February 23, 2024 • 49 mins
From the rolling hills of Montana to the bustling heart of Seattle's medical community, Dr. David Elison's journey is nothing short of inspiring. As a structural interventional cardiologist at the University of Washington, Dr. Elison opens up about the winding road that led him from a potential future as a biology teacher to a lifesaver in the cardiology department. His tale is a vivid illustration of how mentorship can shape a career, and how a profession in healthcare can evolve through the years, adapting to new challenges and discoveries. Tune in for a rich narrative that traverses educational crossroads, personal growth, and the mechanics of the human heart.
Parenting and a career often tug life in opposite directions, but Dr. Elison shares how they can harmoniously coexist in the demanding world of cardiology. He draws an intimate portrait of the 'carpenter' and 'gardener' approaches to raising children while balancing the scales of a new attending's life, all echoed in his own experiences. His personal insights into the symbiotic relationship between home life and the cath lab, alongside a deep dive into the distinctions between interventional and structural cardiology, paint a compelling picture of the modern medical professional's life.
Our episode wraps up with a peek into the future of heart valve technology, where Dr. Elison's humor shines through stories of Montanan misconceptions and the Seattle transition. The conversation pivots to the vital transition period for medical trainees becoming attending physicians, underscoring the criticality of mentorship, supportive work cultures, and proactive steps to avert physician burnout. Dr. Elison's heartfelt gratitude towards his mentors leaves us with a stirring reminder of the profound impact that guidance and camaraderie have on both doctors and the patients they serve. Join us for these heartfelt revelations and candid conversations that get to the very pulse of what it means to be a healer.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:01):
This is Coffee in Cardiology.
Speaker 2 (00:05):
In this podcast we sit down with the faculty from
the University of WashingtonDivision of Cardiology to
discuss the very latest indiagnostics, therapeutics and as
a special bonus, we ask whatmakes our cardiologists tick?
John Michael, we have DavidElisson with us today.
(00:26):
He is one of our newly minted Iguess not so much newly minted
anymore, you've been at this forquite a while but structural
interventional cardiologistshere at the University of
Washington.
I had the privilege of workingwith David as he sort of came up
through his training here, butI would like now if he would
(00:48):
give us an even broader pictureof his journey in medicine,
because it's actually a veryinteresting one.
Speaker 3 (00:56):
Well, thanks for having me guys.
Yeah, I went.
I'm from Montana and I went tocollege at the University of
Montana fully anticipating to bea biology teacher.
My father was a teacher and Ijust sort of always saw that as
a career that I enjoyed.
I was sort of part of the waythrough that.
(01:21):
When one of my advisors in thebiology department was like,
have you ever thought aboutgoing to medical school?
And I was like no, and here weare.
She sort of pointed me in theright direction and really never
looked back.
I did my medical schooling atthe University of Colorado, so I
(01:45):
lived in Denver for four and ahalf years.
Then I've been here ever sinceI came here for residency.
I really liked the Universityof Colorado, but I thought to
myself I should experiencesomething new and different, and
so I came out here forresidency in 2015 and I stayed
on for cardiology fellowship.
(02:06):
I really liked the people Iworked with as a resident and,
following my general fellowship,I was like you know, I really
like the interventionalists here.
I really like the group, I likethe program.
I have small children.
There's a lot of reasons to wantto stay, and I stayed on for
two years of interventionaltraining.
At the end of that, which wasonly eight months ago, the group
(02:33):
sort of welcomed me on as theseventh member of our team.
So I've actually sort of becomea UW lifer minus the undergrad
med school part.
I really love this job.
I've been really excited totransition into my attending
life and it feels like a nicehome for me.
(02:53):
It's a very supportive teamthat the leaders of our section
have created and it's been aneasy and smooth transition into
attending life for me.
So I'm happy to be here andtalk to you guys about it and
let you know about me.
Speaker 2 (03:09):
Well, that's fabulous .
It sounds like you're notexactly the one who's being
forced into all the call anddoing all of that sort of early
guy stuff.
Speaker 3 (03:18):
No, no, I mean I think there's a certain amount
of new guidance.
You know I got Christmas, forexample, but that's to be
expected anywhere you go.
It's obviously easier whenyou're in a seven person group
than if you go somewhere andyou're in a two person group.
But no, I mean, everyone hasbeen incredibly supportive.
(03:40):
I think what's unique about ourinterventional group here is we
really take care of, you knowkind of the broad end of
spectrum in terms of structuraland coronary cases, and it's a
little daunting sort of day onein your attending life to be
like oh, here's somebody who'shaving an end stemmy in Yakima
and their EF is 20% and they'reon a balloon pump and they're
(04:03):
not intubated and they're insort of borderline cartogenic
shock.
Can you do their atherectomyleft main tomorrow, it's like
sure.
So everyone has been verysupportive to me and our senior
members of the section arereally unmatched in terms of
their mentorship and care andyour development, and I think
(04:26):
that's something that's notpresent everywhere you go and it
really, as I interviewed forjobs last year, it really stood
out to me as something that wasreally unique and beneficial
about our group and somethingthat has been obviously a
wonderful thing to have in yourback pocket to go around the
corner and be like hey, bill, 10years, would you mind looking
(04:48):
at this angiogram with me?
Just to have world experts inthe things that you're trying to
do all day as a new person isreally beneficial.
Speaker 1 (04:57):
What is you kind of glossed over the jump to
cardiology.
What was that?
Why?
Speaker 3 (05:03):
You mean from internal medicine.
Yeah, I think I've always beensomeone who struggles with the
decision, which is funny now,because now my life is just
split decisions all day long.
But when I was in medicalschool I sort of liked
everything.
My wife always tells all herfriends that I went through a
(05:25):
six week period where I thoughtI was going to be an
obstetrician and now I dosomething quite remote from that
.
So it's always been hard for meto align exactly my interest
with where I'm headed in themoment it feels.
And I chose internal medicinebecause it sort of allowed that
decision to be kicked down theroadways.
And when I was in internalmedicine residency I liked a lot
(05:49):
of the things that I tried andfor a period of time I thought I
was going to be in GI.
Ultimately I settled oncardiology because I felt, of
all of the systems in our body,I just often feel like we
understand the heart so muchmore than so many other things
in terms of the mechanics andthe physics behind the way it
(06:11):
works and the electricalsignaling.
I found all that veryinteresting.
But then the other point ofthat is that there were so many
things that we could do.
I got very frustrated in thingswhere it felt like, well, you
have this awful disease and I'msorry that always was a great
(06:32):
frustration to me.
And in cardiology I feel likethere's so many avenues of
things that we can offerpatients, many of which improve
not only longevity but also justthe way they feel, and I found
that to be incredibly fulfilling.
And I came into cardiologythinking I was going to be a
(06:54):
heart failure doctor and peoplelike Wayne Levy wrote my letters
for fellowship shout out toWayne and I went into fellowship
thinking that that was what Iwas going to do and that I liked
working with patients withadvanced heart failure.
I liked transplant and thingslike that.
And I just sort of realizedover time that I am much more of
(07:14):
like a Mr Fixit kind of person.
Is that I like sort of aproblem approach, dealing with a
particular issue and how are wegoing to fix it?
What are the tools that we haveto address a particular problem
and what are the imaging piecesthat we're going to use to try
to understand the problem thatwe're dealing with?
(07:35):
I worked in construction beforeI went to medical school and I
actually feel like there is somuch of my day job now that is
very akin to that work.
So that's sort of how I found myway to where I am now, and it
was a sort of stepwise decisionwhere there was a lot of
(07:57):
reroutes along the way, but Ifeel like I've really kind of
found my home.
