Tell us about one of your most memorable clinical cases.
Two patients come to mind. They demonstrate both the intellectual stimulation that medicine and cardiology affords us and also humility that permeates the practice of clinical medicine. Just recently I saw a patient with compensated systemic lupus erythematosus who had been previously managed by Valentin Fuster who had recommended a porcine aortic valve replacement (AVR) and a mitral valve replacement (MVR) for significant aortic stenosis and mitral regurgitation in 2003. She had done remarkably well since that time until recently when she noted progressively marked exertional fatigue. She was noted to have postural symptoms and exertional lightheadedness. Evaluation elsewhere demonstrated a normal SPECT MPI study, a transthoracic echo showing normal left ventricular function with a modest AVR systolic gradient but the mitral valve was not well visualised or adequately interrogated. A routine exercise treadmill test demonstrated a 40 millimetre HG blood pressure drop with near syncope in early exercise with a peak heart rate of 105. She had been prescribed Florinef with no benefit and in fact was admitted for symptoms of congestive heart failure with a BNP of 1000. My subjective assessment was a possible left ventricle inflow obstruction possibly secondary to pannus ingrowth of the mitral valve. On exam indeed there was a diastolic rumble and a TEE confirmed a 24mm mean gradient across the MVR with a calculated MVA of 0.4cm!! She is now being scheduled for repeat MVR.
The humbling case occurred when I was a medical resident running the medical trauma room at San Francisco General Hospital. A 21-year-old female was brought in by ambulance in full asystolic cardiac arrest with ongoing CPR documented for over 45 minutes. After running a long Code Blue drill I pronounced her dead. While giving my regrets to the family, the ED nurse beckoned me out of the waiting room to inform me the patient had taken a breath. After another 20 minutes of resuscitation we finally encountered Osborn waves pathognomonic of hypothermia. Her core temperature was taken and found to be 72 degrees Fahrenheit. I had not thought of hypothermia as it was a warm day outside but a later history divulged that her “friends” after injecting her with heroin had put her in a bathtub of ice when she became unresponsive before seeking medical care!! Her actually EKG with the Osborn waves is reproduced in the Lange textbook series. Unfortunately although the patient attained consciousness, she eventually succumbed to multiple complications include DIC and staph pneumonia.
What are your current areas of research?
Most of my present writings have been in the arena of cardiovascular outcomes research, appropriate use criteria and cardiovascular advocacy.
What advice would you give to young cardiologists?
Despite the present turmoil related to healthcare reform and acute changes in cardiovascular care delivery models, the future for the young cardiovascular specialist is incredibly bright. There is a projected workforce shortage and our aging US population with the retirement age boomer generation tells me there will be terrific job opportunities in the immediate future. The explosion of cardiovascular technology, innovation and new drugs makes this an exciting time to be practicing cardiovascular medicine.
Outside of medicine, what other interests do you have?
I have been a member of the University of San Francisco Master’s Swim team now for over 20 years with my favourite swimming stroke being the 200-yard Butterfly. This event is the only way I can ever win “points for the team” as few people are stupid enough to enter this event. This is a source of some personal pride as for years I more resembled a pithed frog trying to swim the butterfly before developing enough coordination not to drown during the event. I also enjoy drinking fine wines, playing mediocre golf and interacting with my two grandchildren, Violet and Elias.
September 1980 Certified, Internal Medicine
November 1983 Certified, Cardiology
November 1999 Certified, Interventional Cardiology
January 1985 Fellow of the American College of Cardiology
1981–1983 Cardiology Fellowship, UCSF School of Medicine, Moffitt , San Francisco
1980–1981 Chief Medical Resident, UCSF VA Hospital, San Francisco
1977–1980 Internal Medicine Internship and Residency, UCSF Moffitt Hospital
1973–1977 Emory University Medical School, Atlanta, Georgia. Doctor of Medicine. Graduated Summa Cum Laude – First in class
1971–1972 UCLA School of Public Health, Division of Environmental Health,Nutrition Biochemistry, Los Angeles. Masters of Public Health in Nutrition/Biochemistry
1966–1971 Massachusetts Institute of Technology, Cambridge, Massachusetts. Bachelor of Science in Biology
1962–1966 The Peddie School, Hightstown New Jersey
1998–Present Clinical professor of Medicine, UCSF School of Medicine
2009–Present Affiliated faculty, Philip R Lee Institute for Health Policy Studies
1992–1998 Associate clinical professor of Medicine, UCSF School of Medicine
1985–1992 Assistant clinical professor of Medicine, UCSF School of Medicine
1983–1985 Clinical instructor in Medicine, UCSF School of Medicine
2003–Present Regional senior advisor for Cardiovascular Diseases, Northern California Kaiser Permanente
2003–Present Staff cardiologist, Oakland Kaiser Permanente Medical Center
2000–Present Staff cardiologist, Summit Medical Center, Oakland, California
American College of Cardiology (President, 2010–2011)
Society of Cardiovascular Angiography and Intervention
California Chapter, American College of Cardiology
American Heart Association
Alameda County Medical Society
California Medical Association
The California Academy of Medicine