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Featured is the Session 17 Roundtable entitled "Meet the Presidents: How Presidents of Societies Influence the Management of AF" from Western AF 2024. Moderated by Douglas Packer, MD, with discussants Ali Oto, MD; Andrea Russo, MD; Fred Kusumoto, MD; Jodie Hurwitz, MD; Kenneth Ellenbogen, MD; Patricia Blake, FASAE,CAE; Sana Al-Khatib, MD, MHS; and Thomas Deering, MD. 

Discussants: 

Ali Oto, MD

Andrea Russo, MD

Fred Kusumoto, MD

Jodie Hurwitz, MD

Kenneth Ellenbogen, MD

Patricia Blake, FASAE,CAE

Sana Al-Khatib, MD, MHS

Thomas Deering, MD

Moderator: Douglas Packer, MD

Packer: We'll go ahead with the next session, which is entitled "Meet the Presidents: How Presidents of Societies Influence the Management of Atrial Fibrillation (AF). Now, I have to say that that's a little of an unusual topic, but I'm going to have a lot of fun here with you. So, we're going to go ahead and meet the presidents. There are a couple of you that are almost presidents, but we're not going to change that. It's an interesting thing of whether or not a president can have enough impact on a society that they can influence the management of AF or anything else. So, tell us who you are, where you're from, and give us 10 seconds on what you think about presidents of societies influencing the management of AF. We'll take more time as we get back into it. 

Kusumoto: My name is Fred Kusumoto from Mayo Clinic Florida. How can a president influence? Probably not a lot, but the key thing for all to know is that there is a long sort of runway and institutional memory. My presidential year was really building on work that others had done previously and others have continued since then. 

Ellenbogen: I'm Ken Ellenbogen from VCU in Richmond, Virginia, and it's really quite an easy question for me to answer. I'm going to say I'll see what the present president does and learn from all the prior presidents to see what I can do to influence the management of AF, because I'm not president yet. So, I'm still learning a whole lot.

Hurwitz: I’m Jodie Hurwitz, I'm in private practice in Dallas, Texas. I am the current president of the Heart Rhythm Society (HRS). I am very opinionated, as I'm sure everybody up here knows very well. So, I actually do think that there's a way that we can influence this. Just by virtue of how I introduce myself being in private practice, I think that's one way. Because I think that that's something that a lot of the wonderful education that HRS does in a lot of the academic centers that we need to remember that we are in private practice, we really do take care of the whole patient. I can make comments about other things too later on, but I'm sure you will ask that. 

Blake: I am Pat Blake. I'm an interloper here because I'm the CEO of HRS, so I'm not president of anything. But I would say is that what is really important from a CEO perspective and from a staff perspective is to remember how much of our members deal with AF, how many of our members, how much of our education is focused on AF, and how important it is that we look at that from all different perspectives, whether it's advocacy, whether it's patient information, whether it's physician information or allied information, and to keep this on top of our radar screen. Or, as Andrew would say, another past president in the center of our desk.

Russo: Hi, I'm Andrea Russo. I'm from Cooper Hospital in New Jersey, and I'm going to answer yes, and follow up on what Pat said. For HRS, education is one of its biggest strengths, and we create a lot of educational materials. For example, we have guidelines or consensus documents. You've heard a lot about that lately, and the last session with Mina talking about one of the guidelines recently. We did start our own guidelines, and that was on a different topic, not on AF, that was on physiologic pacing. But also, other kinds of education, things like a center of excellence document, scientific statements, we can do those kinds of things, influence, educate, and that can influence the management. 

Calkins: I'm Hugh Calkins. I was president of HRS about 10 years ago. I am at Johns Hopkins. The only comment I would make is one of the things you get to do as president which is impactful is you get to appoint people to writing groups and guidelines groups, etc. So, that's one big impact. Back in the old days, years ago, we started the AF ablation consensus document before I was president, but that continued up until 2017, and there's a new one coming out shortly, sponsored by EHRA and HRS. So, I think guidelines, nominating members to writing groups, the education material, the conference—a lot of the progress and information that HRS focuses on is AF. I think everyone knows how important AF and catheter ablation of AF is to our field—it’s enormous. So, I think you play somewhat of a role, not an enormous role, but I think you can have some impact. Doug was president a number of years before me, and I think he was clairvoyant in realizing how important AF was, and used the bully pulpit to push the AF agenda forward, and I continued on.

