Good afternoon, everyone. Thank you for joining us at Roundtable 1. Today we'll be talking about interactive educational models for prevention of cardiac disease. And we're very grateful to be here with an esteemed panel of speakers, where we'll just be, you know, talking about what we've been doing on the patient education front, specifically what innovative practices we've implemented in our research and or in practicing with patient care. I'll start off with introducing Dr. Sam Sears, who is a professor in the departments of psychology and cardiovascular sciences at East Carolina University. He also serves as the division chief of innovation and research. To my right, I have Julie Hsieh, who's a nurse practitioner at Brigham Women's Hospital, probably doesn't need an introduction, but nonetheless, here we are. And to my left, I have Anna Streeter, who is a cardiac device nurse at the University of Virginia Medical Center. And I think this discussion today has been really fruitful. We know that allied professionals are certainly at the forefront at some of the patient engagement and patient education that happens beyond the visit to an electrophysiologist, but even on the front of the cardiologist as well, right? And specifically at this conference, we're talking about innovation, and sometimes for us that means AI, that means technology. We're getting all these buzzwords about how we're helping patients, but I'd love to kind of dive into some of the ways that we, as providers and as staff, have really driven the patient education front, and maybe we'll start with Julie. Julie, I know that you run the Virtual AFib Symposium out of the Brigham, and over the years it seems like it continues to be successful, and we'd like to hear more about what was the motivation, I guess, to start that, and what were some of the things that you were hoping to achieve and want to continue to achieve through your program? Well, thank you so much, Tiffany. And yeah, the AF program actually started quite a while ago, probably 20 years ago now, where we had it as an in-person program, because there was a need, obviously an ongoing need, for education and support of patients with atrial fibrillation, to learn all aspects of it, as well as kind of the psychological care of those patients as well. And so we would hold it in a ballroom at a hotel in Boston, and we would literally fill that entire ballroom with over 800 people. Dr. Sears has participated several times in the AF program there, and it was a very well-received program. And then fast forward many years that funding became more of an issue, and we had to drop the program temporarily. And then we decided kind of in 2019 to resurrect the AFib program, because there was obviously an ongoing need for it, but we had to kind of think about how we wanted to revamp the program to reach more people. So that was when we came up with the idea of the virtual symposium, and it's worked really well. It's a Zoom-based program where we have it on a Saturday in October, and this year it's scheduled for Saturday, October 5th, from 8 in the morning until noontime. And patients can register on Eventbrite, and it's open to everyone. And how the system works is they will log on that morning. We have a series, little blocks of presentations going over all different topics of AF. What is atrial fibrillation? What are risk factor management, wearables, ablation, anticoagulation, the genetics of AFib, talking about patient preparation for atrial fibrillation. And we also have a clinical psychologist or psychiatrist that logs on to help with kind of the psychological aspect of that as well. And so we have pre-recorded presentations, and then we have an open block session where patients can actually ask questions of the faculty at that time. So it's able to provide some interactive support for patients. We've had great results with typically anywhere from 300 to 500 people that will log on. And we've had people from all over the world. So I've actually, this year we've had someone from the UK join. So it's really improved our outreach to patients now kind of across the globe, because that's the power of the internet, right, that we're able to do that. So we took this kind of conservative, contemporary program and then kind of brought it up into 2024, moving it to a virtual platform. And it's actually worked very well during the pandemic that we were able to continue to provide support for our patients with AFib. Go ahead, Sam. Well, again, I think first off it's that Julie recognized the need and came up with a solution. And I think one of the challenges for us in an EP is that we have technological solutions for everything. But the problem is that it's a multiple interaction. That is, patients actually do need to understand a bit of what we're dealing with, what are we trying to manage, why are we trying to manage it. There aren't that many consumer interactions where you're going to provide a service and then it's important for the people receiving the service to understand, why did I get this service? I mean, nobody goes to the car dealership and goes, hey, I'm getting my oil changed, but it's really important that you understand how oil goes through the engine. Nobody cares. But in medicine, it does matter. And it matters because they may not bring their car back again. And that's actually a problem because their cars break down, except in this case, oh, it's their body. No, it's a great point that you bring up is it's beyond education, right? We're trying to make patients actively participate in their care, right? Because then we know that there's improved outcomes and we understand that they can take this information and pass it out to their family members. This widespread education that can happen even beyond the patient, right? And we've seen this in providing information about arrhythmias, but I'm curious, and I'm working in the device space, what have you seen and what are some of the innovative ways that you're capturing patients and engaging them in the education side of things? So in terms of stressing the remote monitoring, especially since COVID happened, we've been trying to make sure all the patients understand what remote monitoring is and educating them about