Ralph Brindis

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.