Al-Khatib: I'm Sana Al-Khatib. I'm an electrophysiologist at Duke University in Durham, North Carolina. It's a pleasure to participate in this session. I'm not a president yet. I will start my presidency of HRS in 2026. So, I have a lot of great people here that I've learned from and I'll continue to learn from. But in a few words, in terms of how presidents of societies can indeed influence the management of AF, I can summarize it in a few words. A lot of my colleagues have already touched on these important concepts, but defining quality education is really important, but not just in terms of educating our immediate members, clinicians, APPs, trainees, but also educating patients. We have the UpBeat.org website that HRS oversees, and that's a great educational content for patients. The other thing is research. As presidents of societies, we're not conducting the research, but we can certainly engage in discussions and support discussions surrounding research. Finally, I'd like to highlight the importance of advocacy efforts. We all went through a lot of hardships in the past year. Reimbursement for AF ablation was being looked at, and reimbursement did go down. So, I do believe in what the society can do in this space in terms of advocating for the work that we do on behalf of our members as well as on behalf of our patients. 

Deering: I'm the last of the presidents-elect and ex-presidents here of the HRS group. After that, I’d like to hear what Doug Packer says about our commentary. I'll try to be brief and keep within the 10 seconds. We may have a chance to elaborate it otherwise. I think most people have already said what we need to do. I think we need to build programs. For example, within the quality improvement committee at HRS, we've developed 2 considerations. One is called CardiQ, which is a web-based and focuses on centers of excellence and building programs that can be effective. Hopefully, we'll have a little more time to talk about that later. Another one is COMPASS, which is based on engaging institutions to within their EHR, build programs that drive a particular focus in a positive direction to impact outcomes, while simultaneously educating patients and staff as well at the clinical level. I think the second thing, and many people have said this in many ways, is education. Meetings like this where we can interact, bigger meetings like HRS, and then web-based meetings. We've got to continue to grow those and look at all the stakeholders—clinicians, patients, scientists, and administrators—so that together we can get further along. 

Oto: My name is Ali Oto. I'm from Ankara, Turkey. I'm the president of the World Society of Arrhythmia. The history of the World Society of Arrhythmia goes to 1978. Our society's main aim is to be the major resource for pacing and electrophysiology in underserved areas. With this, I would like to bring 2 important facts in terms of AF to your attention. The first one is the risk factors that we have heard over the last 2 days, namely obesity, hypertension, diabetes, are really increasing very significantly in those areas in parallel to an increase in the prevalence of AF and mortality. So, there is a real opportunity there in terms of prevention of AF and also modification of the therapy with lifestyle changes. So, our aim is to collaborate, not in competition with the major societies, to bring knowledge to those areas and try to fill the knowledge gap and influence the management of AF.

Packer: So, that's kind of a broad brushstroke on what presidents do and the kind of concepts that they are pursuing. I want to back up just a little. Pat, so Jodie is the president. How'd she get there? 

Blake: Hard work, for one thing. I'm sure she got there because, as many of you know, it takes it meetings like this. It takes exposure. People need to be known as experts in the field to get on the board and then to ascend into the presidency. But they also have to have leadership qualities. By that, I mean, Jodie is a great example of someone who will speak her mind. She is not afraid to represent private practice, even when she's in a minority. She is not afraid to represent women, even when she's in the minority, and she speaks with authority and expertise, and that's how you become president. 

Packer: Andrea, I have to come back to you. That was a pretty good description of how she became president, but I think it's interesting for a group like this to understand guidance and approaches. Just what we do when someone becomes the president, we have a guidance committee and there's a number of others. Tell us just a little about that and how a president gets it, and why it wasn't the fact that I just voted for her and decided that she should be the president. 

