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      For You News & Perspective Drugs & Diseases CME & Education Academy Video Decision Point
      Life and times of leading cardiologists. Guest: Brian Maurer
      This feature requires the newest version of Flash. You can download it here.

      August 5, 2013
      Recorded: June 13, 2013


      Editor's Note: Sadly, Dr Brian Maurer died on October 13, 2013.


      Dr Robert Califf conducts a series of in-depth and personal interviews with his peers in the world of cardiology to find out what makes them tick, how they feel about the future, and what lessons they have learned during their exceptional careers.

      Dr Brian Maurer talks about his formative years, his ophthalmology-oriented family, working with Dr John Kirklin and others at the University of Alabama, and the enormous changes he has seen over the years in Ireland. He also reveals the secret to a good game of Irish golf.

      Host

      Robert M Califf MD
      Professor of Medicine
      Donald F Fortin Professor, Cardiology
      Vice Chancellor for Clinical Research
      Director, Duke Translational
      Medicine Institute
      Duke University Medical Center
      Durham, NC

      To view Dr Califf's conflict of interest statement, click here.

      Guest

      Brian Maurer MB BCh BAO
      Consultant Cardiologist, Blackrock Clinic
      Past Medical Director, Irish Heart Foundation
      Dublin, Ireland

      Dr Maurer has no relevant financial disclosures.

      Related Links:

      Transcript:

      Robert Califf, MD: Hello. I'm Dr Rob Califf from Duke University. I want to welcome you to this new edition of "Life and Times of Cardiologists."

      As many of you who have watched this series know, I have had a great time interviewing famous cardiologists who have done great things in the world. The purpose of these interviews is to pass on knowledge that would inspire young cardiologists or anyone, really, to practice better and advance the field.

      I'm fortunate today to have Dr Brian Maurer with me from Ireland, who's actually Skyping in for this interview. It’s a very high-tech adventure we're undergoing here!

      Brian has been an icon of cardiology in Ireland. I initially met him as part of the William Harvey Golf Expedition, which is a Ryder Cup–style golfing competition among Americans, British Isles participants, and Europeans. It's been great fun, but in the midst of all this fun we've had some serious conversations about where cardiology is headed and what we can expect in the future. Brian, welcome to Life and Times.

      Brian Maurer, MD: Thank you, Rob. I appreciate talking to you.

      A real Irishman

      Dr Califf: Let's start out with a little bit about your history so people know where you come from. I gather you were actually born in Ireland. Here we talk about Irish Americans all the time, but you're a real Irishman.

      Dr Maurer: I'm a real Irishman. I was born in Ireland a very long time ago: 1941. I graduated from medical school in Dublin, University College Dublin, in 1964. And I completed my internship in Dublin. I did a couple of years as medical research council fellow working on the epidemiology of coronary artery disease with a man called Risteárd Mulcahey.

      I then moved to the Royal Post Graduate Medical School at Hammersmith where I spent six years. I completed that by moving to UAB, where I had the great privilege of working with Dr Joseph Reeves, one of the great American cardiologists of my time, and of course Dr John Kirklin, who was a pioneer.

      They were both pioneers in the integration of medical and surgical cardiology. That was why I went to Alabama in the first instance. Then I worked with Dr Thomas James for a while and then came back to Ireland in 1974, and I guess I've been here since. 

      A small-town environment

      Dr Califf: Let's go back to the very beginning. Tell me about your family. Where was it exactly you were born and what did your parents do for a living?

      Dr Maurer: I was born in the west of Ireland in a small town called Ennis. You would probably know it better as being 20 miles from Lahinch, which is one of the best golf courses in the world, and of which I happen to have been captain and president (a great honor).

      I grew up in that small town. I went to school in that small town. Then in 1958 I moved to Dublin, where I went to college. Of course, you're aware our college system is different. We don't take an undergraduate degree first, or at least didn’t then, so I did six straight years of med school.

      Dr Califf: We call that the British system here. Back to your folks: what kind of an environment did you grow up in? You were close to a famous golf course.

      Dr Maurer: I grew up in a small-town environment. It was a wonderful place to grow up. It's a town of today about 30 000 people. Then it was about 10 000. We had a house that was built on a river. My father was an ophthalmic optician and my mother was an ophthalmic surgeon. My grandfather was actually a general surgeon, so I had medicine in my background.

