Promoting Professionalism in the ACC
E. Magnus Ohman, MD: Hello. I'm Magnus Ohman for Duke in North Carolina, and welcome to another episode of the Life and Times of Leading Cardiologists. I'm very fortunate today to have a good friend, Dr Pat O'Gara, former president of the American College of Cardiology, professor of medicine at Harvard, with us today. Welcome, Pat.
Patrick T. O'Gara, MD: Thanks very much, Magnus. I appreciate it.
Dr Ohman: Most people who went to the American College meeting this year said, "Wow, we haven't focused on professionalism and what an important aspect this is to being a doctor before." How did the topic of professionalism come up at the meeting?
Dr O'Gara: That's a very interesting question. I think that it came up in two ways. One was that the College actually performed a historical review and recognized that it has not officially ratified the Articles of Professionalism[1] that had been published by the American College of Physicians and the American Board of Internal Medicine Foundation more than 10 years ago. I think that was a very impactful white paper that was put out by those groups as well as a primary care group and a group from Europe with respect to the essentials of professionalism in the medical field.
Very prominent leaders authored this, including Troy Brennan, who has had many leadership roles over the years in medicine. And so, this was an opportunity for the American College of Cardiology to revisit what constitutes the essentials of professionalism and especially during a period of time when it seems as if there has been an assault on professionalism, whether you are a clinician, academician, or a researcher.
I think that the concern from a societal level has risen that perhaps we, as physicians, are not to be trusted, and it's a terrible feeling, isn't it? To have worked as hard as you have, as your colleagues have, to establish what you think is credibility and what you think is a genuine interest in doing the right thing for your patients, but then having to balance that against these sensationalist stories about members of our ranks who seem to misbehave; and then we are all painted with the same brush of suspicion and doubt and accorded somewhat less respect than we think otherwise should be the case. From the College's perspective as well as from a personal perspective, the timing seemed to be right to attempt to rebalance the equation, so to speak.
First, we had to admit that we feel strongly about the Articles of Professionalism, just as we feel strongly about doing what's right for our patients; and I felt that it was an opportune time to attempt to convince the doubting Thomases as well as our public and our patients that we as physicians, as academicians, as researchers, as health administrators are very serious about trying to do the right thing. It's probably not more complicated than that.
Dr Ohman: In your professional life, was there a point that you said that professionalism is an area that fascinates you, that brought you to realize that this is an area the College hasn't focused on? Or was this more of a gradual process?
Dr O'Gara: I think it was more of a gradual process than an epiphany. In my observations and interactions with people across a wide spectrum ranging from trainees to seasoned clinicians to patients to patient advocacy groups to Congress and to all sorts of folks in between, I became concerned with the fact that we were no longer seen as a trustable profession to the extent that we were before. Rather than strike out and say, well, you have it all wrong or adopt a defensive posture, I think that we can do a great deal to restore some confidence in ourselves as well as other members of our profession with respect to making sure that we actually execute the highest ideals of patient care. For the vast majority of us, that is our mantra.
Beginnings in a Suburb of Chicago
Dr Ohman: I totally agree. I think many of us wonder: How did Pat O'Gara become the person to carry this mantra? Where did you grow up? Where did your life start in the big picture?
Dr O'Gara: I grew up in a village called Wilmette, Illinois, which is about 20 miles north of Chicago on the shores of Lake Michigan. I grew up in a family of nine children and two parents in a house in the suburbs.
I had a parochial school education, at least until the eighth grade, at which point there were too many of us in the queue, and it was clear that I had to go to the public high school. I grew up in a family of very accomplished individuals who were self-sufficient and self-starters. It was a very fortunate environment in which to grow up because no one stood out. You could do well, but that was really the expectation. I don't recall that there were any asymmetric celebrations for one of the nine to the others of the eight. It's not as if everybody got a trophy, but it's as if there was a certain expectation, and you learned how to accommodate to a larger group. So, whatever individual accomplishments you might have were placed into a broader community perspective right there in the nuclear family.