that. A lot of the device manufacturers kind of have now apps that you can, like the Latitude app they have, then you can see, they can see, like we educate them about the app, hey, you can be connected, like you can see your monitor is working. So that's really important to kind of ensure like the connectivity to educate them about that. But, you know, just like Dr. Sears said, we still have a lot of patients that actually declined the remote monitoring and they want to come in for in-person visits. During COVID, we were actually doing our two visit device checks telehealth, but then we also had a population, a big population that did not want to do telehealth. They still wanted to come in and have that one-on-one. They want to bring their family members. They want to make sure their family was involved in education, but, you know, there is also younger population that's getting the devices. So they're, you know, more open to using the apps and be more remote monitoring and just coming into clinic every like 12 to 18 months. And of course, there's also an issue of having connectivity to where they live. So if you have patients that in Virginia, they live in more remote areas of Virginia, like more like West Virginia area, and they don't necessarily have the connectivity. They don't have a landline, they don't have Wi-Fi, they don't have cell service. They sometimes have to drive several miles down the road to send a remote transmission. So they would rather just come in in person and have that in-person interaction, get their education about their device, about what their heart is doing. They're kind of like, I don't know what happens via remote monitoring. I want to be in person. And that just kind of gives them that reassurance, like, oh, my device is working, kind of like a peace of mind, even though we're kind of always in the background watching them remotely. So we still encourage them to stay connected. But if you want to come in person, that's okay, too. Yeah, I think that's a great point. And I know Sam is really passionate about the human interaction piece, right? So I'd love for you to speak on the importance of not losing that inside of, you know, being innovative and trying to maybe do the more hybrid virtual models of care. Well, hats off to electrophysiology for innovation and for this conference. But the challenge is going to be that I think there's a secret initiative here. People want to somehow move this care to a 100% technologic solution. Even in this month's Heart Rhythm, there's an article about a European clinic that went 100% remote. And Anna mentioned 20%, about 20% of patients don't want remote monitoring. But I think the larger issue here is we focus on things like a-fib burden or shock burden. But the patient burden of living with a disease is substantial. Diabetes, the best example we have, old study but still kind of provocative, 143 minutes a day to live with diabetes where you do things to take care of that disease. So when you start talking about the a-fib burden, you start talking about understanding ventricular arrhythmias, you start understanding fainting spells, patients spend a lot of time managing these diseases. And people go, oh, come on, that study was overblown, 143 minutes, nobody needs that long to take diabetes. Well, with diabetes you have food preparation, you have medication management, you have exercise, you have wound care, and on and on. And so maybe it's bloated, maybe, give me half those numbers. And the point is that there's still a patient burden to these electrophysiologic diseases that I don't think we can tech our way out of, we might be able to tech our way down, but I don't see an escape here. Yeah, and obviously having the wearables and all the data that the patients have but don't interpret, can't interpret, don't know what to do with, that still has to go somewhere, right? And we have to adopt that as clinicians or folks who can interpret that information and provide real solutions, whether that be increasing their medications or thinking about ablation or working their way towards a device placement, right? So you bring up a great point where there is this challenge, right, in trying to make sure that we're not getting too ahead of ourselves and helping to manage patients or lose them as a result of that, right? Hey, everybody loves the tech, man. This is cool, right? It's cool to tech out. But if you think you're going to human out, no way. I think Tom Dearing brought up, he called AI augmented intelligence. So I think that we want to use AI to help support us taking care of our patients in a more efficient, more qualitative, more quality type maneuver. But we don't want to replace the human interaction. I think that takes away from, we want to keep the patient at the center of care. What could you imagine? We have HRX focused on tech. What if we had like HR patient? Would anyone come? The purpose of this meeting is we're going to teach us, teach people how to teach patients. Everybody will be like, I ain't going to that. Yeah, that's actually funny because I think one of the themes that we've talked about during this conference is the patient being the value of healthcare. This is why we're all employed. This is why we're all here, right? Is to center the patient and to say that that's what we prioritize. But are we losing that when we develop these technologies that allow us to really not engage with patients, right? They do by sending us this data, but are we losing the interaction that we gain plus the educational benefit of having that conversation in person? And like you said, people wanting that social interaction, but also wanting that education in person versus receiving that virtually via audio or a voicemail or a patient gateway message or whatever that may be. Well, that's why I think it's important with our AFib program that yes, a lot of that is just watching a video, but then we do have to give the patients time to ask their questions and interact with the providers and you know, make sure that they're heard, right? That their concerns are heard, which I think is important. It's not the data supports exactly what she's saying. If you look at remote care for depression, remote care, any kind of web care for mental