Good afternoon, and welcome to Medi-Axiom's fifth part of a series of webinars on staffing in a COVID, post-COVID world. I'm Denise Bushman. I'm going to be kicking us off here in just a moment. I'm going to give folks maybe another 30, 60 seconds to join, and then we'll go ahead So, good afternoon once again. As I mentioned, I'm Denise Bushman, Vice President of Care Transformations with Medi-Axiom, and just giving you a little orientation to today's webinar. You'll see here on the screen that there are two ways you can interact with us. If you have a question, you can drop your question into this Q&A box here highlighted in blue, and then for an access link to today's presentation, as well as to a link to the ACC Health Policy Statement on Career Flexibility and Cardiology, you can find that in the chat box. So, go ahead and access those. You can download those and have those for future reference, as well as recommendation to other folks that might be interested in today's content. There will also be a link to today's presentation that will be available on the Medi-Axiom Academy site in a couple of days. So, if you have other folks that were interested in attending but not able to break away for today's session, you can lead them in that direction. So, with that, without further ado, I'm going to kick it off here with some introductions. So, first of all, introducing our speakers today, Dr. Dan Bensimon is a Duke-trained advanced heart failure cardiologist who currently serves as the Medical Director of the Advanced Heart Failure and Mechanical Circulatory Support Program at Cone Health. Cone Health is a six-hospital system in Central North Carolina. He is also a former member of the Education and Development Committees of the Heart Failure Society of America, and is on the board of the LeBaron Brody Cardiovascular Research Foundation. Also to note, he's the founder and CEO of Moonlighting Solutions, as well as the founder and CMO of Ventricle Health. And also joining us today is Dr. Thad Waits. He is a graduate of Mississippi College and the University of Mississippi Medical Center. He trained at the University of Colorado, as well as at Emory University. He was a flight surgeon in the U.S. Naval Reserve, and has practiced cardiology at the Ochsner Clinic, and then currently at Hattiesburg Clinic Forest General Hospital, where he serves as co-director of the Cath Lab. He was president of the Mississippi Affiliate of the American Heart Association, as well as twice president of the American Heart Association Southeast Affiliate. And as he would say, his main avocation is with the American College of Cardiology, where he is known as a master of the ACC, and has served on the board of trustees, as well as chairman of the board of governors. He was ACC's chair of the Health Affairs Committee, and is presently chair of the Mississippi State Board of Health. So, two terrific presenters. Looking forward to today's discussion and content. Dan, I'm going to kick it off to you. I'll go ahead and advance the slide, and you can take it away. Thanks, Denise. And welcome. It's always an honor to present with Thad, so Thad, welcome and hello. Thank you. You know, Thad and I have been charged with talking a little bit about what cardiology staffing looks like in 2022 and going forward. I think for a long period of time, we've had a fairly stable environment where there were plenty of cardiologists to go around, and if you needed to see your heart doctor, you could get in to see your heart doctor in a relatively reasonable amount of time. And I think we've seen, which has been accelerated by COVID, I think we've seen really a land shift in that access to cardiologists, the workload on cardiologists, the scenario of staffing has really changed. And I think if we're looking, I think we all are experiencing in all our practices that getting enough doctors to staff our sites, to staff our satellite sites, and really to fulfill call responsibilities have become more and more a challenge. And if it's any notice, I probably get three or four calls a day from a recruiter saying, can I go to Montana somewhere or Nebraska and help out, and it's just becoming more and more common, and the competition is really getting stiff. But I really think to solve the problem is to get out of the mindset of filling gaps and saying, how do we fill this gap and how do we fill this gap? Let's understand the problem a little bit better and perhaps take on another approach. There was a recent paper published and really looking at, and I think the link will be available to you, and you'll see that in the American Journal of Cardiology, sorry, Journal of American College of Cardiology, there is something called the Great Resignation. And we have a massive cardiologist shortage developing. American Academy of Medical Colleges predicted that over the next 10 years, we'll have a shortage of over 124,000 physicians in the United States. If you look at cardiologists in particular, greater than 60% of us are 55 years and older, and over 25%, one quarter, are greater than 65 years and older. And if you look at surveys, and Dr. Waits will talk more about this, about a quarter of the cardiologists will retire in the next two years, and there are a lot of factors attributing to this, burnout, work-life balance, alternate careers, call burden. And so if you look at that, the net loss of cardiologists, so that's the cardiologists leaving versus the fellows coming in, it's predicted that the net loss will be almost 500 cardiologists a year over the next several years. But on the other side, that the number, as our population ages, we put more wearables on people, we're going after better diagnostics, we're going to be diagnosing cardiovascular disease earlier. By 2030, it's predicted that over 40% of the population, an expanding population, will have clinically evident cardiovascular disease. So on one hand, we have a draining pool of physicians, particularly cardiologists, and we have a population that are going to be, that's going to need more and more services. And how do we think differently? How do we serve these patients? And how do we keep our physicians working and happy? So I put together some thoughts about things that we have done in our practice, and some of the things we've worked to try to solve some of these problems. Next