Getting back to the parochial-public inflection point, choosing to go to the local public high school, retrospectively, over my 63 years, was the single best decision I have ever made. It helped me to socialize. It helped me to be challenged by my peers, to enter a much larger group and to see whether or not I could compete at that level. It was a terrific experience ranging from the academics to the opportunities for athletics, which I pursued at that particular age with a passion.
Dr Ohman: What was your sport?
Dr O'Gara: I played basketball and baseball. As you can see and as you know, I don't have much size. I like to say I was bigger then, but I'm not really sure I was. But I was able to play in the 1960s and 1970s, when there were fewer people twice my size competing at the same event. Those were wonderful experiences that really gave me the opportunity to compete and to determine whether or not I could stand on my own. After graduating from high school, I went to Yale University, where I played baseball for an additional 4 years, and that was one of the defining aspects of my college career.
An Inspirational Art History Teacher
Dr Ohman: What did you study as an undergraduate? I presume that was your first visit to the east coast.
Dr O'Gara: That was my first visit to the east coast. It's interesting to compare the experiences now when sending children off to college against the experience of 45 years ago when people were sent off to college with a suitcase and a handshake and told good luck.
Yale was a very different environment from any that I had previously experienced. I studied molecular biophysics and biochemistry, but I chose to do a bachelor of arts rather than a bachelor of science, so that I could have some more time to take advantage of the more liberal aspects of a Yale education and the strengths that they have in fields ranging from art history to history to English to political science to drama and all of the other things that are in a liberal arts education.
Dr Ohman: What in the liberal arts sphere actually attracted you the most?
Dr O'Gara: I have to say that thinking back on it, and I'm sure you'll appreciate this, you don't remember all of the aspects of what happened. But what I remember most strikingly about the nonscientific aspects of my undergraduate education was a gentleman whose name was Vincent Scully, not Vin Scully who is the radio voice of the Los Angeles Dodgers and before that the Brooklyn Dodgers. He taught art history at Yale and without question inspired in me a sense of what I thought was greatness in teaching, and I was just becoming old enough to understand the difference between a good teacher and a not-so-good teacher. By that time, I was a senior in college and thinking a little bit more about what the future would be once I stepped out of the confines of the bubble of being a college undergraduate.
He somehow was able to instill in his students, whether they were undergraduate or graduate students, a sense of joy, investigation, and being able to understand more than just the architectural aspects of a picture and more than just a sense of the lines of sight that somebody might decide would be important when renovating an urban environment. This package of history and literature completely took me by surprise and gave me the sense that there is so much more to learn, if only we had the time to pause to understand the richness that surrounds us.
Back in the days well before PowerPoint presentations, he was a dramatic lecturer who carried around a pole that probably was about 10 feet high; and he used to smack the projector screen to point out various aspects of how the temples to the gods were sited on the Mediterranean Sea and what was happening with the Peloponnesian War and things of that nature. It was just fascinating. Just a real discovery for me.
Dr Ohman: How come you didn't go into art history?
Dr O'Gara: That's a good question. I think that if I had to judge myself, I would say that my right brain is deficient; and my left brain, by contrast, had always been focused on science, biology, and mathematics. I had initially thought that I would pursue a degree in math and then try to become a teacher and a high school baseball coach, but that didn't work out.
Dr Ohman: Something changed.
Dr O'Gara: Something changed. I think what really changed, Magnus, with regard to becoming a math major, was finding myself in a math class when I was a junior in college and saying to myself, "I don't have anything in common with these people." Not only could I not understand the lecture material, but I was afraid that this didn't seem to be the right learning environment for me. So, I pursued something of a more biological nature. It seemed to be the right fit for what my interests were at that time and what my personality was.
Choosing a Career in Medicine
Dr Ohman: How did you decide to go into medicine?
Dr O'Gara: I came about in two ways. I had the opportunity to grow up with a great group of friends. I had some close friends who were two brothers, about 19 months apart in age; they lived a few blocks away, and we all went to school together and competed playing community sports together and, as it turns out, their father was a cardiologist.
Over the years, as we were getting a little bit older and making our way through high school and observing what people did for a living and what was important—these two friends, by the way, are now both interventional cardiologists. Their father was an internist with an interest in cardiology prior to when board certification in cardiology became a reality. When we were in our later years of high school and early years of college, we would travel with him to make rounds in Chicago and see what he did. There's no question that left a mark on me. I was very impressed by his intellect, but I was also impressed with his care for people and had really never been exposed to anything like that.