Russo: That's actually a really important point. So, once we are in a certain role, we have a board of trustees, obviously, that helps to give us guidance. We have committees and subcommittees and task forces, depending on what the urgent matters may be at hand. As president, I think one of the qualities is you need to be a good listener, you need to be a good collaborator, you need to work with other leaders, and also work with the community of electrophysiologists that are like you or not like you to really better understand what the needs are and what we need to do. For example, when advocacy was brought up, those kinds of things, listening to members, listening to what's going on in the world of whatever it may be—it happened to be reimbursement last year, but we need to work with other team members within and outside the society.

Packer: So, I misspoke, but the organization that really runs HRS is the Governance Committee, and under them is the Nominations Committee. People who are members have the opportunity to nominate someone for one of the executive track positions, whether that's second vice president, first vice president, president-elect, or the president. Once that's done, when the Nominations Committee selects the one, everybody gets a vote. They get a vote to make decisions about the people who are going to be making decisions. I think it's important to know that, because the president of the society is not going to come in and say, “we're going to all use artificial intelligence (AI) to ablate AF.” Maybe, but there's going to be a lot more to it than that. So, I'm going to have you start down here now and we're taking this a little bit differently. You said who you were, you said a couple of things that were important. You've said how it is that you got in the position you got in. Now tell me a little about how you are going to change how we practice AF. Now, there have been 2 or 3 things along the way that I thought were quite good. But let's just go down the row again. So how could you change the way we practice AF? 

Kusumoto: That's a question that could actually take certainly a long period of time. From my perspective, what you brought up was really important. I see myself as president, as your elected voice of this organization that is all of us. So, I think that that's absolutely critical to remember. So, to get to your question with regards to that, it is input from people, talking to me, etc, about these problems that we face in our practices, whether here in Florida or in Minnesota or somewhere in the world. I think that that's the important aspect. We can talk about specific programs and people already have, but people have to remember that the genesis of these programs come from input from members, and I think that's the thing that I want to emphasize.

Kusumoto: [In response to audience question] So, this was actually an important thing that came from Christine Albert, who was before me, and then also through Andrew, when you think about the pure advocacy piece, talking then to CPT, RUC, etc, trying to ensure that our voice was heard. I spoke with the heads of multiple sorts of organizations. Now whether or not they listened is yet another separate issue. But nonetheless, I was your elected voice for that advocacy portion. Another thing was to think about arrhythmia management to get to Dr. Oto's discussion in a more worldwide sense. So, one of the things that I worked on was in fact, having a council organization and also a worldwide summit. So, the council piece is because, remember, we've already seen data from the registry. What percentage of people are non-white in those registries? An incredibly small amount. When you look at advanced AF ablation, when you look at left atrial appendage occlusion, pick your registry—they all, in fact, show that there's incredible disparity of care here in the United States, and you can extend that out worldwide. So, to Doug's point, it's important for us to think governance-wise to think about structures to then develop something that will then go on for much longer beyond my presidency. That was the issue with regarding building councils, building summits, things like that. There is a whole host of things, in fact, that impact AF, and then more generally, arrhythmia care that can be done. 

Packer: I'm going to make a couple of comments right now, then we'll flip it back. Whether you're on this side of the pond or the other side, whether you're in Europe or the US, whether you're in Southeast Asia or wherever, you're not going to get anything done if you don't work well with people. It's the sort of thing where you start asking questions to all of the people here, and whenever you have a question or a concern, you always have to vote yes. Somebody else wants to do something else, and you want to do something else. But you vote yes. We are going to work together and it's important, because if you look over that yes, it might be 85% of both sides of the ocean have voted yes. So, you've already decided that you can work together as a president, but you only have 5% of dealing with the details. It might be 80 and a little more than that, but I think it's just incredibly important that we work together, we vote yes even though we disagree, and then we figure out some of the problems and which way we're going to go. One of the most important one of those is guidelines. You saw about 10 different guidelines, and you saw 4 or 5 different names on those guidelines. It's a little tricky when you have that. So, one of the things the president has to do to make a difference on how we practice AF is interact well with others in the world who have the same issues. I hope that that's clear, but if it's not clear, then that president's not going to be able to get very far. We would hope that they would. Hugh, you've been in the middle of that. Your comments? 

