Hi, everyone. I'm Ricky Green. I'm an electrophysiologist here at UC San Diego. On behalf of all our colleagues here in San Diego, we welcome you to our hometown. We are very excited to host. HRS hasn't been here since 2002. We know that San Diego is known for sunny days on the beach, but for electrophysiology, technology, innovation, you have also come to the right place. We have large hospital systems doing cutting-edge research. Our biotech industry has become a hub for global innovation. So what we now truly offer is a location where researchers can take discoveries from bench to bedside, turning them into breakthrough treatments, technologies, and tools that we are very proud to be part of. But back to the beaches. As you can see from the display here, we are very much able to combine work and fun here in San Diego. And we do have some recommendations for you. Of course, take a stroll along the iconic shores of Pacific Beach in La Jolla. Watch the surfers or take a surfing lesson. If you're interested in nature and wildlife, San Diego is home to one of the best zoos in the world. Our zoo is nearby in Balboa Park. You can actually go and visit our two giant pandas, Yun Chow and Chow Bin. You can also enjoy the beautiful gardens and walking path. Don't forget our cuisine. This is the place for fresh seafood and incredible Mexican food. Personally, I recommend fish tacos. A favorite in town is Rubio's. And don't forget to combine it with a local craft beer. Our potters will be playing games tonight, tomorrow, and Sunday. And that's just across the street at Petco Park. It's a spectacular field, combining the best sight lines in baseball. Breathtaking views of San Diego. So now that I have tempted you with all of this, we do want you to spend some time at the meeting, too. I love this meeting. We have an impressive lineup of speakers, panels, poster sessions, and an exhibit hall to explore over the next few days. And HRS is a meeting not only to expand your knowledge, but to reconnect with old friends and make new connections to, we hope, last a lifetime. So let's get this meeting underway. Thank you again for being here. And here's to a fantastic few days of science, learning, and fun. Welcome to San Diego. Please welcome to the stage the president of the Heart Rhythm Society, Dr. Ken Ellenbogen. Here comes the sun. Here comes the sun. And I say, it's all right. Welcome. It is a delight to be in San Diego. Thank you very much, Ricky Green, for your hospitality and that of your city. We are thrilled to be here. We have over 10,000 arrhythmia professionals here for the next three days who have traveled from over 80 countries. When it comes to improving and advancing the care of patients with arrhythmias, this global audience shows that borders and political opinions are just not important. This theme, setting the pace, is about bringing us all together to advance the care of patients with arrhythmias. And it is what I want to talk to you about today. Let me start off by introducing my family. Here is my wife, my kids, and grandkids, a source of immense pride and inspiration. And here is my other family. Call it my work family, the people who inspire me every day to do my best and to help make new discoveries. And today I am here surrounded by my family, the 9,000 members of HRS. You all represent the global community of professionals advancing arrhythmia care. Our society, the Heart Rhythm Society, is an international organization. Our members come from over 90 countries, and our work transcends nations and languages. We EP professionals speak the same language, we face the same challenges, we ask the same questions, and we are interested in the same problems and learning new and better solutions for our patients. Our journals publish great science, the best arrhythmia science, from everywhere in the world. This is how progress is made. This is how advances are made. This is what we wake up to do every single day. We are dedicated to our mission to improve the care of patients with heart rhythm disorders. Let me now share with you some of the exciting initiatives HRS has taken over this last year. First, HRA, Heart Rhythm Advocates, is our new affiliated organization for our profession. We will advocate for EP physicians and their vital role in delivering quality health care and to ensure equitable access to health care services and provide fair reimbursement for what we do. We will advocate for enhancing patient outcomes, we will advocate for protecting research initiatives, and we will advocate for influencing public policy. What could be more important? Next, let's think about innovation in our field in a new way. HRX is HRS's community for innovation, and the HRX live event creates the perfect opportunity for innovators, funders, clinicians, and entrepreneurs to interact and form meaningful connections. What gets me equally excited is our work on a comprehensive digital strategy that will change the face of our society. This plan is futuristic. Imagine opening up your tablet and clicking on the HRS icon. From there, you can listen to an HRS TV episode on evolving therapies for long QT syndrome, or instead you can listen to a special session you may have missed from Heart Rhythm 2024, or find a printable information sheet for a patient who will be undergoing a pacemaker implant and share with them a video of what they could expect. These offerings will cater to every type of health care professional and provide patient information in multiple languages. Beginning last year, we launched a new scientific documents committee dedicated to developing high-impact scientific statements and other scholarly documents. This committee brings together scientists and clinicians from all over the world to provide timely evidence-based insights that inform