health problems, because that's the most developed area, handing somebody a website, handing somebody a book, handing somebody a workbook of any sort, there's still all the data says those work best if you initiate it with a human and you finish it with a human. Because we're freaking humans. Otherwise we'd all read books and be like mentally superstars, okay? But that's not how our lives work. We interpret and feel. I'm sorry we're flawed. I'm sorry we can't tech our bodies into perfection, but we can. Right. And I think that goes back to using AI and using innovation as a tool, right? And not replacement, right? It's certainly a benefit to have access and have people who are willing to develop ways that we can continue to support patients, increase patient safety, increase patient satisfaction, be more convenient for patients. I think convenience is a big thing. And part of that kind of drive is why we innovate, right? Is to make things rapid, to make things faster, better, stronger, whatever. And so I think that's definitely pushing me towards a question where I think us as clinicians and folks who are at the bedside and directly engaged in patient care is one thing. But who are the other stakeholders here, right? Is it industry? Is it health policy? Who are the other people that should be pushing this agenda? So definitely industry and vendors. We definitely I feel like APPs are better at collaborating with the industry, like their advisory boards, right? And we're always giving them feedback on how can they help us with educating the patients. Because we have, you know, always make sure the reps go see the patients when they get their devices, right? Like can you go there, you're the expert, educate them about their home monitoring. Just to, you know, start that as soon as they get it. And then not only that, but also the vendors also want the feedback of other ways they can be more involved. So they have kind of like asked feedback in the past, like is there like certain brochures that you want us to bring in? Is there certain things that we should be posting on websites just to kind of help the patients, you know, to be more engaged and kind of have that also like from their side just kind of having pushed them to also be involved in education. Not just only us at bedside, but also the industry. Yeah, and I think the resurgence of shared decision-making tools and really being held accountable for the quality of the conversation that we're having is really important. I think that's been embedded at least from the ICD perspective really well, but we're starting to embed that into our Watchman conversations, into our, you know, AFib conversations, ablation conversations. But I agree, you know, if we as clinicians could be reimbursed for having these education conversations, I think we would be more than delighted to have them, right? But that infrastructure, as I know it now, does not exist, right? There's some clinics, some clinics are doing what we're calling, you know, shared visits in the sense that there are roundtable discussions of patients who may have the same diagnosis, so let's call it hypertension, right? And they have, they're on medications that treat hypertension, and they're having their first hours, first 30 minutes of the visit is didactic, in which we're talking about hypertension, how to treat, whatnot. But then the second segment of the conversation or the visit is you're actually going around the circle and saying, hey, Julie, today, what dose of lisinopril are you on today? And you're like, oh, I'm on 20, and then we're talking about ways that we may need to go up for this week just because your blood pressures have been high, or, you know, kind of going around the table and getting a sense of how we can help each other manage our conditions that we all live with, right? So that's one approach that's interesting. I don't know what the reimbursement looks like in that realm, but if I could also see that as a way of incentivizing people, clinicians specifically, to have conversations that are rooted in patient education that, you know, again, you're reimbursed for. Well, I could see those groups getting together, you know, you could call them the aces and the betas and the Arnies, you know, we could just have, like, groups of them, it's like, hey, Arnie, are you an Arnie or are you an ace? You know, I think it'd be cool, you could get t-shirts and stuff. But the point is, of course, that there is a power in group participation or the universality, that's what we're talking about, that's what's so powerful about Julie's group, is that there's universality. Everyone has a similar kind of challenge. And the other part I would pick up that you talked about, Tiffany, was just that health policy and therefore health purchasing or reimbursement still doesn't value that empowered patient. We talk about it, but we're not being paid to do that. And as unfortunate as it sounds, behavior follows reinforcers in this case. And so, we are relying more on industry, as Anna said. We have to, by every means, try to educate patients. But in my view, one other thing that we're missing in this, and maybe this relates to health policy, is why is it important for them to be educated? And in my view, the only reason that we want people to make sure they know is so that they are empowered. And specifically, the two endpoints we look for in our clinics at East Carolina is, did we make this patient more confident? And did we make this patient more physically active? By this interaction and by this medical treatment, have we improved the chances this person will go and do? And have we improved the chances that this person will do it with some want to, as a non-diseased person would do? Now, of course, you're 95 years old. I'm not expecting them to run a marathon. On the other hand, I want them to go to the grocery store and push a cart. I do. I want every aisle covered. I don't know if you only need one thing. I don't care. I want every aisle. Because that's the only way, right? It's safe, right? It's safe. So, I don't know. To me, patient education needs a clinical goal that I can understand. A smart patient's a good patient. I get it. But, I mean, so what? They could pass a medical school