Following in My Father's Footsteps
Robert M Califf, MD: I'm Rob Califf. Welcome to the Life and Times of Leading Cardiologists. The purpose of these interviews is to understand people who are making a difference in the world of cardiology or in the world of life. Today we have Janet Wright, who has been a cardiologist for many years and has done many different things in cardiology but now has a very important job with the US government trying to make a difference for the public health of the United States.
Can you tell us about where you grew up?
Janet S Wright, MD: I grew up in a little town called Earl in the northeast section of Arkansas, about half an hour from Memphis, right across the Mississippi River. It's a town of about 3200 people.
Dr Califf: What did your parents do for a living?
Dr Wright: I was pointed toward medicine. My father was a primary-care doctor and my mother was his nurse. My brother became a dentist. I have often said that if my parents had been pilots I would have been a flight attendant at this point. It was a family business.
Dr Califf: Is your brother still a practicing dentist?
Dr Wright: No. Rob died of a myocardial infarction, a couple of weeks after turning 40. I was a cardiologist by then.
Dr Califf: Going back to your childhood, the dinner table probably had medical conversations. What do a doctor and nurse talk about in a small town?
Dr Wright: It was more animated than that, because at that time there were no pagers or answering services where we lived. If patients needed my dad or my mom, they just called our house. We had a family joke that the frequency of phone calls went up during the dinner hour because the light on the water tower went on when we sat down to dinner. Our driveway was my first care-delivery setting. People just came over. They might have had a cotton-gin accident or some other catastrophe and they knew where we lived, so in they rolled.
Dr Califf: Was your dad a solo practitioner?
Dr Wright: He was for most of his years. There was a time when he had a partner, but for more than 50 years he practiced alone.
Dr Califf: Did he deliver babies?
Dr Wright: Absolutely, some in the driveway. We lived half an hour or so from Memphis. The bigger hospitals were there. If something occurred in the driveway that needed immediate attention my mom would run in to the phone, but I would usually be sent across the cotton fields to the ambulance driver. Flash Campbell was his name, and he would fire up the ambulance.
Dr Califf: What sort of nursing training did your mother have? She probably carried out a lot of functions that were more what physicians might have done.
Dr Wright: The most important thing I learned from my mom is listening. My dad was a good listener, but my dad was seeing lots of patients. My dad used to say, "Gladys gets so many stories out of people. I don't understand it. I can talk to them and get a couple of facts, but then out in the hallway, I get the real story." My mother was great at taking a history and opening up that space for the conversations that helped take care of people.
Dr Califf: What were the medical records like?
Dr Wright: All paper and mostly illegible because they were my dad's writing.
Dr Califf: I imagine you had a local pharmacist in town who interpreted the writing.
Dr Wright: Yes, but most of that interpretation occurred over the phone as opposed to trying to read what those prescriptions said.
Dr Califf: Are your parents still living?
Dr Wright: My mom is.
Dr Califf: Does she keep up with your career?
Dr Wright: She has advanced Alzheimer's, so she did all the way up until that disease took its toll.
Basketball and Barbara Walters
Dr Califf: As a kid, did you want to be a doctor from day one? What was your thinking as you were going through elementary and junior high school?
Dr Wright: I'm afraid this story will reflect the times. I never thought about it. I thought I wanted to be a journalist. I wanted Barbara Walters's job. I wanted to be in broadcast journalism. In college I ended up taking science courses because those seemed harder and the pathway was clearer. You took one course, and that led you to another level and then another level. I thought that I would pursue that.
As it turned out, I backed my way into a premed curriculum. I met a counselor in my senior year of college who notified me that I hadn't declared a major. "Ms Wright," he said, "what are you doing here without a major?" When he looked at my courses he said, "Did you ever think about medicine?" and I said no. He asked me what my dad did, and I told him he was a family practitioner. He asked me what my mother did, and I said she was a nurse. He said, "Are you sure that you never thought about medicine?" and that made me think about it more clearly. My father's advice when I told him I was interested was, "Don't do it. You are not going to be able to practice what you have seen me practice. This is changing."