Speaker 2 (08:06):
I think you really encapsulated a lot of the
seduction, if you will, ofcardiology for so many of us
that we can do things thatbenefit people's lives in
multiple different ways, that wedo have answers.
We don't always have answers.
Sometimes we have to have hardconversations, but at least
we've almost always gotsomething, whether it's
(08:28):
medicines or whether it's anintervention.
But the thing I just love aboutyour story is that you're
admitting to a pathway and anorientation that, let's be
honest, isn't found in a lot ofinterventionists.
I mean, a lot ofinterventionists were not
thinking about advanced heartfailure as part of their career
(08:50):
path or biology teacher.
Speaker 3 (08:52):
Or biology teacher for that matter.
Speaker 2 (08:55):
Construction, yeah, definitely makes sense.
But I think that's emblematicof our group here.
The seven of you are not justincredible world-class
technicians, but you'reworld-class thinkers, you're
deep thinkers, you are decisionmakers, or deciders, if you will
(09:15):
, in a way that is beyond justthe technical aspects and I
think the fact that you've andI'm assuming it feels very much
at home because you've been herefor a while, but also you fit
in this group because this isthe nature of your group.
You're incredibly high volume,you're incredibly technical and
yet you have thatpatient-oriented focus.
(09:39):
You have that deep thinking,that integration of the imaging
and the electricity and thatadvanced heart failure meds and
all that other stuff that goesinto what I think it makes you
guys the best interventionists.
Speaker 3 (09:53):
Well, yeah, I agree.
I mean, I think the physiciansthat I have had the greatest
respect for in my trainingpathway are those doctors who I
feel like are actual, realpeople.
I find that those individualshave the best bedside manner in
(10:15):
the way that they talk to peopleand explain a problem, and you
know, so much of what we do isreally salesmanship.
When you get down to it is,you're talking to somebody about
something that they don'treally have a lot of expertise
in or understanding most of thetime.
You know.
This is especially fresh in mymind because my wife and I just
(10:36):
bought a house and we did ourclosing this morning where you
sit across the table fromsomebody who just hands you
document after document that's25 pages long and totally
illegal ease and you're like Ihave no idea what any of this
means, but the person across thetable at the escrow office is
explaining things to you andlike this is why this matters,
this is why this matters, and Ifeel a little bit like that's
(11:01):
often what we do is somebodyfrom you know your dad's
practice in Longview gets sentup because they have aortic
valve disease and they don'thave any medical background and
this is sort of a foreignconcept to them and you're
sitting across from somebodytalking about how you're going
to do something that isinherently surgical and can be
(11:23):
dangerous and is ultimatelyreally important, and I think so
much of that conversation canbe challenging and
time-consuming, but I think it'sreally important and I think
the reason why I have a lot ofrespect for my partners and the
(11:46):
members of our group is that Ithink particularly Drs McCabe
and Lombardi, Bill and Jamie, asour leaders, have really done a
remarkable job of cultivating ateam of people who are real
people and can sit across fromyou and say you know, here's the
thing that we're dealing with,these are the things that we can
(12:09):
do about it, these are therisks.
This is how I see you and I seeyour problem, and I think that
conversation is intrinsicallymuch easier to have if you
yourself are a person and sitacross and have an actual
conversation.
That becomes increasingly lesstechnical when you're just
meeting with somebody.
I have always found that thepeople in our section as a
(12:33):
former trainee in our sectionand I was a member of it are a
truly remarkable group of peoplewith a really broad array of
skills that I just have a greatdeal of respect for it's sort of
like a big family.
I hope they don't feel likethat's dorky for me to say, but
that's always how I felt aboutit and it makes it easy to feel
(12:58):
at home.
Speaker 2 (13:01):
That's good, and I know that your family is one of
those non-dysfunctional familiestoo.
They're very supportive andeven though you get stuck on
Christmas, they're always therefor you.
Speaker 3 (13:10):
Yeah, I mean I think you know my immediate family,
like my parents, we have a veryblended family.
My parents are long-sensedivorced and got remarried and
so in that setting I have anumber of steps of things that
it made for an interestinggrowing up experience.
And my father, he got remarriedalmost 20 years ago now and so
(13:36):
you know, my stepbrothers andsisters are really like my
brothers and sisters and we alllive like tremendously different
lives.
And he refers to us as thevillage people like the YMCA,
because I, you know, I do this.
I'm the oldest.
My closest brother after me ishe's 6'6" and has hair to his
(13:56):
shoulders and full beard andworks at a nice restaurant, lake
Tahoe, and is mostly like anoutdoor ski bum.
And my brother after him was inCatholic Seminary School to be
a priest and then was like, well, you know, I don't know that
that's actually for me and nowhe's an attorney in Montana.
And my closest sister after himflies.
(14:19):
She's a first lieutenant in themilitary and she flies Apache
helicopters and she's currentlyI think it's okay to say this
she's currently deployed inRomania.
And my youngest sister was likea cheerleader in Louisiana and
now she's married and has twokids and I think that background
(14:43):
really shaped kind of who I am.
You know, my dad's very fond ofsaying that there are two types
of parents.
There are carpenter parents andthere are gardener parents.
And carpenter parents sort ofconstruct their child in the way
that they see them being, and agardener parent just sort of
makes the soil for your child tobecome whoever they might be
(15:04):
and my parents were very muchhippies from the 70s.
Gardener parents.
And that's raised me to be who Ifeel like I am and my own
immediate family, my wife.
We met in college, actually,and we've been together for this
will be 15 years coming up thisyear and she's a wonderful
(15:29):
person.
She's incredibly supportive.
I don't actually think I coulddo this job without her being
the sort of independent,individual, supportive spouse
that she is.
We have two little girls.
Our life has been a littletumultuous in the last six
(15:49):
months with our second daughter,but we have two wonderfully
sweet little girls and parentingand being a new, attending and
moving and I think all of thosethings add stressors that are
just made easier by a familythat you can rely on and trust.
And really I really count myblessings for the way that my
(16:12):
wife is when it comes tosupporting this line of work,
because there's nothing quitelike being like just one more
case I'll be home in 20 minutesand then it's like 945, because
the last case took three and ahalf hours and I think there's
something to be said about howthat's not an easy role for a
(16:34):
spouse to play and she reallydoes have a lot of grace and I'm
very thankful for that.
Speaker 2 (16:40):
That is phenomenal.
That is really, really neat.
I'm assuming that, despite yourcarpenter background, you're
planning to be a gardener parent.
Speaker 3 (16:47):
I am very much a carpenter parent.
My first daughter is juststubborn, as the day is long and
I don't know exactly what sortof person she's going to grow up
to be.
But I'm excited to see how thatdevelops and I don't actually
really know how to be acarpenter parent.
I just sort of want my childrento know that I love them and
(17:11):
care about them and I want themto succeed in whatever it is
that they're interested in andfind their own way in life,
because that's really what I didand it's worked out in a way
that I'm very grateful for.
Speaker 1 (17:27):
How about, as a student, to now teach your
parent to our fellows and besupporting them?
Do you also kind of bring thatmentality to how you support
them?
Speaker 3 (17:38):
Yeah, I mean I think I would like to.
Ultimately, there is a realismto the fact that you're dealing
with things that are inherentlylife-threatening and, when done
improperly, can cause harm, andso, especially as a newer person
, I gravitate towards being alittle bit more hands-on and
(18:03):
making sure that each patient iscared for in a way that I would
want my own family member to becared for, and so to that end,
I guide the fellows a little bitmore in a carpenter sort of way
than perhaps just sort of likelaying the foundations for them
to grow.
But I do think where I reallysee this playing out is I want
(18:24):
our fellows to.