test. That doesn't mean we've done enough to empower them. No, definitely. We're using metrics like labs and, you know, it would be a burden to get a sense of how well they're committing to those goals, right? But the reality is there are other metrics, like you're saying, ways of evaluating how well patients understand their condition and how well they see it as vital to their overall survival or benefit or whatnot, right? We do that with our ICU support group over at the Brigham. You know, we really are trying to figure out how effective these programs are, right? Because if we just continue to run them and we're just putting on programming that doesn't matter to people, then they're not going to come and they don't get the benefit, right? We constantly put out a survey after our events just to say, you know, what do you still need, right? What is it that you're looking for? Is it just the community, right? Do we have to take this offline and just make a Facebook group and call it a day? Or is it the content? Is it the content and community offer at the same time? Is it the conversation? You know, I think there's so much that comes from them just gleaning experience from other patients, but then also being able to have the didactic part of the conversation, which I don't know we as clinicians do a good job at before they get the device, before they do the ablation, before they get to you, right? Like there's too late at that point, right? I think the work that we need to do pre is still out there. And that's where I think industry and heart rhythm and, you know, all these organizations that have stake, you know, at play with patient care is where they step in, right? And create conversations and create models that help support patients and feel more educated. And I should also mention there is a Q&A section in your heart rhythm, HRX app. So please, if you have any questions, feel free. Otherwise come to the table, grab a mic, whatever you feel comfortable doing, but we'd love to engage with everyone who's part of the conversation today. Yeah. One of the other things I was going to mention in terms of modeling is, you know, in terms of AFib and risk factor modification. So these, you know, came out in the guidelines, these pillars, weight reduction, sleep apnea, alcohol reduction, watching your blood pressure. Like how are we, you know, we don't really have a standardized way of operationalizing all of this. I mean, we mention it to the patients, but then they come back, they're still drinking, they haven't lost any weight, or they put weight on, and so you're kind of backpedaling here. I thought it was interesting listening to the cardio sleep round table yesterday, was amazing, and talking about sleep as a vital sign, and using the stop bang assessment to look at people's sleep, and I think we're now realizing that it's underdiagnosed, that a lot of people, they're not your standard overweight, thick-necked people that you would think have sleep apnea. I sent a lot of patients to the WATCHPAT study that enrolled patients, and a lot of people that I was surprised that came back that had sleep apnea. So I think we need to do a better job in terms of education with risk factor modification and atrial fibrillation. Well, I would agree. In my view, those consensus documents are aspirational. I know almost no places in the world that are truly going after cardiac risk factors in the AFib world as they would. I think part of it has to do with EP needs to decide, are you gonna be the arrhythmia sheriff and try to prevent crime and arrest crime, or are you just gonna go like, hey, some crimes happen, right, AFib happens, but we can prevent crime. So what kind of sheriff you wanna be? I think we do a good job of being stroke sheriffs. Okay, no strokes are happening around here, right? We're gonna prevent those. But crime happens via a process, not just events. Yeah, I mean, AF is something that's in development, right? This is not something that happens overnight. I mean, it's, you know, typically people have had sleep apnea for years, and kind of the end game there is now their left atrium's dilated, and they've got sleep apnea, and so you're kind of starting after the crime's already occurred, right? Yeah, that's actually a good point, and that is maybe where we talk about before they get to EP, right? Like, a lot of us aren't treating them until they get to us, right? And we're kind of a, we're a subspecialty, and so it's a second-line defense, if you will. But Sam, I know that there was a paper in 2016 that talked about how well we're doing with, this is a particular example, of ICDs and how providers being, it's disappointing, I guess, in terms of what we know and what we don't know about working with, or the hesitation about treating patients with ICDs. Yeah, this is fun, this is like Sam rant. Anyway, no, my next rant is that, okay, so let's say that we go with a total tech solution in EP, right? So we're so good at remote monitoring and everything, and our patients are all out there in the world. The problem is that the overall literacy toward arrhythmias, and arrhythmia care, is actually quite low. And this study that you mentioned in 2016 showed that the rates of passing even rudimentary kinds of questions about how a defibrillator works by internists and geriatricians and hospitalists was scary low, in the realm of about a third, being able to have reasonable knowledge base about that. Now, I don't know why that is. It's not because they're not smart, it's because somehow they're not exposed to the same amount of information, and certainly clinically actionable information about some of these disease states. And as you know, and I think Anna mentioned, or you mentioned it, Tiffany, that our patients come to us having already seen a number of physicians, so they already have acquired some knowledge about their condition, of which some of which might not be exactly how we would approach it, because it's a matter of perspective. I mean, that is, what they were told was absolutely right for that setting, but now we're in a different setting. So I just, I think it's worrisome. I think the expertise of electrophysiology practitioners can't be replaced by technology. I just, in the end, I think