Dr Califf: What did you do? You weren't thinking about a career in medicine.
Dr Wright: Basketball. It was my number-one love in junior high and high school.
Dr Califf: What position did you play?
Dr Wright: I was a forward.
Dr Califf: Did you like to shoot?
Dr Wright: Yes. I was also a guard forward on a state championship team and captain of the team. I was too slow to be a guard and too short to be a forward, but I also liked to shoot. I identify with that.
Dr Wright: You can't score if you don't shoot.
Dr Califf: How many kids were in your high school?
Dr Wright: I don't remember the number in the high school, but there were 18 in my senior class.
Dr Califf: Wow. How did you fill the team?
Dr Wright: It was challenging. In my senior year, the black high school and the white high school in my hometown consolidated. They suspended all sports for that year because there were tensions, and we were all getting to know each other. There wasn't a team during my senior year, but we made do.
Dr Califf: That must have been sad.
Dr Wright: It was sad, but there was so much other good stuff going on at the time that it didn't seem to matter.
Dr Califf: What year was your senior year?
Dr Wright: 1971.
Dr Califf: In South Carolina in 1969 we went through similar things. They didn't suspend anything. We just had mixed teams, and there was a gradual transition. But I am still convinced that the reason we won the state championship in my senior year was that the summer before we went around to all of the black schools and played games in the evenings. They were all completely sold out.
A lot of learning went on there. I did another interview with Clyde Yancy, who is exactly my age, living on the other side of the divide at that time in the South. It was quite an amazing time, wasn't it?
Dr Wright: Yes, it was.
Dr Califf: I feel like Arkansas was in the middle of it. What did you think about all that?
Dr Wright: I happened to be in a leadership position in my high school at the time this all happened. I felt that this was a chance for us to understand each other for the first time. We had been so separate. I had no idea, even though I had been living a mile or two from African American peers. It turned out to be a great learning experience, tense at times but it set a good course.
Dr Califf: Then you went from a small high school to a university. Where did you go to college?
Dr Wright: I grew up in an orange family. Despite living in Arkansas I grew up in a bright orange University of Tennessee family. I went to University of Tennessee in Knoxville.
Dr Califf: Was Pat Summitt in business at that point?
Dr Wright: Pat had just started as a coach at that time, and I actually dated the person that she married. He married Pat on the rebound. It was a very good decision on his part.
Dr Califf: I gather from your description that you worked hard in college. The University of Tennessee is a good party school too, as I remember.
Dr Wright: Yes. I enjoyed my college years. There were various groups and you get involved in things. Raise your hand. I enjoyed my time there.
Medical School in Memphis
Dr Califf: Were there any professors who really stood out and made a difference for you, other than this counselor pointing out the obvious?
Dr Wright: The counselor was actually from Tufts. When he looked at my transcript he said, "You could get into Tufts. You could get into my school." This was about medical school. That caught me off guard. I was such a sheltered person, I didn't know much about Tufts. I had seen the name, but didn't know anything else. The people that I remember from my college years were in campus organizations, student government, and that sort of stuff. I had lots of mentors there who were really helpful to me.
Dr Califf: I'm trying to get a snapshot of your view of the world in small-town Arkansas. At the time extraordinarily tumultuous situations with the Vietnam War and all of that were going on in the world. At the University of Tennessee, how much of the antiwar stuff was going on?
Dr Wright: I read more about what was happening at Berkley than I saw on my own campus. I was involved in student government, and I remember clashes between administration and student government. Other things seemed to be more national issues at the time.
Dr Califf: Where did you end up going to medical school?
Dr Wright: Memphis.
Dr Califf: What was that like?
Dr Wright: In a sense it was going back home because I literally grew up across the river. It was great. My brother was on campus at the same time in dental school, so we had a period of time together again. I also got married while I was in medical school, so that was pretty exciting.