Our field is justever-expanding in terms of what
we can do and what we can offer,and even in interventional
cardiology there areincreasingly finite subsets
where people focus on one thing,and our fellows come in sort of
(18:46):
undifferentiated for the mostpart, and I have appreciated
that our faculty have been verysupportive to that.
They were very supportive to mein my process of doing that,
and I think, as you find yourway through the interventional
landscape, finding the thingsthat you like doing or you feel
fulfilled in doing is reallyimportant, and so I have had
(19:08):
several conversations with ourfellows about how to explore
those things that you'reinterested in and how to
gravitate yourself towards oneparticular thing or not.
It's been very interesting to meas a newer attending working
with our current structuralfellows, particularly one
(19:31):
structural fellow who was afirst-year interventional fellow
while I was the structuralfellow just last year, and so
obviously there's a new teamdynamic there.
That's very different, but Greghas actually been very
supportive to me in my newness,which I really appreciate him
for.
Our other structural fellow,christina, came from outside so
(19:54):
I didn't know her as well priorto this process in transition,
but it's been an interestingchange in roles, sort of the way
that the staff sees you, theway that people interface with
you on the day-to-day, and oneof the things that I thought a
lot about was how I wouldinteract with fellows that I
(20:14):
knew personally when I was afellow, because I think there's
a certain familiarity that cansort of change the dynamic in a
way.
That is not always perfect, butour fellows have really
embraced me and I think they'rea solid and important part of
(20:35):
our team and when I say our team, I include them in that and our
team has really welcomed me andmade this process pretty
seamless.
Speaker 2 (20:46):
I wonder if you could explain a little bit the
difference betweeninterventional and structural
and how that works in thetraining process and also how
that works from the attendinglevel.
Speaker 3 (20:56):
Yeah, so it's a good question.
So you finish GeneralCardiology Fellowship, which
takes three years, and then youcan go into interventional
fellowship.
Previously in decades past, tobecome an interventionalist took
about a year that was beforethe advent of most
(21:17):
trans-catheter heart valves,things like that and so you were
really learning how to docoronary interventions on
patients having heart attacks orwith stable heart disease.
So that was a process that formost took a year.
I don't know exactly the timecourse in which this has
happened, but I'll just say overthe last decade there has been
(21:38):
a emphasis placed on continuingthe development of that skill
set, and so for the first yearyou really spend your time
dealing with coronary arterydisease stent procedures.
And once you have solidifiedthat skill set, there is an
(21:59):
opportunity now increasinglyacross the country not just in
our program to enter a secondyear of training in which you
specialize either in verycomplex coronary artery disease
interventions or you enter aspace called structural heart
disease, which is what I do andprimarily focuses on the
(22:20):
interventional side.
That does not include coronaries, so valve interventions,
replacements and repairs,closing of holes in the heart,
things of that nature, and sothat's how I spend my time now.
I mean all of us who work inintervention have a component of
your life that's made upcoronary interventions, as that
(22:40):
is far and away the most commonthing.
But increasingly people aredoing a second year specializing
in structural intervention toget that particular skill set
related to primarily valveprocedures, and that's how I
spent the entire last yearworking with Dr McCabe and Dr
Chung, as well as Dr Don, whoare my structural trainees over
(23:03):
the course of the last year,which was a unique experience
for me and was really enjoyedthat time a lot and learned a
lot, and that is now how I spendthe other bulk of my time, and
so the section that we have hereis kind of divided into those
(23:26):
two separate areas of focusright.
Yeah, that's correct.
So I don't know exactly howthey might think about it.
But how I think about it isthat there are two silos and we
all intermingle to some degree.
But the complex coronary teamBill Lombardi and Kate Carney
and Lorenzo Asilini, who's thenewest member of their team, and
(23:47):
then Jamie McCabe, christineand myself on the structural
side, and then Zach Steinberg isour guy who does adult
congenital heart diseaseinterventions, which is like a
totally different thing out inleft field.
So the seven of us make up thissection and yeah, we're sort of
subdivided along specialtylines.
Speaker 2 (24:09):
Yeah, and that makes sense from the academic
standpoint, but that's not theway it is everywhere.
A lot of times there's a fairamount of overlap where there's
just focus on the coronaryaspects but not necessarily the
complex coronary aspects.
Speaker 3 (24:23):
Yeah, I would say a lot of my sense of the
structural landscape is thatthere are a lot of people who do
TAVR or trans-catheteria aorticvalve replacement or close
simple holes in the heart,simple connections in the heart,
like a patent for ImmunovalliPFO.
That level of training seems tobe relatively common across the
(24:47):
country.
I think when you're gettinginto the things that we do here
that are more complicated,involve other valves, involve
more complex lesions, subsets,patient complexity, that is
something that is much lesscommon and is particularly
(25:10):
reserved for people who have haddedicated training in
structural heart disease.
Speaker 2 (25:16):
I know even within the structural component we have
sort of areas of specialization.
Speaker 3 (25:24):
Yeah, I mean, I think maybe that isn't necessarily
the way that I would think aboutit.
I think on the structural sidewe have a team lead.
Jamie is my personal mentor andhusband for several years and
he's remarkably gifted and aworld's expert in a lot of what
we do and he certainly does themost complex stuff in our group,
(25:49):
including the fullypercutaneous electrosurgical
things and interventions in themitral and tricuspid space.
Christine is several yearsahead of me and has started to
move into some of that as well.
Right now I'm doing primarilyaortic valve interventions,
closing some simple lesions,things like that to get.
(26:12):
It's not to say that I didn'ttrain in all of those things,
but I think there's ahierarchical approach to some
degree of the most experiencedperson doing the most
complicated things Kind of justmakes sense, and so I wouldn't
say that Jamie does this,christine does this, I do this.
It's more that he leads ourteam and through his guidance we
(26:39):
all are learning and gettingbetter and approaching new
problems in new ways.
And yeah, I guess that is theway that I would think about it.
Speaker 2 (26:52):
Yeah, that makes a lot of sense, this stuff.
If you end up doing most of thetavers at this point because
Jamie is doing a lot of theother stuff, it's more that
great responsibility and greatcomplexity.
Speaker 3 (27:03):
Yeah, and I think that's, as I was saying earlier.
One of the great benefits ofour team is that if I'm referred
a patient who is particularlycomplicated for one reason or
another, there is no closed door.
I just would walk around thecorner and say, hey, what do you
think about this?
And it's a remarkably positiveexperience to have that in your
(27:28):
back pocket and I don't.
In speaking with other peoplewho have been along my training
pathway and now work at otherplaces that's not always the
case and having the support ofpeople who, first and foremost,
(27:49):
want every patient to have agood outcome, but also want you
to continue to develop the skillsets that you've worked hard
and trained to make and want tobe a resource to you in your
continued development.
I mean, we are all continuingto develop always.
There is no point at which yousort of stop, particularly in
this field, and having a team ofpeople where you can say this
(28:17):
is a circumstance that I've notexactly encountered before.
What would you think about this?
This is what I was thinkingabout.
How would you approach this?
That's a gift and I reallyvalue that.
Speaker 1 (28:29):
When the field and everything's evolving very
quickly in structural heart, alot of clinical trials.
What excites you most aboutthat future and what you really
want to be involved in?
Speaker 3 (28:39):
Yeah, I mean, I think the things that are most
interesting to me are thededicated valve prostheses.
Right now a lot of the workthat's done in the mitral space,
for example, is done by theпригeremos queideexecuto's
districts that are I don't wantto use the word gerry-rigged,
but it's a little bitgerry-rigged from pieces of
(29:03):
equipment that are not designedfor that valve.
You know, using a prosthesisthat's made for the aortic
position, off-label in themitral position, for example.
A lot of the clinical trials weparticipate in are in dedicated
valve prosthesis and theresults from those have been
(29:24):
very interesting.