slide, please. So I think, you know, people have always been in the mindset of let's, okay, we have an opening in one of our satellite clinics, let's fill that gap and try to fill that. But that's really a short term solution. And based on the competition out there for the gap fillers, that will lead to consistent vacancies and, you know, moderate if to poor quality in the clinic. Moderate if to poor quality in those situations. So I think the future state is really being proactive about this, really creating a situation in which we're ready for this shortage. And, you know, I see this as almost a competitive approach between practices. You know, how do we do this? How do we protect our practices in the setting of a limited group of resources? And I really think the points fall into four categories that when we talk about this in our meetings, we focus on four different things. One is we focus on how can we prolong the careers of our current doctors? So these are people who know the system, who have the connections with our referring doctors, who are efficient, who know the patients. You know, these are our number one resources. So Dr. Waits is going to talk about how do we keep these people motivated? How do we keep their careers diverse? How do we keep their workloads sufficient? Or I shouldn't say overly sufficient so that they're not burning out. So I think that's really anything we can do to prolong the careers of our current docs is a must. That's the first level. Once you get past that, I think the second thing is to empower our primary care physicians to help us co-manage cardiovascular disease. This has been particularly important to us in several fields. One, with coronary calcium scores now, we have people with, you know, sort of low-grade coronary calcium scores. What do we do with that, right? Can we empower? We have given our primary care people, our current physicians and providers, we've given them workflows. If the calcium score is this, or the percentage is this, this is how you handle those patients. And not everyone needs a referral. We've also done the same thing with our monitoring programs. You know, if people come in, they say they have AFib on their Apple Watch, that is not an instant cardiology referral, right? Here's a protocol. Here, put a monitor on them. If the monitor shows certain things, these are the people we want to see. These are the people we think you can manage. So we've created partnerships and workflows with our primary care physicians to really help co-manage disease states. And I think the potential to do this, heart failure, medication titrations, and other things is really great. And bringing interested parties to the table has really been successful for us. On the third thing then is, you know, we have a lot of low-yield follow-ups. You know, if I have a clinic day of 20 or 22 patients, you know, a lot of those, you know, two-thirds or three-quarters will be follow-up patients where, you know, I may just look at them and say, hey, you're doing great. I may change a little bit. They're diuretic or something. But then we have a couple hundred new patients who are waiting to be seen and can't have an appointment for two or three months. So how do we offload? How do we prioritize seeing new patients and offload some of these traditional follow-ups? Now, none of us want to lose touch with the patients we've been following for decades, but is there a way to spread out the follow-ups so that we can get some help with it? So, you know, we have a pharmacy med titration clinic. We have APPs who are a team-based mentality where our APPs see our patients for us, and they get to know the patients just like we have. There's many patients in my clinic would much rather see my nurse practitioner than me, just to check in with me once in a while. And then finally, there are telehealth options. Now it's something we've been working on is, you know, can we offload some of these device interrogations? Can we offload some of this heart failure medicine titration to remote services where these are services that can't compete with us, right? They can't do echoes. They can't do casts. They can't do stress tests. But they have very competent providers who can titrate a beta blocker or can add Jardians or Entresto and really help us between visits to get our patients up to speed without clogging our clinics and stealing our patients. So, just to be creative and looking at the options of how we get some of these follow-up visits offloaded. And then finally, you know, how do we turbocharge recruiting? How do we really get recruiting up and running and thinking about it differently so we actually create a long-term plan to create a stable recruiting force? I really don't think about it as I need a guy now or I need this person now. What I think about is how do I create a farm team? How do I really get a farm team together that I can develop relationships with trainees that when they come out of training, they'll look at our practice first and say, you know, I got to know that practice. It's someplace I'd really like to work. Next slide. So, you know, we broke down each one into a little bit of a few examples for each one. I'm not going to spend too long on prolonging careers because I think that's really going to do a much better job than I will at this. But, you know, the things we have done for our physicians, previously we used to be, call was such a burden. We said, look, if you're going to go to slow down, you got to be out. You can slow down, but you got to be out in a couple years. You can't stay in slow down long term. It's not good for the practice. It spreads call out to other people. And we put pretty harsh rules on people that once you start slow down, you know, you better know where the door is because you're going to have to find it soon. But now we think about it differently, right? How do we create creative scheduling? How do we put people doing things they want to do, get people in the office and see patients? You know, if you want a three or four day work week, but you're going to spend most of the time in the clinic where we really need to see patients, you know, that's perfectly fine. Let's keep you doing that as long as you want to do that. It's a very valuable thing to our practice. You know, I like that. Can we prolong the slowdown phase? Not say, look, two