John E. Brush, JR., MD
Sentara Cardiology Specialists
Dr. John Brush can’t remember the moment he decided to be a physician. “I just always wanted to be a doctor,” he says. “I had a natural inclination to science and math, and an interest in understanding how things work.”
Dr. Brush earned his medical degree from the University of Virginia in 1980, and completed his internship and residency at the University of Vermont School of Medicine, followed by a fellowship in cardiology at Yale University School of Medicine.
He began his career as a staff cardiologist in the Cardiology Branch of the National Heart, Lung and Blood Institute at NIH, and later served as staff physician in the Cardiac Catheterization Lab at the University Hospital in Boston. In 1992, Dr. Brush moved to Hampton Roads to accept a position with Cardiology Consultants, which became part of Sentara Cardiology Specialists in 2012.
Throughout his career, Dr. Brush has maintained a close involvement with the American College of Cardiology, an international organization with over 48,000 members. He has served on several committees, including the Board of Trustees. It was his involvement with one of these committees that led to the project he calls one of his proudest accomplishments: the Door-to-Balloon Alliance for Quality, or the D2B project. He explains: “When I started as an intern, we treated heart attack patients by putting them in the coronary care unit and watching them, and when complications arose, we took care of them. But we had no way to take care of the primary problem.”
Which was, of course, that their arteries were clogged and their heart muscle wasn’t getting enough blood and oxygen. “About 20 years ago, we started taking these patients to the cath lab. Our national guidelines said we should be able to get these patients to the lab and get an artery open with a balloon catheter within 90 minutes of their time of arrival – hence, door-to-balloon time.”
Unfortunately, until 10 years ago, across the country, only about 45 percent of patients had a door-to-balloon time of less than 90 minutes. “In 2006, when I was chair of the ACC’s quality improvement committee, we decided to work on this,” Dr. Brush says. “I worked with a Yale colleague, Dr. Harlan Krumholz, and we devised a more efficient communications plan, eliminating wasted time and missed phone calls, that enabled us to significantly reduce door-to-balloon time. The percentage of patients who got from door to balloon in less than 90 minutes increased from 45 to 95.”
The success of the project is born out in a November 30, 2016 article in Cardiology Magazine, entitled “Door-to-Balloon 10 Years Later: Successful Model Sets the Stage for the Next Generation of ACC’s QI Programs,” which states
Launched in November 2006, the program involved over 1,000 hospitals and changed the proportion of patients with D2B times less than 90 minutes …. From 2005 to 2010, the median time to percutaneous coronary intervention was reduced by 30 percent, from 94 to 64 minutes. …there is evidence that these improvements have saved lives.
A second point of pride for Dr. Brush is the book he wrote and illustrated in 2015, The Science of the Art of Medicine. “It’s about how doctors think,” he explains. “I got interested in this when I was working with the ACC’s quality improvement committee – I started thinking, what’s the fundamental quality problem? Why do doctors err? Why do we make mistakes? I started doing some reading and stumbled on the field of cognitive psychology, which examines how people make decisions. Also, I was increasingly involved with Eastern Virginia Medical School, teaching internal medicine residents the art of clinical reasoning.
“Doctors make decisions all day long,” he continues, “and the fundamental problem in medicine is there’s a lot of uncertainty. We’re just scratching the surface of our understanding of biomedical science. When patients present with symptoms, we don’t always know what it is at first – sometimes we never know. There are levels of uncertainty and variability that we deal with. We deal with it through reasoning.” The Science of the Art of Medicine deconstructs the process of clinical reasoning.
Dr. Brush initially offered his book for free to Internet readers, intending it primarily for trainees, students, residents and fellows – and physicians as well. It was well received – even garnering a good review from Oxford University – and soon, readers across the world were demanding printed copies. Dr. Brush worked with a publisher in Richmond, Virginia to produce a printed book, which along with the iBook has to date sold more than 4,000 copies. It is widely assigned as supplementary reading for students as they go through their training.
As a result of the success of his book, and the many other papers and articles he has authored, Dr. Brush has been invited to lecture at several universities and medical centers across the country. He was also asked to write the chapter on clinical reasoning in Braunwald’s Heart Disease, the definitive cardiology textbook.
He’s already on to his next exploration: observational research, which he calls the other side of the clinical reasoning coin. “I’m very fortunate in that Sentara has given me some protected time to work on it,” he says. “It’s an opportunity to build bridges between Sentara and EVMS and do some original research projects. It’s just getting off the ground, but I’m excited about where this could lead.”
In fact, Dr. Brush says, he finds his work as fascinating today as when he was as a student: “At 62, I’m learning more on a daily basis than I ever have in my whole career.”