research and clinical care for arrhythmia patients. Most importantly, the committee's work will highlight emerging advances in electrophysiology and address areas of controversy. We will draw on the expertise of the global EP community to clarify progress and help shape the future of our field. I encourage all of you to read our first document online this week on a call to action for better MRI access for patients with CIEDs. Further, HRS is planning to establish a registry for PFA. We will work with the FDA and industry partners to make a registry that allows us to collect information about outcomes with new devices and for new indications. Now, of course, I should mention challenges. The application of all the cardiovascular societies to the ABMS was turned down. Point of fact, ABMS has not approved a single new application in over 30 years, while medicine has changed dramatically. Let me be clear. We will continue to advocate for EPs and work with our partner societies to change the way recertification is done. Stay tuned. You'll hear a lot more about this in the coming months. We have a great organization. I am so proud of the work that our staff and volunteers do, and this meeting is a reflection of their hard work. Please get involved. Please support HRS. We are hosting our first-ever Heart Rhythm Gala tomorrow night. I hope to see many of you there. The gala is sold out, but for those of you who missed the chance to purchase tickets, you can still participate in the fun via the silent auction. And, save the date, April 25, 2026, we're going to have an even bigger party in Chicago. I am truly honored to be surrounded by you, the world community, and the community. I am personally making a commitment with my colleagues, my partners, my friends, my former fellows, to establish an HRS endowment. I've created this fund to allow arrhythmia specialists from all over the world to come to HRS and share their research. It is important that, every year, each of us does something to make our profession and our society a better place. Mine is a small gesture, but please feel free to contribute to HRS in a way that best suits you. So, set your own pace and join us in HRS, HRA, and come to HRS. Welcome to HRS in setting the pace for EP professionals worldwide. Thank you very much. Please welcome to the stage, the Chief Executive Officer for the Heart Rhythm Society, Pat Blake. Good morning. Oh, it's so good to see you all here. Imagine for a minute that it is a bright, sunny, early morning, and you are standing at the starting line of a race. The air buzzes with energy and determination and anticipation. Now, I know many of you are runners, so you understand the situation, and you are eagerly awaiting for that starting shot. At that signal, one runner steps forward, takes the lead, and sets the pace for everyone else. That runner isn't just running. They're defining the tempo, the rhythm, and ultimately the outcome of the race. One of the themes for HRS 2025 is setting the pace. This phrase originates from the world of horse racing, and it has come to mean leading the way or establishing the speed or the rhythm of a particular situation or event. The idea of setting the pace is rooted in leadership, in innovation, in the courage to break new ground. It's about being proactive, not reactive. It's about stepping forward when others hesitate. Well, what does setting the pace mean for an organization like HRS? It starts with taking ownership of our goals and defining what success looks like for us. It's easy to fall into the trap of comparison, measuring ourselves against everyone else, but setting the pace means focusing on our journey, on our strengths, on our vision. That's why you hear the HRS leadership constantly refer to the 2023-2026 strategic plan, which is to advocate for EP, to drive innovation, and to advance knowledge. As Peter Drucker once said, the greatest danger in the times of turbulence is not the turbulence. It is to act with yesterday's logic. Well, this quote reminds us of the importance of innovation and of forward thinking. True pace setters do not cling to the outdated ways of thinking. Instead, they adapt, they innovate, they forge a new path even when the world around them is in flux. Well, HRS has fully embraced the need to forge a new path, which is why drive innovation has been a central pillar for the last few years. It led to the development of HRX as our innovation brand. As Dr. Ellen Bogan just mentioned, this includes HRX Live, which is an immersive event being held for the fourth time, the first week of September in Atlanta. This landmark gathering focuses on early stages of innovation and is supported by a digital component, the HRX Hub, allowing these critical conversations to happen all throughout the year. HRS participants are setting the pace, even beyond traditional EP boundaries. My mother always told me that imitation is the best form of flattery, and we are now seeing other organizations across the world copy the content and or the unconventional meeting style of HRX Live. This innovative initiative is setting the pace for others to follow. But we know that setting the pace begins and ends with our members, our physicians from around the world, our allied professionals, our scientists, our industry partners. These stakeholders also recognize the need to set the pace with our patient community. We're developing plans to even more actively involve patients in the HRS ecosystem. That includes updating resources on our patient website, Upbeat, with an AI-assisted feature to help your patients and, in fact, your potential patients with intelligent responses to their questions. We are rapidly adding features, such as these whiteboard videos here. The site currently contains 10 of these, and more are being developed. The