COMMENTARY

Life and Times of Leading Cardiologists: Noel Bairey Merz

Interviewer: E. Magnus Ohman, MD; Interviewee: C. Noel Bairey Merz, MD

Disclosures

June 26, 2018

E. Magnus Ohman, MD: Welcome to another edition of Life and Times of Leading Cardiologists. We are very fortunate today to have Dr Noel Bairey Merz with us from Los Angeles. She is the director of the Barbra Streisand Women's Heart Center and the Women's Guild Chair of Women's Health at Cedars-Sinai.

I have done a little bit of a Google search, and you might be the only one who has a singer/movie star directorship. We have to ask, how did that come about?

Legacy and Legends

C. Noel Bairey Merz, MD: I was thinking about legacy. I was thinking that women's heart health was too important to be a "flavor of the month." Often, women's health at our federal agencies waxes and wanes because it is associated with reproductive health. There are eras where it is funded and eras when it is not funded because of reproductive issues.

About 15 -20 years ago, I was working on how we could create a legacy where we were not dependent on federal funding. I read in the Los Angeles Times that Barbra Streisand was going on tour, and as per her routine, the proceeds would be donated to a philanthropic cause. She had selected women's health for this particular tour.

I was caring for a social friend of hers who had told me many times that he spent holidays at her home; the couples were good friends. I put together a development package and asked if he would give it to her. I saw him about twice a year—he was very stable. The first time, he forgot and he lost it. It took about 2 years because every time I would see him, I would give him another packet and just hoped that he could remember.

About 2 years later, I was at an American Board of Internal Medicine meeting in Philadelphia. I was in the hotel getting ready to go to sleep, and the hotel phone rang, not my cell phone. The operator said, "Please hold for Barbra Streisand."

Ohman: Did you fall out of bed?

Bairey Merz: I almost hung up, because I thought it was a practical joke. But it really was Barbra Streisand. We chatted for about 1 hour, and that was the beginning of our relationship.

Ohman: That is an amazing story.

Bairey Merz: Patience and persistence are probably the most important [factors].

The operator said, 'Please hold for Barbra Streisand.'

Ohman: The other message is the fact that federal funding waxes and wanes, like all kinds of things, and looking outside for people who want to contribute and have a legacy is obviously very important.

It Started in Texas

Bairey Merz: I grew up mostly in northern California, but I was born in Texas and I am a Texan. Because my dad was in the Air Force, we moved around a lot, but finally settled in California. When he got out of the Air Force, he was a journalist. I grew up in Modesto, California, which is a small, rural, and mostly ranching community in the middle of the state. I had horses. I rode my bike everywhere. I went to school with ranch kids, most of whom were not going to go to college. It was a very great childhood. I was not protected and had complete freedom. I guess, at that time, there wasn't much you worried about. Maybe there were things that my parents should have protected me from, but it wasn't like how we worry about and protect our subsequent generations.

Ohman: We might be too overprotective. It is interesting to me. Cindy Grines, whom I interviewed a few years ago, grew up on a farm. There is something about being independent and being allowed to do the things that you want to do. Were you in a big family or small family?

Bairey Merz: I was the oldest of three kids and the only girl, so I learned early how to tell my brothers what to do.

Ohman: That helped you later on in your career. Where did you go from Modesto?

Swimming to Chicago

Bairey Merz: I was a highly ranked competitive swimmer from California. At one point, I was the third fastest 50- meter freestyle sprinter. That was before Title IX, so if you didn't go the Olympics in high school, you pretty much weren't going, because there were no supported women's sports. I applied and accepted a scholarship to the University of Chicago. It was the first female athletic scholarship in the country. Now you are thinking, "Wow. You were a competitive swimmer, highly ranked, and you went to Chicago?" They didn't really have a real pool, but when the University of Chicago opened their doors, they always accepted women full on, like 50% women and 50% men.

I went to college in 1973, when the athletic director was Mary Jean Mulvaney, a barnstormer. She was responsible for getting women's collegiate sports eventually into the NCAAs. The University of Chicago had a male athletic scholarship, the Amos Alonzo Stagg Scholarship, because when they originally started, they were in the Big Ten. Mulvaney lobbied the president of the university and got a female scholarship, of which I was the first awardee. She used to pony me around to these meetings, and sometimes older female athletic directors of women's sports thought I was tainted because I had accepted scholarship money. This was the beginning of breaking through and Title IX, and separate is not equal. Women's sports had no support.

Ohman: Was there any thought of going to the Olympics when you were at Chicago, or were you more academically oriented?

Bairey Merz: I was more academically oriented. Again, there were inadequate training facilities. My other liability was that I was a lot faster at the 50- meter than the 100- meter. At that time, the 50- meter was not in the Olympics; they just had the 100- meter event.