Calkins: I think your point is well taken. I mean, it's a worldwide effort. It's really wonderful to see how AF has gone from the days when people thought it was a placebo effect and were calling for sham trials to show it worked, and I think Doug and I once went to CMS to really argue for payment for AF ablation. But along the way, we obviously partnered with societies all over the world and together, we encouraged trials and put together guidelines. I think we really made a lot of progress, but the work is never done. Jodie and her team are working hard to push AF ablation and management forward in every way they can. It's very discouraging when the reimbursors slash your payment for services, but HRS is always there fighting for the electrophysiologist. They represent people in our profession. They care about patients with cardiac arrhythmia disorders. One other comment about just being president of this organization, it's about having a certain skill set, but you also get involved early in your career, one committee, and then you do a good job, and then you get to be head of that committee, you do a good job, and you work your way up. No one becomes president unless they've put in 10 to 20 years of volunteer time, and that's time away from your family, your work. It’s really a big commitment, but people that prioritize the organization and show some expertise ultimately can express their interest in being on the leadership track. That also comes with sort of a price. I mean, one of the things when you're the president of HRS is you have to give up all conflicts of interest for several years before, during, and after, so no one gets rich quick being the president of HRS, because you cannot consult for any companies. The rules used to be different, but now in the modern world, the things have changed. So, everyone who becomes president has to basically rid themselves in any of these outside interests, which really is a testament to their devotion to the society and the organization. They are putting their pocket where their mind is and where their commitment is, and I salute anyone that enters this track, because they're giving up something. They benefit tremendously, it's the high point of my career, but I think that needs to be mentioned.

Packer: You've told us a lot about what happens and how are you going to interact with people, and I'm going to ask Jodie to tell us. I'm assuming that Hugh didn’t make all the decisions around here. Nobody up here does when they are in this position. I'm saying this because this I think is a big key on how you can wiggle things around so that you can drive something and actually succeed. So, Jodie, did you make all the decisions this year or last year or the year before that? Who made the decisions? 

Hurwitz: Only in my household, right? No, that's a great question, and I think it relates to what everybody has been talking about and what I was going to say even before I was asked this question, which is that one of the things that you have to be when you're president is, in some ways give up your one huge passion of what you're going to do during your presidency, of course, and you have to be a listener. You have to be a really good listener, and you have to be a good convener. Obviously in the last year or so, it's been a little more US-centric than perhaps we would like, and we're working on changing that, because as everybody has mentioned, AF is really ubiquitous worldwide. But that's really what is important. As you said, you're very busy, but one of the advantages is that you get input from lots and lots of different committees and people within HRS and outside of HRS. So, you can hear a continual similar message. As the president, you can get a real sense of what's important and, whether you like it or not, the fact that you're going to be the one who's going to have to bring it forward. 

Packer: Tom, give me a 3-year timeframe for just exactly what you do to bring it forward, like Jodie said. 

Deering: I think the very first thing you need to do is you need to connect. You know, you cannot make a decision arbitrarily and you cannot make it in the abstract. So, what you want to do is develop relationships and figure out what the issues are. I think secondly to bring something forward is it is most important for someone as one is going up in the presidential track is to defer upward but to ask a lot of questions to learn more by determining what people need to find out about. So, I think asking questions is very important. Then, I think what you should do is come to some area where you're going to have to start making priorities, as it was said once before, we can do anything but we cannot do everything. So, we do have to prioritize. Like Doug said, we want to say yes, and we do, but we've got to figure out which of those things we're going to bubble up to the top. Then we've got to be good consensus builders so we can bring people together, modify our decisions, and that is a multi-year process. We have to put aside on the table, those things that we think are most important and look at the bigger picture by asking those questions. I would say connect, ask, drive, facilitate, and lead. 

Packer: Do you have any other comments to make? 

