Next Generation is a BWH Clinical & Research News (CRN) column penned by students, residents, fellows and postdocs. This month’s column is written by Bradley Wertheim, MD, the inaugural Burke Fellow in Pulmonary Heart Disease.
John Donne famously wrote that “No man is an island, entire of itself; every man is a piece of the continent, a part of the main.” The same can be said in medicine: No organ is an island. The interplay of one organ with another can dictate health or disease. Yet, through medical school and clinical training, we become biased in thinking about only one organ at a time. Out of custom and efficiency, we draw artificial distinctions between a “lung problem” under the purview of pulmonology and a “heart problem” under the purview of cardiology, and the like. However, there are many diseases where this heuristic fails, and ultimately, patient care suffers.
Pulmonary heart diseases are one such example. Straddling the border between two disciplines, they encompass a variety of disorders affecting the structure and function of the lung, which strain the right side of the heart and compromise its ability to pump effectively. Pulmonary arterial hypertension (PAH) is the archetypal condition in this family, and is characterized by elevated blood pressure within the lung arteries due to progressive narrowing and destruction of blood vessels. Historically, survival in PAH was poor, rivaling that of aggressive cancer. Over the last three decades, survival has improved, owing to better understanding of the disease and the development of three new classes of targeted medications. In spite of this progress, the illness can still be devastating, and unfortunately, many patients still have symptoms for years prior to receiving a definitive diagnosis and starting effective therapy. This is in part due to the rarity of this condition, lack of awareness by clinicians and traditionally siloed approach to diagnostic reasoning. As the inaugural Burke Fellow in Pulmonary Heart Disease at Brigham and Women’s Hospital, I am working across traditional academic boundaries to better understand and treat this frequently overlooked population of patients.
An unlikely premedical experience stimulated my interest in heart-lung interactions. Building gas stations for the family contracting business, I enjoyed the practical troubleshooting of pumps, electrical circuitry and piping. My father taught me about Ohm’s law, V=IR, where the voltage in an electrical circuit is equal to the product of flow and resistance. As a medical student in BWH’s Barbara Cockrill’s, MD, pathophysiology course at Harvard Medical School, I learned that the same equation is applied to describe blood flow through the pulmonary circulation. I became a pulmonologist, in part, because I enjoy the application of math to describe air, blood, oxygen and carbon dioxide transit through the lung. I also realized that I love intensive care medicine and the challenge of caring for the sickest patients in the hospital.
My first year in the Harvard Brigham and Women’s Pulmonary and Critical Care Medicine Fellowship reinforced my interest in cardiopulmonary physiology. At the bedside and in the intensive care unit, I learned how we apply principles of lung medicine to improve the filling and pumping function of the heart, which can improve oxygen delivery and carbon dioxide removal. I ultimately realized that I wanted to dedicate my professional life to understanding these relationships.
During my Burke Fellowship, I have enjoyed a number of experiences that would otherwise not have been available to me through a traditional training pathway. I am lucky to count many lung and heart physicians as mentors and teachers. We have an active inpatient pulmonary vascular disease service, staffed by both pulmonologists in my department and cardiologists in the Boston Adult Congenital Heart Disease (BACH). In addition to working on our inpatient service, I gained exposure to advanced heart disease and heart failure management, cardiac imaging, and the medical and surgical aspects of lung transplant. I have also been fortunate to participate in the care of patients on extracorporeal membrane oxygenation (ECMO), a life support system that can temporarily function as an artificial heart and lung for those patients with critical failure of either organ. A highlight of my training involves our work with the Dyspnea Center at BWH, during the assessment of patients referred for unexplained shortness of breath. Under the guidance of Aaron Waxman, MD, PhD, David Systrom, MD, and Alexander (Sasha) Opotowsky, MD, MPH, MMSc, I am learning to interrogate human physiology through invasive cardiopulmonary exercise testing and right heart catheterization, in order to more precisely identify and manage pulmonary, cardiac, and other limitations to breathing.
My clinical training through the Burke fellowship is also launching my career as a physician-investigator. These rich experiences at the bedside will help me think more creatively as a researcher. Under the guidance of Bradley Maron, MD, I will begin a project to search for early signatures of disease in those patients with elevated pulmonary blood pressures who do not yet meet current diagnostic criteria for pulmonary hypertension. With better understanding of early disease pathogenesis, we hope to facilitate prompt diagnosis and treatment, in time to preserve right heart function.
The Burke Fellowship in Pulmonary Heart Disease is bridging the respective islands of heart and lung medicine at BWH, and I am thrilled to be a part of it.
“134. John Donne (1572-1631). Respectfully Quoted: A Dictionary of Quotations. 1989.” Accessed April 4, 2016. http://www.bartleby.com/73/134.html.
Strange, Geoff, Eli Gabbay, Fiona Kermeen, Trevor Williams, Melinda Carrington, Simon Stewart, and Anne Keogh. “Time from Symptoms to Definitive Diagnosis of Idiopathic Pulmonary Arterial Hypertension: The Delay Study.” Pulmonary Circulation 3, no. 1 (2013): 89–94. doi:10.4103/2045-8932.109919.