W. Randolph Chitwood, Jr., M.D. FACS, FRCS (Eng)W. Randolph Chitwood, Jr., M.D. FACS, FRCS (Eng)

Eddie and Jo Allison Smith Distinguished ChairEddie and Jo Allison Smith Distinguished Chair

Senior Associate Vice Chancellor for Health SciencesSenior Associate Vice Chancellor for Health Sciences

East Carolina UniversityEast Carolina University

Greenville, North Carolina, USAGreenville, North Carolina, USA

�� Be sure that there is a need at your institution and region for the Be sure that there is a need at your institution and region for the

niche that you would like to develop.niche that you would like to develop.

�� Be sure that your niche is not already taken at your institution.Be sure that your niche is not already taken at your institution.

�� Evaluate your regional competition and how the similar areas Evaluate your regional competition and how the similar areas

have been developed and been successful.have been developed and been successful.

�� Garner support of senior surgeons at your institution. Be sure Garner support of senior surgeons at your institution. Be sure

they agree understand and hopefully like your plan.they agree understand and hopefully like your plan.

�� If cardiology is involved market yourself to them as a a program If cardiology is involved market yourself to them as a a program

developer.developer.

� Self-Assessment

�� List your known skills, expertise, and outcomes.List your known skills, expertise, and outcomes.

�� Evaluate your nonEvaluate your non--clinical collateral strengths (i.e.. Engineering, business, clinical collateral strengths (i.e.. Engineering, business,

informatics, technology, industry relations)informatics, technology, industry relations)

�� Determine your strengths that can develop a niche.Determine your strengths that can develop a niche.�� Determine your strengths that can develop a niche.Determine your strengths that can develop a niche.

�� Review your nonReview your non--clinical and clinical support commitmentsclinical and clinical support commitments

�� Evaluate your communications network within the hospital admin and Evaluate your communications network within the hospital admin and

other staff (doctors, nurses, support staff)other staff (doctors, nurses, support staff)

�� Be sure you have a time window in your schedule to develop a nicheBe sure you have a time window in your schedule to develop a niche

�� Evaluate your support structure Evaluate your support structure –– Division Chief Chair and AdministrationDivision Chief Chair and Administration

�� Select a specialized area that you would like to Select a specialized area that you would like to

developdevelop

�� Percutaneous mitral and aortic valve therapyPercutaneous mitral and aortic valve therapy

�� Percutaneous Endovascular Aortic ReconstructionPercutaneous Endovascular Aortic Reconstruction

�� RoboticsRobotics

�� Arrhythmia therapyArrhythmia therapy�� Arrhythmia therapyArrhythmia therapy

�� Complex Aortic Root SurgeryComplex Aortic Root Surgery

�� Complex ThoracoComplex Thoraco-- abdominal abdominal SSurgeryurgery

�� Mitral Valve RepairMitral Valve Repair

�� Ventricular Assist DevicesVentricular Assist Devices

�� TransplantationTransplantation

�� Pediatric cardiac surgeryPediatric cardiac surgery

�� Informatics and database developmentInformatics and database development

�� Intensive Care Unit CareIntensive Care Unit Care

�� Let your superiors know that this is what you what to Let your superiors know that this is what you what to

do.do.

�� Proffer your detailed strategy to them.Proffer your detailed strategy to them.

�� Prepare a paperPrepare a paper--based strategy plan and business plan based strategy plan and business plan

for your chosen niche for your chosen niche –– no money no mission.no money no mission.

�� Let your hospital leaders in on your early plans and gain Let your hospital leaders in on your early plans and gain

their support.their support.

�� Have senior surgeons an cardiologist introduce you to Have senior surgeons an cardiologist introduce you to

mainstream experts in your chosen niche. mainstream experts in your chosen niche.

�� Meet your younger peers that have selected a similar nicheMeet your younger peers that have selected a similar niche

�� Develop a coalition with your peersDevelop a coalition with your peers

�� Volunteer yourself for committees on important national Volunteer yourself for committees on important national

organizations organizations –– AATS, STS, ACC, ISMICS, SHVDAATS, STS, ACC, ISMICS, SHVD

�� Get to know industry representatives on major clinical trialsGet to know industry representatives on major clinical trials

�� Meet and Get help from outside experts who have been Meet and Get help from outside experts who have been

successful at developing a clinical niche successful at developing a clinical niche

�� Develop a team approach Develop a team approach –– cardiologists, staff, and cardiologists, staff, and

administrationadministration

�� Meet with the team to outline your plans and the projected Meet with the team to outline your plans and the projected �� Meet with the team to outline your plans and the projected Meet with the team to outline your plans and the projected

outcomes and financial benefit for the institutionoutcomes and financial benefit for the institution

�� Garner full team support Garner full team support –– a corporate mentality.a corporate mentality.