Then I had the good fortune in college of being surrounded by peers who could bring out the best in each other. I had two close friends with whom I played baseball, both of whom had previously decided that they wanted to go in the direction of medical school. After comparing myself and speaking with them and working things out, I thought that that would be a good fit for a combination of things that I had wanted to accomplish. So, I applied and was lucky enough to get in and went to Northwestern.
Dr Ohman: So, back to Chicago.
Dr O'Gara: Back to Chicago, and the school was, as you know, in the city. It's not with the undergraduate campus, which is about 15 miles north in Evanston. And that turned out to be a terrific place for me, for a couple of reasons. Largely, it allowed me an opportunity to live and commute in a big city independently and figure my way around again, another way to increase my socialization in being able to do things of a practical nature.
I also had the benefit of a close group of high school friends, none of whom had anything to do with medicine, who kept me well balanced for 4 years playing in 3 competitive basketball leagues at night and fast-pitch softball leagues during the spring and summer. This was an opportunity to try to live a more well-rounded life as a medical student before things got to be a little bit busier.
Dr Ohman: When did you meet your wife? You're a busy man here.
Dr O'Gara: We met actually through her sister, who at the time was married to one of my ex-teammates from my college baseball team. He was from Michigan, and the two of them had moved back to Chicago, and I had maintained a friendship with him and his wife at the time. Her sister, who is now my wife, moved to Chicago around the time that I was preparing to leave to begin my internship training out in Boston, and I simply arranged for her to meet this group of high school friends that I had, and we stayed in touch during the next year and a half or so and then re-met, so to speak, and the rest was history.
Boston Training and Early Career Mentors
Dr Ohman: And so, off you go to Boston.
Dr O'Gara: I did all of my internship, residency, cardiology fellowship, and then a year of being chief resident at Massachusetts General Hospital (MGH). After I finished that, I did a year and a half at the National Heart, Lung, and Blood Institute (NHLBI) with my good friend Bob Bonow. Steve Epstein was the chief of the Intramural Clinical Branch at the NHLBI at the time, and Marty Leon was also part of the faculty within the Clinical Branch at that time. It was just fantastic exposure.
Dr Ohman: In these early years when you were at MGH, did any mentors start emerging?
Dr O'Gara: Yes. Well, you might be interested to know that before I decided to go into cardiology, I thought I was going to be an orthopedic surgeon because I had an interest in sports medicine. I had little exposure as a medical student, and I decided to observe a hip operation and it wasn't for me. So, I moved on, and I think an internship and residency at MGH was a very powerful influence on me. I had the opportunity to be exposed to spectacular role models across the entire spectrum of internal medicine at that particular point, and within a short period of time, I came under the influence of Roman DeSanctis. Without question, on a personal level across many aspects of my development, Roman has had the single greatest influence on me in terms of what constitutes an excellent clinician, an outstanding teacher, and a genuinely compassionate human being who cares deeply about his patients but also cares deeply about his trainees and about the institution for which he works.
It's hard not to fall under his spell if you're interested in clinical cardiology. What I like to say is that Roman taught me how to become a doctor, quite simply. I think that it's different from aptitude on a knowledge-based test. It's different from aptitude alone, and it's different from communication.
Dr Ohman: What are those hallmarks? This is an interesting aspect because I think it ties into the professionalism part.
Dr O'Gara: In Roman's case, what I observed was world-class clinical acumen, the kind that I always felt you couldn't really teach. It's as if he had a sixth sense. He also had a photographic memory, but he wouldn't say anything of that nature. He had a photographic memory in terms of being able to say to a small group, this is an unusual problem, but I remember the last three I saw over the course of the last 25 years, and this is generally what happens. I think that his knowledge base was deeper than anyone else's. He had a way to integrate this seamlessly without necessarily drawing attention to himself in the process, and had an ability to inspire others to achieve their best.
Dr Ohman: Well, he clearly inspired you to a whole different level.