there is something that's going to have to happen in EP clinics that can't be teched out. I just, I get it, but providers are still a powerful force. Yeah, I'm curious, Anna, any thoughts on that? Yeah, just going back to educating providers, we're actually big on that at UVA, trying to focus on educating general cardiology fellows, because they're kind of like the first, right before that crime occurred, right, when they're getting diagnosed. So we're definitely making sure they're educated with a device, in the device world, and understanding what it means to, like what can a patient do, and what can a patient do to help them what can a pacemaker do, because a lot of them coming in from their internal medicine residencies, right, they have no idea what a pacemaker does, what a defibrillator does. So definitely like, you know, educating the fellows, and I think a lot of the APPs are very involved with the fellows in other facilities too, just, you know, catching the newcomers early and just educating them what it is, so they can kind of help to spread the word for the patients. You mean like a police academy? Yes. Stay with me here. Yeah, I was gonna kind of manage too, you know, we're still dealing with, I mean, how many times do you get messages, emails about MRI screening, right, that that's become the new frontier in terms of getting questions from cardiologists and primary care physicians, can this, so bogged down, I mean, every week I'm getting messages from other providers, you know, can this patient have an MRI? So that's kind of another thing we have to deal with. I love that because that's a more modern example than the 2016 paper, right, so a more urgent sort of time sensitive change, and that's, and the level of literacy is still probably not great about MRI suitability capability. And I mean, I think they should be leaning on us to find out this information, but, you know, it's labor intensive on our end when you're getting these email messages and now you've got to try to look up the information for them and provide that to them, so is there a way we can do better with that? Yeah, great questions. We have about like four minutes left, I don't know if the audience has any questions, but you're more than welcome, again, to put it in the app or bring up, yeah? Since Julie invited me to sit down, I will put my two cents in as a pediatric person. Something that's been pretty successful for us is in their single ventricle population we have a home monitoring program, and I think that's pretty much standard of care in any large center now that sends babies home between their stage palliation. And I'm almost wondering, as I sit here, is there an analog for your AFib, for your lifestyle management, where we're asking these families to send us weights and feedings, and we're also having that human touch of a nurse who's, so they're sending us data, it's a digital line, but there's a nurse managing that, and there's that empathy piece that keeps them accountable and compliant. I think for your AFib lifestyle measures in adults, that might be kind of useful. Yeah, thanks, Jamie, that's a great point. And I can't say that we're doing that routinely, at least at the Brigham. Oftentimes patients are certainly keeping track with their wearables about their AFib burden, or we're doing a really good job post-procedure, when we have them wear a monitor, or they leave with a cardio or a blood pressure, and they're checking it intermittently just to make sure that they're not having recurrent AFib. But I can't say that it's this ongoing evaluation or monitoring that allows them to continue to be engaged, but then also gives them the reassurance or the empathy that they're looking for in terms of not being abandoned. At least in our practice, that's essentially how it's worked out. But I'm curious if that's been the case, Julie, Sam, in your practice as well, and Anna. Yeah, I mean, usually a lot of these patients, I try to make sure that they have some tool at home that they can use to kind of empower them to kind of monitor themselves going forward. So that if they do have AFib ablations of a shelf life, so they may at some point downstream have recurrent AFib, and having a tool at home that they can easily record that and send that into us, I think is important. In terms of the remote monitoring patients, we usually kind of tell our patients, just because you have a device, it does not mean we are able to watch it 24-7. And depending on the manufacturers, you might have different alerts set. And if you're already anticoagulated, we're probably gonna have the AFib alert turned off. So we're just always educating our patients, just trust your body. Like if you're having symptoms, please call us, please send a manual transmission. So we're just kind of re-educating them that the remote monitor can't catch everything, just because we might have your alerts off. Perfect, and we do have a question in the Q&A. What are your thoughts of AFib centers of excellence with an interdisciplinary approach to preventing further AFib? Should every center aspire to develop one of these programs? Great question. I would say yes to that, for sure. You know, we do have a center of excellence at the Brigham and Women's Hospital, and it's actually interesting that we run by General Cardiology, that they have taken ownership of that. But they have done a nice job. Elliot Antman, who kind of leads up the center, he was the lead author on something that was published on CardiQ. About AF center, it's called the AF Playbook. If you haven't seen it, check it out. It provides a step-by-step approach how to set up an AF clinic. So if you have any questions about that, that's a great resource. And if you're not familiar with CardiQ, that there's multiple resources on there about atrial fibrillation. I agree, I think the answer is yes. We wanna aspire to that. And actually, that gets closer to your point about pediatrics and single ventricle, because pediatric cardiologists are comfortable saying, the buck stops here. I mean, there's gonna be, they're gonna have pediatricians who are gonna be like, whoa, I'm good with a lot of what's wrong, but single ventricle, oh, I'm out. Well, I think AFib doesn't have that quite I'm out