Russo: Yes, in addition to those terms, in addition to you need to be agile, you need to be able to switch over quickly from one to the other. For example, the end of my year was during COVID. You need to switch over. We worked with our colleagues in China and other places in Europe and elsewhere to be able to learn from each other and to be able to create some consensus documents, things like that. So, you need to be a good collaborator, a good listener. I think what's also important is we do have strategic planning. So, there is strategic planning every 4 years or so within HRS, and that's not just the leadership track, and it's not just the board of trustees, it involves other members, both in the US and otherwise. So, we decide among the group and through a building of information and consensus as to where things need to go, what are the different parts that we need to focus on. We were going to focus on digital health, and all of a sudden, COVID came around and it was kind of a jumpstart. We had to quickly refocus. So, you need to be agile on top of everything else.

Packer: I think when you're going into this, then you have to have your envisioned future. What you are predicting is going to happen in the next 3 years, and then what are your goals, what are your specific gains? What is the synthesis step to it? What are the logistics, the tactics, the metrics, and that sort of thing that need to go in and at the bottom, after having done all of that, then maybe AF gets spit out? Do you have a question?

Westby Fisher, MD: Thanks so much. Wes Fisher from Chicago. It is a rare opportunity to have all the presidents of HRS or in the future here under one roof. Most of you I know or have known or will know. As you know, I've been working on maintenance of certification for our field, and to reiterate, it's been an 11-year battle so far. Now we're going to have a big thing that's bubbling up in our professional community. It has kind of had a 10-year cycle. Younger people are now getting exposed to it, feeling the pain, feeling like little mice in a corner, they're being trapped and cannot do anything about what's going on. Do you think HRS is going to have an opportunity to do anything about what's going on? I suspect not, because we are somewhat beholden to the ACC as an organization, as I've understood. This has been a long-term problem and highly entrenched, and I get it. I certainly don't blame anyone at that table, because I think you guys have done a great job in your capacity. But I do think this American Board of Cardiovascular Medicine is likely to have very significant conflicts of interest selling our data to third-parties through ABMS Solutions, LLC. There's no question that the ACC makes most of its revenue from the NCDR databases. You guys have excluded all your conflicts of interest, but there is a lot of other conflicts of interest that are a big problem. Paying $960 every 2 years to maintain 3 board certifications is ridiculous. It's a tax. We have no accountability. That number has increased over 463% in the last 10 years. We really have to do something to allow us to have an alternative board. I think it may have to go beyond the American Board of Cardiovascular Medicine. To think that we're a separate subspecialty from medicine is crazy. We are medicine doctors also. I know there has been an effort to try and address this at a higher level. But I just encourage you guys to understand this is a big issue. I'm going to lose my ability to practice medicine if I don't pay up, and feeling extorted like this, which every doctor in the United States, again this is a US issue because no one in Europe has to do this ridiculous thing called maintenance of certification. There is no proof it does anything for our patient care equality. I've been doing practice 22 years, and they're telling me that I cannot practice anymore, and that's ridiculous. So, I wish you guys would put that at the top of your radar this year. If there's anything at all you can do to help us end this monopoly situation, it would be greatly appreciated, and I appreciate the opportunity to at least be heard. Thanks.

Packer: It's already in the strategic plan. 

Hurwitz: Can I just briefly address that? We've heard you loud and clear. We've heard lots of people loud and clear. I would think that every US physician in this room understands what you're saying and supports you. I hope I am not being Pollyanna in thinking that this new board will help change things significantly. Right now, the biggest message is don't change what you're doing because we don't know where this is going to be headed, but we do hope and look forward to some answers by the end of 2024. I want to tell you that I'm actually one of the people who will be representing HRS on the new ABCVM board. 

Packer: So, we started out saying we're going to decide how a president or society can change things as far as the management of AF. Well, that's it. We've gone through a lot of the actual steps that have to be taken. It's not something that magically happens, but it certainly is heard. Let's finish up with just a couple more comments about AF. Ken, give me something a little more concrete about how we as a society and the president, are going to change the management of AF.