videos are currently offered in English, Spanish, and Portuguese. Our goal is to direct and connect patients and caregivers with the best possible resources. But no one can be a pacesetter without effective communication. Now, I know that some of you may think we communicate with you too much, one email or two a day, maybe too much. But what we realize is that members are utilizing an increasing number of channels in their daily lives. And HRS plans to connect with you in the numerous ways that you get your news, your information, and your education. Just this year, we added multiple new channels to connect with all of you. And no doubt, this slide will look different next year. We're also very excited this week to introduce the new HRS website, and we hope this provides you and your team an efficient, useful tool. Very importantly, we are running this race with our international colleagues. In this turbulent world, HRS members understand that many, many people depend on the EP community. We will continue to set the pace in cooperation, in empathy, in kindness, and in believing that bringing people together in settings like this is more important and more powerful than any divisive tactics. True pacesetters lift each other up as they go. They initiate positivity, they support each other, they seek to contribute to a world in a way that leaves it better than they found it. With that in mind, it is with profound mixed feelings that after 46 years as an association professional, I will be retiring from HRS and the association profession at the end of 2025. It has been my true honor and joy to serve as your CEO for the past six and a half years, and I look forward to continuing in this role for the next eight months as a search for the next HRS CEO is in progress. But today, let's remember that you, as members of HRS, will be the first to step over that starting line. You will be the true pacesetters for the world of EP. You will set the tempo and create the rhythm to continue to move this profession into the future. Let's lead with courage, innovate with purpose, and inspire those around us to rise above any challenges we face, because this world needs pacesetters, and this race is yours to lead. Thank you. Please welcome to the stage the Vice President and Program Chair of the Heart Rhythm Society, Dr. Sana Al-Khatib. Good morning, everyone, and welcome to sunny San Diego. I am delighted to see all of you here in person. Those of us who have been in EP for more than five years remember that we were supposed to hold this meeting in San Diego in May of 2020, and we were all very excited about that prospect. Sadly, our excitement was crushed by the COVID-19 pandemic that made it impossible for us to meet in person. Instead, we pivoted to a virtual meeting. That we are here in person today is solid proof of our strength, resilience, and unwavering commitment to advancing our field and supporting each other. My journey with HRS started in 2000, when I went to my first HRS meeting as an EP fellow. 25 years later, I still remember how fascinated I was by my experience at the first meeting. Not only did I learn immensely from attending sessions and interacting with leaders in EP, but I was able to start forming relationships with friends and colleagues that have continued to the present. Since then, I've been able to make it to every HRS annual meeting, thanks to my coworkers who covered for me, except the two years when I was expecting and was ordered by my OB not to travel within a month of my delivery dates. I remember recording my presentations for those meetings and knowing what I know today, I wish there was an option for me to join virtually. As I reflect on my many years of coming to the HRS annual meeting, certain things stand out. I have undoubtedly formed enduring friendships and collaborations that wouldn't have been possible without coming to the meeting every year and solidifying these relationships over time. My clinical practice has been informed by robust evidence presented at HRS, like made it to trial, scanned half data to mention a couple. As a result, my patients have greatly benefited. The ideas for several research projects I completed were birthed at some of these meetings. I was able to establish research collaborations with colleagues and mentees that remain strong to this date. I had the pleasure of getting to know leaders in our field, like Eric Prystowski, Al Waldo, who I miss, and Gillis and Curtis and Andrea Russo to mention a few. So now I challenge you to ask yourself the following question. Why are you here? Many of you were at our last in-person meeting in May of 2024. What do you remember from that meeting? I bet what you remember the most is the experience you had, the emotions you felt, and the personal growth you have achieved. As the chair of the program committee, I have the distinct pleasure of previewing all of the exciting elements of this week's events that you are about to experience. But before I do that, I want to wholeheartedly thank each and every member of the program committee who worked tirelessly to help us put together a spectacular and member-centric program that I know you will enjoy and cherish. I thank the abstract chair, Dr. D.J. Lachiretti, for his helpful contributions to the program. I also express my heartfelt thanks to the HRS staff and everyone else who has contributed to creating this program, including all of you here who submitted your science for our sessions. I am super excited to share with you that this year we received a record number of abstract submissions at 3,453, the most in HRS history. Our late-breaking clinical trial submissions were also the highest we've ever received. While I'm very excited about and proud of all aspects of our program that was designed to set the pace, as you