Dr Califf: I'm thinking about Memphis. We are doing a project right now in a place called Quitman County, Mississippi, which is right down below Memphis. I imagine that you were in the other direction, but probably in a similar overall environment.
Dr Wright: Yes, because some people don't know that Mississippi River has a delta over there on the other side in Arkansas. It's the same condition.
Dr Califf: It's an amazing place of very deep culture and poverty, but also a lot of people who are thoughtful about things. It's a fascinating area. Coming back to Memphis to medical school, did you know what kind of doctor you wanted to be?
Dr Wright: I knew pretty early that I didn't want to do internal medicine. It felt too huge. I did not think that I could master that many conditions and keep up with them the way that I wanted to. Early on my radar was up for something that I could go deeper into that would perhaps be slightly narrower. I thought I was going to go into obstetrics (OB). I love the physiology. I love the patients. I like the surgery as well as the medical and the obstetric end of it. Then I took a frank look. My husband at the time asked me to take a look at the lifestyle. He said, "We'll never be able to have kids. You'll be up all night. It will be unpredictable. For us you should not go into OB." I thought, okay, the next thing is cardiology. I loved cardiology.
Dr Califf: I have a son who is in medical school now and he is in his OB/GYN rotation. I think it is surprising him to be enjoying it. Others around him might be giving him similar advice about lifestyle, but it sure seems like a great thing to do if you love it. Your husband was a medical student also? What did he go into?
Dr Wright: Ear-nose-throat.
"My Die Was Cast" For Cardiology
Dr Califf: You can't just go into cardiology. Usually there is somebody mentoring you or helping you through it.
Dr Wright: There certainly was at Tennessee, and then I took some rotations and was deeply influenced. I went to Texas under Dr Willerson. I spent 6 weeks there as a medical student, so I was rotating through. Then I went to San Francisco and was exposed to some of the greats there, again just in medical school. My die was cast at that point. I wasn't in a fellowship yet, but I knew that was what I wanted to do.
Dr Califf: How did you finagle these rotations in medical school?
Dr Wright: That was a gift that my husband had. He looked ahead and thought of places to go. I absorbed that from him. They were all good decisions.
Dr Califf: One of the great joys for me was being an intern and resident at [University of California, San Francisco] UCSF with Kanu Chatterjee and Bill Parmley and others there who were just unbelievably great teachers. And the new from Moffit Hospital is not bad.
In medical school, did you do any research?
Dr Wright: I didn't. I was always seeing myself in practice, not that that should have kept me from doing research, but I didn't do any. I headed towards the private-practice zone.
Dr Califf: It still bothers me that in most medical schools, if you just take the courses and follow the directions, you can come out as a doctor. It seems like you do a lot of rote stuff and then you do an apprenticeship in rotations. The deeper-thinking part of it seems left out. If you were redesigning medical schools now based on your experience, what would you recommend?
Dr Wright: As much exposure to those giants that we talked about and as early as possible. People need (or I needed and would have benefited perhaps) from having contact with people who have that deep experience and that broad perspective, especially in cardiology. We are a global specialty. Early and frequent contact would have helped.
A Far Cry From Arkansas
Dr Califf: You finished medical school and went on to do an internship. Where did that take place?
Dr. Wright: I was in San Francisco for an internship and residency and then for a fellowship.
Dr Califf: You were really taken with San Francisco.
Dr Wright: I was. I was a runner at that time, and to be able to run in February and August and have it feel just about the same was a new experience to me coming from the south.
Dr Califf: I can relate to that. The lack of sweat is entirely different, isn't it?
Dr Wright: I would have to look at the calendar to find out what month it is because you can't tell. Those changes are very subtle.
Dr. Califf: Who was your main mentor at UCSF?
Dr Wright: I think of Mel Cheitlin, Nora Goldschlager, Tom Ports, and Elliot Rapaport. I received benefit from all of their wisdom.
