Editor's Note:
Interviewee Ileana L. Piña, MD, MPH, from Montefiore Medical Center, Bronx, New York, originally hails from Havana, Cuba. Dr Piña embodies the immigrant's story by overcoming early hardship through hard work and determination. This interview was recorded April 2, 2016.
The Early Years: From Havana to Tragedy in the United States
E. Magnus Ohman, MD: Hello. I'm Magnus Ohman, and I'm here today with Ileana Piña. She is a professor of medicine and associate chief of cardiology at Montefiore Medical Center in New York. She and I are going to talk about the life and times of leading cardiologists. It's fun to have you here, Ileana.
Dr Piña: Thank you. Thank you for thinking of me.
Dr Ohman: You have been a leader in many parts of medicine, not only in heart failure. You have spent a considerable amount of time in regulatory medicine, which is very unusual, so we look forward to hearing more about that. But before we get to that, you were born in Cuba?
Dr Piña: I was born in Havana, Cuba, and came to the United States when I was 6 years old. I turned 6 years old 2 weeks after we arrived.
Dr Ohman: Did you come the legal way?
Dr Piña: We were legal. There was still a lot of unrest, and my father and my mother wanted me to learn English. My father wanted to work for Pan American World Airways. In those days, you had to be an American citizen to work for Pan Am. And so he thought, "Well, let's get a residency. I'll get citizenship for all of us, and then go back to Havana and work at the Havana Airport for Pan Am." That was his dream.
Dr Ohman: When was this, roughly?
Dr Piña: This was in the late 1950s. He died of a myocardial infarction at the age of 42, after we had been here for only 3 years, when I was 9 years old.I have actually seen the slides of his coronaries. He had single-vessel left anterior descending (LAD) disease—the "widow-maker." He was fine at 8:30 in the morning, and by 3:30 PM he was gone.
Dr Ohman: For a 9-year-old child, this is a traumatic event.
Dr Piña: It was incredibly traumatic, and even more traumatic for my mom, who worshipped the ground my father walked on. He had taken me to school that morning. I waved goodbye to him at 8:30 in the morning before I marched in. Catholic school, of course; if you're Cuban, you're Catholic. And by 3:30 PM, he was gone. I remember waking up the next morning and saying, "I don't have a daddy anymore."
I credit my mom for being very brave. We had no one in this country. All our family was in Havana—both sides, Mom's and Dad's. She thought that the political situation was so unstable that we should stay in the United States. At that point, we were not US citizens.
The Cuban Revolution
Dr Ohman: Very wise move. This is actually before the Bay of Pigs Invasion.
Dr Piña: Oh, yeah. We used to go back and forth to Havana a lot. Back then, you could still do that. My grandmother was getting quite old and had dementia, so we would spend my summer vacations in Havana. My mother would take care of her mother and let her sister get some rest.
Havana is not a distant memory to me. It's a very close memory. When they saw what was happening, the banks being taken over and the militias marching on the streets, her sister said, "Get out of here before there's more trouble and you get stuck over here."
Dr Ohman: You were in Florida at the time?
Dr Piña: Yes, we went back to Miami, where I grew up.
Dr Ohman: Now let's fast-forward to a number of years later. Are you looking forward to going back to Cuba?
Dr Piña: No.
Dr Ohman: How are you feeling about this?
Dr Piña: Very, very sad. I think many of us feel very sad because the revolution really destroyed my family. It destroyed a lot of families. And a lot of people died. We don't want to forget those people, and we don't want to forget the roots of our liberties. We believe in liberty and personal rights, of which there are none down there.
Dr Ohman: It's interesting, because many of these issues come up—a lot of trauma and issues around war. At some point you have to move on, but you must never forget.
Dr Piña: You can't forget.I'm very conflicted. A part of me wants to go home. A part of me just can't.
Dr Ohman: And healing takes some time.
Dr Piña: Yes.
Hunger and Hardship: The High School Years
Dr Ohman: So you were in Florida at the time, in Miami. You were in high school?
Dr Piña: Yes, an all-girls high school. We lived in the housing projects because when my dad died, we had 30 cents in our pockets. My mother was working odd jobs. Now there were two mouths to feed and no dad to work. I am very grateful to the United States, because Social Security survivor benefits carried my mother and me for several years.
And then we moved to the projects. Again, I'm very grateful because, had we not been living in the projects, I wouldn't have been able to go to the high school that I went to. So we had many years of hunger and living in the projects. And then my mom died when I was 19.