You know I don't know if yousaw just last week the FDA
approved the evoke valve, whichis a dedicated tricuspid valve
prosthesis which we had theprivilege of participating in a
few of those implants with DrMcKabe last year and the results
were really remarkable intreating a valve lesion that we
previously had.
(29:45):
No, I shouldn't say no, that wepreviously did not have great
management strategies, for therewere valve repair options that
would work but were challengingand difficult, and this is sort
of the first dedicated devicemade for this problem and it
just got FDA approved.
And so I think seeing thosethings come down the pipeline,
(30:07):
participating in that researchprocess is really what kind of
gets me out of bed in themorning.
Those are the things that Ithink in 10 years, looking back
and being like can you believethat we used to solve this
problem with this equipment isgoing to be sort of an
(30:28):
interesting path.
You know, jamie is, I think,about 10 years out of practice
now and it's interesting to hearhim talk about even the way
they did TAVR 10 years ago, inwhich they would do a small
surgical cut down at the grointo get the sheath in and just
things like that that were made.
(30:49):
What is now, you know,approaching an outpatient
procedure sort of thing, isreally remarkable to reflect on
just the expansive growth of thespace in the last decade.
Speaker 1 (31:01):
What are the biggest changes there?
Is it the delivery mechanismand like, being able to get the
angles, or is it more the actualmechanical device?
Speaker 3 (31:10):
Yeah, I mean, I didn't live through it so I
don't know exactly.
I never used the previousequipment, but it's just that
they've.
The companies who produce thesevalves have had iterative
changes over the last severalyears in which they make the
delivery equipment smaller, moredeliverable, just easier to use
.
There's been stepwiseiterations on just the valve
(31:33):
itself sizing.
They now treat the valves witha compound that is designed to
help prevent structural valvedegeneration over time, similar
to what they use in thestructural or in the surgical
valves.
So it's just these smalliterative changes that make
things, you know, better andbetter and better and better.
(31:53):
We're actually participating inthe trial right now of the most
current iteration of one of ourmore common valves, and so I
think those changes that occurover time just make things safer
, more reliable and ultimatelymore effective and safer for
patients, which is, you know,the common goal here.
Speaker 2 (32:18):
Yeah, I remember when we didn't care about the
tricuspid regurgitation at alland now it's.
It is dramatically different,both in all the developments and
the things that we can do, butjust in the way we're thinking
about diseases and we'rethinking about improving
patient's lives and the ways todo that.
Speaker 3 (32:39):
Well, I mean, it's not even that far.
You know, I began my fellowshipin 2018.
And even I remember being inthe echo lab grading tricuspid
regurgitation and being like,well, that's an awful lot of
tricuspid regurgitation.
You know, we probably are notgoing to pay a lot of attention
to that.
It's probably something that'snot going to impact this person.
(33:00):
And then, you know, moving mylife into this structural heart
disease space, we would seethese patients who have been
living with tricuspidregurgitation for many, many
years and it had really startedto impact their lives, and I
think our understanding ofcertain things is just changing
as there is increasingavailability of things to do.
(33:22):
You know, it's always easier, Ithink, to approach a problem
when you have a solution in yourback pocket, and this is the
thing that we can, you know, tryto work on, as opposed to a
problem.
For us, there is no obviousanswer, and so that's the sort
of thing that I find veryexciting is that, over the
course of just in the time thatI've been in training, we've
(33:42):
gone from, you know, maybe thisis not as important of a
valvulation to well, actually,it really is just something that
takes longer to present itself,and now that we have ways of
dealing with it.
We really probably should bemore attention to it and that's
an interesting you know, that'sjust one example of something
that's interesting.
That's changed over the courseof even my time in training.
Speaker 2 (34:03):
Yeah, but you know it is fascinating how that has
made us delve deeper into thesethings.
Clearly, tricuspidregurgitation is much more
multifactorial than most of theother valvulations.
It's much less primary, if youwill.
It's not really a leafletproblem with such an anesthetist
or a personoid or you knowsomething like that.
But that doesn't mean that itshouldn't be treated.
(34:26):
It doesn't mean that it's goingto cause a problem and it
doesn't mean that using atreatment which may not be a
primary treatment modality cannonetheless dramatically affect
something that is secondary ortertiary or whatever.
Speaker 3 (34:39):
Yeah, exactly I think I agree with what you said
completely.
I just think that just becausethe problem is secondary doesn't
mean you can't address it.
Speaker 2 (34:48):
I guess is the way that I would say it.
That's a good way to put it.
That's a better way to put it.
Speaker 3 (34:54):
So those are the things that I find most
interesting is there's clearly alot of attention on the
industry side for thedevelopment of products to
address problems like this, andthat participating in that
science, the development of thisfield, is really what I find
most interesting.
Speaker 1 (35:13):
And who knows, GI might have a solution for some
things to address.
Speaker 2 (35:18):
Eventually they'll spill over.
Speaker 1 (35:22):
So, as a Montanite, montanian, montanin, yep,
montanin, what's a good story of?
Maybe the who is Dave Elison,as a Montanin, now Seattleite.
Speaker 3 (35:34):
Oh man, okay, let me think about this for a second,
maybe bow hunting a bear orsomething.
Speaker 1 (35:42):
We all do that in Montanis, yeah, right.
Speaker 3 (35:45):
It's sort of when you leave the hospital with a
handgun and your hunter safetypermit, I really love the
outdoors.
One of the things that I grew updoing a lot is skiing and one
(36:12):
of the things that I find mostcalming I guess in a job that
often feels very chaotic andstressful and busy and all the
things is just being outside,and my wife and I used to hike
(36:38):
all the time, go on runs, andthat we really started that when
we lived in Missoula together.
It's easier in Montana and Ithink kind of to give you an
emblematic view of the big skystate, we used to just walk out
(36:59):
her door to the end of her blockand we're in the woods, and
that's not present in Seattlebut it is.
It's truly an escape that Ivalue and I find that being able
(37:22):
to turn your brain off issomething that I really
cultivated in the woods, and Istill have very fond memories of
camping with my dad and mybrothers.
My dad liked to go wintercamping, which in Montana is
(37:45):
really awful, as you mightimagine, but there's something
about the stillness of the snowin the winter, in the cold, that
I crave, and I think in theplaces that I go now in
Washington, getting out into thesilence of nature is something
(38:08):
that I find incrediblymeaningful and tranquil, and I
think if there was somethingabout Montanans that I would
want people to know is that wedon't ride a horse to work.
There is electricity.
Where I went to high school,it's that there is a society of
(38:29):
people that live in the outdoorsand, um… you know, my father is
a geologist by training and heworks for the Bureau of Land
Management in Montana and heworks particularly on farming,
water rights.
How are you going to irrigatesaid quadrant of land?
(38:49):
I'll call him in the middle ofDecember, you know, and he's
like standing in the river andhe's like it's cold today.
Yeah, I can believe it, and Ireally think that that is just
something that is impacted who Iam and what I like to do and
(39:11):
where I find peace, and though Ilove this job, I think getting
away from it is important, andfinding something like that that
quiets your brain, allows youto recenter, is something that
I've always found incrediblymeaningful and important.
Speaker 2 (39:28):
That's fabulous.
Oh sorry, Go for it.
Are you still remodeling thingsas a carpenter?
Speaker 1 (39:35):
Oh.
Speaker 2 (39:35):
I just remember you came over.
We had you over for dinnersomething during your training
and you were remodeling thisincredible, amazing thing in one
of your.
Speaker 3 (39:47):
Yeah, in our old home , the upstairs was sort of a
bunch of unfinished space, avery livable area, and I would
have needed about six months tofix it myself, to turn it into a
bed, bath, master, which iswhat we had envisioned.