Dr O'Gara: Absolutely. And I'm sure you've had some similar experiences. You know who those people are. You don't let go.
Nonclinical Opportunities at the NIH
Dr Ohman: So, you finished your cardiology fellowship at MGH. How did you end up going to the National Institutes of Health (NIH)?
Dr O'Gara: It was a wonderful benefit provided by the chairman of medicine at MGH at that time for whom I had worked as chief medical resident. This was back in the day when there was only one chief resident per year, and we developed a close friendship. He asked me in so many words "Now, what is it you'd like to do to begin to develop your career?" I think what he was really saying was that you're about ready to jump off from the protected environment of being a trainee to being able to stand up and maintain your own independent source of funding and your identity as a contributor to the synthesis of medical knowledge or education.
I said to him that having "grown up" in the MGH environment and knowing that there was a strong connection with the NIH, certainly back in the day of the yellow beret, when many of my immediate predecessors had gone to NIH as clinical associates for a few years during the Vietnam War and had learned quite a bit about how to do research and carried that forward in their career, I thought a similar experience was what I needed. I thought I actually needed to take myself out of a clinical environment to make sure that I could apply myself to a nonclinical discipline. So I went to the NIH in early 1985. I had two small children at that time
Dr Ohman: Was it a popular move in the family?
Dr O'Gara: Well, it was a very popular move with my wife because she had begun to observe the number of hours spent on clinical affairs at the expense of taking care of the family responsibilities. It was a chance for us to recalibrate as a young family and a chance for me to basically say that I couldn't trust myself to remain attached to a clinical environment for fear of just wanting to do more clinical work at the expense of the broader picture (ie, what is the contribution are you going to make? Who are you?)
I went to the NIH thinking, well, I'm an interventional cardiologist. I had trained in interventional cardiology back in 1983 with Igor Palacios and Peter Block back in the day prior to the availability of balloon valvuloplasty, and we were doing coronary angioplasty with catheters that hadn't yet been achieved over the wire system. But I loved it. I just couldn't do enough cases. I thought I'd go to the NIH, and I would learn something along the lines of interventional cardiology with Marty Leon, and Richard Cannon was there, and Kenny Kent had just left. I thought it was going to be a great environment.
I met with Steve Epstein, and he said something to the effect of, "Well, that's very good that you have this interest in interventional cardiology. It's just not a fit for what we need right now. You're going to work with Bob Bonow." I thought to myself, oh my goodness, I have to become a nuclear cardiologist. I'm going to lose part of my identity in this because of the difference in phenotypes between interventionalists and the noninvasive guys. I don't know if I can reconcile this in my own frame. I said, "Of course, Dr. Epstein." And that was the luckiest, most fortunate thing that happened to me since meeting Roman DeSanctis. I started a friendship and a mentoring relationship with Bob Bonow in 1986. We are moving into our 30th year of being very close friends. Our families are close. Bob has made several major contributions to understanding valvular heart disease, ischemic cardiomyopathy, and all sort of things in between. It was just the right fit. It was just what I needed in order to see the bigger picture.
Dr Ohman: You never wanted to become an interventional cardiologist after those few years at NIH with Bob Bonow?
Dr O'Gara: Well, I went back to MGH ,and then I was on the faculty there for a period of 9 additional years, and during the time that I was at MGH, I was a member of the interventional cardiology rotational team. I was in the cath lab 2 days a week. I saw patients in the office, and I was also the director of the cardiac care unit and director of the medical intensive care unit. I had gone from this lovely environment at the NHLBI, learning how to do research, and, of course, was immediately guilty of jumping back in with both feet into all of this clinical activity. This must be part of my identity.
Dr Ohman: It sounds like it's almost an addiction for you.
Dr O'Gara: Almost. Well, I think it probably was at some point and certainly in the MGH environment where being a clinician was really the currency of the realm. You wanted to be recognized by your peers as well as by your surgical colleagues and all sorts of people in between.
Looking back on that, I had a wonderful opportunity at the cutting edge of cardiac intensive care, interventional cardiology, and cardiac surgery at a relatively young age. Retrospectively, I think that having the ability to have done that allowed me to do other things later during my career that I had absolutely no way to plan or envision.