Dr Califf: That's a great group. I learned from all of them. I still remember that Elliot was the editor of Circulation when I was an intern. He used to leave the manuscripts lying all over the place. People would have to pick them up. They were supposed to be confidential, but he was reading everywhere. It was a great chance to learn. Who were the people in fellowship with him?
Dr Wright: Those were all fellowship folks. I was at the county hospital; I was at the General. At that time the [hospital] was taking two fellows every two years. I came late to my fellowship because of my first pregnancy. I delivered a couple of weeks before the end of my internal-medicine residency, delayed the start of my fellowship a little bit, and then started. So, there was one other fellow at the time. His name was Peter Wolk. I ended up joining him in practice in Northern California after the fellowship ended.
Dr Califf: What town was that?
Dr Wright: Chico.
Dr Califf: That's a far cry from Arkansas.
Dr Wright: It is, but it's a small town, about 70,000 people with a couple of other communities that size around it. It's about 90 miles north of Sacramento.
Dr. Califf: One thing that is interesting about cardiology is that is has one of the lowest percentages of women of any specialty. Only urology is lower.
Dr Wright: Orthopedics is pretty low also.
Dr Califf: Why cardiology? What do you think is behind that?
Dr Wright: It has been studied. One of the deterrents for women is the image of the lifestyle as being 24/7 in the cath lab. There are certainly women who know they want to do that and do it well, but some women are looking for careers that they can incorporate into their lives. That has been a deterrent.
Dr Califf: How many kids did you have?
Dr Wright: Two.
Dr Califf: Are they doing well? What are they up to?
Dr Wright: I have a daughter who is a pediatric occupational therapist in Los Angeles, and my son is a computer engineer in Amsterdam. I was present at his birth so I know that he's a US citizen, but he's very Dutch now. He's starting his sixth year.
Dr Califf: If he looks like you he probably fits right in.
Dr Wright: He's Euro. Yes he does.
Dr. Califf: You were in practice in cardiology there, with two kids. How many members were in the group?
Dr. Wright: Our groups waxed and waned. When I joined, there were four of us. We swelled to seven and at times dropped to three or four. I was there for 23 years.
Dr. Califf: Did you have a lot of calls? Did you work in the cath lab?
Dr Wright: Yes. I was an interventionalist until about the last 5 years of my career, and I was a low-volume operator, as we say. I kept doing caths and pacemakers, but lots of clinical cardiology right up until the end.
Making Time for What Mattered
Dr Califf: When I first met you, there weren't any doubts that you were into medical politics. How did that happen?
Dr Wright: Maybe the American College of Cardiology (ACC) advocacy work?
I got involved with ACC early and got the benefit of sitting around tables on task forces or committees that were doing very interesting things. I learned so much and became further involved. A lot of that work, especially in the early years in, was in the advocacy area because I was practicing, so I was familiar with some of the issues.
Dr Califf: How did you make the time for that?
Dr Wright: Don't you make the time for the things that are really important? That volunteer work filled something in me that was meaningful. Somehow those minutes fly by, but you find them.
Dr Califf: Your partners didn't object?
Dr Wright: They didn't. One of my partners thought that any work I did for women in cardiology was a waste of time, but that was just my buddy. No, they didn't object. They also found value in it in some way.
Dr Califf: When you look back at the practice in Chico, what are your reflections on the current state of cardiology practices? I want to get into your current endeavors in a minute. You were in the middle of doing it, and now you are looking at it from a meta-approach.
Dr Wright: Two things worked on me and through me over the years. One was that after you have practiced for a while and you see a new patient, you often see that patient on the cath-lab table at some point in time. You know that you or your partner is going to see them, and you hope that it will be in the cath lab, because of their disease. I was not very successful at steering patients toward a healthier path. I kept a notebook and wrote down the names of people who came back for follow-up or had lost weight or started an exercise program. I was able to influence a paltry number of people. I was frustrated by how downstream I was in the treatment chain. Although it was extremely satisfying, and I was grateful that I had the skills to open up an artery, I just kept thinking, why can't I do something upstream?