So we had it quoted out.
(40:08):
Well, maybe here's a good storyabout being a Montana.
We had it quoted out a coupletimes and they were quoting me
like $90,000 to have five or 600square feet remodeled.
And I called my dad.
I called my father and he waslike you told them they're not
building the whole house, right?
(40:29):
So, anyway, I ended up.
You know, my wife and I sat downand we're like well, this is
what we'd have to do.
This would be a lot of work.
We would need a lot of nightsat home with nowhere to go, and
that was like March of 2020.
And so, all of a sudden, therewas nowhere to go and nothing to
(40:49):
do.
And so we took on this projectof remodeling our upstairs and I
was really happy with the waythat it turned out.
But I do, I like building.
I like the process of thecreative thinking behind how you
envision something's going tolook.
I enjoy that a lot where, aswe're moving into our new house,
(41:10):
my wife's already like I wantyou to build this over here and
then build that over here.
Speaker 1 (41:16):
Okay, it just takes a little while YouTube or actual
experience.
Speaker 3 (41:19):
Well, I worked in contracting for about eight
months, which is a wonderfulcareer actually.
I really liked it.
But now plug for YouTube.
Like you can figure out how todo literally anything on YouTube
if you just like.
Look up the specific thing thatyou're trying to do, and then
(41:42):
you have to bust out thebuilding code and you have to do
a little bit of research beforeyou start into something.
But it's not altogether thatdifficult to figure out what you
want to do.
I'm sure every contractor outthere listening is like rolling
over in their grave, but I dofind some interest in that
process and figuring out howyou're going to deal with this
(42:08):
little thing.
You know, remodeling my housethat was built in 1947, I think
you know you take it down to thestuds and you're like oh, it's
four inches shorter at the otherend of the room.
That's going to be weird todrywall.
That sort of thing is aninteresting represents an
interesting problem to me that Ithink is fun to work through.
So, yes, I'm still building,though at a considerably slower
(42:32):
pace.
It's harder with two children,but yeah, I love that work.
Speaker 1 (42:41):
How about you just entered his faculty?
Maybe something you wish youhad known or would tell someone
exiting fellowship, or evenmaybe entering fellowship.
Speaker 3 (42:54):
Yeah, I think that, boy, if I had a perfect answer I
would give it to you.
I guess the thing I would tellsomebody who is entering
practice, particularly as aninterventionist, is, I would say
, think really hard about whoyou're going to work with.
I feel like people enter thepractice of interventional
(43:22):
cardiology with a set of skillsand I hope I don't offend
anybody by saying that we're ingeneral a confident, type A, you
know successful bunch, and Ithink it is very humbling to
work in our field.
And when you are entering a newgroup, I think who you spend
(43:45):
your time with and who you workwith and who you work for makes
all the difference.
I mean, I think if I had tocome to work every day and deal
with every single complicatedthing that I wasn't exactly sure
on by myself, I don't thinkthat's an environment that I
would feel very great about.
(44:05):
And I think all of thechallenges of transitioning from
training to attending life aremade better by your mentorship
experience.
And those can be the clinicalthings you know, like how am I
(44:29):
going to deal with thisparticular patient problem.
But it's also there's so manythings about the medical complex
, the administrative complex ofworking in like a huge
institution that you don't,you're sort of sheltered from as
a fellow, as a trainee, ingeneral, that as you enter
practice, it's criticallyimportant to have people that
(44:52):
you can trust and rely on toprovide you sound advice about,
you know, navigating the nextcouple of years.
Particularly people who havelived through that pathway and
have done some of the thingsthat you're talking about doing
and you know can provide you thefeedback like that is not worth
(45:13):
your time.
That's something that's goingto be a lot of time invested and
not a particularly good returnon that investment.
Those sorts of things are reallywhat make the transition smooth
, and I think it really boilsdown to who you work with, and
so it's my very rambling way ofsaying that you should trust
(45:34):
who's hiring you and if you goto groups that can't give you a
real solid description of whatit is that your day job's going
to look like and who you'regoing to reach out to if you
have a problem and what yourinterface with your surgical
partners is going to be like, Imean, I think that should be a
(45:56):
major red flag and it's one ofthe primary reasons why I wanted
to stay.
But I'll let you know when Iget it all figured out.
It should be in the next weekor so.
I would think so.
Speaker 2 (46:12):
Now that really brings it full circle.
You know, it's really amazing tohave you stay on with your
experience and obviously justjumping right into this
attending role.
It's not as new as it could havebeen if you were coming from
outside but to be known to know,to know what you're getting
into and then just to kind ofplop right in there and start it
(46:35):
up has just been a tremendousasset, I think, for us, and
hopefully it's going toincreasingly prove so for you as
well, going forward.
But I think that's really goodadvice.
I think that, as we all do that, as we all think about the work
environments that we're in andto what extent we get to choose
those or to what extent we getto shape them, if we can make
(47:00):
that kind of environment that'ssupportive, that family-like
environment in which the doorsalways open, as you said, and
there's greater responsibilityand there's, I think, here
particularly this idea of apatient first attitude.
That's our primary goal, ourprimary duty.
That will create something thatwill attract the best and
(47:21):
brightest, particularly thosewho've seen it, want to stay
like you and will also do thebest thing and allow us to have
the most fulfilling careers.
Speaker 3 (47:31):
Well, I think particularly yeah, I think it's
well said in a climate whereincreasingly you hear about
things like physician burnoutand the increasing
administrative burdens ofmedicine and how those
contribute.
I think what stands out to mein the things that I focus on as
(47:56):
means to avoid burnout arereally cultivating those
relationships and I think youstated it nicely how you're
going to craft that environmentsuch that you attract people who
are the best and brightest andwant to work in this space, in
this field, in this place,because it can be daunting and I
(48:19):
think, as I've moved from myfellowship to my attending life,
particularly I would like tosay thank you to Jamie and
Christine, who have reallywelcomed me into our group and
are my proverbial shoulder tocry on.
You know that is having peoplein your corner, I think, is
(48:44):
truly the best.
Speaker 2 (48:48):
Yeah, well, maybe that may that be true for all of
us.
Absolutely Great.
Speaker 1 (48:54):
Well, thank you, Dave , so much.
Yeah, thanks for having meGreat conversation.
Speaker 2 (48:57):
Yeah, absolutely, I really appreciate it.
Speaker 3 (49:00):
Yeah, of course, happy to do it, thank you.
This is Coffee in Cardiology.
Speaker 2 (00:05):
In this podcast we sit down with the faculty from
the University of WashingtonDivision of Cardiology to
discuss the very latest indiagnostics, therapeutics and as
a special bonus, we ask whatmakes our cardiologists tick?
John Michael, we have DavidElisson with us today.
(00:26):
He is one of our newly minted Iguess not so much newly minted
anymore, you've been at this forquite a while but structural
interventional cardiologistshere at the University of
Washington.
I had the privilege of workingwith David as he sort of came up
through his training here, butI would like now if he would
(00:48):
give us an even broader pictureof his journey in medicine,
because it's actually a veryinteresting one.
Speaker 3 (00:56):
Well, thanks for having me guys.
Yeah, I went.
I'm from Montana and I went tocollege at the University of
Montana fully anticipating to bea biology teacher.
My father was a teacher and Ijust sort of always saw that as
a career that I enjoyed.
I was sort of part of the waythrough that.
(01:21):
When one of my advisors in thebiology department was like,
have you ever thought aboutgoing to medical school?
And I was like no, and here weare.
She sort of pointed me in theright direction and really never
looked back.
I did my medical schooling atthe University of Colorado, so I
(01:45):
lived in Denver for four and ahalf years.