Medical School at Harvard, Residency at UCSF

Bairey Merz: Then I went to Harvard Medical School. My mother was convinced I was going to London after that because I just kept moving further away from California, but I told her I would be back. At Harvard, I met and married my husband, who was in the same class : Dr Robert Merz, FACC. When we were starting the relationship, I told him that if this was going to go anywhere, he needed to realize that we were going to move to California. He said, "That's why I am dating you. I've always wanted to live in California."

You had these young, predominantly men lined up on ventilators, and you were just hoping that they could live long enough for their mothers to come and say goodbye.

Ohman: That is so funny. When you were at Harvard, were there people you felt had a huge impact on your career?

Bairey Merz: I decided I wanted to be a cardiologist after doing cardiology with Dolph Hutter. He was such a fabulous teacher and great cardiologist, who really cared for his patients. He had all the smarts, but he also had all the empathy and availability. I said, "That's amazing; I want to be like that."

Ohman: Did you then go back to California, or were there some intermediary steps in between?

Bairey Merz: No, we matched. We were in the first year of the couples match.

Ohman: You have done a number of firsts.

Bairey Merz: Yes. Why me? I don't know. It was the first year that they offered the couples match. We had put in that we wanted to do the couples match, so we were asked to make an appointment with Dean Federman, our student dean. We nervously made this appointment. We went and sat in these overstuffed leather chairs, waiting for him to come in, and wondered what he was going to tell us. Maybe we can't do this. He sat down and he said, "Robert, Noel. In order to go into the couples match, you have to be married or engaged. Which is it?" We looked at each other and we said, "We're engaged."

Ohman: Were you?

Bairey Merz: No, but we set the date. We graduated and got married the next day. We were honest—we really did get married—and we matched at University of California, San Francisco (UCSF). Many people tried to talk us out of leaving Boston. It is like that New Yorker cartoon where you are stepping off the end of the Earth.

Ohman: Like there is nothing beyond the Appalachian Mountains.

Bairey Merz: When they could tell that we were serious, they said, "Well, okay. You can go to UCSF, because Holly Smith is there." So, that is where we went.

Ohman: Fellowship back in those days was busy with call every third night or so. How did you combine life, marriage, research, and all the things you did?

Bairey Merz: At UCSF, we had the great pleasure of being mentored by Kanu Chatterjee and Bill Parmley. Amazing icons. Rob Califf was a fellow when we were residents.

Ohman: You were in a very esteemed group including Ralph Brindis, the former president of the American College of Cardiology (ACC), and Dean Kereiakes.

Bairey Merz: Ralph was the chief resident. Eric Topol was my resident.

Ohman: We will not ask too many questions, but...

Bairey Merz: Yes, I can tell you heard stories.

Ohman: I am sure they were wonderful, but we have heard a lot about these years. That was a very innovative time and of course, there were all the social changes in San Francisco at the time.

Bairey Merz: Absolutely. It was the beginning of the AIDS epidemic, and it wasn't called AIDS ; it was called GRID, "gay-related infectious disease." That was later considered politically incorrect, and as we learned more about it, we came around to a better understanding. A lot of the combination therapies by Cedars-Sinai Infectious Diseases that ultimately started saving lives started in San Francisco.

Ohman: Was there knowledge that there were any cardiovascular issues with it at the time?

Bairey Merz: No, not at that time. You had these young, predominantly men lined up on ventilators, and you were just hoping that they could live long enough for their mothers to come and say goodbye.

A Developing Interest in Research

Ohman: In your fellowship, there was no emphasis on women's health. How did you charge toward this career path?

Bairey Merz: As an investigator, why do we go to the National Institutes of Health? Because that is where the money is. I was always interested in research. My husband was always interested in practice and clinical care, so that was a nice work/life balance for us. We tried to be on-call at the same time, so that was also good. We went to Cedars-Sinai largely because Kanu Chatterjee said that this was the largest program in the country at the time. They had six fellows per year, and it would allow us to be on-call and also take holidays together.

Ohman: You went together for residency and fellowship as well. Since being a fellow, you have been at Cedars, all the way through.

Bairey Merz: I haven't moved.

Ohman: How many on faculty at Cedars have that honor?

Bairey Merz: P.K. Shah was there as early junior faculty ahead of me, as were Dan Berman and Bob Siegel.

Ohman: So, four of you really. That is amazing. Did your interest in women's health start when you were at Cedars?

Bairey Merz: Yes. I was always interested in physiology. One of the early lessons that Dolph Hutter taught me was that physiology trumps anatomy, and if you are a good physiologist, you are going to know. It is like being a pathologist ; you can figure it out. I spent a lot of time thinking about ischemic heart disease. I also did advanced imaging at the time. We were moving from planar thallium to SPECT, and it was like, "Oh, somebody turned the lights on." You could actually see what was going on.