The second thing that worked on me over time was the fact that what went on in the room with the patient and family to steer them toward a healthier lifestyle was not recognized in the reimbursement system. You could even view that time as a waste. I could do procedures in the office or in the cath lab and bring much more revenue into my practice. It paled in comparison with seeing patients who needed that one-on-one kind of care. Those two things together steered me toward a different future.
Dr Califf: I would argue that in today's leading academic medical centers for cardiology, it's still pretty much just as you described. It's not that people don't want to spend the time, but it's very relative-value-unit [RVU] driven right now. Our smartest people are frequently in meetings about how many RVUs are being generated.
Dr Wright: Exactly. I didn't mean to imply it was not important. It's what drives the machinery at this point. It's frustrating if you feel that you could make a different kind of contribution if everything were flipped.
To Washington to Save a Million Hearts
Dr Califf: So, you ended up in Washington. How did that happen?
Dr Wright: I was on ACC's board of trustees when a new CEO (Jack Lewin) took the chair. Jack thought it might be interesting if a cardiologist was on the staff of ACC. We chatted about that. He created a new division, Quality and Science. I ended up in that position. I spent three years on the college staff, left my practice in California, and one day at Heart House the elevator doors opened. I was on the elevator, Jack walked in waving a piece of paper, and he looked inner lit, like something wonderful had happened. He said to me, "How would you like to save a million hearts?" I said "I'm in." I thought my job would be finding out how ACC could contribute to an effort to prevent a million heart attacks and strokes. One thing led to another, and I ended up changing jobs into federal service.
Dr Califf: What is your job now?
Dr Wright: I'm executive director of Million Hearts. Million Hearts is a Department of Health and Human Services initiative to prevent a million heart attacks and strokes in a 5-year time frame, 2012 to 2017. It's co-led by the Centers for Disease Control and Prevention [CDC] and the Centers for Medicare and Medicaid Services [CMS]. The idea is to bring together the public-health and community and prevention expertise from the CDC but marry it up to the payment and policy heft of CMS. The work is actually done by more than 110 partners, including ACC and the American Heart Association and many others working through public health and healthcare interventions.
Dr Califf: I can't help asking this question because of the conversation we had, leading to this. Is the cardiologist's office the place to save a million hearts or is it in the community?
Dr Wright: It's both. It's in the healthcare clinic, the office, the practice, not only in cardiology but also in primary care and the gynecologist's office, wherever people go who have heart disease or are at risk. That is where the interventions can take place. I absolutely agree that there is a lot of public health that can help almost automatically make us healthier. One of the interventions that we are after is to eliminate artificial trans fat from the food supply. The numbers are staggering of the impact that it can have—3000 to 7000 deaths a year or up to 20,000 heart attacks a year can be prevented if we can get that stuff out of the food supply. So we are working on both fronts.
Dr Califf: What are the top three things that need to happen?
Dr Wright: On the healthcare side it's less than three things. It's one thing. It's getting excellent "ABCS," which is aspirin for those who need it, blood-pressure control, cholesterol management, and smoking cessation. That will do it on the healthcare side. On the public-health side, it's gradually bringing down the sodium intake—20% would make a huge difference. Eliminating the trans fat and lowering the smoking prevalence, but that's goes hand in hand with the S on the healthcare side.
Dr Califf: What levers do you have to make that happen?
Dr Wright: They are all over the map. There are 19 agencies involved with Million Hearts. They all have specific actions. The US Food and Drug Administration (FDA) is going to issue some determination about the trans fat. There is also some sodium guidance that is going to come out so that we can work voluntarily with the food industry to gradually lower sodium. Partners on the healthcare side are big groups, small groups, academic medical centers, and organizations, all working toward this ABCS excellence.
A Crash Course in Bureaucracy
Dr Califf: How have you found working with the federal government?