�� Collect and review all operational and clinical data and make Collect and review all operational and clinical data and make

midmid--term corrections.term corrections.

�� Process Process engineer each critical step and engineer each critical step and you you have have control of these control of these

changes.changes.

�� Be sure you have appropriate team training as a unit and Be sure you have appropriate team training as a unit and casecase--byby--�� Be sure you have appropriate team training as a unit and Be sure you have appropriate team training as a unit and casecase--byby--

case case review review each each procedure.procedure.

�� Travel to other centers and define your approach Travel to other centers and define your approach for for your your

procedures and/or operationsprocedures and/or operations

�� For early cases have an expert clinical proctor to be sure that your For early cases have an expert clinical proctor to be sure that your

political political base is covered and your outcomes are positivebase is covered and your outcomes are positive..

�� Review your data weekly and have a weekly meeting to share your Review your data weekly and have a weekly meeting to share your

results with the team and administration.results with the team and administration.

�� Adopt a mantra of continual process and outcomes improvement.Adopt a mantra of continual process and outcomes improvement.��

�� Celebrate the successes with the team and the administration. Let Celebrate the successes with the team and the administration. Let

them know that you have brought benefits to the patients and them know that you have brought benefits to the patients and

institution. institution.

�� Involve your colleagues and communicate your program developments Involve your colleagues and communicate your program developments

with them.with them.

�� Get to know the Chief Operating Officer, Chief Medical Officer and CEO Get to know the Chief Operating Officer, Chief Medical Officer and CEO

of your hospital.of your hospital.

�� Keep the medical school dean dean and health sciences vice Keep the medical school dean dean and health sciences vice

chancellor apprised of your program successeschancellor apprised of your program successes

�� Develop an annual report outlining clinical outcomes, financial Develop an annual report outlining clinical outcomes, financial benefit, benefit,

educational advantages, and clinical trials opportunities afforded to the educational advantages, and clinical trials opportunities afforded to the

institution by the program you have developed.institution by the program you have developed.

�� You will have to develop a relationship with industry partners to You will have to develop a relationship with industry partners to

develop your program.develop your program.

�� Get senior innovators to introduce you to the principals for each Get senior innovators to introduce you to the principals for each

company.company.company.company.

�� Industry support renders access to engineers, business people, Industry support renders access to engineers, business people,

and other expert clinicians in your chose field of endeavor.and other expert clinicians in your chose field of endeavor.

�� Be sure to learn about regulatory pathways, protecting Be sure to learn about regulatory pathways, protecting

intellectual property, patents, university and hospital intellectual property, patents, university and hospital

requirements for financial disclosurerequirements for financial disclosure

�� Most of us work in a university settingMost of us work in a university setting

�� Be sure that you disclose any financial relationships with industry.Be sure that you disclose any financial relationships with industry.

�� It is OK to have financial relationship as long as you:It is OK to have financial relationship as long as you:

�� Disclose everything Disclose everything –– usually not a negativeusually not a negative

�� Use personal vacation time and no university resources for profitingUse personal vacation time and no university resources for profiting�� Use personal vacation time and no university resources for profitingUse personal vacation time and no university resources for profiting

�� For FDA trials send a letter disclosing your relationships.For FDA trials send a letter disclosing your relationships.

�� Be sure that your relationships donBe sure that your relationships don’’t taint the trial and cause t taint the trial and cause

university or FDA problemsuniversity or FDA problems

�� If possible when doing FDA trials it is best not to have any financial If possible when doing FDA trials it is best not to have any financial

relationships with the sponsoring company.relationships with the sponsoring company.

�� If you believe more in the mission of the trial than the money If you believe more in the mission of the trial than the money ––

probably best to have not conflicts to provide the best credibilityprobably best to have not conflicts to provide the best credibility

�� Failing to disclose financial relationships with companies.Failing to disclose financial relationships with companies.

�� Inappropriate relationships with medical students, staff, and other Inappropriate relationships with medical students, staff, and other

doctors.doctors.

�� Abuse of any thing: DWI, Drugs, Internet stupidity, staff Abuse of any thing: DWI, Drugs, Internet stupidity, staff

relationships.relationships.relationships.relationships.

�� Using university or hospital resources for personal gain.Using university or hospital resources for personal gain.

�� Financial dishonesty: you must have a real budget.Financial dishonesty: you must have a real budget.

�� Not ”laying hold of your vasomotor nerves” Not ”laying hold of your vasomotor nerves” –– ANGERANGER

�� Loss of clinical and administrative credibility.Loss of clinical and administrative credibility.