Dr Ohman: Your mother must have been incredibly strong.
Dr Piña: She was a very strong woman.
Dr Ohman: These are incredibly traumatic events: living alone, away from family, all of these aspects.
Dr Piña: Her sisters didn't come from Cuba until about a year before she died. And then my father's family came from Cuba 2 years after my mother died, which is when I moved in with my godmother and my grandfather.
Dr Ohman: Were you the only child?
Dr Piña: I was the only child.
From Community College to Medical School
Dr Ohman: Wow. So then you had to decide without parental support where to go to college.
Dr Piña: I did. I started at the community college in Miami. It was a great experience. When I left Florida for work, I ended up being on the Board of Trustees of the college that I attended. It was cheap, I could afford it, and I had three jobs and 18 credit hours. It was the only way.
Dr Ohman: So how do we go from community college to medical school?
Dr Piña: Well, I thought I wanted to be a laboratory technician because it was science and I loved the smell of hospitals. Since as early as I can remember, I just loved that smell that's in the hospital.
Dr Ohman: Is it the ether smell?
Dr Piña: It's ether and alcohol, and there was just something about that wonderful smell. So I figured, "Well, if I could be a lab tech, it's good." But I had a 4.0 grade point average (GPA), and my wonderful professor at the junior college said to me, "You're the only one here with the grades to get into medical school, and you want to look at urine bottles for the rest of your life?" And I said, "You've got a point there."
And I thought, I'm older, I had already missed 2 years, and I'm by myself. How am I going to pay for all of this? So I went back home and talked to my godmother, who was my aunt. I said, "What would you say if I told you I was going to apply to medical school?" She said, "Go for it." We've had a lot of people in our family who were either physicians or pharmacists, on my father's side, so she supported me.
I applied in September and got in in December. Then I had to find money, because back then, $1500 per year was a lot of money.
Dr Ohman: It was.
Dr Piña: I got an award, but it was a payback loan, from the Women's Club in Miami. I still had to work because I had to pay for rent, the car, the gas, and the insurance. I worked at the junior college, teaching at night. I ran their study lab and was drawing blood.
Dr Ohman: That's amazing. Which medical school did you go to?
Dr Piña: The University of Miami.
Dr Ohman: It's amazing that you can do all of those things and get through medical school. It makes you wonder about children today, although they say that they have to learn more. But that is an amazing story.
Dr Piña: This is pre-Internet, pre-UpToDate on the computer and everything else. The only year I could not work was my junior year, because we had rotations. You couldn't hold a job. But by senior year, I was doing history and physicals on weekends.
Surgery Internship
Dr Ohman: That is fantastic. So now you've finished medical school. You've got to go to residency.
Dr Piña: I did the internship in surgery.
Dr Ohman: Good for you. Were you going to be a surgeon?
Dr Piña: I wanted to be a trauma surgeon.
Dr Ohman: And what was the influence to get you to think about trauma?
Dr Piña: I don't know. It was exciting.
Dr Ohman: Full of action?
Dr Piña: Yes. I used to spend my Saturdays volunteering in the emergency department so that I could learn how to sew. I did that during my freshman and sophomore years, and I thought, "This is really cool." We had what we called "Room 5s." On Friday nights, in the magic city of Miami, the Knife and Gun Club meets.
It was a very exciting time. I was one of only two women in the surgical program. But I didn't like the lifestyle of the surgeons. I saw many people that I knew in medical school who were then in their fourth or fifth year of surgery. I didn't like them. They had changed. We were on call every other night, and being on call every other night changes your life. I said, "I don't think I want to do this and look like that 5 years later and be unhappy with myself."
Dr Ohman: So you were already thinking about life/work balance. It's important. So what did you do?
Dr Piña: I switched over to medicine.
Dr Ohman: Still at Miami?
Dr Piña: No, I went to the University of South Florida, in Tampa. The chair of internal medicine was Roy Behnke. He was an amazing clinician. I ended up being chief resident with my best friend, who is the incoming president of the American College of Cardiology (ACC): Richard Chazal. We studied for boards together and were chief residents together, and that really bonds you for life. I liked cardiology. Robert Myerburg, whom I deeply respect, brought me back to Miami. I was a "fellette." I was the only woman fellow, so I called myself a "fellette" with the boys.
Dr Ohman: This is pretty amazing. You've actually gone for surgery, which is not a woman's specialty, by and large. Although it has changed now, back in those days it was almost unheard of. And you were one of the few women fellows at the University of Miami.