Ellenbogen: As I said when we were talking about AI, everything we do is digital. Everything we do is a bunch of zeros and ones. I think we are going to be on the forefront of many new technologies. Every time someone talks to me about a new technology or new idea, I always say, you need to be at the HRS annual meeting, because you don't have to convince me. You have to convince the thousands of people who are members of HRS: the physicians, nurses, and technicians. So, if you have a new idea, then you should be out there where you can meet people and your idea can be refined or improved by those people, or they can say, this is great, I want to do it. I've been around 37 years doing this, so I've had a lot of opportunity to work with both academia and industry, and the one message I give them all the time is you need to work with HRS to get that idea out to other people, to people who can implement it in their practice or in their research. Whether we want to make sure physicians understand the importance of anticoagulation, great. We can provide education about that. It's always trying to get the people with the ideas involved with HRS members. It's about the members, the community of people who belong to HRS. 

Packer: There are a number of other things that are changing and the society is moving to move that change along.

Al-Khatib: Yes, I just want to go back to the point that Andrea raised about the strategic plan that we go through. It's actually a great exercise that we go through every 4 to 5 years, and it's informed by a lot of input from the members. So, the word that you mentioned that I love is connecting with our members and staying connected so that we hear you loud and clear, and understand what the challenges are that you're facing that we are largely facing in our practice as well. So, in response to the feedback that we got and how things transpired over the last couple of years, advocacy now has become an important part of what we do. It is an important part of the strategic plan. We want to do our best to be more proactive than reactive, so hopefully you're going to see that shift in how we're going to do things. The other thing I want to embrace is innovation. This has always been such an important focus for us within HRS, but now we're elevating it even more. It is a big part of our strategic plan going forward, and I think that will help us with AF management. Some of you may have attended HRX, which is a great initiative from HRS. I had the pleasure of co-leading the meeting for a couple of years, and I can tell you there's so much that gets discussed in relation to AF, and I encourage everybody who's interested in that to attend the meeting in September, it's going to be in Atlanta. But this shows you all this great emphasis we have on innovation that's covered at HRX, the annual meeting HRS, and many other things that we do as a society. Again, our role is not leading the innovation, but rather enabling you to be innovators and successful. 

Oto: I would like to bring another issue to your attention. We have been talking about using new technologies and plan on using more, but there is actually nothing about sustainability or future generations for our environment. For example, a daily carbon footprint for AF alone per day globally is about 125 tons of CO2. So very scary. We have to also consider this and put it in all our strategic planning for the sake of future generations.

Packer: That's a great point. We're just about done. Pat, last words? You know that I'm going to have some words after that. 

Blake: So, first of all, it is certainly a great honor to be CEO for HRS. I've been in the association profession for many years, and I am awed every day, as is my staff, really, of working with this incredible group of people. As you know, our vision is to end death and suffering due to heart rhythm disorders. One of my responsibilities is to make sure that the staff is aligned with the president's vision and with the board of trustees' vision, and in fact, with the strategic plan. My staff will tell you that we reorganize every time we get a new strategic plan, which actually is about 3 years now, because 4 and 5 years is too long. To Andrea's point about being agile, you have to have shorter periods of time and you really do have to adapt. There is no question about that. The days of being able to stick with one strategic plan for 5 and 6 and 7 years are long gone. So, it's really important that we listen to the membership. The board of trustees really is the guiding force for the presidents. The presidents have a 4-year run up to the presidency, so they have a lot of opportunity to listen to all of you. I think that's one of the keys. It's my job to make sure the organization is structured to execute what the board of trustees and the president wants us to do. So again, it’s a great honor, and thank you Nassir for being here and being one of those board of trustees that helps guide the president and the organization. Doug, back to you.

Packer: That's great. So, I think we went about this in a slightly different way. We discussed why it is that no one president can just jump up to the podium and change policy, but there is a fairly straightforward way that the society is organized. A fairly straightforward way that you can get from one step to the next step. I think the society is in pretty good shape. It’s a pretty good organization and I think that there are ways through it to deal with some things. We didn't spend a lot of time dealing with some of the issues of finances, regulatory and FDA, NHLBI, RUC, RVUs, and the whole issue of CMS. But the system works. It fights to make AF ablation possible.

The transcripts have been edited for clarity and length.