feel, but electrophysiology is gonna have to say, are you guys gonna be where the buck stops? And with AFib, or are we gonna do something, PFA or ablation of some sort, and then say, okay, going out to the community, we're really, are we gonna be proceduralists or are we gonna be disease management specialists? And I think that still is a question to be had. Is this discipline gonna continue in which directions? So I don't know the answer. I'm just not sure what's gonna happen, but I think there are gonna be some forks in the road here, probably health policy will be placing that fork about what's reimbursed and what's not, but I don't think we're gonna be able to do everything for everybody forever, so we're gonna have to figure this out one way or another. Yeah, I completely agree with that. And I think you're right. Some of the legislation that's come on already certainly drives our practice to some degree, which is unfortunate, but again, is real, right? These are some of the stakeholders in the conversation of patient education. I just wonder, I don't know if you're getting this in your practice, Sam, but are patients, what are patients saying? Do they want, I'm sure they want to be engaged, they want to be part of their care. I mean, it's evident with the data that they send on Patient Gateway that it's very much the case, but I'm wondering, are we looking at this the right way? Is this, do they, giving them more access to their information, giving them more power into this conversation, does that actually translate to them feeling more empowered? Does that make sense? Yeah, so we have both the European survey from about two years ago, and then all qualitative data. There's multiple meta-analyses available with both ICD patients or AFib, and there's no doubt that they want more contact. They want more psychological contact, they want more, they want to know what their ILR says, they want to know what their device, now, whether or not we send them their transmissions is a whole nother question, but what they don't want is a plug-and-play situation with arrhythmias. They don't feel safe with a call me, I'll call you, don't call me, or whatever. We'll call you, don't call us, which is the opposite of what Anna just said, basically. If you need me, I'll call you. And I think that because, whether you like it or not, people think that a symptom in the heart is always significant. Problematic, right. Every single symptom of every single sort. And so, you've got to understand that the average layperson doesn't, they don't have categories for mild, medium, and severe. They're all severe. No, that's a great point, and this is exactly why education is important, right? We can capture, we can help patients become more informed about, this is you stay home because nothing's happening. This is, mm, you should probably call someone. This is, you need to go to 911, call 911 now, right? We can give them that scale, which, to your point, I think a lot of people just unfortunately associate anything in the chest as bad, which is not inappropriate, right? That's fair to say. But I do think, part of this is the 30 minute visit that you get to have this discussion is not even enough, right? And so, if we had more time that, again, was reimbursable, that we can have these conversations so that they don't trickle off and come back with more questions or have to have another visit, that would be fundamental, right? Because then we can have the opportunity to actually say, well, these are bad. These are, you know, put them into categories that are digestible as opposed to just thinking about it in one particular way, right? The interesting juxtaposition here is the patients that have, you know, multiple shocks and they'll call you to get permission to go to the emergency room. Like, so what do you think? I'm like, I think you need to go to the ER. So, it's interesting how they kind of, they know they have to go, but they don't want to go. They just need you to push them. Yeah, we can argue the emergency room is not the most hospitable place to be sometimes, you know? Like, no one wants to be there if they don't need to be, but certainly educating them on the severity of what could happen is definitely important, which I think sometimes we don't capture well enough. Yeah, well, the good news is that Julie and I wrote a paper years ago about what to do in shock, and at least in that case, it's clean cut. We can give them very direct two or more shocks. You're coming to the ER. We don't care how you think or feel. But most of the other things we deal with in EP are more subtle, and they're not so demarcated where we can say, for sure, do this. And again, that's gonna make it more challenging for us. Yeah, for sure, especially, you know, you have those patients that come in with like slow VT into clinic. You just roll in, and you're just like, wait a minute. And, you know, they're completely asymptomatic. You shouldn't be here. Like, how do you educate those patients, right? And that goes back to, like, device did not detect that. We didn't get alert for VT at 100, but that's obviously not safe to drive. But, you know, we have the same issue where, you know, when the patient gets a device, and we do an education at discharge and two-week post-op visit, we're definitely stressed at like two more shocks, the same thing, go to the emergency room. One shock, you feel fine, call us. We can take a look, and then we'll go from there. But if you had a shock, and afterwards you don't feel good, you passed out, definitely emergency room visit. And, you know, but it's always hard to treat the AFib patients, right? Because everybody has different symptoms, and some of them call us, and they're definitely concerned. Like, I've been in AFib for days. Like, why nobody called me? So that's definitely, I feel like sometimes we're not doing a good job educating them on that. Like, it's okay if you had AFib for a couple of days, and you felt okay, and you're anticoagulated, you're taking your medications, but I don't think we're, you know, doing such a great job. Kind of reiterating that. Well, just the concept of slow VT. I'm sorry, you're not making sense, right? Oh, how about pacing, and different, the word means different things