Then I've been here ever sinceI came here for residency.
I really liked the Universityof Colorado, but I thought to
myself I should experiencesomething new and different, and
so I came out here forresidency in 2015 and I stayed
on for cardiology fellowship.
(02:06):
I really liked the people Iworked with as a resident and,
following my general fellowship,I was like you know, I really
like the interventionalists here.
I really like the group, I likethe program.
I have small children.
There's a lot of reasons to wantto stay, and I stayed on for
two years of interventionaltraining.
At the end of that, which wasonly eight months ago, the group
(02:33):
sort of welcomed me on as theseventh member of our team.
So I've actually sort of becomea UW lifer minus the undergrad
med school part.
I really love this job.
I've been really excited totransition into my attending
life and it feels like a nicehome for me.
(02:53):
It's a very supportive teamthat the leaders of our section
have created and it's been aneasy and smooth transition into
attending life for me.
So I'm happy to be here andtalk to you guys about it and
let you know about me.
Speaker 2 (03:09):
Well, that's fabulous .
It sounds like you're notexactly the one who's being
forced into all the call anddoing all of that sort of early
guy stuff.
Speaker 3 (03:18):
No, no, I mean I think there's a certain amount
of new guidance.
You know I got Christmas, forexample, but that's to be
expected anywhere you go.
It's obviously easier whenyou're in a seven person group
than if you go somewhere andyou're in a two person group.
But no, I mean, everyone hasbeen incredibly supportive.
(03:40):
I think what's unique about ourinterventional group here is we
really take care of, you knowkind of the broad end of
spectrum in terms of structuraland coronary cases, and it's a
little daunting sort of day onein your attending life to be
like oh, here's somebody who'shaving an end stemmy in Yakima
and their EF is 20% and they'reon a balloon pump and they're
(04:03):
not intubated and they're insort of borderline cartogenic
shock.
Can you do their atherectomyleft main tomorrow, it's like
sure.
So everyone has been verysupportive to me and our senior
members of the section arereally unmatched in terms of
their mentorship and care andyour development, and I think
(04:26):
that's something that's notpresent everywhere you go and it
really, as I interviewed forjobs last year, it really stood
out to me as something that wasreally unique and beneficial
about our group and somethingthat has been obviously a
wonderful thing to have in yourback pocket to go around the
corner and be like hey, bill, 10years, would you mind looking
(04:48):
at this angiogram with me?
Just to have world experts inthe things that you're trying to
do all day as a new person isreally beneficial.
Speaker 1 (04:57):
What is you kind of glossed over the jump to
cardiology.
What was that?
Why?
Speaker 3 (05:03):
You mean from internal medicine.
Yeah, I think I've always beensomeone who struggles with the
decision, which is funny now,because now my life is just
split decisions all day long.
But when I was in medicalschool I sort of liked
everything.
My wife always tells all herfriends that I went through a
(05:25):
six week period where I thoughtI was going to be an
obstetrician and now I dosomething quite remote from that
.
So it's always been hard for meto align exactly my interest
with where I'm headed in themoment it feels.
And I chose internal medicinebecause it sort of allowed that
decision to be kicked down theroadways.
And when I was in internalmedicine residency I liked a lot
(05:49):
of the things that I tried andfor a period of time I thought I
was going to be in GI.
Ultimately I settled oncardiology because I felt, of
all of the systems in our body,I just often feel like we
understand the heart so muchmore than so many other things
in terms of the mechanics andthe physics behind the way it
(06:11):
works and the electricalsignaling.
I found all that veryinteresting.
But then the other point ofthat is that there were so many
things that we could do.
I got very frustrated in thingswhere it felt like, well, you
have this awful disease and I'msorry that always was a great
(06:32):
frustration to me.
And in cardiology I feel likethere's so many avenues of
things that we can offerpatients, many of which improve
not only longevity but also justthe way they feel, and I found
that to be incredibly fulfilling.
And I came into cardiologythinking I was going to be a
(06:54):
heart failure doctor and peoplelike Wayne Levy wrote my letters
for fellowship shout out toWayne and I went into fellowship
thinking that that was what Iwas going to do and that I liked
working with patients withadvanced heart failure.
I liked transplant and thingslike that.
And I just sort of realizedover time that I am much more of
(07:14):
like a Mr Fixit kind of person.
Is that I like sort of aproblem approach, dealing with a
particular issue and how are wegoing to fix it?
What are the tools that we haveto address a particular problem
and what are the imaging piecesthat we're going to use to try
to understand the problem thatwe're dealing with?
(07:35):
I worked in construction beforeI went to medical school and I
actually feel like there is somuch of my day job now that is
very akin to that work.
So that's sort of how I found myway to where I am now, and it
was a sort of stepwise decisionwhere there was a lot of
(07:57):
reroutes along the way, but Ifeel like I've really kind of
found my home.
Speaker 2 (08:06):
I think you really encapsulated a lot of the
seduction, if you will, ofcardiology for so many of us
that we can do things thatbenefit people's lives in
multiple different ways, that wedo have answers.
We don't always have answers.
Sometimes we have to have hardconversations, but at least
we've almost always gotsomething, whether it's
(08:28):
medicines or whether it's anintervention.
But the thing I just love aboutyour story is that you're
admitting to a pathway and anorientation that, let's be
honest, isn't found in a lot ofinterventionists.
I mean, a lot ofinterventionists were not
thinking about advanced heartfailure as part of their career
(08:50):
path or biology teacher.
Speaker 3 (08:52):
Or biology teacher for that matter.
Speaker 2 (08:55):
Construction, yeah, definitely makes sense.
But I think that's emblematicof our group here.
The seven of you are not justincredible world-class
technicians, but you'reworld-class thinkers, you're
deep thinkers, you are decisionmakers, or deciders, if you will
(09:15):
, in a way that is beyond justthe technical aspects and I
think the fact that you've andI'm assuming it feels very much
at home because you've been herefor a while, but also you fit
in this group because this isthe nature of your group.
You're incredibly high volume,you're incredibly technical and
yet you have thatpatient-oriented focus.
(09:39):
You have that deep thinking,that integration of the imaging
and the electricity and thatadvanced heart failure meds and
all that other stuff that goesinto what I think it makes you
guys the best interventionists.
Speaker 3 (09:53):
Well, yeah, I agree.
I mean, I think the physiciansthat I have had the greatest
respect for in my trainingpathway are those doctors who I
feel like are actual, realpeople.
I find that those individualshave the best bedside manner in
(10:15):
the way that they talk to peopleand explain a problem, and you
know, so much of what we do isreally salesmanship.
When you get down to it is,you're talking to somebody about
something that they don'treally have a lot of expertise
in or understanding most of thetime.
You know.
This is especially fresh in mymind because my wife and I just
(10:36):
bought a house and we did ourclosing this morning where you
sit across the table fromsomebody who just hands you
document after document that's25 pages long and totally
illegal ease and you're like Ihave no idea what any of this
means, but the person across thetable at the escrow office is
explaining things to you andlike this is why this matters,
this is why this matters, and Ifeel a little bit like that's
(11:01):
often what we do is somebodyfrom you know your dad's
practice in Longview gets sentup because they have aortic
valve disease and they don'thave any medical background and
this is sort of a foreignconcept to them and you're
sitting across from somebodytalking about how you're going
to do something that isinherently surgical and can be
(11:23):
dangerous and is ultimatelyreally important, and I think so
much of that conversation canbe challenging and
time-consuming, but I think it'sreally important and I think
the reason why I have a lot ofrespect for my partners and the
(11:46):
members of our group is that Ithink particularly Drs McCabe
and Lombardi, Bill and Jamie, asour leaders, have really done a
remarkable job of cultivating ateam of people who are real
people and can sit across fromyou and say you know, here's the
thing that we're dealing with,these are the things that we can
(12:09):
do about it, these are therisks.