      Dr Califf: Did you know you were going to be a doctor from the beginning?

      Dr Maurer: No. I only went to med school because when I left secondary school, I was deficient in science. I had a classical education. I had Greek, Latin, and English. I went to university college and said, "Hell, I'll do pre-med for a year," so I get some background in the sciences. Then I'll go back and become a lawyer and make a lot of money or something. But I just never went back and I never made a lot of money.

      A family of opthalmologists

      Dr Califf: Did you have brothers and sisters growing up?

      Dr Maurer: Yes. My sister is an ophthalmologist, an ophthalmic surgeon actually. She's now retired, and my brother took over our family business and still lives down in Ennis in the west of Ireland.

      Dr Califf: This ophthalmology thing was really serious in your family. You never felt pressured to be an ophthalmologist?

      Dr Maurer: No, I didn't. It's very interesting. It's very interesting how careers evolve. I really got into medicine by default, as I've just told you. I stuck it out, stayed there, and said, "I'll get my degree. Then maybe I'll go do something else." But then it happened I got interested.

      Heart disease at that time was really very exciting. We were just beginning to understand the pathogenesis and the etiology of coronary artery disease. We were able to tackle the sequelae of rheumatic fever, which was already declining, but the valvular disease that it left behind was very much there. Every week seemed to bring a new insight, so I got interested in that. Then one thing led to another, and I guess I never left it.

      I went to Hammersmith postgraduate medical school where I had the great privilege of meeting guys who've become lifelong friends. It was so exciting at that time. It was the beginning of angiography. It was the beginning of coronary artery surgery. It was the beginning of our ability to use drugs in a way that we understood to help people with heart disease.

      Dr Califf: One other thing I wanted to just check in about, one of the fascinating things to me about these interviews has been learning more about people's families. These days we talk a lot about the fact that the majority of doctors in training are women, but in a field like cardiology in the US it's still only about 20% female, 80% male. But you grew up with a mother who was a surgeon. Was that common in Ireland at the time for women to go into surgical--

      Dr Maurer: [Interposing] No. It was uncommon. My mother was a graduate of Trinity College, which is one of the three Dublin medical schools. It was unusual at the time. She did her postgraduate training in London at Northfield Hospital. Then came back and managed to get her job in County Clare, which was out in the boondocks really. But she met my father and she stayed there.

      Med school: the European system

      Dr Califf: To someone like me, the European system seems a bit mysterious. You don't get those great years of undergraduate general education, but it seems very efficient. Did you ever wish you had more undergraduate time, or were you happy with going straight through and being focused on being a doctor?

      Dr Maurer: I think I've got to answer that question two parts. First of all, I think the American system is better. I've been campaigning for us to convert here for the last 20 years. We now have a graduate entry program. One of our universities, University of Limerick, is totally graduate entry. Between 30% and 40% of medical-school students in our other colleges are going to be graduates within a couple of years. We're gradually moving toward your system.

      Yes, I think it was a great mistake for the British and the Irish to abandon the idea that you have to have a general university college education before you specialized. We were able to make up for it because our universities were small and the med students mixed around the place.

      I, for instance, was in a university hall of residents where there were 100 other kids and they were from all disciplines and all areas. In many ways I had the advantage of both systems, but I do think now that the medical degree is such a, shall I say, relatively narrow part of human experience in general, it would be better if all our medical graduates had an undergraduate degree first.

      Alabama and UAB

      Dr Califf: When you arrived at University of Alabama, what year was that?

      Dr Maurer: 1972.

      Dr Califf: I can sort of relate to this. I grew up in South Carolina, which is another part of the Deep South. Probably a little bit warmer than the climate that you were used to, but also that was a very interesting time socially in the south. Did you feel right at home or what was your experience when you first showed up in Birmingham?

      Dr Maurer: When I told my wife we were going to go to Birmingham, she looked at me and she practically refused. She wondered why I wasn't going to Mayo or to Cleveland or to Boston. I had a British-American traveling fellowship, so I could go where I liked. When we got to Birmingham, we both loved it. It took a little while to settle down. The worst of the racial problems and so on appeared to have passed at that stage.

      One of the things that I learned there and a very important lesson for me was that the American political system and the American polity in general is so strong that you were able to overcome what could've been a very real, very violent revolution in your country. I don't say there wasn't any violence and some of it happened in Birmingham in Alabama, but you know it was as nothing compared to what one might have predicted. It's left me with an enduring respect for the American political system.