years and out or five years and out. You know, how do we figure out satellite staffing has been really a big burden for us. It's a really important referral base for us. We don't want to lose our referral base, but it's really creates a task on our partners to go staff these satellite sites. How can we be creative about that? And think of alternate solutions to staffing our satellite sites. And then finally, you know, I, you know, the slogan goes, right? Call kills, calls kills, you know, it makes, it makes physicians retire 10 years earlier. It's, you know, people feel it's bad for their health. It's not a good work life balance. It's a necessary thing, but the volumes are often not that high, but it takes people out of productive spots. So figuring out not only how to address call on, you know, on an intermittent basis, but really to figure out how do we have a durable call coverage program, which doesn't take away from the care and the providers we use during the day. So I'll leave that at that for now and sort of switch over to the empowering primary care physicians to co-manage CV cardiovascular disease. You know, the wearable data, I'm sure this is true in most people's practice. We love wearables, but you know, it's really a high burden and you have a lot of worried, well wearing these devices and they have a fib on their monitor and they're calling and they want to be seen quickly. And they call your friends and try to work you into your clinic. And really has become a quite a burden on our clinic to deal with all this wearable data. And so really empowering primary care physicians to help be our partners in this and getting monitors on people and helping to interpret some of this wearables have been a really helpful thing. And we have some pretty well fleshed out programs for heart rhythm monitoring, for coronary calcium screening, where we put clear guidelines. Somebody gets a coronary arteries calcium score, there's clear guidelines on the bottom of the report of what to do with the number and when to send that patient to cardiology. And I think, you know, I just mentioned a couple of them. I think there's a lot of room here to build more of these workflows and become partners. Next slide. So we talked about the third, the third part was offloading fobs and med titrations. And we talked about the use of APPs, PharmDs, and telehealth visits to really offload some of these follow-up visits. And we actually track what percentage of your visits are follow-up visits versus new patient visits. You know, I think a lot of us like to see our old patients back. And it's a little bit more difficult to see the new patients. But we actually want to track and incentivize people to see these new patients, to grow the practice, to have, you know, those new patients are the people who need to be seen often more acutely than the follow-ups. They often need testing and the people who continue, you know, maintain the health of the practice as far as number of patients, procedures, and volumes. So I think that's really important to focus on, on the new patient to follow-up ratio. And then, you know, I think as you can see here, if you use some of the, if you use your APPs and NPPs, sorry, APPs or NPs or your PharmDs or these telehealth options, there's really a low risk for patient loss. If, you know, one of the biggest risks, I think, for patient loss is not the fact that one of your accessory people is seeing these patients. The risk is if you can't get patients in. Referring docs call for appointments and they say, look, it's going to be three months before someone can see you. They'll pick up the phone and call someone else across town who will say, I'll see them tomorrow or the next day. So I think it's really understanding what the risk here is. And the risk is being inability to see patients in a short period of time. And then sort of the last issue, as we alluded to, is this turbocharged recruiting, as I call it. You know, I really think this farm team mentality, you know, for our practice, we have had, we have used, we're fortunate enough to have three training programs in our area. And we have used fellows for probably 20 years now to help us with night and weekend call, and they've become part of our team. In fact, you know, I started the program when I was a fellow in 2000 or 2001. And, you know, when I finished my training and did a little bit of academics and realized maybe that wasn't the best way for me, joined this practice in 2005, and I've been here since. So developing that sort of farm team and saying, hey, listen, how do we really integrate that into our practice and let younger doctors help us? They get experience on call, they get extra money to help pay their bills, and we get a farm team to help us with recruiting and staffing. And I stress to people, we spend a lot of time with our moonlighters. These aren't just guys who are taking our call. These are part of our families. We treat them as partners. We're available to them on the first night they're here, they get a three or four hour orientation. We come in, we help them. It's very, very important to us that they feel like they are our partners and not someone who is just staying up at night for us and we're leaving the hospital. They do a hugely valuable service for us and we treat them as such. And it also allows us to give the opportunity here to create a prolonged interview on both sides. They get to know us, we get to know them. About 50% of new hires will leave their new job within two years just because they figure out it wasn't a good fit, they learned something about the practice. We found that creating these relationships really reduces that number dramatically and everybody can sort of test the waters first. So these are just some ideas. My time is running short here. So these are just some ideas of how to think differently. The old model of staffing, let's call a recruiter or a headhunter, get some doctors in here, let's get a locum's doc in here. It's not gonna work, it's gonna fall apart. Certainly it may fill some holes now, but if you really wanna set your practice up for success, there's a lot of issues other than recruiting that need to be taken into account to really this huge shortage that's upon us is only gonna get worse. So I'll stop there and I'll turn it back. Oh, I have one more slide. Thank