heard from Pat, I would love to highlight the following sessions shown on this slide. Please join as many of these sessions as you can. I want to assure you that we worked very hard to deliver on the number one reason many of you come to this meeting, networking. We created a series of engaging platforms for the latest science, among many other networking opportunities. New this year, you will have an opportunity to connect with our late-breaking clinical trialists and seek answers to questions like how do I apply the results of this trial to my practice? In closing, I thank everyone in this room for being here, for sharing our passion for innovation and vision of transforming patient care and commitment to advancing our field all over the globe. Please have a fantastic meeting. I look forward to connecting with all of you this week. And now it is my honor to introduce our keynote speaker and my personal mentor, Dr. Robert Califf, the immediate past commissioner of the FDA, a renowned cardiologist and a pioneer trialist in cardiovascular medicine. Dr. Califf's talk is titled, The Procedures are a Success, but the patients aren't doing so well. And then I'll be back to ask him some questions. Please join me in welcoming Dr. Califf. ♪ If everybody had an ocean across the USA ♪ ♪ Then everybody'd be surfin' like California A's ♪ Wow, that's a nice introductory song there. I wish I was a surfer, but. And first of all, let me just say it's amazing the speakers before me, they're so polished. I'm just a country doctor from South Carolina. So I don't expect to be as polished as them. I even have notes, which none of them had. What I wanna do today is to take you on a brief 12-minute journey through my life as it relates to you all as electrophysiologists and a bit about where we are today. This will be an America-centric talk, but I know this is an international meeting, and I think for all of you who are not from the US, you're probably wondering exactly what's going on here, and I'm not gonna tell you exactly what's going on, but I will have some thoughts and hopefully some relevance as you go through this meeting and also deal with these very uncertain times. So first of all, a bit of history. I feel like my personal history is very intertwined with electrophysiology. I decided to go into cardiology because I saw a patient defibrillated while I was an orderly working in a hospital. And then as a medical student in 1976, I got to be one of the first to apply this amazing, very sophisticated technology called the Holter monitor. You guys have heard of that, I think. And I put Holter monitors on about 380 people who had coronary disease. And a sign of the times, enough of them died within one year that I could write a paper about the prognostic features of those Holter monitors. We all thought it was gonna be the heart rhythms because we could measure heart rhythm continuously for the first time. To our shock, it turned out to be left ventricular ejection fraction that was the dominant predictor of the risk of sudden death. We meekly said, although there were no implantable defibrillators at the time, we said if there was gonna be an intervention, ejection fraction might be the thing to look at. And of course, you know the history of that. I then became a coronary care unit director, very focused on acute coronary syndromes and myocardial infarction. But the EP lab was part of the coronary care unit. Some of you may be old enough to remember some characters named John Gallagher and Mel Scheinman. Mel Scheinman was doing a sabbatical at Duke at the time and it was an amazing time. Every single day there was a new discovery and every single day while I was making rounds, I could hear yelling and shouting as they argued with each other about what it all meant. I then had the chance, being in charge of a research institute, to be part of the SCUDHEF trial. In my view, one of the cleanest clinical trials ever done to show life-saving technology, the defibrillator. It was an amazing collaborative effort of dozens of centers and it showed that in fact, you do save lives, so congratulations to you and it's amazing what you're doing with this. I then went on to believe that if we analyzed the waveforms of electrocardiograms, we could tell a lot about what was gonna happen to people. But at the time, we had regression algorithms, there was no artificial intelligence and you know where that's gone now. What an amazing time it is. So throughout my career, I've been part of an enterprise which has combined bioengineering, clinical evidence development and clinical expertise with people who I'm really honored to be part of the program today with Sana and Ken, both of whom I learned from in my career. Quick word about evidence generation. We used to make fun of cardiologists, they weren't, they just did procedures. But I gotta say, electrophysiology is leading the way in terms of generating evidence through the combination of randomized clinical trials, but also, and I heard it discussed today, registries and an increasing ability to surveil the population using electronic health records, claims data and of course, the remote monitoring where again, you all are leading the way, including digital interface with people so they can record how they feel about how they're doing in their health journeys. You are as close as any profession to a true learning health system, although as I'm about to say, we're obviously not there yet. So as I sit for my perch, having just finished my second term as FDA commissioner, I can honestly say as I go around the world, people are in awe of what you all are accomplishing with this combination of technology, human application, knowledge and it gets better and better every day. It's just amazing to see the technology applied to areas like