      John Kirklin, Joe Reeves, Tinsley Harrison

      Dr Califf: You must've also met someone who is a very good friend of mine, or I was fortunate to have him as a friend, John Kirklin.

      Dr Maurer: I was very fortunate to work with Dr Kirklin. As I said at the beginning, it was a close cooperation between Kirklin and Joe Reeves and the departments of medicine and surgical cardiology that brought me to [UAB]. 

      In fact, I'll tell you the real story: whilst I went to the ACC, in Dallas I believe. Joe Reeves, who knew I had a British-American traveling fellowship, kind of cut me out, booked a seat on the plane for me to go down to Birmingham the following day. I made rounds with him and he said, "Why don't you come and stay with us? We're the future."

      Dr Califf: I think this is worth a little bit of reflection because probably if you had asked people in the 1960s: "Would Birmingham be the place where a juggernaut of cardiovascular medicine would develop that would really change many areas of cardiology?" [They] probably would've said, pretty unlikely, it’s not the place you would normally pick. These people came together and created an amazing center.

      Dr Maurer: I think the prime mover was Tinsley Harrison. Dr Harrison was still around when I was there. He used to come in and make rounds. He was a man whom everyone had enormous respect. People don't remember now, but Harrison was the guy who first introduced nitrates into routine medical practice back in 1948. He actually suggested that nitroglycerin be used as an ointment and put on the chest. That was a long time before John Parker in Canada. Harrison did so many other things, including of course you know the eponymous textbook of medicine. I had the privilege of having to prepare for his teaching rounds and I learned a great deal from him.

      An out-of-the-way place

      Dr Califf: Do you think in these times one could pick a place that would seem a little bit out of the way by big city-slicker standards and make it happen they did the way they did at UAB?

      Dr Maurer: I think it's always going to be that way. We've got used to now the megacenters, and we think that everything happens in there. If you look at the real advances in cardiology, they tend to come from the outside field.

      Take Andreas Gruentzig for instance. Whoever would've thought that angioplasty would've come out of Switzerland and Gruentzig would be the pioneer? There are so many other instances that one can give. Maybe one of the reasons is that if you're in a place where you're a very small fish in a very large pond, you tend to be maybe a little intellectually repressed. If you're in a place where people listen to what you have to say and give you the change to think originally—I'm not saying this doesn’t happen in the bigger centers, it does—I think it's more likely to happen with smaller centers.

      Dr Califf: That's a very interesting perspective. You had a great time at Alabama. You probably learned about football and the way we play it here.

      Dr Maurer: I really never got to understand the game and I still don't, but I did watch the Navy match here last year. I said this is a great, exciting sporting spectacle, but that's about as far as I could go.

      Change in Ireland: institutional, societal, and medical

      Dr Califf: Then you went back to Ireland. Tell the audience what you were thinking as you got ready to go back home.

      Dr Maurer: Well, I guess you have to think back to the Ireland of the 1960s and the 1970s. The country had stagnated ever since independence in the 1920s. We'd gone through an economic war. We'd been neutral in the Second World War, which meant we didn't participate in much of the restructuring of Europe that occurred due to the Marshall Plan after the Second World War. We had an extremely conservative government and an extremely conservative society. My generation was the first that really began to look out for it and we were determined to make a change.

      One of the reasons I went back to Ireland in the '70s was to be part of that change. In fact, one of the briefs that I got when I came back was to try to establish an integrated cardiological service for the south of Dublin City. It took me nearly two decades to do that. One of the things I learned was that you don't measure progress in months or years. You actually measure it in decades and sometimes in generations. One has to be very patient.

      Dr Califf: It's interesting the way you say that, at least from my perspective. I noted that when it seems like there's a great policy idea that could really change the way things are done, the idea seems to surface; there's a wave of enthusiasm among some people; and then it gets killed by others. It always seems like about 10 years later, all of a sudden it's a mainstream idea. The problem with that of course, Brian, is that you begin to run out of decades and you get impatient for things to happen.

      Dr Maurer: Well, I'm now in my eighth decade, so as you get to where I am now, you begin to learn patience again. You're absolutely correct. There are certain things that are so obvious that you can adopt them and you can implement them. The major advances actually are in medical science and in the application of medicine. There's always a time lag between the innovators and the pioneers and the application into the code of practice as a whole. That time lag is somewhere between five and 10 years, generally speaking, not for the major institutions, but until it becomes part of the corpus of medical practice. You've got to be happy with that.