Falling Into Heart Failure
Dr Ohman: How did you get interested in heart failure? Did that come later?
Dr Piña: No, I kind of fell into it. When I finished the fellowship, Bob Myerburg said to me—and I'll never forget these words—"You will always have a home here with us." So I stayed on faculty. I looked around and said, "Now where could I be the queen?" The exercise lab needed some help, so I said to Bob, "I want to do the exercise lab." And he said, "You've never been that into it." I said, "I don't care. Put me there." And so I taught myself exercise testing. I took several courses in cardiac rehabilitation and started the cardiac rehab program at the University of Miami.
And then we started doing some clinical trials. This was in 1982.
Dr Ohman: I think it's amazing. It's hard for younger people who are listening to realize that trials in those days were 20, 40, or 50 patients.
Dr Piña: A little bit here, a few there. We were looking at a drug called nicorandil, which was still circling the wagon. It was an Upjohn study.
Dr Ohman: Right, and it's an antianginal therapy.
Dr Piña: That's exactly right. At the same time, Dr Myerburg had a grant from the National Institutes of Health (NIH) for amiodarone.
Dr Ohman: Also an antianginal.
Dr Piña: And procainamide. He would send me patients to put on the treadmill. I had been told that if somebody has an ejection fraction of 25%, you do not put them on the treadmill. That was the wisdom. But are you going to say no to your chief?
Dr Ohman: Probably not.
Dr Piña: If you're a junior faculty member, you do not say no to Bob Myerburg.
Dr Ohman: He was well ahead of his time.
Dr Piña: He was. So was Bernard Lown.
Dr Ohman: So it obviously took 20-odd years to prove that in the trial that you and Dr O'Connor worked on—HF-ACTION.[1]
Dr Piña: Yes. But see, I've watched the patients walk. This was before angiotensin-converting enzyme (ACE) inhibitors. They would walk and walk and walk, and nothing happened. So I said, "Wait a minute." That is when I really started studying cardiopulmonary testing. Joe Franciosa was in Alabama. Karl Weber and Joe Janicki were writing about gas exchange.
I bought the first Medical Graphics machine for VO2 testing in Miami and started doing cardiopulmonary testing—really cut my teeth on that. And I realized that there is no relationship between ejection fraction and function, with our own data.
Dr Ohman: Amazing. How did you start realizing that it was the peripheral organs that determine that?
Dr Piña: Well, the people at Duke started doing some great work: Michael Higginbotham, Martin Sullivan, and Frederick Cobb. The late Fred Cobb started doing some really seminal work, and they were showing that oxygen extraction was perhaps more important than cardiac output. And that's how I got into heart failure. By doing trials, we could show improvement in function. I still have slides of flosequinan with exercise, showing the improvement in PVO2, and of course, the mortality was increased. So that's how I got into the clinical trial.
Dr Ohman: Did family come along the way?
Dr Piña: I have a daughter, which is probably the best thing I've ever done in my life. Miss Victoria. And Victoria went to Duke.
Dr Ohman: She did?
Dr Piña: She's a Dukey, a Blue Devil. And now she's in veterinary school at Ohio State, finishing her third year. I'm very proud of her. She's a good student and a good girl. Bilingual, Cuban underneath.
Dr Ohman: Oh, the colors never go out.
Dr Piña: No, they don't.
Dr Ohman: So you moved from Miami?
Dr Piña: I went to Philadelphia. I got recruited by Hahnemann University Hospital to run their heart failure cardiac rehab program. We called it the "Cardiac Fitness Center." Dr Frankel was my chief there. He has since retired. And then Alfred Bove, another individual whom I deeply, deeply love—and he knows it, because I tell him every time I see him—asked me to come to Temple University, where I really learned transplant and left ventricular assist devices (LVADs) and rehab in LVAD transplant patients.
Dr Ohman: Which was sorely needed at the time.
Dr Piña: We were the top program in the country. There were five of us, and we were very, very close. And then I got recruited to Cleveland, to Case [Western Reserve University] to run their program. And then in New York, Mario Garcia, my chief, recruited me. Meanwhile, I got an MPH, and did a 3-year Veterans Affairs (VA) Quality Scholars fellowship.
Dr Ohman: So working on the side has continued.
Dr Piña: Yes.
Dr Ohman: You're not settling. It's interesting because you were a self-starter. You've really just moved forward on multiple levels.
Dr Piña: No silver spoon in this mouth.
