The water is wide. (Next!).

KEY CONCEPTS

* Changes in the Practice of Cardiology

* New, Emerging Technology

* Adapting to Technological Advances in Health Care

* The Point at which We Have to Change

* The Courage to Cross the Great River

Trying to predict what cardiology will look like in 10, 25, or 50 years is an almost absurd act of imagination. Perhaps even more than most branches of medicine, it has been changing so fast that it is hard to recognize from year to year. When we contemplate the changes that cardiology and the rest of health care are facing, we know that none of these changes will ever be "just technical." They will all be deeply human, and each one will be very difficult for some people. As people and organizations, we all come to that point where we have to change. Where we are is not working, we can't go on like this, we have to do something different. After boldly setting off to go someplace new, after some basic work is done to escape the original presenting problem--we reach the Great River. This is a point at which small, incremental changes won't do and we truly need to see ourselves differently. There is no bridge, no easy way across. This is where we must gather our resources and courage, remind ourselves of why we came this far. Yet many of us don't, and settle for something comfortable rather than cross that wide, turbulent river.

New Orleans: I'm sitting at the riverside, staring east across the great river to the lights of Algiers on the west bank. Up on the bank behind me in the hot night, one of the Vieux Carre 's ubiquitous street musicians plays a mournful sax. I recognize the old folk tune: "The water is wide, I can't get o'er, neither have I the wings to fly..." They say you come here to see if your ticker still works, between the hot Jambalaya and the cool blues Joints, the hot strip clubs and the cold midnight cemetery tours, you'll test the old pump. I'm here for that-and more.

Here in New Orleans, I have held in my hands a beating human heart-made of titanium and plastic. The company will try out its "replacement heart" on real people starting next year, and its display here at the Annual Scientific Session of the American College of Cardiology (ACC) is one of many that would startle and shock most people.

Almost an absurd act of imagination

This year is the 50th Anniversary of the ACC. The College has invited me to scan the technology of the next 50 years: What will "heart docs" be doing in ten years, in a generation, in half a century? So I came to New Orleans to get a close look at the present state of this peculiar art, and to interview some of the researchers that are creating the future, I've got an ace team of cardiologists helping me--Alfred Bove, MD, of the University of Pennsylvania; William Weintraub, MD. of Emory University in Atlanta; and Leonard Dreifus, MD, of Florida, a former President of the ACC--but I've really got my job cut out for me. Cardiology, perhaps even more than most branches of medicine, has been changing so fast that it is hardto recognize from year to year. What it will look like in 10, 25, or 50 years is an almost absurd act of imagination.

The field of cardiology is exploding

As recently as the mid-1980s, researchers debated whether there was any way to treat the damage created by an acute myocardial infarction. Major studies would include control groups who received no treatment at all. Then aspirin turned out to have a major effect in preventing further heart attacks by blocking the formation of platelets in the blood, Now the market and the FDA approval pipelines are full of drugs that work like aspirin, but more strongly. In the late '80s and early '90s, balloon angioplasty became the rage. It worked, but it wasn't permanent. About half the patients had to come back again and again, as the vessels re-filled with plaque, or developed restinosis. The repeat business was hard on the patients, good for the finances of hospitals and doctors. In 1994, Johnson & Johnson developed the stent. Once it was accepted (a major uphill battle), return cases dropped to 15 percent. Coronary artery bypass grafts have for years been a major business of hospitals across the country. Now a number o f drug companies and medical researchers are working on angiogenesis, tricking the genes of the cells in the artery to begin growing again, growing new arteries to replace the clogged ones. The next step, already under study at Baylor College of Medicine in Texas and elsewhere, would be to take muscle cells from elsewhere in your body, genetically alter them into myocytes, and place them in the heart to replace dead tissue. The time will come when you will be able to regrow your heart in your chest.

Studies of the genes, in fact, promise to unpack a plethora of new possibilities. We used to think of genetic therapy as a way to fix such genetic diseases as sickle-cell anemia. Researchers now understand that every disease process involves genes that turn on or off. This means that every disease is open to management and cure once we understand which genes are turning on or off, which are cause and which are effect, which are the key links in the chain.

Those are just the headlines. Cardiology is exploding, morphing monthly into new and strange guises. How I am going to put together a 50-year forecast, I don't know. It may well be that, as Dr. Dreifus put it, in 50 years there will be no need for cardiologists: "My hope is that somehow we will have gone the way of the polio docs."

The water is wide

But the water is wide. Each change we contemplate brings organizational and personal changes, changes in vocabulary, skill set, and point of view, changes in colleague relationships and in organizational structure. What did all those polio docs do? Where did all those research programs go? And all those people who made iron lungs? No one was sorry to see polio disappear, but its vanishing act changed the lives of many people.

When we contemplate the changes that cardiology and the rest of health care are facing, we know that none of these changes will ever be "just technical." They will all be deeply human, and each one will be very difficult for some people.

There is an adage that comes from the 12-step world: People change when the pain of where they are becomes greater than the perceived pain and difficulty of changing.

As people and organizations, we all come to that point where we have to change. Where we are is not working, we can't go on like this, we have to do something different. At this point we often engage an outsider to act as a guide to that new place: an organizational consultant, a life coach, a therapist.

Talk to anyone in that business, and they will tell you what often happens next: the person or the organization ("the client") sets off boldly and with great determination to go someplace wholly new, like a pioneer "lighting out for the territories." They may even have a goal, a dream, their California, their Oregon, their Salt Lake City.

They work away boldly for a while, then after a while--after some basic work is done, and the client has escaped the original presenting problem--they reach the Great River. They reach a point at which small, incremental changes won't do, a point at which they truly need to see themseives differently, to be someone they have not been before. There is no bridge, no easy way across, just some small and risky ferry rafts. This is where they must gather their resources and courage, remind themselves of why they came this far, of what California means to them, what they hope to build in Salt Lake City.

Yet many of them don't. They say, "You know, to tell you the truth, I am a lot more comfortable than I was before we set out, And this looks like a good spot. There's land here, and safety, and of course plenty of water. I think I'll just stay here. Thank you very much, here's your pay.

What's your Great River?

But when you leave them, you can always hear them singing, and it's not a song that says, "This is the place." The song is always, "The water is wide...."

If you haven't stood there, you will. All of us in health care will, probably repeatedly, over the coming years. What is your Great River? What is your Oregon?

Joe Flower Is Principal of The Change Project, in Larkspur, California. He has written about change in health care for over a decade. Author of hundreds of articles, he is a Contributing Editor for the Healthcare Forum Journal and New Scientist, a system host of The Well Computer Conference, and a faculty member of HealthOnline. If any of the ideas presented in this column resonate with your experience, drop Joe a line at The Physician Executive, or at [e-mail] on the Internet.