The Professional Memoir of an Academic Cardiologist
Two occurrences led to the idea of putting down on paper some of my professional life experiences. But why do it? Perhaps some of my experiences would be helpful to others. For instance, my career trajectory has taken some strange turns, at times being typical for the time period in which they occurred and others totally due to circumstances of which I had little control. Being aware of this odd road map may open up unrealized possibilities for those considering an academic career, demonstrating that the way to a satisfying career may not require a predefined plan. Another words, be open to new opportunities and experiences. This memoir will focus on my professional life and only peripherally on my personal life, sparing friends, family and wives any embarrassment.
The first occurrence “inspiring me” to put “pen to paper” (actually keystroke to Google Doc) was the request from a younger colleague to write a letter supporting his grant application. As part of his application, I had to write a Biosketch with a section I’d never seen before entitled “Contributions to Science.” That seemed a bit grandiose since the title made me think of contributions like the decoding of the Human genome, the first Polio vaccine and the Wright Brothers first flight. However, even these contributions did not occur in a vacuum and often the names who should be credited are debated. Taking that broad approach to “contributions” enabled me to break my career into five areas in which I played a role in specific contributions to science.
The second occurrence was this anonymous quote in the flyleaf of a book I was reading: “there is a time in a man’s life when he stops looking ahead and looks behind.” This resonated at this time in my life. Looking back with this framework made me realize that often the things that I was most proud of in these periods were not the contributions but how I reacted to certain difficult circumstances. Naturally since this is my story I’m the “hero” and the “minor” characters and/or organizations are the “villains”. This is certainly a simplification since these organizations and individuals have made important impacts on me and the world in general. I’m thankful for the opportunities they gave me and I hope my actions benefited them. But at least individuals are not identified and probably come off better in their own memoirs. I have nothing but the deepest respect for the organizations that I’ve been part of and hope that my actions enhanced them.
This memoir will start at the beginning of my academic career progressing through scientific areas to which I contributed, mixing in the complicated circumstances and conflicts that I encountered. A word of warning, while we all should take principled stands, be sure to only pick the battles you have the chance of winning and are important enough to possibly damage your position within a good institution
Let’s begin with my path to becoming an academic cardiologist. The repeated positive impact of mentors and peer groups was critical. On leaving high school, my career choices were the seminary, physics, the USAF Academy and medicine. I had tentative acceptances from all four and the order above represents my least to my most favorite. The seminary is explained by my respect and admiration of the wonderful St Joseph Nuns in grade school and the Marianist Brothers in High School who were my teachers. My love of Physics came from taking the Novice license tests and becoming an active Amateur Radio enthusiast. And not to forget Brother Roland, my high school physics teacher who allowed anyone who got A’s to sit in the back row and read science fiction books. All have been incredibly helpful in my medical career and in consulting and developing electronic medical devices. However, when asked how I’d do, my advisor at Carnegie Institute Technology said that I’d be an “average Physicist”. This contrasted with the advisor at Saint Vincent’s College (SVC), (which also had a seminary as a career back up) who told me I’d be an “outstanding physician” and supported that assessment with a scholarship.
The real competition was with the USAF since I was keen to be an astronaut/pilot. They offered me a slot but required that I take a year of preparatory math and science courses. That did not seem to be as enthusiastic an acceptance so I chose my Dad’s alma mater (SVC). SVC turned out to be a great choice. The Monks were fantastic teachers and pre-med was the premier curriculum. They taught us so well that I scored in the 99th percentile on the Biology qualifying exams. We started with 70 in the biomed major and ended up with 6 applicants to medical school. While classmates went to Harvard, Georgetown and other schools I chose the University of Pittsburgh which was at home and where my Dad had received his Dental degree.
I didn’t leave my USAF dreams behind though and enlisted with an USAFMC internship which paid me a Lieutenant’s salary thru 4 years of medical school. As part of my AF commitment I was required to spend my sophomore summer flying across the US in a beautifully restored DC-3 (Figure 1.)The Douglas DC-3 was a twin propeller-driven airliner widely used during World War II. The other passengers were 7 medical students in the program. We traveled for day visits to USAF research and test facilities and then ended with a month long internship at Wright Patterson USAFMC.
Figure 1. DC-3 currently displayed at the Wright Patterson USAF Museum. It is called the plane that “changed aviation” and was used by many commercial airlines prior to WWII. This is probably the plane we used and at that time was bright silver.
PITT was an excellent medical school and my major problem was being bored till clinical years since the Monks taught us the basics so well. Also, Issac Asimov’s “Wellsprings of Life” (https://en.wikipedia.org/wiki/Isaac_Asimov) was a big help. Medical school was followed by a general internship and two years of Internal medicine residency at Wilford Hall USAF Hospital (Figure 2) and then a sponsored 2 year Cardiology Fellowship at the University of Alabama. My USAF training benefited from the Berry program which kept many good academic physicians out of Vietnam if they extended their commitments.
Figure 2. Dr Steve Beering (left, Chief of Medicine at Wilford Hall and later Dean at the University of Indiana), me in the middle and Dr Ray Fitch, Director of the Residency Program. Bottom: Residency class at WHAFMC.