This is how I see you and I seeyour problem, and I think that
conversation is intrinsicallymuch easier to have if you
yourself are a person and sitacross and have an actual
conversation.
That becomes increasingly lesstechnical when you're just
meeting with somebody.
I have always found that thepeople in our section as a
(12:33):
former trainee in our sectionand I was a member of it are a
truly remarkable group of peoplewith a really broad array of
skills that I just have a greatdeal of respect for it's sort of
like a big family.
I hope they don't feel likethat's dorky for me to say, but
that's always how I felt aboutit and it makes it easy to feel
(12:58):
at home.
Speaker 2 (13:01):
That's good, and I know that your family is one of
those non-dysfunctional familiestoo.
They're very supportive andeven though you get stuck on
Christmas, they're always therefor you.
Speaker 3 (13:10):
Yeah, I mean I think you know my immediate family,
like my parents, we have a veryblended family.
My parents are long-sensedivorced and got remarried and
so in that setting I have anumber of steps of things that
it made for an interestinggrowing up experience.
And my father, he got remarriedalmost 20 years ago now and so
(13:36):
you know, my stepbrothers andsisters are really like my
brothers and sisters and we alllive like tremendously different
lives.
And he refers to us as thevillage people like the YMCA,
because I, you know, I do this.
I'm the oldest.
My closest brother after me ishe's 6'6" and has hair to his
(13:56):
shoulders and full beard andworks at a nice restaurant, lake
Tahoe, and is mostly like anoutdoor ski bum.
And my brother after him was inCatholic Seminary School to be
a priest and then was like, well, you know, I don't know that
that's actually for me and nowhe's an attorney in Montana.
And my closest sister after himflies.
(14:19):
She's a first lieutenant in themilitary and she flies Apache
helicopters and she's currentlyI think it's okay to say this
she's currently deployed inRomania.
And my youngest sister was likea cheerleader in Louisiana and
now she's married and has twokids and I think that background
(14:43):
really shaped kind of who I am.
You know, my dad's very fond ofsaying that there are two types
of parents.
There are carpenter parents andthere are gardener parents.
And carpenter parents sort ofconstruct their child in the way
that they see them being, and agardener parent just sort of
makes the soil for your child tobecome whoever they might be
(15:04):
and my parents were very muchhippies from the 70s.
Gardener parents.
And that's raised me to be who Ifeel like I am and my own
immediate family, my wife.
We met in college, actually,and we've been together for this
will be 15 years coming up thisyear and she's a wonderful
(15:29):
person.
She's incredibly supportive.
I don't actually think I coulddo this job without her being
the sort of independent,individual, supportive spouse
that she is.
We have two little girls.
Our life has been a littletumultuous in the last six
(15:49):
months with our second daughter,but we have two wonderfully
sweet little girls and parentingand being a new, attending and
moving and I think all of thosethings add stressors that are
just made easier by a familythat you can rely on and trust.
And really I really count myblessings for the way that my
(16:12):
wife is when it comes tosupporting this line of work,
because there's nothing quitelike being like just one more
case I'll be home in 20 minutesand then it's like 945, because
the last case took three and ahalf hours and I think there's
something to be said about howthat's not an easy role for a
(16:34):
spouse to play and she reallydoes have a lot of grace and I'm
very thankful for that.
Speaker 2 (16:40):
That is phenomenal.
That is really, really neat.
I'm assuming that, despite yourcarpenter background, you're
planning to be a gardener parent.
Speaker 3 (16:47):
I am very much a carpenter parent.
My first daughter is juststubborn, as the day is long and
I don't know exactly what sortof person she's going to grow up
to be.
But I'm excited to see how thatdevelops and I don't actually
really know how to be acarpenter parent.
I just sort of want my childrento know that I love them and
(17:11):
care about them and I want themto succeed in whatever it is
that they're interested in andfind their own way in life,
because that's really what I didand it's worked out in a way
that I'm very grateful for.
Speaker 1 (17:27):
How about, as a student, to now teach your
parent to our fellows and besupporting them?
Do you also kind of bring thatmentality to how you support
them?
Speaker 3 (17:38):
Yeah, I mean I think I would like to.
Ultimately, there is a realismto the fact that you're dealing
with things that are inherentlylife-threatening and, when done
improperly, can cause harm, andso, especially as a newer person
, I gravitate towards being alittle bit more hands-on and
(18:03):
making sure that each patient iscared for in a way that I would
want my own family member to becared for, and so to that end,
I guide the fellows a little bitmore in a carpenter sort of way
than perhaps just sort of likelaying the foundations for them
to grow.
But I do think where I reallysee this playing out is I want
(18:24):
our fellows to.
Our field is justever-expanding in terms of what
we can do and what we can offer,and even in interventional
cardiology there areincreasingly finite subsets
where people focus on one thing,and our fellows come in sort of
(18:46):
undifferentiated for the mostpart, and I have appreciated
that our faculty have been verysupportive to that.
They were very supportive to mein my process of doing that,
and I think, as you find yourway through the interventional
landscape, finding the thingsthat you like doing or you feel
fulfilled in doing is reallyimportant, and so I have had
(19:08):
several conversations with ourfellows about how to explore
those things that you'reinterested in and how to
gravitate yourself towards oneparticular thing or not.
It's been very interesting to meas a newer attending working
with our current structuralfellows, particularly one
(19:31):
structural fellow who was afirst-year interventional fellow
while I was the structuralfellow just last year, and so
obviously there's a new teamdynamic there.
That's very different, but Greghas actually been very
supportive to me in my newness,which I really appreciate him
for.
Our other structural fellow,christina, came from outside so
(19:54):
I didn't know her as well priorto this process in transition,
but it's been an interestingchange in roles, sort of the way
that the staff sees you, theway that people interface with
you on the day-to-day, and oneof the things that I thought a
lot about was how I wouldinteract with fellows that I
(20:14):
knew personally when I was afellow, because I think there's
a certain familiarity that cansort of change the dynamic in a
way.
That is not always perfect, butour fellows have really
embraced me and I think they'rea solid and important part of
(20:35):
our team and when I say our team, I include them in that and our
team has really welcomed me andmade this process pretty
seamless.
Speaker 2 (20:46):
I wonder if you could explain a little bit the
difference betweeninterventional and structural
and how that works in thetraining process and also how
that works from the attendinglevel.
Speaker 3 (20:56):
Yeah, so it's a good question.
So you finish GeneralCardiology Fellowship, which
takes three years, and then youcan go into interventional
fellowship.
Previously in decades past, tobecome an interventionalist took
about a year that was beforethe advent of most
(21:17):
trans-catheter heart valves,things like that and so you were
really learning how to docoronary interventions on
patients having heart attacks orwith stable heart disease.
So that was a process that formost took a year.
I don't know exactly the timecourse in which this has
happened, but I'll just say overthe last decade there has been
(21:38):
a emphasis placed on continuingthe development of that skill
set, and so for the first yearyou really spend your time
dealing with coronary arterydisease stent procedures.
And once you have solidifiedthat skill set, there is an
(21:59):
opportunity now increasinglyacross the country not just in
our program to enter a secondyear of training in which you
specialize either in verycomplex coronary artery disease
interventions or you enter aspace called structural heart
disease, which is what I do andprimarily focuses on the
(22:20):
interventional side.
That does not include coronaries, so valve interventions,
replacements and repairs,closing of holes in the heart,
things of that nature, and sothat's how I spend my time now.
I mean all of us who work inintervention have a component of
your life that's made upcoronary interventions, as that
(22:40):
is far and away the most commonthing.