Dr Wright: There is some sociology, some psychology, and a lot of pathology. Most of that is probably on my side. It's fascinating. The cultures are different from one agency to another. The language is very different. I have heard two agencies argue about what the word policy means. It can get into that much detail. There are people who dedicate their lives to federal service. They work extremely hard. They have very high standards of performance. They are constantly looking for ways to move the obstacles out of the way.
Dr Califf: I have worked a lot between the FDA and National Institutes of Health. It was a real revelation that there were lawyers in the different agencies that protect them from other federal agencies in some of these transactions because budgets are important, and one might want to make a rule and the other might have a different view. It is fascinating.
Dr Wright: Yes. If you ever needed examples of how we are all connected, I can certainly see it in the little view that I have, but watching these agencies interact—when you pull one thread, it affects another one. We have heard a lot of ahas! within Million Hearts as the agencies have worked together.
Dr Califf: Where do you stand now? It's a 5-year program.
Dr Wright: We are closing out the third year. I didn't know that in the United States, we do not have a national surveillance system for cardiovascular disease.
Dr Califf: You can't count them.
Dr Wright: Exactly. In Million Hearts we are counting. There is a methodology for counting, but we are not going to know what happened in this 5-year period until one and a half or two years after the fact. The great thing is that we are building a patchwork quilt of data sources in the absence of the timely refreshed data set that we should have nationally. We have seen hotspots of very high performance, and we want to make a lot of noise about those. We can't tell how we are doing except by looking in the rearview mirror two and a half years later, so we can't do quality improvement on a very rapid cycle.
Dr Califf: That's a great point. Isn't it crazy that Google knows everything about us, but we don't know about our performance for heart attacks and strokes?
Dr Wright: Right. The good news is that we know that systems that have electronic health records can pore through those and look at their performance. It's much more important that the teams know how they are doing and that they get timely data than for us know nationally, but I would like to have both.
Reimbursement Reform Pipe Dream?
Dr Califf: One problem that I keep seeing in the work that I'm doing is individual health systems have particular people that they cater to in their plans. What we really need are geographically completely defined populations. You can look really good in one subpopulation, but the people in the next neighborhood might not look so good, especially with our reimbursement system.
You are working with CMS. Are you going to fix the reimbursement system?
Dr Wright: I wouldn't hold your breath, but I am enthusiastic about new models that allow team members to spend more time with patients who need more time and to be held more accountable for the outcome than for the throughput. They are so new that the jury is still out, but I am hopeful, as are all of the people who have been working on this.
Dr Califf: It has been a lot of fun to get your history. I am struck by the possibility than when you finish the 5 years, you will have learned a lot and have insight into issues that are not well-known because of the background you have and the positions that you are currently in. You could do a lot of teaching. Do you get to teach much now other than your focus on your main mission?
Dr Wright: I am laser-focused on this. This mission of Million Hearts appeals to me from a professional standpoint, obviously, but also a personal one. It's true for so many people who have been working on it. I have certainly done much more learning than I have done any amount of teaching. All it has done is expose what I still don't know and am curious about. I'm looking forward to more learning.
Dr Califf: It's great to be in that position. My last question is usually about advice.
Dr. Wright: You are going to give me advice?
Dr Califf: Oh, no. I have plenty of advice for you, but that's for a different day. If you were a young person headed for cardiology training now, what kind of things would you be looking for? What should people be thinking about?
Dr Wright: That's a broad question. If I were going into cardiology now I would come in with a network because everybody of that age has a network. I was pretty solitary—pretty solo. I would encourage young people to cultivate or carry that network through their training and their career choices because of the learning opportunities and the ability to build on what other people know so you get where you want to go faster.
Dr Califf: That's great advice. Thanks for joining me.
© 2015 WebMD, LLC
Cite this: Robert M. Califf, Janet S. Wright. Life and Times of Leading Cardiologists: Janet Wright - Medscape - Feb 18, 2015.