ablation, the ability to monitor people at home and to make such a difference. But that's sort of a optimistic view. Let me give you the cup half empty view of it now. And let's talk about the United States. As we stand here today, the United States is in last place among high income countries in terms of our health outcomes. We're an average of four years behind the average of high income countries in life expectancy and even further behind when it comes to healthy life expectancy because we have an enormous burden of chronic disease built up in our population. These outcomes are not uniform across our country and in fact, those of us sitting in this room are probably expecting a very long life in good health and the data would bear that out. We have the disparities that we've all known about a long time, race and ethnic based disparities. We also have sex based disparities and here, I always feel compelled as a man to point out that men on average now in the U.S. are living five years shorter than women and in fact, we have a very serious problem with young men in terms of their health status and the accruing risk factors in this population. But the emerging risk factors that we're learning more and more about every day are really becoming a dominant theme that we need to pay more and more attention to, particularly in a specialty with your characteristics. Income, total wealth, education and geospatial location, that is where people live. A college graduate in the United States can expect to live eight years longer than someone who is not graduated from college. Those of us who have accrued a significant amount of wealth can get the best healthcare, but 55% of Americans could not raise $5,000 today if they had a health emergency. And 67% of Americans, when asked whether this is a true or false statement, say true. I have to take care of my own health because no one else cares. And this is in a situation where we're all probably working for practices or companies or health systems where we talk about being patient centric. And so while we have the best of technology and it's on display at this meeting, we're failing at first base. We're not getting the basics done in this country. And in fact, those of you who are professionals probably started out as a general cardiology practice of some kind. And the biggest issue we have beyond the very basics, and in fact I just want to make this point, if we could reduce gun violence, suicide, drug overdose, and alcohol deaths in the United States to the average of other high income countries, it would take care of half of the difference that I've talked about. These are the biggest factors. But the next biggest factor is cardiometabolic disease. And here we are, as you know, in a situation where we have the answers to every component of cardiometabolic disease, all of them involving generic drugs that are very inexpensive, except for weight loss where they're not inexpensive and we have a job to do there. But the fact is, we do have treatments now for every aspect of this, but we're not delivering them effectively and it's showing up in our health statistics. So where does that leave electrophysiology? And my plea to you today is that while you do the work that you're gonna talk about here today, that you reserve some of your energy and thinking to working with colleagues to develop better systems to deal with what's really causing the big health problems in the U.S. that we're not solving. And of course, the U.S. is not alone in this regard. Other countries are having very similar problems. There's just a very striking article in the New England Journal showing that if you look at Europe and the U.S., this relationship with wealth is true across the high income world. You gotta have money to have good health, essentially, for much of this. Now, what's the one other thing that I wanted to get across to you today? As I look at technology, people are constantly asking me when I was FDA commissioner, what should we do with AI, where should we apply it, where should digital health go? And I am 100% for the amazing things that are happening in this field as it relates to better and better use of stereotactic methods to do things like ablation, to deal with arrhythmias in a sophisticated way. But I think the number one place where we need to apply AI and digital technology is in people's homes. And we had a project at the FDA, which is still ongoing, called Home as a Healthcare Hub. And a simple way to think about this is imagine the average clinician and the average patient in the U.S. trying to deal with a situation in which every time someone develops a new possible way to monitor people, an app is developed, and then these apps are put out there in a way which is completely unorganized. And it's confusing to people. Now, the aviation industry dealt with this a few decades ago. There was a time when every time an engineer thought of something new to measure about flight, they would just develop a new gauge and stick it in random order in the cockpit in different planes. The pilots eventually had a revolt. They said, we can't fly the planes because we don't know which instruments to look at. And I would argue that's the plight of the average patient and the average clinician in the United States today. What they did in aviation was to declare a timeout. They did an enormous two-year human factor study and came up with a standard configuration for the cockpit. So if a pilot got in a plane, although different planes have different levels of sophistication, you basically know where the instruments are and what you need to look at in order to navigate the plane. And we need that in healthcare. Now, we also have to overcome two factors which I think are very difficult for a specialty organization to overcome that are