�� Let regional referring physicians that you have Let regional referring physicians that you have

developed a new program.developed a new program.

�� Let them know that it will benefit their patients.Let them know that it will benefit their patients.

�� Visit referring doctors for a faceVisit referring doctors for a face--to face description of to face description of

what you are doing for patients.what you are doing for patients.

�� Develop a brief (nonDevelop a brief (non--self aggrandizing ) brochure that self aggrandizing ) brochure that

describes your team, the clinical results thus far, and describes your team, the clinical results thus far, and

referral information.referral information.

�� Develop a personal relationship with referring specialists as Develop a personal relationship with referring specialists as

well as primary care doctors.well as primary care doctors.

�� Write letters to referring doctors with discharge information Write letters to referring doctors with discharge information

as well as a letter thanking them for their referralsas well as a letter thanking them for their referrals

�� After each procedure immediately call referring doctors After each procedure immediately call referring doctors

regarding patient regarding patient outcomes as well as any complicationsoutcomes as well as any complications

�� Derive a followDerive a follow--up plan with referring physicians.up plan with referring physicians.

�� Follow each patient at an appropriate interval after your Follow each patient at an appropriate interval after your operation or therapyoperation or therapy

�� Communicate with referring doctors after your patient Communicate with referring doctors after your patient visit.visit.visit.visit.

�� For complications offer continued followFor complications offer continued follow--up patient up patient visits.visits.

�� Develop a specialty clinic for patients in the niche you Develop a specialty clinic for patients in the niche you have chosen.have chosen.

�� Database your clinical results.Database your clinical results.

�� Calculated risks during niche development are necessary Calculated risks during niche development are necessary –– you must you must

be willing to innovate and step out in front of the herd.be willing to innovate and step out in front of the herd.

�� DonDon’’t become ensconced in past traditional operations and t become ensconced in past traditional operations and

proceduresprocedures

�� Have your colleagues understand the risks and the necessity of their Have your colleagues understand the risks and the necessity of their

support.support.

�� Drag your colleagues into the “risk boat” Drag your colleagues into the “risk boat” –– be sure that you have be sure that you have

senior support and action from your colleagues.senior support and action from your colleagues.

�� Make them realize that your venture is part of the overall program Make them realize that your venture is part of the overall program

advancement.advancement.

�� Often failure can refocus to a young surgeon.Often failure can refocus to a young surgeon.

�� DonDon’’t collapse under the strain and get help.t collapse under the strain and get help.

�� Seek advice from out of institution colleagues as well as your Seek advice from out of institution colleagues as well as your

partners.partners.

�� Redirect your program by their advice.Redirect your program by their advice.

�� ReRe--strategize to getting “back on the horse”.strategize to getting “back on the horse”.

�� Proceed with more caution and with more support from the Proceed with more caution and with more support from the

administration.administration.

�� ReRe--evaluate any failures and process engineer the program evaluate any failures and process engineer the program

toward success.toward success.

�� DonDon’’t be afraid to share your program successes with others.t be afraid to share your program successes with others.

�� This is true even for competing programs.This is true even for competing programs.

�� Develop credibility with other programs by sharing your experiences.Develop credibility with other programs by sharing your experiences.

�� Teach other programs to have the same talents that you have acquired. Teach other programs to have the same talents that you have acquired. �� Teach other programs to have the same talents that you have acquired. Teach other programs to have the same talents that you have acquired. Help them avoid pitfalls that you have experienced.Help them avoid pitfalls that you have experienced.

�� You will be considered to be an important advocate and developer your You will be considered to be an important advocate and developer your clinical niche.clinical niche.

�� It is all about patient care It is all about patient care –– and you will be considered a leader and and you will be considered a leader and educator.educator.

�� The nice route is collaboration and not a have selfThe nice route is collaboration and not a have self--serving institutional serving institutional program.program.

�� If you follow these guidelines.If you follow these guidelines.

�� If you are free in disbursing information from your program and educating If you are free in disbursing information from your program and educating

othersothers

�� If you CRONICLE YOUR RESULTS AND MARKET CAREFULLY. If you CRONICLE YOUR RESULTS AND MARKET CAREFULLY. However, However,

Sir William Osler once said “beware of the Delilah of the press”Sir William Osler once said “beware of the Delilah of the press”Sir William Osler once said “beware of the Delilah of the press”Sir William Osler once said “beware of the Delilah of the press”

�� If you believe that it Is not about you but your niche and program.If you believe that it Is not about you but your niche and program.

�� If you ask other teams to come and visit your program and you help define If you ask other teams to come and visit your program and you help define

their clinical niches and path for program success.their clinical niches and path for program success.

�� If you become involved with professional programs and committees and If you become involved with professional programs and committees and

publish your work.publish your work.