      When I was referring to change, I was talking more about institutional change and societal change. That's where one has to be patient. For instance, the health system to which I came back and in which I first practiced was essentially based on the 19th century Poor Law system of Great Britain and Ireland. The last 30, 40 years has seen us turn that around into a modern type of healthcare delivery system. We haven't finished yet. We're still going through, as you're going through, many problems in terms of trying to decide how we pay for and bring optimal healthcare to our people. That's not just us. I think that's universal.

      Dr Califf: I agree. That's entirely universal. I’m just getting right ahead to China next week. As I look at it, there's a lot that China is going through right now that's very fundamental.

      Reversing the brain drain

      Give us some idea of what the healthcare system was like when you arrived and how it's changed over this time.

      Dr Maurer: When I arrived, we were a country at that time that had three million people, our population's now four and a bit million. We had something like 60 hospitals to serve this population, all of them trying to do everything. We had five or six units that were playing at doing some form of heart surgery throughout the country. The first thing we had to do was merge them and set up essentially a national unit, which was appropriate to a population of our size, and make sure that we concentrated our skills.

      Our healthcare delivery system has always produced a surplus of doctors, at least until very recently it has. So many of the people who grew up with me at medical school were exported. Rob, you know many of them in the States. You met many of them over the years. There are people who are lost to our system. I think they've contributed greatly of course in the United States and Canada and in Britain, but they're lost to us.

      So the first thing we had to do was try to reorganize the delivery of healthcare so that we could attract the people who would actually implement the advances that were being made into medicine and who were also, shall we say, of a caliber of people who would be accepted internationally. That didn't come too easily.

      The actual system of delivery that we had was one in which about 30% of the population was eligible for entirely free healthcare insofar as it existed. Another 30% were eligible for free hospital care insofar as it existed. The other 40% had to pay. A system of private health insurance had been introduced about 10 years before and was covering most of these people.

      So, the first job we had to do was to concentrate our resources and to try to attract more people back. It took a long time to do that because as you know, the people who have to provide the money (and in Ireland it's the government by in large) don’t want to spend the money. They don't want to employ more people. A civil servant once quoted to me, "I can't hire another one of you. You cost me four million a year." That was the attitude.

      Things did change. They have changed, and I think today our problems today are the same as your problems. [We're] trying to cope with the extraordinary success of the advances in medicine.

      I sometimes think, Rob, that if we declared a moratorium on research for 10 years and took that time to digest the advances that we've made over the last 40 years, we might be better off. Of course, you know that isn't possible and it'll never happen and it shouldn't happen.

      When you look at today's genomic medicine, for instance, and then look back at 1964 when I graduated, the only effective cardiological active drug was digoxin/digitalus. We were beginning to get diuretics. We had mercurial diuretics. We were beginning to get the thiazides. The beta-blockers were introduced about 1963 if my memory doesn't betray me, but they weren't in widespread use and we didn't know how to use them and so on. It was an entirely different world.

      From clinician to leader

      Dr Califf: Brian, you participated in the restructuring of Irish medicine. Did you have a busy practice yourself? Did you work in a cath lab? What was your trajectory as a clinician?

      Dr Maurer: I was what you might call a general cardiologist. I started out, as I told you, doing my general training. I spent a stint at the School of Hygiene and Tropical Medicine in London trying to understand statistics and epidemiology. My technical training was at postgraduate medical school at Hammersmith and at UAB. I was involved in the development of diagnostic techniques, which was my biggest job when I came back to Ireland, particularly angiography and setting up cath labs. Obviously I went along with the developments and intervention as they came along. Then I was attached University College Dublin, St Vincent's Hospital, where I mainly worked. It's one of the two major teaching hospitals to that university. I was director of the department of cardiology there for two and a half decades nearly. I retired in 2006, but I didn't retire. I changed my job description rather. Different matter. I don't think retirement is something that comes to people like us.

      Dr Califf: You then evolved into more administrative and leadership roles. Tell us a little bit about your leadership roles and how that played out in Europe and your relationship with American leaders.