I had many great projects. I was mentored by Dan Berman and Alan Rozanski. One of the projects that Dan gave me was to look at his large SPECT database and test the hypothesis that the area of ischemia on the SPECT will be the future infarct. I ran that analysis, and I ran it again. I ran it three times before I went and showed it to Dan. It was not showing up—they were having heart attacks in other areas.

Ohman: This is before the group in Winston-Salem, North Carolina, showed that the infarcts actually come from minimal lesions.

Bairey Merz: We didn't know that at that time, and this too was around the time that Cedars-Sinai was doing angioscopy, meaning looking and showing that it was a plaque rupture. It wasn't just a slow but sure narrowing. The point is, those outliers were most often women. Alan Rozanski and I had a New England Journal of Medicine paper[1] about mental stress testing. Again, nobody had shown that these two were connected. The most severe reactions in terms of surges of heart rate and blood pressure were in women. The ejection fraction would drop even though they did not have obstructive coronary disease.

We started seeing a lot of outliers, and women seemed to most often be the outliers. Then you start to think, "Well, maybe they are just different. Maybe they aren't really outliers, and maybe the physiology is different."

Family Life

Ohman: Were you able to have a family in this very busy life?

Bairey Merz: Yes. My husband and I were both from a family of three, and that number felt about right for us. We have three adult daughters, and all are off doing good things in the world.

Ohman: Did any of your brothers or anyone else in the family go into medicine?

Bairey Merz: No, I am the only one in my family, and my husband is the only one in his family. My mother's surname premarriage was Galt, as in the Galt Apothecary Shop in [Colonial] Williamsburg. My mother is colonial, so her family goes way back. The apothecaries, if you remember, were the physicians, and the barbers were the surgeons. She likes to take credit that this is in the family.

Ohman: Has she reminded you of that over the years?

Bairey Merz: Yes, all the time.

I stand on the shoulders of many, many women and men who made very effective social change, so that we can all live successful and productive lives and have successful and productive societies.

Ohman: Going back to your mother and father, we didn't talk much about them. Were they role models in their own way for you?

Bairey Merz: Yes, absolutely. They were the kind of parents who left you alone. We had a lot of freedom, but there were a lot of expectations. We were expected to do well in school. We were not paid for grades. We were expected to work hard at whatever it was we did, whether that was a sport or science club. We always ate meals together. My father came home for lunch. We lived across the street from grade school, and we would have lunch together.

Challenges for the Future

Ohman: You have now become the national face of women's heart health.

Bairey Merz: I stand on the shoulders of a lot of people, but that's okay. I will take it for now.

Ohman: Where do you see us going from here?

Bairey Merz: We have a lot of challenges in continuing to understand sex and gender differences in cardiovascular medicine, as well as holistically across medicine. If you really think about it, this is what personalized and precision medicine is. Why are women and men different? Our DNA is different, XX and XY.

Regarding sex and gender, observation of differences, understanding mechanistic pathways, and then deploying diagnostics or therapeutics if they are sufficiently different to more personalized care is the future for all of us, I think. That will improve women's heart care, but it also will improve men's heart care because we are always averaging things.

A lot of things are the same; statin efficacy is the same, and we have enough data to say that. There are other things that probably are not the same, and there are many that are clearly not the same. Myocardial infarction with nonobstructive coronary arteries (MINOCA) is much more prevalent in women. Do we have any effective knowledge of or therapy for it? How about heart failure with preserved ejection fraction? It occurs mostly in women. Do we have effective therapies? No, so we have a lot of work to do.

Ohman: To finish off, you gave a TED Talk.

Bairey Merz: Yes. I gave one TED Talk. I was asked to do it by Barbra Streisand, who was asked at the Cal Poly Center in Los Angeles to do a TED Talk. She said, "I will introduce this fabulous physician at Cedars-Sinai whose center I endowed." Barbra introduced me, and then I did the TED Talk on women's heart disease. The political is personal and the personal is political, and we all have to stand up and advocate. We need more funding.

Ohman: That is a wonderful story, and from my vantage point the fact [is] that it started with Title IX. It's quite amazing.

Bairey Merz: Women today in the United States and other Westernized countries are quite privileged compared with our mothers and prior generations. I say I stand on the shoulders of many, many women and men who made very effective social change, so that we can all live successful and productive lives and have successful and productive societies. Women really hold up the sky. The more committed that you are for diversity, the better, because teams make better decisions when they have diversity. The ACC now has this very strong commitment.

Ohman: Diversity really helps us all. I want to thank you for participating—this has been a really great story for all of us to hear.

Bairey Merz: It's an honor and a pleasure.

Ohman: I want to thank you, the audience, for participating with us today.

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