particularly dominant in the United States. That's fragmentation and sub-optimization. We live in a healthcare system where every component is trying to defend itself and optimize its own finances. And I don't blame you for wanting to make the heart rhythms of society powerful and good, but if you do that without considering the effects on the rest of the system, I would argue that's a mistake. And the same would go for the clinical practices or the health systems that you work for. And so now the final word I want to say is, what about what's going on today? I think all of you are probably aware that we're in a time of tremendous change in the United States. And whether you're for it or against it, I think it's fair to say that the basic foundations upon which our profession are built are under assault right now. And it may be that because of what I said about where the U.S. in health outcomes, that it's merited that it's under assault right now, or you may disagree with that. The analogy that I've been using with people is Humpty Dumpty. Now, I would bet that most of you know the first verse of Humpty Dumpty. All the king's horses and all the king's men couldn't put Humpty Dumpty back together again. So the federal agencies, the universities, the health systems, which as if Medicare and Medicaid cuts occur the way it looks like will happen in the budget, will be under tremendous stress with significant loss of jobs, there will be more tumult yet to come. The good news is as Humpty Dumpty aged, people wrote additional verses. And there is a version with a fifth verse, which says all the king's horses and all the king's men did put Humpty Dumpty back together again. And I think the question for all of us today is in the U.S. and maybe other parts of the world, when things are disaggregated, when they're torn apart, when there's chaos, what can we do to build something back which is better than what we had before, acknowledging the problems that cause so many people to be upset and angry at our systems? And what can we do to put it back together in a better way, which leads to better health outcomes? So with that, I would just say four quick things to consider. First of all, I am obviously haven't been FDA commissioner, very concerned about large structures and policies. But the fact is, doing your jobs well is the most important thing that you can do. And I'm really excited about what's going on at this meeting. You're gonna be better and better at what you do. But secondly, I would urge you to think about colleagues over these next few months, because there will be disruption of people that have been living on grants at your academic institutions and changes in your clinical practices and hospitals as the payment systems are changed. Third, I would urge you to reserve a little bit of time to think about what you can do to ease the transition into a better system. And then finally, of course, there's always room for optimism. Keep in mind that Humpty Dumpty can be put back together again. And we'll all get through this. Thank you. So, Dr. Caleb, thank you so much for sharing these insights with us today. What's on everyone's mind, and you alluded to it quite a bit during your talk, we're seeing all these significant changes in healthcare. You talked about all the threats. You tried to infuse some optimism, which I love. Thank you. Can you tell us a little bit more about how we can turn some of these challenges into opportunities that can help us both on the clinical side, as well as with research? Sure. One thing I hope people will not do, there will be a tendency, I think, in periods of instability to protect yourself, and as individuals, I'm all for that. But as organizations, I don't think this is a time to try to isolate and protect yourself. Become part of the change, and get involved. If you're at a university, universities are losing billions of dollars in funding as we speak, and there's going to be disarray because of that, and we need to work together and not try to separate from the system in that regard. I'd also say, keep colleagues in mind. As you look at what Americans are saying about their views about us, those of us who are in the elite, making a lot of money, and doing things that we think are important, they're saying we don't really relate to these people. We can't even get to see them with an appointment. It takes forever. This is why I think we need to work on systems that integrate AI technology, primary care, and then specialties like electrophysiology into a system that gets people more of what they need in a timely basis, even if they live in a rural area, which I think we'd all agree is entirely possible now with the technology that we have. We just haven't put our minds to making this happen. Then to mention one other thing, which I think, actually, I have no idea how to fix this, but there is no question that there's 24 by 7 social media attacking the very idea that there is such a thing as an expert. We are under the assumption that if people come to see us in the clinic and spend 15 minutes or an hour, that what we say is going to be what they remember. As they're driving home, they are under assault by people who are selling other things than traditional evidence-based medicine as we know it. People are very much affected by that. As a community, and this is where a place like Heart Rhythm Society, I think, can make a big difference. We need to knit together a much more effective presence in the information ecosystem that gives people reliable information that they can trust and depend on, because it's very hard for them to get it right now. Absolutely. Well, thank you so much for that. Let me pivot a little bit to talk about what HRS, as a society, can actually do in this space. You gave us this very provocative