at different times. So, not surprising, our patients are like, slow VT, I thought you meant that was fast. You know, just, we have terms we use so quickly, and fast, with a facile way, and our patients are like, well, I don't know what you mean. So, it's complicated. No, I think you're spot on. And you can even say that sometimes, if that was seen by a general cardiologist, they would maybe not catch it. It's possible, or a PCP, right? But going back to a point that you made about a device not catching slow VT, you know, where there's this reliance on technology, right? But what are the limitations that we're facing by putting so much emphasis on embedding it into our practice, right? You know, AI's not perfect. We obviously have to feed it information, and we also have to assume, and provide it accurate information, right? How many times do you get ads about things that aren't real, and you're like, huh, is it real? And it's very hard to tell, right? And you can imagine patients have that same experience, where there can be this difficulty in deciphering what's real and what isn't, but then also, you know, the severity of the information, right, and where the source and all of that. That's certainly a question when it comes to developing AI technologies, right? Yeah, let me just check it out. Yeah, I think, you know, there are just so many opportunities here, right? We're seeing industry pushing the agenda on patient education. We're seeing providers push the agenda. Certainly regulators and health policy continue to be stakeholders in the conversation. But are there other ways that patients would want to obtain education? You know, obviously, the most common source is Google. Everyone says, well, doctors, and we've all done it, I'm sure. But is there, would there be another, you know, place that patients would go for information? It would, you know, I think HRS with the upbeat.org, you know, website certainly is trying to do a good job in at least starting the conversation there, giving the patient tools to learn about atrial fibrillation and risk factors and anticoagulation and treatment options. But is there an ideal place that we would say, why don't you just go to the website and just go to the website and find out more information? Is there an ideal place that we would say, why don't you go check this out and come back to me? Even if that's at the PCP level or, you know, at the cardiology level. Well, I think we are seeing patients engage in this space. So we have one podcast is called Heart Warrior from a gentleman in Belgium who has just cranking out great content. Or you see even on Reddit where people are on there and I get on, I'm like, wow, this is super technical for Reddit. And our patients are, they're seeking something more whether we give it to them or not, I think they're going to get it from somewhere. Hopefully those are trusted sources, but obviously the internet has both pros and cons. I just wanna, you know, I know we've only got five minutes left and kind of this topic to bring up is a loaded topic that we could do an entire round table on for sure, but doing education in non-English speaking patients is a huge challenge and I struggle with that because it's, you know, obviously getting an interpreter in but everything time-wise can take twice as long to interpret things and then you don't even know when you've delivered something in their language if they're still understanding it or not. So, you know, that's a frontier that I think we as healthcare providers struggle with mightily and struggle with a solution. How to fix that. Yeah, I think, I mean, one way is certainly increasing the diversity of people who are having these conversations and educating patients, right? So that's, I think that's a common goal for all industries right now, certainly for medicine. So that's one piece. And the other piece, you know, that's a perfect place for AI to actually step in, right? And be able to provide real-time translation, real-time tools that would benefit patients in that visit as opposed to them sitting there super confused that they're still not capturing their information. The other piece is I think on YouTube, if I'm not mistaken, HRS did publish a segment in Spanish for atrial fibrillation with some of the Spanish-speaking providers. So that's definitely- Spanish and Portuguese. Exactly, so those are great resources to share with your patients who are native or speak Spanish and Portuguese. And Tiffany, I know that for your support group that you run for your defibrillator patients that you do, you know, offer that in Spanish to patients that we have engaged some of the providers. I don't know if any patients have taken advantage of that yet, but at least you've made that first step effort to provide a Spanish-speaking person at the support group to provide support. Yeah, I agree. It's definitely a missed opportunity and a place of opportunity, you could say, where we could continue to, you know, revitalize resources in that space just because they are a big population who are not receiving that information to a digestible way and maybe with a cultural context, there's so many ways that people can take that on that information, so great point to bring up. Thanks, Julie. Any other questions from the audience members? I don't see anything beyond that first question. Yeah, why don't you come up? Aileen Farrick, everyone. So, sorry, I don't mean to, I don't know why you don't see them, but here, there was one for Sam. What are your concerns for increased health anxiety, cardiophobia, in relation to our increased consumer-based device usage? What do you recommend to prevent harm when increased our data, oh, I'm sorry, our digital health presence? Well, fortunately, we have a paper on this recently. One of my graduates wrote this paper, Lindsey Rossman, about showing 20% of people who use wearables actually become more anxious as a result. I think the key for wearables is why do you want to wear one? If it is curiosity, I like to mention cats, since curiosity somehow is related to cat health. I'm not sure how, but, but, so, curiosity's not a great reason to use a wearable. What is a good usable reason is, is that we're gonna take some opportunity for some period of time