Even though I was “free” since paid by the USAF, it was difficult to be accepted by an academic Cardiology program for fear that their program would be “diluted”. During the interview at University of Alabama in Birmingham (UAB), I begged and promised to “be no trouble”, never complain and work harder than anyone else. I also interviewed at Emory in Atlanta and was amazed when Dr Hurst answered all my important questions (Do you have an Lipid Research Clinic (LRC), Myocardial Research Unit (MIRU) or Specialized Center for Organized Research (SCOR)) with “no but I’ll teach you a philosophy of medicine”. UAB had all those NIH programs which I considered critical to my training more so than “philosophy”. My interest in clinical exercise physiology got me the attention of Joseph Reeves, Chief of Cardiology, who became the major Mentor in my life (Figure 3, T Joseph Reeves). Joe wanted me to stay in Birmingham and offered to use political influence to get me out of my USAF obligations. This was just not an option for me since the USAF had done so much for me including freedom from school debts.
Figure 3. T. Joseph Reeves, 1923–2007, my major mentor and professional advocate. He was a skillful clinician, teacher and researcher and a wonderful friend and role model. Losing a doubles tennis match as Joe’s partner to a faculty member and his research fellow was a big disappointment.
First Area of Contribution: Screening of Asymptomatic USAF Aircrewmen
After the UAB two year Cardiology Fellowship, I was fortunate to be chosen for a premier assignment at the USAF School of Aerospace Medicine (SAM). SAM was started after WWII and had a prestigious reputation for research and evaluation of aircrewmen and astronauts. Bruno Balke PhD (exercise physiologist, flight surgeon) came directly from the Luftwaffe and was followed by Larry Lamb MD (cardiologist). The ECGs recorded annually on all active duty USAF personnel on flying status were interpreted and stored on microfiche at SAM. All individuals with abnormal ECGs or cardiovascular diagnoses or symptoms were sent to SAM for evaluation for flying status. SAM was well funded and had a very advanced Cardiopulmonary Exercise lab (Figure 4.), my real area of expertise.
Figure 4. The Cardiopulmonary Exercise Lab at USAFSAM. I made a point of always being a subject in any of my physiological studies (that’s me on the treadmill). Exercise ECGs were being digitized and the recorders were installed in a cabinet from NASA.
The first cardiac catheterization lab was set up in a small GI x-ray room. While I did my first caths in a very difficult situation we quickly went to two other labs with the best equipment available. The two labs were built not because of volume but because management could not decide whether to go with a vendor who used 35mm film and another using digital imaging so we got both of them.
The USAFMC recruited me to bring SAM back to scientific prominence and appointed me Director of Cardiovascular (CV) research and the Cardiac Catheterization Lab (1972–1976) at USAFSAM (Figure 5). This position came with excellent equipment and 12 staff including PhD’s, nurses, Sergeants, corpsman and several physicians. The School had a Philco 2000 computer (one of the first solid state computers, Figure 6) but was in the midst of deciding like everyone else which minicomputers to buy: DataGeneral Eagles or DEC PDPs (for more information, check out “Soul of a new machine”, by Tracy Kidder, 1981). SAM was like a candy store for me: I had been enamored by exercise testing at UAB and now had one of the best labs in the world … and a skilled, motivated staff.
Figure 5. Schematic drawing of USAFSAM and its mission. The device at the upper right is a human centrifuge which naturally I took a “joy” ride in.
Figure 6. The Philco 2000, one of the first solid state computers
Given the facilities and equipment, some things were easy at USAFSAM; like when I talked to my team about continuing a treadmill study I had started with Joe at UAB. To my surprise they said they had already done it. I asked where it was published and they said nowhere but all the data was in boxes over in a corner. We resurrected that study and used the Philco 2000 and Hollerith card sorter to do the analysis and then published it as a seminal paper in the Journal of Applied Physiology.
SAM had a reputation of publishing good works but the CV division had not done much after its last civilian leader, Dr Lamb, left for academia. The process for submitting a paper was an impediment. Before it could be submitted, papers had to go through seven departments besides statistics, and this could take months. Fortunately, my boss, a LtCol, made the mistake of telling me that the “regulations were for those who wanted to be average”. My modus operandi became submitting the paper to a journal at the same time I submitted it for SAM approval. This led to a publication rate similar to the golden years of Balke and Lamb; and to a brief time when a court-martial was considered for my short cuts.
My first publication there was an AGARDograph which I put together for our CV research group and was widely distributed throughout NATO (Figure 7). In the end, my efficiency reports were outstanding and I was being considered for rapid promotion, War College and the Pentagon.
Figure 7. AGARDograph describing the CV research going on at USAFSAM when I was there. It was widely distributed within NATO and was much appreciated for making USAFSAM research recognized within our peer group. Frank Yanowitz went on to a stellar career in Cardiology at the University of Utah and as an accomplished jazz pianist.
Other things were more complicated, like being the only catheter pusher in a Sones lab whereas I only had 4 months of Judkins catheter training in Fellowship. The big debate at the time was whether the Sones cut down approach with a catheter only with a single slight bend at its end was safer than the percutaneous pre-formed catheter method preferred by Judkins who was a radiologist. Mason Sones was our civilian consultant cardiologist so we only used the Sones technique and I had to learn it from doing several cases with the cardiologist who started the lab and was ending his tour of duty. Management was good enough to send me for a week with Dr Sones at Cleveland Clinic. Mason was very friendly and I teased him when he used preformed catheters on tough cases. An image that has never left me was following him into the lab with a cigarette sticking out the side of his mask.
After that observational experience, I came back with confidence and did hundreds of cases on asymptomatic pilots. I was very impressed with the USAF pilots: they were very professional and committed to their career. Unfortunately the standard practice was to “ground” pilots for minor coronary lesions. I’ll never forget the time a pilot asked “Doc, how would you feel if you were told you could not practice anymore”? This question is one that has stayed with me and especially resonates with my work as a sports cardiologist.