Leap from that experience, in the mid-1980s through the mid-1990s, to an experience that I've had over the last 7 or 8 years as the cochair for the steering committee for the NHLBI Cardiothoracic Surgery Network. I have to believe that part of the reason for which I was asked to consider the role or have continued in the role is this interface I enjoy so much between cardiac surgery, cardiology, intervention, and structural heart disease. I don't think I would have had that credibility without being forged in an experience at a younger age.
Valentin Fuster, Making a Difference
Dr Ohman: So, you don't stay at MGH all your life. You jump ship at some point.
Dr O'Gara: I jump ship, and I think that it's a complicated story, but let me summarize it briefly for you. After Roman and Bob, the next major impact on my career from the point of view of a mentor or role model was Valentin Fuster, who came to MGH to be the chief of cardiology in the early 1990s.
That was a sea change for MGH and for me personally, and I think that for all of us who have had the opportunity to work with Valentin, it's an immeasurable experience. It's a spectacular process to go through, not because Valentin has such an energetic and almost indefatigable intellect and a fountain of creative ideas but also this deep, deep desire to make a difference and to make a difference during the period of time you have available, and not to talk so much, but to actually do something.
Valentin showed me what the benefit is of being a member of an academic faculty. He brought a new way of thinking, but he established an academic faculty in a place where people had been more inclined to be individuals rather than a cohesive group. People like myself and Kim Eagle and others were heavily influenced by that and just took right off and started working; and, in fact, that was the first time that I began to collaborate with your colleagues at Duke University around the Coumadin and Aspirin Reinfarction Study (CARS)[2] and my first meeting with Rob Califf, Chris O'Connor, and Bob Harrington.
Valentin was at MGH for a relatively short period of time. But his being there for that period of time and then his departure kind of forced me to re-evaluate where I was going with my career, what difference could I make, and where I needed to be in order to make the difference I wanted to achieve.
Dr Ohman: And Brigham seemed to have a little bit of that coming?
Dr O'Gara: Right time, right place.
Finding Work-Life Balance
Dr Ohman: So, you didn't settle for two children. I know that.
Dr O'Gara: Yes, we have three children.
Dr Ohman: So, the children, did they see much of Dad during this time?
Dr O'Gara: Well, I think that they would remember seeing me. I think that we could all be better as parents in our kinds of work environments. I was involved as the president of the local community little league team for a few years when the boys were competing at that level, but the kids are now ranging in age between 28 and 33, and I think that I gather from them that there is still enough of a twinkle about the childhood that they had that dad was okay. But, personally, I think I could have done better in terms of my relative priorities, availability, and the simple things that I strongly caution my mentees about—the work-life balance and not to follow in the footsteps of people like myself but to think more broadly about what their priorities are and to be less worried about constantly accomplishing the next thing in order to secure your standing.
Dr Ohman: But there is an interesting tension there—being sort of the Val Fuster to achieve everything while you can vs the more balanced. What would you say to trainees in general now? How do we reconcile those two?
Dr O'Gara: I'm encouraged that many of the academic medical centers and the universities to which they are attached have developed new pathways for promotion, for example. I'm very pleased with what I see in terms of the 360 evaluations that allow clinical educators like myself to succeed in their own environment in order to be accorded the same privileges in rank as others. I think that we as academic medical centers and health systems have become much more sensitive to this. We don't want a work force that is fatigued, narrowly focused, and always thinking about their career. We actually want a work force that understands the chaotic world in which we're living and can bring things to bear from experiences they have in their church or their synagogue or volunteering to be part of the school committee and getting things done and having these practical experiences in life that could be very enriching but also I think help your family in the process. I think some of our mentees are a lot better at it than we were. I admire the younger ones who can say, "At 5:00, this is where I'm going to be. Yes, traffic is terrible, but I need to be 15 miles out because I'm going to be at that next practice or I'm going to be at that next piano recital." And I think they're better at it than we were.
Dr Ohman: It's obvious that the art history teacher at Yale had a profound effect, and it's fascinating to hear your story. Thank you.
Dr O'Gara: Thank you very much for having me, Magnus.