you, Denise. So just the point, staffing doesn't equal filling gaps. Customize the schedule to meet the needs of today's cardiologists. Create strategies to unload important but low yield visits and empower PCPs to help figure out your call team and build farm team opportunities for you to be the leader to get the first look at all the doctors that are available. I appreciate the time, Denise. Thanks for having me and I'll turn it back over to you. Very good. Thanks so much, Dr. Benchelman. That was just an excellent overview of where we sit with the problem and some potential ideas for being creative. So just to continue today's webinar, I'm going to hand it over to Dr. Thad Waits, already introduced. So with that, let me just advance the slide here and let you take it away, Dr. Waits. Thank you very much, Denise. And Dan, that was a fantastic talk. I really enjoyed that. And I will point out that Dan and I were saying ahead of time that we have some overlap. I'm glad we have overlap because I would hate for there to be so many problems out there. We have enough as it is, but I would hate if mine were unique to what yours are. And the solutions also, I'm glad there's some overlap here that you'll be seeing. I thank you very much for the opportunity to be here. Thank you, MedAxium. And thank you, Jerry Blackwell, my good buddy, president of MedAxium. He and I have been friends for a long time. My talk will be predominantly coming from this health policy statement that's on your screen now, 2022 ACC Health Policy Statement on Career Flexibility and Cardiology. Within the Science and Quality Committee, there is a subcommittee, I think it could be called, the Cardiology Solution Set Oversight Committee. And they were in the background doing all of the reviews, all the processing of the work and so forth. But the writers are the people that are presented on the screen. And one reason I wanted to show the writers to you, I guess one reason I'm in there, but predominantly is to point out that they come to cover the whole gamut of the career of cardiologists and APPs and mid-levels, et cetera. They cover everything. So we have three former presidents of the ACC, all three women. And we have people that are in academics. We have people that are in large practice. We have people in solo practice. We have three of us that are senior cardiologists. There are FITs that are part of the writing committee. There are governmental team members that are part of this. So it's a very diverse writing committee. And from that, we had all the ideas develop about what we can do regarding flexibility. Next slide, Denise. The goals of our paper, we wanted to review opportunities for flexibility across all the career span. We want some policies. We want to propose systems, policies, and practice solutions that create workforce flexibility, not just Dan out in his practice alone, trying to beat this whole thing, but for the ACC to form some policies that will help its members. Promoting wellbeing while preserving excellence in clinical care is very important. A good deal of the paper has principles, and I will go over those more in summary than in detail for you. Next. So I think we've kind of said to you why we need some workforce help. Cardiologists work more hours annually than many other medical specialties. I was interested to see in a survey, we're not number one, but we're in about 10 or 12 of the 40 something specialties that were surveyed. But very few of us just work part time. Burnout is definitely on the rise. There is in the world growing interest in flexible scheduling, and we need to make sure that we have that in cardiology. We need to address diversity and inclusion. You know, we have a diversity and inclusion section now in the college and a great interest in developing the diversity and inclusion that we need in the world and in the world of cardiology. All of this will improve retention, and it can improve career longevity. Next slide. Our background on this is recruiting a diverse and talented cardiology workforce provides both challenges and opportunities. Flexibility in the workforce is likely to play a much larger role in the future in the choice of who your employer is going to be. And we have seen that an organization's ability to compete for talent may be defined by the options available for flexibility. Next slide. And outside the world of cardiology, even outside the world of medicine, we're beginning to see there's a lot of focus on initiatives that reduce burnout, trends in industry and other sectors for more comprehensive leave policies are coming up, which lead to improve workforce health and productivity. Workforce needs in cardiology inclusive of the benefits associated with both recruitment and retention of senior cardiologists is very important. I'm one of those senior cardiologists, and if we could just keep more of my buddies in the field, then that will help with the overnight calls and the STEMI backups and all of that kind of thing. Next slide. We didn't just work on the things I've already mentioned, there were quite a number of other things that are mentioned in the article and go into details about how to handle these. For example, increasing the workforce, as Dan and I are gonna be talking about in multiple ways, impact on compensation. That's a real hard nut to crack in this. Professional society leadership. So when we have a deputy at Echipouria or Dan Edney that spend just tremendous amount of time being the leaders of our society, what do they do with their practice back home? And we need some real flexibility in that. We need career dedication in early and mid career as well as in late career. There are laws about the Family Medical Leave Act, we need more information on that. And the paper we have stories about what has happened to people just coming out of practice who didn't really understand the Family Medical Leave Act. Parental leave is very important. Sabbaticals, can you really have sabbaticals in the medical world like you do in other parts of the academic world? And then cognitive testing, should that be something that's done in every practice? It is being done in some practices kind of on a test basis, testing the testing to see if that's something that would be of value in your hospital and with your senior cardiologist. And then for those who pass the cognitive