Our cath lab team included two excellent nurses and one other physician (Figure 8, A.J. Thompson, in the middle). AJ and I became best of friends and though from totally different backgrounds, could take each other’s place during procedures or pilot interviews. Even his Arkansas drawal and my Pittsburghese didn’t distinguish us. He was an all-state basketball star and a whiz in the cath lab. He was so good I stepped down and he took over the lab. After we both left the service he would regularly invite me to come join his practice. His best honest enticement was that “Little Rock was not the end of the world but you could see it from there.”
Figure 8. The USAFSAM Cardiac Catheterization Laboratory staff (AJ in the middle and me on a lower step next to him).
Therein followed my first big principle driven conflict. My boss had decided to ground any pilot with a minor non-occlusive lesion. Also a major reason requiring a cardiac catheterization on the pilots for flight clearance was exercise induced ST depression in an anteriorly oriented electrode placement not commonly used. I had presented data showing that using standard criteria in this lead was a false positive and not associated with ischemia. When presented to him he stated that this was research and that we could do anything we liked since this was the military and that consent was not needed. When I brought up the issue of ethics and fairness he dismissed me. It so happened that a General who was getting another star and a promotion liked to play Tennis with me and was coming up for his yearly treadmill test. He asked me to attend his test and explain things to him. He did superbly but had ST depression in the problematic lead. I told him his test was normal and he was cleared for promotion. I took the ECG tracing to my boss and said: “I told George his test was normal; we will no longer use this ECG lead to ground pilots, right?” He had to agree but he never forgave me. He brought in a series of higher ranked physicians to take my titles but still gave me outstanding efficiency reports and let me run the section.
I presented seminal data on the coronary angiographic findings and follow up of aircrewmen with abnormal ECGs and abnormal exercise tests in peer reviewed journals and brought well deserved recognition to USAFSAM. These studies were critical to the understanding of Baysian statistics and screening. I developed an international and national reputation and my USAF superiors were appreciative. They even kept me from a routine transfer for a year deployment in Turkey where they needed a psychiatrist and not a cardiologist.
The situation between my boss and I was tense, we were civil but not as friendly as we had been, I was no longer his “wunderkind”. One morning at our review session report with all the flight surgeons and trainees in attendance a case was presented and he said the pilot had to be grounded. I objected and gave solid reasoning why not. He announced that “I did not respect him” and I countered that “I could not respect the decisions he was making”. After the conference I initiated a friendly discussion about me leaving SAM and him supporting my application for Chief of Cardiology at Wilford Hall, the medical center 30 miles from SAM where I did my residency.
Management at Wilford Hall was happy to accept my application but said I had to spend a year as assistant chief since another applicant was returning from a tour in the Philippines and was senior to me but was going to retire soon. It was implied that Charlie would let me run the department and the fellowship program. Sure enough, Charlie was an excellent clinician and teacher, used the time to relax and I ran the department. There was a good group of faculty and fellows there and we improved the program. All the ECGs and studies were transferred to microfiche and we worked on a grant to get the department computerized. The clinics and conferences were improved and I edited and wrote portions of a co-authored manual of Cardiology which became our standard of practice (Figure 9).
Figure 9. Co-authored Core Curriculum for the Cardiology Service at Wilford Hall USAF Medical Center the year I was Assistant Chief of Cardiology. The art on the cover was from the personal experience of the illustrator who had this image as a memory from his loss of consciousness during a cardioversion.
The next point of principled conflict arose quickly. The equipment at the flagship hospital Wilford Hall paled compared to the excesses at SAM. The Cardiac Cath Lab was years behind the times and the coronary angiograms were blurred and unreadable. Within my first month, I made an appointment to meet with the Colonel who was Chief of Staff. He knew me from when I was second in the Residency program and supported my application so I thought he’d take my assessments seriously. When I told him that the Cath Lab did not meet the standards of practice he let loose with a series of vulgarities accompanying the message “that if you don’t like the Cath Lab I’ll send you so far away you’ll never see another”. During this period my first wife had developed head and neck cancer and needed a series of treatments not available in the AF so we depended on my superiors to allow her to receive treatments elsewhere. In spite of these pressures, I managed to reply: “Colonel, you must be having a bad day. Just tell me what to do and I’ll leave you alone”. His message, still surrounded by vulgarities, was that I should do a staff study, “you know , one of those things with folders and tabs”. Within a week I came back with a staff study justifying a new cath lab. He took one look at it and said: “Vic, this is amazing! You are going to go far in your USAF career”. I guess he was having a better day and had forgotten his previous response that included “far away”.
The grant I had submitted was funded for four million dollars to computerize the Cardiology Department and I was to become Chief. However, the Hospital Commander, a neurosurgeon, who had signed off on the grant did not want to have it interfere with his plans to cut costs and told me as much. Putting together his attitude, that the Chief position was administrative with little time for clinical and research work and that Julie needed better care than we could be assured in the USAF led me to give an ultimatum to management. This consisted of a commitment from management to support installation of a new Cath lab, computers for clinical use and giving me research time, all paid for by the USAF grant I had just received. Otherwise, I would resign from the USAF as soon as my obligated time was completed.
Preparing for rejection, I contacted Joe and said I wanted to return to academia. He had left UAB and gone into private practice in Galveston. Joe said: “Where do you want to go, Harvard or University of California in San Diego (UCSD)?” These were Universities that had multi-center SCOR and MIRU grants like Joe had at UAB. He said, “If I get you an interview with Braunwald or Ross you have to go”. We chose the warm weather of San Diego, hit it off with John Ross and took an Assistant Professor position there. I was to be Director of Cardiac Rehab at the La Jolla VA and University Hospital. This came with a small house close to the Hospital (and the Beach) dedicated to cardiac rehab (Figure 10), a portion of the SCOR grant funding and some money to buy equipment.