title. Our procedures are a success. Yeah, hopefully everyone's procedure is a success. But patients are not doing so well. You alluded to the fact that there are several barriers. What can a society like HRS do about that? I think I've alluded to it somewhat already. Here, because we're sort of, you used the term fork in the road, which has a double meaning now, of course. I think the case has been made now by, for example, the Maha movement, that we're not doing so well in the United States. But I do want to point out that at the turn of the last century, life expectancy was half of what it is now. We've seen a gradual increase in life expectancy until about a decade ago, where both cardiovascular and total mortality have leveled off. It's not that we're terrible. It's just we're not doing as well as other countries, which are focusing on other things. I think the key for heart rhythm society is to walk and chew gum at the same time. I would hate it if there was any reduction in the mad rush to use of technology and making procedures better. I think that's absolutely essential. But we've got to spend more time, as I say, figuring out how we integrate with the rest of healthcare, so that we're not just dealing with people when they come in for their ablation, but they're being taken care of so they don't need an ablation as often. One thing I'm 100% sure of, none of you have to worry about jobs, because if you look at the risk factor profile of our 20 to 40-year-old population in the U.S., there's just an overwhelming amount of cardiometabolic disease, which is going to create a tsunami of chronic disease that we're all going to have to deal with. So I think blunting that is a really important component. Indeed. As you heard from Dr. Ellen Bogan, we actually have established heart rhythm advocates to really intensify our advocacy efforts. In this time and age, how do you think a society like HRS can most effectively advocate for our patients, for our research, for our practices? Well, I would hope you would advocate in the way that you said. One touchy issue is advocating for pay. And I'll just say bluntly, having been in Washington for a while now, there's not a lot of sympathy for the pay of electrophysiologists. I'm sorry. And so if you want to really raise suspicion that you're advocating for the right reasons, go in and start with your pitch for pay and go from there. It won't sell very well. And so, but I think all of us understand that the number of people with atrial fibrillation, ventricular dysrhythmia, and left ventricular dysfunction, it's just a big part of the population. They're vastly underserved right now, mostly because they can't get to see you. And as I've learned talking, like I had a great talk with Eric Prostowski, who I consider a mentor, and even Eric in his advanced stage of expertise to seeing a lot of people with sort of routine bread and butter AFib, for example, that other people could take care of just as well if they were supported so that your expertise can be appropriately used. And I would really advocate for systems that can deliver that. I know this is hard because it's hard enough just to do a good job with what you're doing, but this is not a time for us to shrink back. There's a real risk that the whole system is going to be turned upside down and we'll all be taking vitamin supplements for our cardiac arrhythmias, which I don't think would be a very good way to go. Well, as we talk about all these changes that we're going through, and I'm sure a lot of people in this audience, if not everybody, is aware of all the cuts that are being incurred in terms of institutes within the NIH, in terms of the research funding, the infrastructure. So that actually concerns a lot of our members who focus a big time and part of their time and effort to research. Are there opportunities there in terms of as things get rebuilt or reformatted or re-channeled where we can hope for some improvements? Can we perhaps modify those changes to get the outcomes that we want? Yes. And one thing I want to go back to your last question and combine it with this one, I think people vastly underestimate the interpersonal nature of advocacy in the United States. So many things happen in Congress because a congressperson had a person, had a relative with a problem. In fact, I'm told that the long COVID trials were completely stopped. Yes. There was a Republican senator as long COVID, and he called up and said, don't do that. And they reinstated the funding. And so there's so much that goes. And so visiting interpersonally with members of Congress is a really important thing to do if you want to advocate. We're going to see a very interesting time at NIH now. We have a new NIH director. He's written a lot about large studies and kind of things that could be very favorable to the field of electrophysiology. But you've got to get in there and make sure that there's a whole contingency of the population and their elected representatives who don't see much value in science. They really don't see where it pays off for the people that they care about. So you've got to sort of bridge that gap and really advocate strongly. And it could turn out as we put Humpty Dumpty back together again, I would bet all of us have things about the old system we thought were terrible that we'd like to fix. Let's take advantage of this now. And whether it's the NIH we're talking about or the FDA or your own local health system, let's really advocate for fixing it. As you heard, please be proactive. Please reach out. Let's try to write our scenario here. So let me ask you another question in relation to clinical practice. It seems to me that even before these changes, clinicians are being asked to do more with less, fewer resources, a lot of stress, a lot of... How do