test, they don't need to work full speed until they drop. So there are need to be some policies about how you can have the slowdown phase. Next slide. The final part of what I have for a slideshow we'll be talking about the principles. Now you'll see I have somewhere around 12 or 14 here, but there are even more than this in the paper. And while I have just a few words, this is like doing a tweet. I've managed to pare it down to fewer words, but I highly encourage you to read the paper and to see all the ideas that are built into these principles that I'm about to tell you about. So one principle, all cardiologists should have access to flexibility in hours and work commitments. That flexibility will provide value throughout the career. It needs to be policies. And I think that's one of the biggest thing that this paper wants to say. It can't just be my practice. It can't just be Dan's practice. It can't be just the academic programs that have these policies. We need to have a set of policies that apply to the entire world of cardiology. The options out there should be transparent. It shouldn't be something hidden. Yeah, we're gonna do this for you, but we can't do it for the next guy. Everything needs to be very transparent. Policy should include strategies for a wide range of circumstances. And it's just amazing how many different things we talked about in the writing paper that you have to deal with to try to correct in order to have flexibility. And some people might've thought when we said flexibility, we were talking about only hours and the work type, but this is a lot more than just that. Next. The leadership, and that would be the leadership of either the academic institutions or the program directors, or maybe your executive heads within your own practices. I know my practice didn't have per se a leader of cardiology, but we do need to have an administrative leader. And then the overall clinic has boards and so forth. Well, all of those leaders need to provide and support this flexibility. And we hear about implicit bias, and that is sexism and racism, but it can also be ageism. So we need to recognize and mitigate against the effects of this bias. Training program policies should reconcile training requirements with parenthood and early career family life. Very important. Policy should ensure that aging cardiologists can fully engage in all aspect of their job description. In malpractice, how do you cover the tail insurance? There should be flexibility that allow you to continue to work even after you quit that all night call schedule, even after you quit some of your clinical schedule, but you would still like to be contributing to your practice. There needs to be ways to make sure you can have malpractice insurance on that. Cardiology's program should provide policies and support systems for wellness and for burnout related to poor work-life balance. And I believe, Denise, that's the last slide. It is, and I would now open it to the group for discussion and question answering. Thank you. Yeah, thanks so much, Dr. Waits. Really an important document. So glad that the ACC had a group of keen minds working on that to publish that. Like I mentioned earlier in the webinar, there is a link to the document in the chat box that you can access. So with that then, I think what I'd like to do is just open it up. I don't see any questions currently in the Q&A, so I'm just gonna toss one out there. I'll start with you, Dr. Bensimon. Just curious, you know, I was interested in your statement about call kills, as well as comments around you don't have to do it all. I think one of those things that we've felt in the past when it comes to practicing cardiovascular professionals is that we are the experts, and as the experts, we need to be the one directing all the care. And many times that means that we need to also do all the care. Would you talk a little bit more about striking the balance between being the expert director of the care and what you can give away, and to address maybe some of the concerns for those who feel like they might be given away too much knowledge? Yeah, I think it's a great point. I mean, I think there's a critical differentiation, right? STEMI call is an emergency that needs to be handled by a small group of well-trained, highly experienced cardiologists who can't be replaced. Don't confuse that for night call. Night call, for in my hospital, is 20 calls a night for an elevated troponin in someone who is not having symptoms, is for AFib that can be reasonably controlled with medications, and we can see them in the morning. But it's become to the point where in the past, a lot of practice, including our own, we own that, right? We say 24 seven for our hospitals and our communities, we will be there and we will take care of that. And it's taking a personal toll on our practice. Our doctors are just, we're just burning out. So I think we have to be careful about what we own and what we don't, right? And now we have to start thinking about, okay, what can we share? What can we give back? Or how do we cover it with other ways? What we used to do for our practice is we'd have one of our partners be on call for two nights in a row, and then you'd be out for the next two days, and then you resume. So not only did it take our partners out of the predictability and the clinic during the day, where we could see 20 some patients, read echoes, we now had someone staying up all night doing four or six consults, getting really beat up, and then being out another two days. So we really said, okay, what can we take care of that we absolutely need to take care of? And what can we share and hand off? You know, there are critical care doctors in the hospital that can handle a lot of this work. There are hospitalists and the doctors that are well-trained. And I think there's a difference between being the front line and being ready and available if you need backup. And figuring those out is, I think, really a key to protecting our physicians going forward. Right, really good point. You know, and I think the other thing that I heard there is providing other folks with protocols, guidelines, direction, so that it's clear as to how to manage things so that you can maybe salvage some of those calls that would otherwise come. So that if you have something that's very, yeah, again, very