Figure 10. The front of the “cottage” and the inside and the beach area that we used to debrief after the day. At the rehab center, that’s me on the left with Jon Myers next to me (where he remained for the next 35 years), Dave Jensen in the middle and Mike Sullivan is on the right who later went to UCI Medical School. At the beach, that’s me in the middle in the orange T shirt giving a “medical lecture”. The cartoon was drawn by a patient and nicely summarizes my final frustrations with cardiac rehabilitation and why I left the field. TUG’s tavern was actually our favorite meeting place, now long gone and replaced by a fancy pub.
While I was at UCSD, Bernie Chaitman and I co-Directed a series of American College of Cardiology Heart House meetings on exercise testing. At one entitled “Computerized Exercise Testing” I met David Mortara and described an analog system I was piecing together to process ECGs for my studies using the start-up money from Dr Ross. Dave said: “I can do it digitally” and manufactured the first US digital ECG recorders which were used in our SCOR. Dave became a good friend and introduced me to the industry side of research. He later founded Mortara Instruments and we worked together on a number of devices and projects, including the recorders for a multi-center study I’ll describe later.
I felt bad about leaving the USAF and all my friends and colleagues but I did leave them with a new cath lab and much needed and undated clinical equipment. One of the biggest personal changes coming from the USAF to UCSD was losing the tan from playing tennis and knowing what to wear everyday in Texas (a blue uniform) and switching to marathoning and 10K’s (Figure 11).
Figure 11. Texas tan and uniform while in Texas and then running in San Diego (hard to find tennis partners since everyone was out on their yachts). Never very good but ran a number of marathons and lots of 10K’s. All my daughter Beth remembers of my running was that I painted my feet with mercurochrome to avoid infection from blisters. She was my only reliable tennis partner in San Diego.
Second Area of Contribution: The Cardiovascular Effects of Cardiac Rehabilitation (PERFEXT)
While Director of Cardiac Rehabilitation at University Hospital and the San Diego VA (1977–1983), I was Principal Investigator of an NHLBI funded randomized trial of Cardiac Rehabilitation. We demonstrated physiological adaptations but minimal changes in nuclear perfusion in patients with known cardiac disease. The acronym for this seminal study was PERFEXT for PERFusion EXercise Trial. My experience in rehab led to being Co-founding Editor of the Journal of Cardiac Rehabilitation with Mike Pollack PhD. It has just had its 40th Anniversary (Figure 12). Another publishing experience at that time was the first Edition of “Exercise and the Heart” now in its 5th Edition with Jon Myers as a co-author (Figure 13).
Figure 12. Selected covers from the 40 year history of the Journal of Cardio-pulmonary Rehabilitation.
Figure 13. The first (1993) and fifth Edition of Exercise and the Heart (2006)
The next conflict came soon after arriving at UCSD. A famous brilliant physiologist was director of Computer Technology for Cardiology. He had no training in Information Technology (IT) nor the experience I had at SAM. One of the first things I did to upset him was to introduce the department to computerized word processing. Next when I realized how backward the computer support for data basing and statistics was I convinced management that we needed to hire a computer specialist and leave Jim happy in his dog labs. This turned out to be better for everyone.
Conflicts and differences over principles were minor and rare at UCSD. John Ross ran the Cardiology program brilliantly and mentored all of his investigators. John attracted junior International researchers and farmed them out to us all to help with our research. I made friends who I still know to this day and many of them moved into key positions when they went home. This also led to a number of invitations to lecture in other countries and good friendships. One trip I remember well was to Argentina where my sponsor (Hugo Morales-Bollejo) arranged for two beautiful Gaucho horses for my daughter Beth and I to ride. My daughter is an excellent rider while I prefer bikes and fortunately Hugo noticed my anxiety and jumped on the horse and rode off with Beth.
A major incident that did occur involved a junior investigator who was plagiarizing and falsifying data. He had become the young star of the department because of his many publications. I co-authored his first paper which was a review and was impressed by his obvious writing skills acquired from work as a journalist. At one point though I became aware of discrepancies in his numbers and analyses. I had a private meeting with John and said: “I think you could put Bob into a room with 2 series of random numbers and he could come out with a significant P value”. John intimated that I might be jealous but later my concerns were validated by independent external reviewers. We were mandated by an internal review board to examine all writings with Bob and declare our part with data analysis. This was complicated because honorific authorships were encouraged to help everyone’s career and increase collaborations. Sad to say, but some of his co-authors, myself included, had to say we never got to validate the data in most of his publications with us.
UCSD was a great University and San Diego was a wonderful place to live but personal reasons led to a move to the University of Irvine (UCI) and the Long Beach VA (LBVAMC). I was offered Chief of Cardiology at the VA and assistant chief at UCI and decided to take it. It was sad to leave but I took John Ross’s parting advice: “get someone to do the clinical work” and brought Eddie Atwood MD with me and Jonathan Myers PhD “to do the research”. The move came with some money for equipment and I made one of my worst computer decisions. IBM had just released the first personal computer and the major competitor was the DEC Rainbow which included a modem that could connect over the phone to the new DEC PDP minicomputers used at UCSD. I was hoping to access databases created at UCSD and complete our studies but the DEC Rainbow lost the DOS software battle with IBM and was soon assigned to the waste barrel of computer obsolescence.
