I am 67 years old, and I work full-time in academic cardiology. So this past week, I thought it was appropriate to do something I had never done before. I made my first 20-year career plan. That might sound a bit odd, but throughout my professional career as a physician, I never had a 5-year plan, a 10-year plan, or a 20-year plan. I just did things that I loved doing. I became a physician at the age of 22. After completing my training in internal medicine and cardiology, I joined the faculty at the Mount Sinai Hospital in New York City, because as a fellow, I became enthralled in the nascent field of heart failure. My excitement was based on two simple observations. First, there was little we could then do to treat heart failure. Second, it was clear that everything that I was taught about heart failure in medical school was wrong. In medical school, I was taught that heart failure was due to a defect in cardiac contractility. I was told that maintaining elevated filling pressures in heart failure was important to support cardiac output. I learned that it was critical to keep blood pressure at a certain level to sustain coronary perfusion. All of this was wrong. In the 1970s, echocardiography and bedside pulmonary artery catheterization were emerging technologies that allowed cardiologists to assess the structure and function of the heart easily for the first time. These advances allowed our assumptions about heart failure to be tested. I let my colleagues know that I was interested in heart failure, and I was able to reserve one bed in the CCU for hemodynamic monitoring. I studied each patient with heart failure for days, talking to them continuously and comparing what they told me with what I could measure. And I followed every patient closely after discharge and brought them back for re-evaluations. I did it because it was joyous. During the entire time, I do not remember completing any billing forms or charging patients for my services. I received a fixed non-incentivized salary. The level of compensation was barely above that of a cardiology fellow. At the start of my faculty appointment, my career goal was to publish just one original research paper in a peer-reviewed journal before leaving academics to go into private practice. That was the only career plan that I had. But that is not how things turned out. Instead, I fell in love with my research, and I devoted my entire being into the pursuit. I read constantly; made diagrams on blackboards, and then reworked them; formulated new theories, and then rejected them. Nothing made sense. Drugs that were supposed to work for heart failure lost their efficacy after several days. And drugs that had few early effects exerted dramatic benefits if they were given for longer periods of time. Our measurements of the structure and function of the heart did not predict what would work and what would not. After 100 papers, I still did not understand heart failure. Obviously, we were not measuring something that was really important. Some of my friends were putting new data on the table. Gary Francis, MD, and his colleagues at the University of Minnesota were measuring neurohormonal factors, and Karl Swedberg, MD, PhD, at the University of Gothenburg in Sweden, was generating early data showing the efficacy of ACE inhibitors and beta-blockers. The threads of a new theory were in place, and I synthesized them into a new framework. Heart failure was a neurohormonal disorder, rather than purely a hemodynamic derangement. It was 1992, and Mike Weisfeldt, MD, had just become Chairman of Medicine at Columbia University College of Physicians and Surgeons. In recruiting me, he asked a simple question: What could you accomplish if you had 20 to 25 faculty members working in heart failure rather than just one or two? It was my dream position. Weisfeldt created a division devoted only to heart failure, which was entirely separate from cardiology. Within a few years, we recruited 20 to 25 of the best young minds in the field. Everyone had an independent area of research focus. Essentially, we split heart failure into separate questions, and found the best person to solve each one. These young investigators emerged as leaders in the field of heart failure in their own right. And we had the nation's busiest heart failure service. In a decade, the team spearheaded a reinvention of the discipline. It could have lasted forever, but around 2004, medicine was rapidly becoming a business, and I needed a new mission. In recruiting me, the dean at the University of Texas Southwestern, Robert Alpern, MD, created a new department, the Department of Clinical Sciences. It had the broad and ambitious goal of developing young clinical investigators across all medical disciplines, not just cardiology. Again, I built the enterprise from scratch, recruiting dozens of new faculty. But, after nearly $100 million in peer-review grants, I really missed heart failure. In 2014, I had the privilege of presenting the results of the PARADIGM-HF trial, a trial that fulfilled my own 20-year dream about neprilysin inhibitors, a trial whose results strongly supported the neurohormonal hypothesis of heart failure. So I decided it was time to go back full-time to the field I loved. In recruiting me, Baylor University Medical Center had one request: reinvent the field of heart failure again. So now I am focusing on epicardial adipose tissue, the intersection of heart failure and diabetes, the interplay of new neurohormonal mechanisms, and the appropriate role of new devices and procedures. What is my most important source of professional happiness? I have trained hundreds of cardiologists, and through osmosis, I instilled into them the same joy that I experienced about asking research questions. As a result, many of the new drugs and devices for the treatment of heart failure in 2019 have been spearheaded by the wonderful faculty who I amassed at Columbia University 25 years ago. They are a bit older now, but I am so proud of them. All of this -- without any thought or guidance of a long-term plan. On a recent flight, the passenger next to me happened to be a cardiologist, who noticed I spent the entire flight writing a paper. Curious, he leaned over and asked: Why are you working so hard? Isn't it time to plan for retirement? My response: Do you think that writing a paper means I am working? I am doing what I love. I am changing the way that people think. This isn't work. This is joy. Together with my family, friends, and a few serious hobbies, this is life. But the passenger made me think. I never had a long-term plan. I simply moved from one position that I loved to another that I loved. But maybe now, at the age of 67 -- after 45 years in medicine -- I actually needed a plan. So I sat down and drafted my first 20-year plan. It took about 15 minutes. Here it is: Every year for the next 20 years, I want to ask difficult questions, challenge conventional wisdom, make my colleagues smile and angry, and be joyous in my pursuit to understand and conquer heart failure. And whenever I can, I want to write essays that might appeal to others, provoke feelings of joy and insight, and describe the world the way it is and how it might be. Physician burnout? Yes, it is a critical problem. But it results from doing what you are paid to do rather than doing what you love. My 20-year plan sounds pretty good to me. I am really not worried about fulfilling it. My only concern: what plan am I going to come up with in 2039? Source