clear and direct for folks to be able to manage when it is, when you can be clear and direct, that that really does help reduce some of those extra calls that you receive. Dr. Waits, I suspect that, as maybe the more senior cardiologist amongst the two of you, you've seen quite an evolution in that. Would you, yeah, would you like to speak a little bit about your experience for what you've seen as to the ability to share management with other providers, be they PCPs or other specialists? Right, I'm glad you asked. From my own experience, when I gave a call a few years ago, I realized that what I really hated giving up, what I would, I'm sorry, I'm saying that wrong. What I did not mind giving up was all of the calls. What I didn't, what I wish I still had was the excitement, but not the time of night and so forth of coming into those STEMIs. So I guess I'm not saying that very well. The STEMIs is not what bothers us, as I think Dan would agree with me, it's the calls, it's the way it says, is there going to be transported to just so many other things that are going on? So let me say that in my state of Mississippi, we have a statewide STEMI network and we try to have organized ambulance service calls and so forth. And we certainly follow the guidelines and we try to keep our registry clean with getting things at a timely way. But still, the false activations are killers for the team. And so we need lots of education on what's a true STEMI and what's not a true STEMI and so forth. So that would help a lot. And then with our APPs, they have been a tremendous amount of help to my partners who are still taking the call because we now have a program where the APPs do cover the calls in the hospital and the cardiologists take over appropriately when necessary. And the APPs can't handle whatever is going on at the hospital. Yeah, I think what I heard there really a couple of things, obviously, but that really work life balance begins with well thought out workflows. So to get good balance, you need good workflows. And short of not having good workflows, you may then be unintentionally burdening your providers, be they APPs or the cardiologists themselves. So Denise, if I had anything to say, I would say that is the singular biggest message I wanted to deliver today. This is a purposeful, intentional approach to how you staff your entire program, including call, including satellite sites, including physician retention is be intentional. Think about it. Don't just try to plug holes. And it's like the paper that Dr. Waits referenced. That was a really intentional, thoughtful document where they sat back and look at all the factors. I would I would advise every practice now to sit back and look, what are we going to need in five years and how do we get from here to there? Mm hmm. Yeah, and it's really that that thoughtful approach that allows one to be innovative. And like you said, when you're so busy just trying to put the Band-Aid on the solution, it's hard to think creatively than if you've anticipated that potential issue and been creative in advance. I love the idea about talking about kind of creating the farm team, if you will. And instead of playing the short game, you play the long game and understand that working with those medical students who might be interested in a career in cardiology or who might be interested in even being your primary care provider at one point, that you then have created a relationship that encourages them to be your partners in the future, either directly as a cardiologist or indirectly as a primary care provider. So, you know, spending a few hundred thousand dollars now to create programs that work may mean the survival. It may mean millions to you in five or ten years when you you're giving up satellite sites because you have no way to staff them and you lose a whole referral network that you didn't want to lose in the past. So spending a little extra now to to shore up those satellite systems and your programs, just the thing that Dr. Waits mentioned about being creative with the scheduling, it may feel like, oh, we can't give that doctor that much. It's too much. There's nothing that's too much to keep a good, experienced doctor that's been the heart of your practice for 30 years. That's an invaluable asset to you. Yeah, the the world of lawyers know about rainmakers and in the paper, we refer to some of the senior cardiologists as potentially being the rainmakers for the program. And if they're still part of the program, maybe seeing patients in clinic, maybe handling some procedural things, maybe being the imagers. And if there are any number of things that senior cardiologists can do and that don't involve the night work, et cetera, and still be the face of the program and and maintain that rainmaker status, I really love the way Dan talked about that. And the farm team, those are both really great concepts. Yeah, right. Exactly. And I think the mention of maybe along the line of the rainmakers that experienced cardiologists who has time then to see those patients in clinic and even addressing the new patient to follow up ratio, understanding if you can increase or maintain your access, certainly increase that that can then result in additional procedures. And this is when I'll put in a harmless plug for a harmless self-serving plug for the MedAxian MedAccess database in which what we're able to do there is help individual practices who've submitted their data understand what their new patient visits are to follow up to then procedures performed. So you get a better feel for new patients to follow up visits and how that might then translate to actual procedures performed. So another way in which you can get some objective data to support the need to have those additional clinicians in clinic seeing patients, again, a respected face to the community for who the cardiologist is to see those folks as well. And I'm just curious a little bit about how either one of you in your practices have seen changes in younger cardiologists perhaps wanting to have not less than full time schedule, maybe not the first few years they're out of fellowship, but relatively early on in their careers. Talking with some folks just the other day who made a comment that a cardiologist who's not even 50 is already talking about the fact that they'd like to see. So, Dan, there's hope and