Third Area of Contribution: Prognostic Studies in Veterans
While Chief of Cardiology at the LBVAMC, I developed the cardiology databases for follow up studies of Veterans who had ECGs and exercise tests. The techniques we perfected were the basis for the Veterans Exercise Testing Study (with our best acronym, VETS), including many thousands of treadmill tests and the ECG studies. Jon and I brought this with us to Palo Alto and it is still on-going. The VETS project provided an important opportunity to address clinical, exercise test, and lifestyle factors and their association with outcomes in Veterans. These studies have been the source of hundreds of peer reviewed publications in major journals and have led to clinical risk factors and scores widely applied internationally.
One of the things that I’m most proud of is the way the VETS project has provided a medium for many students, fellows, residents and other colleagues to learn the basic principles of epidemiologic research, the importance of archiving data, managing statistics, and to publish their first papers. Jon and I have done our best to teach these principles to dozens of young researchers but we have also learned a great deal from them. These studies have demonstrated the prognostic value of both the ECG and the exercise test and dealt with issues including the health benefits of exercise, the obesity paradox, the inverse relationship of exercise capacity and health care costs, heart failure and early repolarization.
During this period there were several ancillary occurrences relative to my expertise in exercise testing. The first was the release of a software program making it possible for any exercise lab to use our data gathering and reporting techniques. This was based on the hypothesis first proposed in the grant I received at Wilford Hall, that physicians could be enticed to collect data if the system used would generate a chart-ready report (Figure 14). The other was an invitation to present some of the results of our exercise test studies at a meeting in Copenhagen. I was invited by the Chief of Cardiology at the State Hospital, Kari Saunamaki. We became good friends and he became part of our academic Rat Pack (Bill Herbert, Paul Dubach. Paul Ribisl and Jon Myers) who have gathered yearly for the past 20 years with our wives for summer vacations and email nearly weekly regarding political and scientific news.
Figure 14. Our exercise test data gathering and reporting software program.
One of the reasons why I was recruited was a serious problem with Cardiac Surgery. The politically connected Chief of Surgery had a high mortality rate and they hoped I would “pick better cases for him”. As it turned out, the problem was not with patient selection but with his surgical skills. After a year there picking “better cases” we reviewed all the cases and surgical complications, leading me to urge management to prohibit the Surgeon from operating. Even though the numbers told the story, I was convinced when the surgical residents told me that his “glasses and sweat were falling into the patient’s open chests” and they questioned his skills. He was the only thoracic surgeon on staff but despite what that would do to Cardiology, I declared to the Chief of Staff that we would no longer refer patients for by-pass surgery at Long Beach VA but would refer them to University or Memorial Hospital. Since at that time, percutaneous coronary interventions (PCI) could not be performed without surgical backup, that would have ruined our fellowship and hamper recruitment of quality faculty.
Therein followed a series of external investigations to review our PCI program where we defended PCI’s without in-house surgery. Finally the surgeon agreed to not operate and to allow local surgeons to keep our Cardiac Surgery program going. My Exercise Test book competitor, Myrv Ellestad was a big help in getting us some excellent local surgeons to help out till we could recruit a head of Cardiothoracic surgery. Myrv and I had authored the two leading exercise testing textbooks but his generous collegial spirit was stronger than his competitiveness.
Fourth Area of Contribution: VA Cooperative Study of Quantitative Exercise Testing and Angiography
I was the originator and Co Principal Investigator for Quantitative Exercise Testing and Angiography (QUEXTA) which applied computer techniques to both exercise testing and coronary angiography. It was seminal in that it also removed work up bias by only including patients with chest pain who agreed to both exercise testing and coronary angiography prior to any testing. This essential element of assessing diagnostic tests had never been applied in evaluating patients with possible coronary artery disease (CAD) and dramatically demonstrated that testing has a lower sensitivity and higher specificity when applied in clinical practice than in clinically selected patients. The planning started at UCSD with a brilliant young Biostatistician from the VA Cooperative Study Group (VACSG) and a Cardiology Fellow. It was an honor to have a project that I designed tentatively accepted by the prestigious VACSG for implementation. For the move to Irvine, the study was transferred to the local VACSG with a new statistician and I hired the Fellow for his first academic position. Both of these changes later proved to be disastrous.
From medical school, my heroes in medicine were epidemiologists and biostatisticians. My career goals in Cardiology were to plan and accomplish a randomized trial and a multi-center study. I read the Seven Countries and Framingham Studies and the MrFIT trial papers and wanted to emulate Keys, Kannel and Blackburn but on a smaller scale. PERFEXT was my randomized trial and QUEXTA was planned as an eight center study. I put all of my energies into the design, recruitment and training of centers and the analysis of the data. I traveled to all the centers to assure that patient selection and data collection were done properly. One of the morale builders we used was a T-shirt with all the centers on the back like a rock star tour.
In retrospect, I joined the VACSG when it was going through a rough period. Or perhaps the staff were not ready for my combination of experience and enthusiasm. My impression was that their data management capabilities were outdated as were the biostatisticians that managed the projects. I suggested that they move from mainframe dependence to personal computers and demonstrated how that could be done but they were resistant to new ideas. In the end, when QUEXTA was finally initiated, I decided to manage the data as we had already done to parallel their methods. Also money and time did not seem to be critical in the VACSG; progress was at a glacial speed and we were funded for years of planning and pilot stages. Once we got data collection started, there was a constant threat of ending short of our recruitment target and defunding due to new budget problems. The head statistician confessed that I knew more about evaluating test characteristics than he did and all he wanted to do was get the results in his file cabinets to show his supervisors in the Central Office that the study was done. Publication did not seem to be a goal or important.