we address that? How do we ensure that clinicians feel that they are getting the support that they need so that they can continue to provide excellent care to their patients? That's a great question. Let me separate my role as a former FDA commissioner from my career as a clinician and clinical investigator and administrator. I'll come back to what I said during my talk. Financialization of the system and sub-optimization of each of our enterprises, I think, is a huge culprit. We had a meeting in Washington yesterday and the day before on primary care research. What we heard from the primary care physicians is the only time they're acknowledged by the systems is when someone calls them up to say, you're not generating enough RVUs. And so the pressure to just see more and more people and generate revenue for a system, that's financialization. And if I were showing slides, I would show the slide of the values of professionalism versus the values of running a business. They're not the same and they're in conflict. And I would be surprised if many people in this audience thought professionalism is winning over running a business right now in the United States when it comes to healthcare. Really the business is driving the practice and not the professionalism of the practice. So what do we do? We have this disruptive force called artificial intelligence. There's every reason to believe that within three years, doctors will not need to write down anything when they go into a room to see a patient. I was amazed by a hospital being built in Houston that will have no hardware. You just walk in and you start talking and everything is recorded. That's at least the theory. We'll see how well it works and how long it takes. Then the existential question is, will the doctor and the nurse and the pharmacist be told, see two or three times as many people because half your time is now saved? Or will they be told, spend more time giving people what they want? And I referred to this Harris Poll. Americans know they're not getting what they need. And there's no computer that's going to fix it for them. One political statement I would make, Doge, I think, has proven that if you turn software engineers loose with no content experts, you get a real mess. So I think we really need to be advocating at this time that as our ability to go back to the old days, being able to go into a room and talk and touch a patient, that we be given the time to do it in a reasonable way and not just be put on the treadmill. That's going to take organization and acting out in a good way. But I think it's going to need to happen. That's very well said. I completely agree. Last question has to do with, as you know, EP is built on innovations. We have a lot of new products coming to the market, what have you. Question that is on many people's mind, is this day and age, what is the best way to get new technologies through the FDA and getting approvals and all of that? How do you see that also transforming? Well, I would guess that if you took a poll of technology developers in the U.S., they would say the biggest issue is not getting through the FDA, the biggest issue is getting reimbursement. And so I think the most important thing is as technology is developed, whether it's a drug or a device or a biologic, you have to have the life cycle of development completely in mind, because the standards at FDA for devices, unless they're very high-risk devices, are not as tough as the drug standards. But then you can get approved by the FDA to go to the market, but if no one's going to pay for it, not going to be very helpful to patients who may need it. And so I was just at Rockefeller doing a symposium on drug development, and the message there was from the day you think you have a biological target, you should be thinking about who's going to use the treatment, and you should be doing the studies that provide clear evidence that the benefits outweigh the risks when applied to that population for that target. And I would give exactly the same advice for device developers. One revelation that I've had, you know, between my FDA stints, I worked at Alphabet for a number of years, Google, and I used to think, you know, we know that out of, say, 1,000 drugs that are thought about, only about 100 make it into clinical trials, and of the 100 making it into clinical trials, only 10 actually make it to market. And I thought devices are a lot easier, but what I've learned at Google, every single day I had a software engineer that would be in my office saying, I've got a great device for this or that. And most of them actually die on the vine before they even get foreign development. So device development's also hard. And I think having a clear view of what the thing is going to be used for, does it meet a human need, and is there someone who will pay for it, that's really the hardest part. If you have good evidence, the law says if the benefits outweigh the risks in the view of experts in the field, through well-done clinical studies, you got it made. Excellent. Well, thank you so much, Dr. Califf, for being with us and for sharing these insightful ideas with us as well. Very inspiring. It's really a privilege. Thank you. Thank you so much. Thank you for attending. And I'll turn it over to Dr. Brian Bogan. Thank you so much for coming. I've known you for 40 years, and it's really your honesty and integrity that always has been your hallmark trade. You say it the way you see it, and we thank you for coming. Right or wrong? We're only human. Thank you, Rob. Let's get a picture of you. We want to thank you. Here we go. Just got it. Everyone, have a productive and fun Heart Rhythm Conference. Thank you. This has been Heart Rhythm 2025. Go and learn. Have fun.

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