not even yet 50 who's saying, like, you know, I think I want to cut back and be more of a 0.8 FTE. Are you seeing that more so? And is there any sort of commentary as to what that means for the cardiovascular community? Well, Dan, I'll start if that's OK. I want my partners to listen to this talk. And so I'm going to say truthfully that none of my partners have taken that route. They're all super hardworking. But we do have more or less three tiers of our group with maybe in the top tier and then several people in the mid-level and then a big group in the lower level. And I'm talking about by age, not by any other derivation there. And so, yes, absolutely. The middle group is saying, golly, I want to consider backing off a little bit later on. And the lower group is saying, well, we can't cover call if any of you, if all, certainly if all of you dropped out at the same time. So you've got to plan for all those things, as Dan was already saying. And you may need to have some real careful look at compensation and how you handle compensation when you take a certain amount of time off. And there is flexibility on like taking call during the week, but not the weekend or vice versa. And and mainly for those for everybody, remember that farm team. And I think I know I say and Dan and I were talking about this earlier, we need to get the academic institutions to understand how important it is to training and most places for their fellows to be able to go out in the field and work in the private hospitals and the community hospitals on the weekends, certainly not taken away from their work schedule as as fellows, but in their flexible time that they can come be part of the team. And that's going to be very important. I'd like to just comment a couple of things. First of all, Denise, I want to we have a question in the chat. I see that. So but, you know, you have to remember, we are not in a vacuum. Every practice is in the competition for the same resources. You know, when that and I trained, you know, it was a badge of honor to be on call every other night, to be the guy, to be there, to always be around. It is not that way anymore. And as frustrating it is to people like me who still spend 80 or 90 hours a week in the hospital and a 38 year old, not a 48 year old, a 38 year old physician comes in and says, I don't want to take call. I don't want to participate in that. I want to work at 80 percent. You know, our instinct is to say you're not one of us. Right. You're not trained in the way we were trained. You've got to stop thinking like that. Right. They're one of your partners. They're a big asset. They can see they often have skills like imaging. They add something to your practice. You have to take out of the equation the fact that without you, we can't cover call. That person's a big resource to your practice. As frustrating as it may be to to try and figure out, oh, the schedule, you have to find ways how to just like that point out, how do you use this person in your overall scheme? Because if you don't use them, someone else will and you will lose. So we are not in a vacuum. There's somebody waiting to grab that doctor, somebody who already has their call program, their PCP relationships, their telehealth support. They have all of the background figured out. That doctor walks right in and becomes a very valuable part of the practice. So you have to understand their needs. You have to meet their needs or you're not going to be successful. It's just like any other business in the world. You can have two jobs, one's a four day work week and a one day virtual. The other day is a five day work week. The four day work week is going to win every single time. And you're not going to have any doctors when when the people like that. And I say, OK, we're done. We can't do it anymore. We walk out. You're not going to have anybody left unless you start becoming creative and permissive right now. Right. And I think that point of whole the harsh rules get in the way as much as they might have been intended to think they were well, you know, well-meaning. They just get in the way. It's not the cardiology of the future. This is not the same. You can't let people make decisions who want to think about how it was 20 years ago. With that, I want to make sure we address that question that was in the Q&A. The question being, do you think cardiology hospital is a trend? And then how might it help a practice or a hospital? So either Dan or Thad, go for it. Well, I think it is definitely a trend. We don't do it in my own hospital. But in this hospital, we have GI hospitalists and neuro hospitalists. So I wouldn't doubt eventually we'll have cardiology hospitalists. But where we do it. So we got a blend in this hospital. We have a piece that are covering the night telephone calls for the cardiologist and covering some things within the hospital, too. And that that that takes care of at least 60 percent or so of what cardiology hospitals would do. So I think the answer is, yes, that is a trend, but it's not going to be for every hospital. Yeah, I agree. I agree. It's it's a major factor. So we don't we just want to it's not just something we use at night. Right. On our hospitalist team, we have hospitalists that are who partner with our advanced heart failure team. They see that we selectively have heart failure patients that aren't going to cardiology admitted to their service. And they have rounds. They meet us afterwards for rounds and we provide advice to them and they can offload a lot of the the low acuity heart failure from us. So we have this partnership with the hospitalist during the day and at night. It is a you know, when we we create call solutions for a lot of people and one of you know, if you're in an area where there's a lot of trainees or fellows, great, you can use them in areas where they're not. Then the answers are APPs, cardiology hospitalists. The trick is keep the number small, know the people you're working with and have them not be afraid to pick up the phone when they need that because someone needs to go to the lab. So they are a huge part of the farm team. And, you know, you pick up these free agents. You know, these are people who come over on waivers, right? These are very, very important solutions to to call programs that people should absolutely pay attention to. Yeah, absolutely. Got