When the study was completed and we started analysis, the VACSG biostatisticians weekly generated 5 lbs stacks of teletype printer outputs. My Co-PI kept directing them to do analyses that had little to do with the hypotheses that we were testing; ie, that computer analysis of the ECG could better diagnose clinically meaningful coronary artery disease than standard visual techniques. Finally I presented to the review group complete ROC AUC analyses from the parallel data collection that we did. They accused me of breaking the blind even though this was not a randomized double blinded trial and I was put before a review board. After that was resolved, they confirmed the results and I wrote the final paper. Normally my name would go last as the senior author but VACSG insisted my name go first. This felt like a guilt-satisfying gesture but baffles me to this day.
That was the only paper to come from that multi-million dollar effort. Numerous methodological papers could have been published that would have improved clinical interpretation of exercise tests. A follow up study for prognosis was a no brainer. Personally I was disappointed since I had hoped that computerized techniques would improve the diagnostic characteristics of the exercise ECG. As my wife Susan pointed out, a more positive conclusion could have been that computer analysis was as good as expert ECG analysis (I read and coded all the tests). Despite enormous frustration, the support provided by the VA Cooperative Study made this unique study possible and perhaps they are not as uncooperative to junior investigators now. It is one of the rare studies of any diagnostic technique to remove work up bias and demonstrate its true test characteristics in clinical practice.
Fifth Area of Contribution: Sports Cardiology
For the past 28 years I have been the Cardiology Consultant for the Stanford Medicine program and from 2015 to 2020, the Director of the Stanford Sports Cardiology Clinic. During that time, our group has contributed to advancements in sports cardiology. We have presented data regarding the application of ECG screening and of the causes of sudden cardiac death in athletes. Our meta-analysis demonstrated that inherited arrhythmic diseases are the most common cause of sudden cardiac death in young athletes. Our group published the first definition of quantitative ECG criteria (Figure 15, as featured on the cover of Circulation) which markedly lowered the false positive rate for screening young athletes. Also, Euan, Marco and I participated in the development of the International Criteria that are currently the standard for screening (Figure 16). We have also published studies regarding early repolarization, LVH, P wave morphology, repolarization abnormalities, QT prolongation and ectopy in young athletes. Certainly Early Repolarization requires at least a figure since it occupied considerable publication efforts.
Figure 15. Quantitative ECG measurements for young athletes featured on the cover of Circulation, 2011 and a special issue of the Journal of ECG concerning Early Repolarization.
Figure 16. Montage from the second meeting in Seattle where Jon Drezner (left upper corner) artfully got the many expert participants to agree on what later became the International Criteria for ECG interpretation of young athletes. That’s me at the bottom right corner presenting some thoughts regarding ST depression at rest that Jon managed to ignore by saying my ideas “were ahead of their time”.
An important development while at Stanford was meeting Dr David Hadley PhD. Dave directed research and development at a series of medical companies and turned to me for product evaluation. This led to a number of studies regarding ECG data and outcomes that gave Stanford students the opportunity to publish abstracts and papers. We eventually formed a company that manufactured inexpensive ECG recorders and used the criteria developed for screening young athletes. Being PC based, the software Dave wrote enabled including all the demographics and responses to the ACC/AHA risk factor questions right on the ECG report (Figure 17 a, b and c)
Figure 17a. The ECG recorder (called 20/20) for screening young athletes as packaged for the NCAA college athlete ECG study.
Figure 17b. Demographic screen completed prior to performing an ECG
Figure 17c. ECG printed from 20/20 with demographics, sport information and screening questionnaire results
Perhaps I’ve mellowed out with age since the opportunity or need for justified conflict has lessened. I have had to take a principled stand on a colleague who was not doing his job and documenting the incompetence of technicians I was supervising. This latter experience was the most painful since even after giving them special instructions I was labeled “a bad supervisor” and sent to human relations classes. There were some tragedies during the past decade that have not been mentioned since individuals could be recognized. A close colleague committed suicide, there was a sad “me too” episode and the deaths of peers that we all experience as we age. But I now listen more than I talk and don’t take myself so seriously. When I look back over my career I’m happy to appreciate how many colleagues have wanted me to join their academic program or private practice. One of the nicest things said of me was that I always put people working for or with me ahead of my own career.
Not Your Typical Memoir
The story I planned to tell is now over. The important experiences from my professional life and from the contributions I made to Science have been described. My plan was to avoid personal situations such as marriages, divorces, tragedies, illnesses, hobbies and family issues but a few are mentioned. These personal experiences are very different from person to person and affected by chance, the way we have been raised, our peer groups and mentors. There are alot of professional self-help books that can provide better lessons on how to live your life than I can (Particularly recommended are those of David Jensen (https://www.amazon.com/David-G-Jensen/e/B001K8XZXK/ref=aufs_dp_fta_dsk). However, there are some loose ends and experiences that were important to the course of my career that should be addressed.
My Dad is mentioned numerous times but never my Mom. She was at least as important to me for providing a model for the golden rule: “treat others as well as you’d want to be treated”. She could spell any word and typed very fast, often helping me with a term paper, even if at the last minute. She gave me and my three siblings individualized care and she was the most wonderful person in my life. She lived through difficult times with no complaints and never had a bad word about anyone. She was very religious and served as president of the local parish Christian Mothers Group. She died at age 50 while standing up to give a talk at a meeting in the church basement. This happened after my freshman year at college and had a profound effect on me.