      Dr Maurer: Well, it was very interesting. First of all, I made some very close friends during that the time that I was in the United States, and they have remained very firm friends. You will know some of them from the Harvey trophy, guys that would be considerably older than you and maybe even a little bit older than me. They've been a great support to me. In the '70s and '80s I would've been back and fourth across the Atlantic three or four times a year to go to various meetings, to visit places, and so on, pick up ideas and discuss things.

      European cardiologists started to develop really about the end of the 1970s in [background noise] becoming integrated. The development of the European Society of Cardiology, with which you are very familiar, probably the biggest expansion of that occurred in the 1980s and into the 1990s. It is now, as you know, an enormous organization comparable to the ACC and so on.

      I unfortunately developed my own disease in 1981. I developed unstable angina, which came on me while I was giving a lecture on how to treat it. I ended up having bypass surgery at that time. That made me rein back a little from many of the things that I was doing. I specifically concentrated over the next couple of decades on developing cardiology as opposed to other aspects of medicine and indeed general politics.

      I guess Ireland's about the size of Alabama in terms of population or maybe a little bit bigger. By the 1990s, we had a situation comparable to Alabama in terms of the number of people we had to deliver service to and the institutions that we had. We've never of course had the rich burdens that you guys have had.

      Part of the leadership role, as you describe it, was inspiring younger people. I think that's extraordinarily important. Also, trying to recognize what the next big advance is going to be. I remember saying back in the 1980s that I was bored with coronary artery disease and doing angiograms and I wanted to think about heart muscle and heart failure. I got a guy called Ken McDonald to go and work with Jay Cohen. He spent six years with Jay Cohen. Then he came back and joined us in the 1990s and he pioneered our heart-failure program. That was the kind of thing that gave me. . . . It's actually given me great satisfaction to watch these young people growing up.

      Family: a wife and three children

      Dr Califf: Fantastic. Along the way you had your own family. Your lovely wife has spent time with us. Did you meet way back in undergraduate medical?

      Dr Maurer: We were vaguely acquainted when we were undergraduates. We tended to move in somewhat different circles. I don't know if people are interested in this, but we first met in a meaningful way at her brother's 21st
      birthday party. The reason we met was that we were both older than anyone else there and we gravitated toward each other during the course of the evening. One thing led to another, and a year later we were married. Timmi was born in England and she's a teacher of languages. She came from a medical family and she knew what she was letting herself in for.

      Dr Califf: Well, she definitely has a great personality and is tremendous to be around. In your own family, do you have children?

      Dr Maurer: I have three children. My eldest daughter's an architect and architects are two a penny in Ireland at the moment, so she's gone back to college and she's doing some work in fine arts. My youngest daughter, unfortunately, had health problems some years ago, but she's a teacher. And my son, who's the middle guy, lives and works in Bosnia and has been there ever since the end of the war. He married a Bosnian and he's… well, I don't know whether I should say this or not, but I told him last year that he fulfills my definition of a Balkan intellectual. He seems to have acquired a great deal of influence and has no visible means of support. He does pretty well. He's very involved in the peace and reconciliation process in Bosnia. He'd—

      Dr Califf: [Interposing] Well, that's a worthy cause for sure. My dad was an architect. He's still living, but he did okay. I still remember the many interns he had who struggled because the money in architecture only goes really to the top people. I identify with your statement about your daughter.

      Dr Maurer: Well, when the recession hit us three years ago, 90% of architects in this country found themselves without a job. An awful lot of them emigrated. Katherine decided to stay, and she's making another career for herself, so that's fine by me.

      Ireland now

      Dr Califf: Let's skip right up to the future now. First of all, just a quick question about your current view of where Ireland stands at this moment. As you said, there was a massive recession that we've all heard about. We hear that Ireland has done relatively well compared to let's say the Southern European countries in working its way out of this.

      Dr Maurer: Well, we're in the middle of a deep recession. That's very obvious. Our government [took on] the enormous debt which had been accumulated and they seem to be doing a good job of it. We were told by the European Union we're the poster boys, but I'm not at all sure. The recession has really hurt an awful lot of people here and we have a 13.7% unemployment rate, which is not as bad as Spain and it's not as bad as Greece, but it's bad. It's particularly hitting the young. My biggest fear is that having reversed the trend of emigration from Ireland, which lasted from the great famine from the 1840s on until 1960, having reversed that and got people to come back to Ireland and been able to recruit and see population growth, we're now going to hemorrhage our talented young people again. That's my biggest fear. Hopefully it won't pan out that way.