to gather information. If gathering information's the reason, that's a pretty good reason. But somehow, looking for wearables to reassure us that we're gonna live forever probably is not a great use of wearables. So, health anxiety increases when people get small amounts of information to somehow reassure them, but the small amounts of information don't actually reassure them. They just simply lead them to look for more information. And so, I think the motive about why somebody monitors is the key. In those who have health anxiety, I think it's really important to talk about things that are serious versus dangerous, and things we can control and not control, and ways in which we mitigate danger versus be powerless. And when we can get to those conversations where there's some rationality to the impetus, then we can get closer to an outcome that we want. It's interesting because in the previous round table, there was a whole discussion about that, on how young people now are coming in, thinking they have palpitations, bringing this data in, and how the clinicians were saying how difficult it is to deal with them psychologically when you spend 10 more extra minutes with them, and then you have your other patients waiting in the waiting room. How do you handle that? Ambiguity equals anxiety, and when people are unsure about high-stakes things, they get anxious. Yeah, there's also a question on the same heels of that. With technology, there's a high expectation from patients regarding data feedback in a timely manner, right? I think we deal with this all the time, that they're like, why aren't you checking it now? Or, why don't you know where I am right now? And, I had an arrhythmia yesterday, but you didn't know until today. There's a lot of anxiety built up around that, too. That's so common for us, I find. How do we deal with these expectations? And, I think, to Sam's point, it's all about reassuring them about why we're monitoring, right? And, what are the danger zones that we need to be prepared to talk about, and what are the symptoms that we're concerned about? And, it's a difficult thing, because with more tech, there will be more data, and with more data, we'll be flooded with information, whether it's noise or it's real. So, in my conversations with patients about having their wearables, I'm saying, alert me if it's for X amount of time. I'm using duration, oftentimes, as one metric. And, severity, if you're having palpitations here and there, okay, send me a tracing, and we'll get back to it. But, unfortunately, I don't know that we can keep up with the degree of data that we'll continue to receive as there's more competition in the space, to be honest. I don't know if anyone else feels differently about that. I mean, I think, patients ask me all the time, they read their MyChart, the patient gateway encounters, and they're like, what does all that mean? They get four SVT events, and what's their AFib, overall AFib burden, and one of the things in here was asking about paternalism can be a problem because you don't want to just dismiss their concerns about it and say, look, we would have called you if there was a problem. I don't think that that's necessarily the right way to approach that. So, I do try to spend time, I explain, I pull up the report, I go over it with them. Again, I see that as an opportunity to educate them about it. And then, after I've gone through it with them, I would say, our policy is that if there was a problem, we would have called you before this note even appeared in your chart, so try not to just say, it's fine, don't worry about it. And the other thing is being, the humility piece, is like, sorry, we did not catch that, right? Patients want to know that we also make mistakes, right? We are people, and I think that's a missed thing that doesn't often get emphasized, is that these are opportunities for us to be better. We missed it this first time, but we hope to not, we will not miss it again, right? We'll optimize, we can make these plans going forward to try to make you feel more empowered and feel like your concerns are being heard and that we, nonetheless, don't miss that episode in the future, right? We can turn on this alert, we can turn off this one and kind of optimize you in that way when it comes to devices. But with arrhythmias, I think it's, I think it continues to be a challenge in that population. You know, we have a psychiatrist who joins us for our ICU support group, but, and obviously for the virtual AFib symposium, but if they had access to a cardiac psychiatrist or a psychologist, I think our problems would be solved, but I don't think that's also really the. Yeah, I don't think the Calvary's coming, just so you know. Can I bring up one last question, which again, could probably be a total discussion, but I have so many of my patients who say, why can't I see my data on my device? That's my data, I own it. And I think it's more the ILR patients than it is for the, you know, device patients. And sometimes I say to myself, yeah, you know, what should they be able to see and how can we control that in the future? But Julie got us all by talking about their access to their records. So it's like suddenly they can't have this, but they can have our summation of their care. I mean, certainly we've kind of crossed the bridges of needing to communicate anything we communicate anywhere directly to the patient as well, because if it's in their record, we have communicated directly to them. So I think the day is coming where it's a reasonable request from patients to device companies to have that data available. In fact, to me, it's kind of inconsistent with the policies that are already in place about our records. Yeah, I couldn't agree more. That's a great point to go out on. So it's 3.35 and we're ending our session. Thank you so much for your participation. Thank you so much to our panel speakers. Thanks for the input from Jamie and Aileen. Thank you so much. And we look forward to everyone enjoying the rest of the conference. Thank you.

interactive educational models

cardiac disease prevention

patient education

patient engagement

Virtual AFib Symposium

technological innovations

wearables

remote monitoring apps

multidisciplinary approach