The only sabbatical I’ve taken was a three month summer in 2000. Tony Columbo and lectures on “Sex and the Heart” sponsored the trip. Tony set up helpful Italian colleagues for our stay in Lake Como. I had hired Tony out of my fellowship program at UCI as a junior faculty. After a year he had an offer back at home to direct a Cath lab in Milan, Italy but was afraid to go without assurance he could return to the US if it did not work out. I assured him that I could keep a slot for him and so he went home and became famous as an interventional cardiologist. For my sabbatical, the plan was to help his research program with my database skills but language was a barrier: I spoke Windows and he used only Apple OS. The Sex and the Heart theme was driven by a review we had written in Current Problems of Cardiology (Figure 18)
Figure 18. Two issues of Current Problems in Cardiology (CPC’s) are put here because they are pertinent to this memoir since I’ve done ten CPCs over the years . When entering a new area of study I’ve made a point of producing a thesis-like document that establishes at least some personal expertise.
Lecturing supported us while there and one lecture was the opener for a Biomedical Engineering Meeting in Finland. The Finns struck me as very serious people so I asked Susan what I could do to loosen them up; She said “give the wrong talk”. So I started the talk with the beginning of my “Sex and the Heart” talk though the title for their meeting was “Prevalence and Prognostic value of the rest ECG”. After several slides I stopped and said to the chairman: “you look troubled, what’s the problem?” He stammered “wrong talk” and I countered with “Oh, I’m jet-lagged, this is the talk for Berne Switzerland and not Helsinski, so sorry” and then started the correct talk. When I was done, the chairman said “can you give the other talk too?” Jon claims the sabbatical was a life changing event for me, claiming I never wore a tie again but I think he exaggerates. My strong advice is to take as many sabbaticals as you can.
In the summer of 2002, I developed a health issue that drastically affected all aspects of my life. After installing shutters at home, I developed such bad muscle and joint pains that I could barely get off the floor. Susan and I were to go to a performance by the Cowboy Junkies, a favorite of mine mainly because they did a cover of Sweet Jane, the Lou Reed classic. I had run a daily 5 to 10K for years but polymyalgia rheumatica (PMR) ended that. Also it made rounding and getting to work or traveling very difficult for a number of years. Around this time, Susan and I had collaborated on several pocket sized manuals one of which was translated into Japanese (Figure 19).
Figure 19. Almost as much fun as writing a book is admiring the covers. The cover for the Japanese translation on the right is one of my favorites.
Important to mention are several colleagues who followed me from UCSD to UCI and Stanford. Eddie Atwood did the “clinical work” for me and has won many teaching awards from all three universities. Jon Myers got his Masters in Exercise Physiology while we were at UCSD, then his PhD while at Long Beach/Irvine. His theses were based on PERFEXT data and he continued to work on all our databases. Jon is recognized as one of the leading academics in the exercise sciences (https://www.acsm.org/docs/default-source/event-documents/annual-meeting-documents/2022-san-diego-ca/award-winners/2021-citation-award/2021-myers-final.pdf). Jeff Froning was a computer programmer who helped with developing the methods for data gathering. Continuity is important to any researcher and these long term friends and colleagues were critical to any successes we had together.
Critical also to these contributions have been the many students and international visitors who have volunteered time with us. Jon and I have been “counselors” at Camp Froelicher at all of our facilities where many students spent their summers. We are very proud of them all and try to follow their careers. Bill Herbert and Paul Ribisl, both PhD’s in the exercise sciences, spent time with us at Long Beach and have been collaborators. Paul Dubach, a professor of Cardiology in Zurich, Switzerland shared visits with Bill and Paul and provided International collaboration and a Swiss retreat for Jon. All three of them are now close friends. I’ve mentored many talented students and junior faculty but never take credit for their successes realizing that I was fortunate that they chose to spend time with me.
The structure of this memoir has been to follow the sequence of scientific advancements to which I contributed. For each I’ve tried to explain how I created a pathway, built strong teams, and achieved successes — enhancing clinical care and publishing good research. There are common threads throughout that make these points for readers interested in an academic career:
1. Nothing of value comes easy,
2. Anticipate and address institutional constraints and unreasonable supervisors (it helps if they recruited you to make institutional changes like was often my situation),
3. Always make good patient care your primary concern,
4. Research infrastructure and extramural funding means nothing without dissemination of knowledge that leads to improved clinical practice.
5. The key point for colleagues and former students, especially those still immersed in their careers, is you’ll never go wrong if you base your toughest decisions on the humanistic values that you learned from your role models.
To my parents, family, teachers, colleagues, students and excellent Institutions that employed me
Selected from Contributions to Science and Monographs
1. Screening of Asymptomatic USAF Aircrewmen
a. Froelicher VF, Thomas M, Pillow C, and Lancaster MC. An epidemiological study of asymptomatic men screened by maximal treadmill testing for latent CAD. Am J Cardiol 1974;34:770–776.
b. Froelicher VF, Thompson AJ, Wolthius R, Fuchs R, Balusek R, Longo MR, Triebwasser JH, and Lancaster MC. Angiographic findings in asymptomatic aircrewmen with electrocardiographic abnormalities. Am J of Cardiol, 1977;39:32–38.
c. Froelicher VF, Thompson AJ, Noquero I, Davis G, Stewart A, and Triebwasser J. Prediction of maximal oxygen consumption. Comparison of the Bruce and Balke treadmill protocols. Chest 1975;68:331–336.
d. Froelicher VF, Brammell H, Davis G, Noguera I, Stewart A, and Lancaster MC. A comparison of three maximal treadmill exercise protocols. J Appl Physiol 1974;36:720–725.