Entering the Regulatory World
Dr Ohman: This is fantastic. So how did you get connected with the US Food and Drug Administration (FDA)? Helping them in their regulatory world is now a very large part of your work.
Dr Piña: It's a huge part of what I do. Back in the early 1990s, Barry Massie recommended me to the Cardiorenal Advisory Committee (which you've been a part of). I sat there with Eric Topol on one side, Rob Califf, Joann Lindenfeld, Marvin Konstam. They're all my friends today. Milton Packer was our chair. On the first day of the meeting, I said to him, "Don't look at me. Don't talk to me. Don't ask me anything. I am having abdominal pain just sitting here in this huge auditorium."
When I finished my tours, I got moved to the device panel. My current boss, Bram Zuckerman, who is chief of the Center for Devices and Radiological Health (CDRH), asked me to come inside. And I love it.
Dr Ohman: Share with us a little bit, because most people might not see that this is unusual. You're a practicing cardiologist, but you're also very involved in the regulatory piece. How do you reconcile those two? One is the regulatory rigor, and then the other part is how we practice medicine. You know, none of us read the label anymore. We never did.
Dr Piña: But we should be reading labels, because we work very hard at labels. I have nothing but admiration for my colleagues at the FDA. They work extremely hard. They really are fair and balanced. What I have brought—and this was really Bram's vision—is to have clinicians who are doing this every day to come in and become consultants. And now I'm officially a medical reviewer. I've been doing medical reviewing for about 10 years now and bringing my experience to the forefront.
When somebody says, "The heart failure patients look like this," I can say, "Well, no, they actually look like this," because I see them every day. We've been doing devices since the 1990s, with LVADs. I bring them that experience. I know the literature, and I know things like quality-of-life instruments because we're using them every day.
I'm very careful not to cross lines. I respect the device industry, but I don't talk to them because I need to keep my integrity on this side. I can do Medscape and theheart.org because they're very neutral. It has been an incredible piece of my life. Milton told me on the first day that I would never look at a clinical trial [the same way] again, and he was right.
Dr Ohman: It's totally eye-opening. As you know, I have some involvement as well.
Dr Piña: We like having you on the committee.
Dr Ohman: If every woman in cardiology did what you did, that would be fantastic. So how can more women be involved at this level? It is truly unique.
Dr Piña: Well, I may say some things that are a little bit of an anathema. I don't really believe in separating ourselves by gender. I'm a cardiologist. My gender, my color, my creed, or my ethnicity really shouldn't matter. I earned my stripes by doing the work, and that's what should be respected. Everything else should be immaterial.
Dr Ohman: But it's fair to say that many women don't see that they can do all this. I think you're absolutely right, but you've done more than most people ever do.
Dr Piña: Well, the boys are my best friends. I always say "the boys and me." And I have formed incredible friendships with the male cardiologists that I deal with—friends who call just to see if you're okay. We write to each other. We text each other all the time. And we really care about each other. I find that a lot in the men [I know], which is very interesting. And I can go out drinking with them if I have to.
Dr Ohman: We need more of you.
Dr Piña: And we sing together, too, yes.
What's Next?
Dr Ohman: Ileana, what's the next phase of life? What are you moving on to next?
Dr Piña: I've been thinking of getting an MBA.
Dr Ohman: You don't have enough degrees?
Dr Piña: No, I'm going to take some courses. Duke has a really nice set of courses that I can do online. As cardiologists, we now understand quality. We're very involved. I'm very involved with the American Heart Association on the advocacy side. We need to be there because the government side needs to know what we think. And it was time for a physician to understand the quality world, which is why I did the fellowship. The MPH has changed the way I think. You know how things change you? The MPH has changed the way I think. I think a lot about public health.
And now, the business aspect is next. We're terrible business people. We physicians are awful. And yet, we're being faced with all these models of care: medical home, bundled payments, accountable care organizations (ACOs). Do any of us really understand what they mean? I'd like to learn more. You stop learning, you die.
Dr Ohman: Right, and you've proven that you can continue learning for a long time. Maybe the Centers for Medicare & Medicaid Services will be your next stop.
Dr Piña: I wanted to be Surgeon General.
Dr Ohman: Well, Ileana, this has been fantastic. I really appreciate you sharing this with us.
Dr Piña: My pleasure. Thank you for asking me.
Disclosures: Ileana L. Piña, MD, MPH, has disclosed the following relevant financial relationships:
Served as a director,officer, partner, employee, advisor, consultant, or trustee for: GE Healthcare; Novartis
Received research grant from: National Institutes of Health