to got to love the football analogy or baseball analogy to that, too. So clearly, I think another important step in. And like you said, it's building a relationship with either your APPs, your hospice, whoever it is, so that they aren't afraid to consult with the cardiologist when they need to. And it's making sure they have the skills to begin with. Right. So it's promoting education, training, teaching as you go so that everybody has a broader understanding of the work that they do. So it's supporting the entire team. So the entire team can support the work. So along that way. And that may be those again, it could be casual conversations, as well as something more formal, as probably, you know, we do have the MedAx Academy with APP training that that's another way in which hospitals members can use or even non-members can use that training for their APP staff. So, you know, and I think Denise, just, you know, to put a plug in for you guys, you know, this is where MedAxium can create, you know, a shared database, a shared knowledge base of how other practices have done this, you know, and what are creative solutions? How can you answer those questions? I think this is really certainly if I were being part of MedAxium and the administration is really looking to help practices, how do they wrap their heads around this shortage and how do they take some of these ideas and really implement them at their practice? I think the consulting that you've done, you know, MedAxium has consulted with our practice in the past and the information sharing from other practices that we obtained during those meetings, I'll tell you, was invaluable. And we learned how to think as, you know, we were so democratic about it. We gave the power to everyone to make a decision. And we really learned that putting that power in the hands of a few who really knew the challenges was a better way to get things done. And I'll never forget that lesson we learned from MedAxium probably a dozen years ago, and it's changed the way we operate our practice. Yeah. Wow. Thanks. I appreciate those comments. So we're pretty much at the top there. I think I see one other question here. So here's one last question and then we'll wrap it up here. The question from Joseph Marine is any strategies for reducing the burden or workload of call for cardiologists? If call can be reengineered to be less demanding of cardiologists time, energy and sleep, it may be more palatable for younger physicians. So I think I have to say, go ahead. Yeah. I have I know Dr. Joe Marine, and I can tell you he is a wonderful leader of the ACC, a former chair of the Board of Governors and current membership chair. And Dr. Marine, we have touched on that a little bit in earlier things. For me, I will point out again that my biggest thing on call was the telephone calls as well as the arranging for the ambulance to get to you, talking to the outlying emergency department, trying to figure out, is this a true STEMI or is this something else, et cetera, things that were not really medical knowledge or were not procedural knowledge that only myself and my team could do. So just even having a APP to do those things makes a huge amount of difference. And then in the trend, we may have the hospital cardiologist in the future or or something, some potentially even something in between with internal medicine hospitalists that cover the cardiology part of it. So those are my thoughts. Dan, you I'm sure have some other really good ones. Yeah, I think we covered a lot of it, Joe. And, you know, I think that the two major things we need cardiologists on call for STEMI call and for shock call. Those are the two things we need cardiologists to be available and be able to do it. I think we need to just as your your point, you pointed out, we need to reengineer calls so that we're not taking troponin calls in the middle of the night. We're not handing a low level a fib in the middle of the night. And we certainly aren't using our biggest and best resources to handle those issues at the moment. So it's I think it's a very it's it's imperative that practices look at their call structure and instead of putting their foot down, say, you have to take call to the young doctors. Be imperative. How do we get creative and say, how do we get help to unload this call from our practice, something that we've done forever and start thinking about it differently and helping practices get to a place where they're not always the last man standing to come see a patient? Your comments couldn't be better taken. Yeah, well, and may I just say, in addition to that, one of my things is type two myocardial infarction. Which is what we're talking about when we're saying troponin. So we need education. We need a lot of education about this is how you handle a type two. And it doesn't necessarily require a cardiologist. And that's what Dan was saying. And then in your risk to ratified mortality on NCDR, you need to watch out for that, too. That's a very important part of getting your mortality rate toward the average, if not even better. And with how you handle type two. Yeah, really important points. I think when my last thing that just strikes me that we've just kind of talked about again is that workflows enhance work life. So making sure that we've had a thoughtful approach to what you can do to maintain the well-being of those providers you currently have and then thinking forward to the providers you will have in the future and making sure you've got a team that's ready to go when you need them. So with that, I think I'll wrap this up. Thank you so much to both you, Dr. Benjamin and Dr. Waits for a thoughtful presentation and just a tremendous discussion. Thanks to all of those of you who have joined us today. And like I said, the slides are in the chat, as well as the link to the health policy document. Feel free to share the availability of this recording with your friends and hope it creates additional discussion that's fruitful in your own organizations. So thanks again for joining us today. We're so glad you were with us. And we look forward to future webinars with MedAxium. Thanks, Denise. Great job. Yeah, thank you. Thank you, MedAxium. Great.

cardiology

post-COVID

flexibility

burnout

primary care physicians

recruiting new cardiologists

workforce gaps

career flexibility

shortages