      Dr Califf: I hope not also. We need all countries to thrive, given the way the world has shrunk. We're all depending on each other.

      The role of clinical cardiology

      Brian, if you were a cardiologist today, someone finishing training, what would you do? What would your recommendations be to someone in that position?

      Dr Maurer: I don’t know. I'm too old probably. I mean I'm absolutely fascinated by the prospects that genomic medicine opens up for us. I think that's the way to go. I think intervention—I hope I'm not going to offend too many of my friends by saying this—you can train persons of limited intelligence to do intervention if you simply want a stent. You really can. I think interventional cardiology at one level is going to become—I'm going to make a lot of enemies now—a bit like radiology. It's going to become possibly a nonclinical subspecialty.

      And I would hope that clinical cardiology, using all the diagnostic techniques that are available to us, will make a comeback. I worry very much about the fact that the interventional cardiologists today do so much without getting another opinion. I know we pay lip service to the need to get another opinion in elective cases; in practice, as you well know, it's not done.

      In the past, if we were going to intervene, say with surgery, we had to consult a surgeon. You had to get a second opinion. You had to have the other guy tell you what he could do. Now the interventional cardiologists can be the judge, jury and occasionally the executioner. I'm not all together happy with that. I do think there's a place in the world for clinical cardiology, which has been diminished by the easy access to intervention.

      Private practice vs academic practice

      Dr Califf: Briefly, Brian, that does bring up an issue that interested me as I've interacted with many fellows who have come over from Ireland, spent time here, and gone back. It does seem like in Ireland right now the private practice of cardiology is quite lucrative relative to general sorts of practices and it may even be a limitation in encouraging people to spend time on intellectual pursuits or academic pursuits. Is that a misperception on my part or is that an issue?

      Dr Maurer: No. I don't think it's a misperception, and I think that the recession, which has resulted in salary cuts for physicians, cardiologists amongst them, is going to make that even worse. I think there is a real danger that we may develop a private system at the expense of the academic system. I do believe that we can actually evolve in such a way that we get a kind of mixture that you have in the United States, where the two are compatible. There is no doubt that in Ireland, as well as in the United States, private practice is more lucrative than academic practice, and has been over the years.

      We did have a system of mixed private and academic practice and public hospital practice, which essentially was based on people honoring their commitments to their public sector and whatever else. I think we're in danger of losing that because people are becoming disheartened. The difficulties of working in the public sector at this particular point are making it quite difficult for us to recruit people at the top level.

      Dr Califf: It sounds like there are plenty of challenges in the ebb and flow.

      Golf and friendship

      Let's zone on a critical issue, that of golf. You have held quite a prominent position in Irish golf as captain of one of the most famous clubs. What advice do you have for golfers who are making their way to Ireland? What should we watch out for when we're there?

      Dr Maurer: Well, if you want to enjoy the Irish experience, you must play links golf. Parkland courses. We've got great parkland courses, but so has the rest of the world. What we and Scotland and parts of England have are great links, and you and I played some of them in Lancashire last year. They're wonderful. Have the links experience. The only other advice I can give you is keep your head down and don't overswing.

      Dr Califf: Excellent advice.

      Dr Maurer: I think one of the things of course that makes golf in Ireland so, shall I say difficult for people who aren't used to playing it, is that our links courses usually have a wind. The wind is never the same two days in a row, so it's great fun.

      Dr Califf: I'm taking a large bag of golf balls, so I'll be ready.

      Dr Maurer: I really look forward to seeing you in August.

      Dr Califf: That would be great. Brian, any parting words for our audience here before we finish?

      Dr Maurer: No. Well, I'd just like to thank you for giving me the opportunity to talk. I'm not sure that I've been of any great help to anyone. I'd like to say one of the things that I loved about medicine and cardiology and one of the things that made it that I don't really regret not having pursued another career at the beginning is the fellowship and the friendship at an international level, the European, American, Australian, Indian, all around the world.

      I've been ill recently and I was most touched—two of my former fellows whom I had trained made a journey to see me, one from the Sudan and one from India. I don't think that happens in too many professions.

      Dr Califf: That's a great note to end on. Brian, I look forward to seeing you in just over a month and having many other interesting conversations like this. Thanks very much for joining me.

      Dr Maurer: Thank you very much, Rob.

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