2. The Cardiovascular Effects of Cardiac Rehabilitation (PERFEXT)
a. Froelicher VF, Jensen D, Genter F, Sullivan M, McKirnan MD, Witztum K, Scharf J, Strong ML and Ashburn W. A randomized trial of exercise training in patients with coronary heart disease. JAMA 1984;252:1291–1297.
b. Froelicher VF, Sullivan M, Myers J, Jensen D. Can patients with coronary artery disease receiving beta blockers obtain a training effect? Am J Cardiol 1985;55:155D-161D.
c. Myers J, Ahnve S, Froelicher VF, Sullivan M, Friis R. Influence of exercise training on spatial R-wave amplitude in patients with coronary artery disease. J Appl Physiol 1987;62:1231–1235.
3. Prognostic Studies in Veterans (VETS)
a. McAuley P, Myers J, Abella J, Froelicher V. Body mass, fitness and survival in veteran patients: another obesity paradox? Am J Med. 2007 Jun;120(6):518–24.
b. Froelicher VF, Morrow K, Brown M, Atwood E, Morris C. Prediction of atherosclerotic coronary death in men using a prognostic score. Am J Cardiol 1994;73:133–138.
c. Myers J, Prakash M, Froelicher V, Do D, Partington S, Atwood JE. Exercise capacity and mortality among men referred for exercise testing. N Engl J Med. 2002; 346: 793–801.
d. Pargaonkar VS, Perez MV, Jindal A, Mathur MB, Myers J, Froelicher VF. Long-Term Prognosis of Early Repolarization with J-Wave and QRS Slur Patterns on the Resting Electrocardiogram: A Cohort Study. Annals of Internal Medicine. 2015 Nov 17;163(10):747–55.
e. Weiss JP, Froelicher VF, Myers JN, Heidenreich PA. Health-care costs and exercise capacity. Chest. 2004 Aug;126(2):608–13.
4. VA Cooperative Study of Quantitative Exercise Testing and Angiography (QUEXTA)
a. Froelicher VF; Lehmann KG; Thomas R; Goldman S; Morrison D; Edson R; Lavori P; Myers J; Dennis C; Shabetai R; Do D; Froning J. Quantitative Exercise Testing and Angiography. Ann Intern Med 1998; 128:965–74
5. Sports Cardiology
a. Uberoi A, Stein R, Perez MV, Freeman J, Wheeler M, Dewey F, Peidro R, Hadley D, Drezner J, Sharma S, Pelliccia A, Corrado D, Niebauer J, Estes NA, Ashley E, Froelicher V. Interpretation of the electrocardiogram of young athletes. Circulation. 2011 Aug 9;124(6):746–57.
b. Ullal AJ, Abdelfattah RS, Ashley EA, Froelicher VF. Hypertrophic Cardiomyopathy as a Cause of Sudden Cardiac Death in the Young: A Meta-Analysis. The American Journal of Medicine. 2016 Jan 20.
c. Asif IM, Roberts WO, Fredericson M, Froelicher VF. The Cardiovascular Preparticipation Evaluation (PPE) for the Primary Care and Sports Medicine Physician, Part I. Current Sports Medicine Reports. 2015 Jul 1;14(4):246–346.
d. Froelicher V, Wagner G. The ECG and the pre-participation examination of young athletes. J Electrocardiol. 2015 May-Jun;48(3):281–2.
- Chang J, Froelicher VF. Clinical and exercise test markers of prognosis in patients with stable coronary artery disease. Current problems in cardiology. 1994 Sep 1;19(9):539–87.
- Ashley EA, Raxwal VK, Froelicher VF. The prevalence and prognostic significance of electrocardiographic abnormalities. Current problems in Cardiology. 2000 Jan 1;25(1):1–72.
- Phillips WT, Kiratli BJ, Sarkarati M, Weraarchakul G, Myers J, Franklin BA, Parkash I, Froelicher V. Effect of spinal cord injury on the heart and cardiovascular fitness. Current problems in cardiology. 1998 Nov 1;23(11):641–716
- Froelicher VF, Perdue ST, Atwood JE, des Pois P, Sivarajan ES. Exercise testing of patients recovering from myocardial infarction. Current problems in cardiology. 1986 Jul 1;11(7):373–444.
- Engel G, Beckerman JG, Froelicher VF, Yamazaki T, Chen HA, Richardson K, McAuley RJ, Ashley EA, Chun S, Wang PJ. Electrocardiographic arrhythmia risk testing. Current problems in cardiology. 2004 Jul 1;29(7):365–432.
- Alloggiamento T, Zipp C, Raxwal VK, Ashley E, Dey S, Levine S, Froelicher VF. Sex, the heart, and sildenafil. Current problems in cardiology. 2001 Jun 1;26(6):381–415.
- McManus BM, Waller BF, Graboys TB, Mitchell JH, Siegel RJ, Miller Jr HS, Froelicher VF, Roberts WC. Exercise and sudden death — Part II. Current problems in cardiology. 1982 Jan 1;6(10):3–57.
- Koppes G, Mckiernan T, Bassan M, Froelicher VF. Treadmill exercise testing, part II. Current problems in cardiology. 1977 Dec 1;2(9):5–45.
- Perez M, Fonda H, Le VV, Mitiku T, Ray J, Freeman JV, Ashley E, Froelicher VF. Adding an electrocardiogram to the pre-participation examination in competitive athletes: a systematic review. Current problems in cardiology. 2009 Dec 1;34(12):586–662.