Jeffrey Moses

Can you describe the journey into medicine and interventional cardiology?

My earliest aspiration was to be a mathematician. I had a gift for mathematics, and enjoyed the elegance of the problem solving and the ability to “see the answer” from broad concepts and then translate them it into numbers. However, when I hit adolescence people became more relevant, and I became much more interested in medicine. I think biology became more relevant to me in a variety of areas, and the impact of the application of science on people’s lives just seemed to be more gratifying than the abstract world of mathematics. So from the time of high school, through college, I think I was committed to the medical field, but did not know enough about the specifics of the individual specialties to really choose my path. One of my fascinations in medical school was with the interface between psychiatry and neurosciences. This was still in the heyday of psychoanalytic theory and behaviourism was just emerging. I think I was fortunate enough to be at Penn, where the behaviourists were emerging and applying a bit more practical scientific rigor to the work on psychiatric disorders. In addition, it was the dawn of psychopharmacology and that seemed to be a clear interface between neurology and psychology. I actually did a fair amount of advanced psychiatric work in my undergraduate and had a residency lined up, but at that time the residency was requiring me to skip my internship and I felt that would have been a waste of a medical degree, so I then turned to internal medicine. Ultimately, I think I fell into cardiology because in allowed an opportunity to apply cardiovascular physiology in everyday work. The Swan-Ganz catheters were just being used and the idea of titrating drugs, and other ministrations, to optimise cardiac parameters in real time, was very gratifying. At Penn, pathophysiology was strongly emphasised further whetting my appetite. Of course, as I am quite long in the tooth, interventional cardiology was in its infancy during my fellowship and I was privileged to scrub-in in some of the first balloon angioplasties done in Philadelphia. It was a very exciting time and quite fluid, when we think of the rigidity of clinical investigation in the current era. The idea of just taking a course and flying over from Switzerland and coming back with a bunch of balloons in your bag and joining an NHLBI registry as a form of trial for approval seems to be quite quaint now.

I was also, at that time, fascinated with electrophysiology, and did do a fair amount of work in the early days of invasive electrophysiology, especially during my first seven years at Cornell. But, I think, interventional cardiology ultimately seduced me because of my previous work in the animal lab, and the idea of being able to make observations in the coronaries of a living human was just eye-poppingly amazing to me. Now, today, when we have sophisticated imaging techniques, intracoronary physiology and the ability to manipulate the structure of a coronary artery almost at will, seems that my early fascination was justified. Ironically, one of my first bosses, who shall remain nameless, felt that Gruentzig’s work was “interesting”, but it was “monkey work”. Well us monkeys helped create a new field of investigation and treatment and were able to transform millions of lives.

Who are your greatest influences and what advice from them do you still apply to your career?

I can cite three individuals: one is Dr Jim Carter, who is an internist/endocrinologist at Penn. He was my Attending, as an intern and resident and really opened my eyes at what a well-versed, clear thinking internist could do for his patients. His comprehensive understanding of the patient and his systematic and deductive thought formed a model for me in my approach to my patients to this day, and I do not know if he realised the impact he had on me.

The second influences were a pair of individuals, who I came to work with my first year at Cornell. They were Michael Collins and Jonathan Goldstein. They were true “cath-jockeys” and in spite of my training as a fellow, I had never really encountered individuals who were truly fascinated with the technique itself. They taught me that cardiac catheterisation was not just a mechanical process, but actually had an artistic aspect to it. This was totally revelatory to me. Fortunately, Mike Collins and I have remained fast friends, and I worked with him again for the last 12 years, after he took a sojourn in Florida in private practice.

Lastly, I think the individual I think who was most formative in my approach towards interventional cardiology is Martin Leon. While he is my colleague and great friend, his vision when he was at the NIH and at the Washington Hospital Center, of integrating advanced techniques and scientific rigor into interventional cardiology, was something I adopted very early. It is because of his passion that I felt that integrating clinical research an essential ingredient for a successful programme and to render optimal treatment.

How has interventional cardiology evolved since you became an interventional cardiologist?

Well, I have witnessed its transformation from day zero, from the early days of unpredictable life threatening complications, endless battles with groin bleeding, sleepless nights concerned about abrupt and late closure, to the largely controlled environment we have now; with predictable outcomes with advanced coronary stent techniques and complementary physiology and imaging. It is the difference between a wooden sail boat and a space shuttle.

Amongst all of the technologies you have seen in the last 20 years, what has fascinated you the most?

I do believe, if I have to take one single transformative technology in the last 20 years, it has to be the percutaneous aortic valve. This is largely due to the fact that I had the good fortune to be involved in it at its inception, when it was a highly speculative and almost “crackpot” idea, and witness its evolution into a technique that is saving the lives of thousands of patients around the world. This has been the most fascinating scientific and clinical journey of my career.

This ties up into another question about one of my most memorable clinical cases. This had to be a recent procedure that my father had at Columbia. My father is in his mid-80s, and had known moderate aortic stenosis; he suddenly became symptomatic and quite limited as the aortic stenosis progressed. I remember the look in his eyes when I told him about his disease, and that he needed an aortic valve replacement. They were pleading with me to find a way to avoid surgery at his advanced age. It was heart rendering. My dad, “fortunately”, is reasonably healthy, but did have enough comorbidities to qualify for the PARTNER trial. He had a successful valve implantation and was home in two days. That, more than anything, gave me the sense of the impact of the work we are doing on the most profound and personal level. When you are thinking about the growing population of able elderly, with a simple problem of a stenosed aortic valve, and the ability to rectify that with a catheter based procedure, that requires minimal or no invasion, the personal experience with a loved one made this my most memorable recent case.

What is the most interesting paper you have read recently?

A little gem of a paper, McNulty et al JACC CVInt 2011,4;1020, which elegantly and simply highlights some of major flaws in some conventional thinking. This study looked at patients who had unprotected left main stenting, and compared outcomes of those who were inoperable, with the operable patients. They observed profound differences in mortality, as you would expect. The only problem with the data is that they demonstrated that the ACC-NCDR database failed to capture over 80% of the conditions elements that made the patients inoperable. This is fascinating to me because it undercuts the entire premise of the current comparative effectiveness initiative cross-correlating the STS and NCDR databases. If you cannot separate out the surgical from the nonsurgical candidates in the PCI database, how do you compare these apples to these oranges? This must be addressed but will not be I fear. It just indicates how, conventional wisdom can sweep along an entire field, without anyone questioning the basic elements of the data set. These rapid fire sound-bite solutions to some of the most complex medical questions, and the certainty that people have about “current evidence”, disregarding the nuances of data entry and quality, the quality of clinical trials and subtleties of patient recruitment is sending this field, in some ways, in some questionable directions. They just get fascinated with the statistical methods.