
O’Connor: You know, that’s a very complex question, but I think that there are a couple of small points that should be made. One is that having a single voice at the top of the academic division of cardiology and the clinical heart center is extremely important. Now, it can be two people, but there should be a singular voice on the very important aspects such as commitment to a learning health system, compensation models that do reward academic work, a culture of balance, of work-life balance, and unselfishness is very important.
I think one of the things that I learned very early from Rob Califf when he was a co-PI with Eric Topol of the TAMI trials — they did about 10 phase 2 thrombolytic trials — and it turned out that Rob, despite being the leader and designing all those trials, he was first author on only one of the 10 trials and he handed some to fellows, junior faculty, and many of them to his partner Eric Topol. And I saw that and I said, boy, that really engendered a lot of goodwill amongst a lot of people.
Ahmad: That is a really good point, Dr. O’Connor, that will lead to my next question. I’ve rarely seen anyone develop talents better than you. Your mentees are some of the leaders in heart failure now — you have Michael Felker, Eric Velazquez, Adrian Hernandez, [and] my colleague Rob Mentz is a rising star. How is it that you identified and developed such talent in what seems to be a . . . you did it multiple times when other people are only able to do it maybe once or twice?
O’Connor: I think that the experience that helped me was obviously having good teachers, like I mentioned before Dr. Califf, Dr. Greenfield, Dr. [Galen] Wagner was a great teacher, but also I would say raising four kids. I learned a lot by raising four kids on how to mentor fellows and junior faculty, and that is you’ve got to put them on a bicycle at some point and push them down the hill and see if they can ride the bike or fall. And so I had a lot of fun mentoring fellows and faculty by putting them in experiences that I knew they would be uncomfortable with, but I would be behind them enough so that I wouldn’t let them fall. And I think that kind of learning environment was one that benefitted many of the people you’ve mentioned.
Ahmad: I think that’s remarkably true, and just from a personal point of view, I remember one of my most difficult days as a fellow I got a phone call from you on my cell phone, and you called me to your office and spoke with me and made me feel dramatically better. I was really awestruck by how the Chief of Cardiology would know that something is going on with one of their fellows and reach out. And that really meant a lot and I’ll always remember that, and I learned a lot from that. Dr. O’Connor, can you speak to your experience being at Duke for most of your life, I would say, and your kids are there, and then transitioning to Inova, which is such a difficult health care system? What are the things that you’ve learned, what are the things that you plan to do, and how do you see this as an example of where health care systems are going toward the future?
O’Connor: As you know, it’s always a difficult decision and a complex one that you make when you leave an institution you love and you’ve been there for 31 years, but I really felt like I had accomplished what I wanted to, by moving Duke Cardiology into a position of being a top 4 heart and vascular institute and center. And I said to myself, for the next 10 years, do I just want to sort of maintain what we’ve done here, incrementally, improve it slightly, or do I come back to my hometown, which I always promised my dad — he’s no longer living — I would, and take a very potentially strong health care system, and with benefits from some academic physician leadership transform it to a top heart and vascular institute with I think the most important achievements in the world?
And in a setting where 95% of health care is delivered, that is in the independent academic health systems or the health systems that are not affiliated with universities or medical schools, and to me, that was going to be one of the ultimate challenges. Could I take the Duke playbook and utilize the things that I’ve learned and transform the health system from one that was good but not great to a great one? And that’s really why I made this decision. And it’s really been fun and challenging in the first 2 years, but I have to say that it’s a goal worthwhile.
Ahmad: That’s wonderful, Dr. O’Connor, and we can tell, but you know you could be like LeBron James and come in from the outside and win the championship. You’re also the Editor-in-Chief of JACC: Heart Failure, which has rapidly risen to probably the best heart failure journal that’s out there. How do you see that role in the overall scheme of leadership in medicine, and how you can steer the health care system? I’m a big fan of your editorials that you write for JACC: Heart Failure. For example, how have you developed as an editor and what do you see as the role of these journals in the future of health care?
O’Connor: I think these journals have become very important vehicles of communicating, not only scientific breakthroughs but ideas, the exchange of ideas, and by pinning it with social media — which you’re outstanding on — I think really can help what I want to do, which is transform the way we practice medicine. And that is the ultimate goal: everybody is committed to learning health systems, that is everyone who’s in practice is taking observations and advancing them so we have new knowledge, and putting them in registries or biorepositories, or contributing to randomized control clinical trials, practical trials, sophisticated trials, etc. But to take the entire physician portion to be committed to learning health systems, and I think the journal can help get there because we touch 30,000 cardiologists through the journal. So I think it’s a very important role and I take it very seriously.
Ahmad: To round this out, how do you see the future of cardiovascular medicine and its practice? We know that reimbursements will be going down. The pharma companies, for a lack of a better word, have been burnt with development of heart failure and other cardiovascular therapies, so there are entities going more and more toward things like cancer. How do you see the future of the landscape in both research and practice in cardiovascular medicine?
O’Connor: Well, Tariq, you make a very good observation that the investment in cardiovascular development is [slowing] mostly in a large part because companies and sponsors, public sponsors, are not seeing return on the investment because of barriers to implementation. So we have a very fractured health system. That’s why I think in the position I am here, if I could fix the fractured health system in one area and use it as a model for the rest of the country, it would be an important contribution.
The challenges I think going forward is that we have to really emphasize a unified, aligned physician team that starts with the family practitioners, the allied health professionals, the internists, the general cardiologists, and then let’s say the heart failure specialists. That has to be a team. Heart failure doctors only take care of less than 1% of heart failure patients, and so everything we say and do in our professional work as heart failure specialists, we’re only scratching the surface, and most people we’re not touching.
The second thing I would say is that we have to make a major emphasis in prevention. You know, 95% of the U.S. population will have hypertension, I think 85% will have abnormal BMIs, diabetes will be in our clinical trials now that we see 40% rates of diabetes. As I said, this is unsustainable, and this all will translate into heart failure as well.
It’s a catastrophe in general and we have to do something, what I would call off-strain, and I think the health systems could be the area where we bring this all together, where we could tie implementation of evidence-based therapies and the electronic health records at time of interaction with the patient who we would make major commitments to participating in research via compensation models, and that heavily has helped us in population health to keep people healthy and out of the hospital.
And this means looking at more novel strategies. We need to be partnering with entities that are very sophisticated with social media but also the knowledge of behavioral science and adherence to exercise and healthy diet. So there’s a lot of work to do, as you know, to get our population healthy, our colleagues and patients healthy, and to fix this health system, but I see that as an enormous and worthwhile challenge.
Ahmad: That’s absolutely wonderful, Dr. O’Connor, and if anyone can do it, it’s going to be you. And I have to tell you, having interacted with you has been one of the most important professional interactions of my career, and I’ve learned so much from you, and I know that you’re going to do even more to change the landscape of medicine and how it’s practiced across the world.
Thank you so much, Dr. O’Connor. One of the other things that I’ve learned is that I will not get as stressed out when I’m taking care of my two kids because hopefully that will help me become a better leader as well. They’re 5 and 3, so it can be pretty challenging, but you’ve done such a remarkable job with your kids. So thank you for talking with us, and good luck with everything in the future.
O’Connor: Thank you, Tariq. Thank you very much.