But increasingly people aredoing a second year specializing
in structural intervention toget that particular skill set
related to primarily valveprocedures, and that's how I
spent the entire last yearworking with Dr McCabe and Dr
Chung, as well as Dr Don, whoare my structural trainees over
(23:03):
the course of the last year,which was a unique experience
for me and was really enjoyedthat time a lot and learned a
lot, and that is now how I spendthe other bulk of my time, and
so the section that we have hereis kind of divided into those
(23:26):
two separate areas of focusright.
Yeah, that's correct.
So I don't know exactly howthey might think about it.
But how I think about it isthat there are two silos and we
all intermingle to some degree.
But the complex coronary teamBill Lombardi and Kate Carney
and Lorenzo Asilini, who's thenewest member of their team, and
(23:47):
then Jamie McCabe, christineand myself on the structural
side, and then Zach Steinberg isour guy who does adult
congenital heart diseaseinterventions, which is like a
totally different thing out inleft field.
So the seven of us make up thissection and yeah, we're sort of
subdivided along specialtylines.
Speaker 2 (24:09):
Yeah, and that makes sense from the academic
standpoint, but that's not theway it is everywhere.
A lot of times there's a fairamount of overlap where there's
just focus on the coronaryaspects but not necessarily the
complex coronary aspects.
Speaker 3 (24:23):
Yeah, I would say a lot of my sense of the
structural landscape is thatthere are a lot of people who do
TAVR or trans-catheteria aorticvalve replacement or close
simple holes in the heart,simple connections in the heart,
like a patent for ImmunovalliPFO.
That level of training seems tobe relatively common across the
(24:47):
country.
I think when you're gettinginto the things that we do here
that are more complicated,involve other valves, involve
more complex lesions, subsets,patient complexity, that is
something that is much lesscommon and is particularly
(25:10):
reserved for people who have haddedicated training in
structural heart disease.
Speaker 2 (25:16):
I know even within the structural component we have
sort of areas of specialization.
Speaker 3 (25:24):
Yeah, I mean, I think maybe that isn't necessarily
the way that I would think aboutit.
I think on the structural sidewe have a team lead.
Jamie is my personal mentor andhusband for several years and
he's remarkably gifted and aworld's expert in a lot of what
we do and he certainly does themost complex stuff in our group,
(25:49):
including the fullypercutaneous electrosurgical
things and interventions in themitral and tricuspid space.
Christine is several yearsahead of me and has started to
move into some of that as well.
Right now I'm doing primarilyaortic valve interventions,
closing some simple lesions,things like that to get.
(26:12):
It's not to say that I didn'ttrain in all of those things,
but I think there's ahierarchical approach to some
degree of the most experiencedperson doing the most
complicated things Kind of justmakes sense, and so I wouldn't
say that Jamie does this,christine does this, I do this.
It's more that he leads ourteam and through his guidance we
(26:39):
all are learning and gettingbetter and approaching new
problems in new ways.
And yeah, I guess that is theway that I would think about it.
Speaker 2 (26:52):
Yeah, that makes a lot of sense, this stuff.
If you end up doing most of thetavers at this point because
Jamie is doing a lot of theother stuff, it's more that
great responsibility and greatcomplexity.
Speaker 3 (27:03):
Yeah, and I think that's, as I was saying earlier.
One of the great benefits ofour team is that if I'm referred
a patient who is particularlycomplicated for one reason or
another, there is no closed door.
I just would walk around thecorner and say, hey, what do you
think about this?
And it's a remarkably positiveexperience to have that in your
(27:28):
back pocket and I don't.
In speaking with other peoplewho have been along my training
pathway and now work at otherplaces that's not always the
case and having the support ofpeople who, first and foremost,
(27:49):
want every patient to have agood outcome, but also want you
to continue to develop the skillsets that you've worked hard
and trained to make and want tobe a resource to you in your
continued development.
I mean, we are all continuingto develop always.
There is no point at which yousort of stop, particularly in
this field, and having a team ofpeople where you can say this
(28:17):
is a circumstance that I've notexactly encountered before.
What would you think about this?
This is what I was thinkingabout.
How would you approach this?
That's a gift and I reallyvalue that.
Speaker 1 (28:29):
When the field and everything's evolving very
quickly in structural heart, alot of clinical trials.
What excites you most aboutthat future and what you really
want to be involved in?
Speaker 3 (28:39):
Yeah, I mean, I think the things that are most
interesting to me are thededicated valve prostheses.
Right now a lot of the workthat's done in the mitral space,
for example, is done by theпригeremos queideexecuto's
districts that are I don't wantto use the word gerry-rigged,
but it's a little bitgerry-rigged from pieces of
(29:03):
equipment that are not designedfor that valve.
You know, using a prosthesisthat's made for the aortic
position, off-label in themitral position, for example.
A lot of the clinical trials weparticipate in are in dedicated
valve prosthesis and theresults from those have been
(29:24):
very interesting.
You know I don't know if yousaw just last week the FDA
approved the evoke valve, whichis a dedicated tricuspid valve
prosthesis which we had theprivilege of participating in a
few of those implants with DrMcKabe last year and the results
were really remarkable intreating a valve lesion that we
previously had.
(29:45):
No, I shouldn't say no, that wepreviously did not have great
management strategies, for therewere valve repair options that
would work but were challengingand difficult, and this is sort
of the first dedicated devicemade for this problem and it
just got FDA approved.
And so I think seeing thosethings come down the pipeline,
(30:07):
participating in that researchprocess is really what kind of
gets me out of bed in themorning.
Those are the things that Ithink in 10 years, looking back
and being like can you believethat we used to solve this
problem with this equipment isgoing to be sort of an
(30:28):
interesting path.
You know, jamie is, I think,about 10 years out of practice
now and it's interesting to hearhim talk about even the way
they did TAVR 10 years ago, inwhich they would do a small
surgical cut down at the grointo get the sheath in and just
things like that that were made.
(30:49):
What is now, you know,approaching an outpatient
procedure sort of thing, isreally remarkable to reflect on
just the expansive growth of thespace in the last decade.
Speaker 1 (31:01):
What are the biggest changes there?
Is it the delivery mechanismand like, being able to get the
angles, or is it more the actualmechanical device?
Speaker 3 (31:10):
Yeah, I mean, I didn't live through it so I
don't know exactly.
I never used the previousequipment, but it's just that
they've.
The companies who produce thesevalves have had iterative
changes over the last severalyears in which they make the
delivery equipment smaller, moredeliverable, just easier to use
.
There's been stepwiseiterations on just the valve
(31:33):
itself sizing.
They now treat the valves witha compound that is designed to
help prevent structural valvedegeneration over time, similar
to what they use in thestructural or in the surgical
valves.
So it's just these smalliterative changes that make
things, you know, better andbetter and better and better.
(31:53):
We're actually participating inthe trial right now of the most
current iteration of one of ourmore common valves, and so I
think those changes that occurover time just make things safer
, more reliable and ultimatelymore effective and safer for
patients, which is, you know,the common goal here.
Speaker 2 (32:18):
Yeah, I remember when we didn't care about the
tricuspid regurgitation at alland now it's.
It is dramatically different,both in all the developments and
the things that we can do, butjust in the way we're thinking
about diseases and we'rethinking about improving
patient's lives and the ways todo that.
Speaker 3 (32:39):
Well, I mean, it's not even that far.
You know, I began my fellowshipin 2018.
And even I remember being inthe echo lab grading tricuspid
regurgitation and being like,well, that's an awful lot of
tricuspid regurgitation.
You know, we probably are notgoing to pay a lot of attention
to that.
It's probably something that'snot going to impact this person.
(33:00):
And then, you know, moving mylife into this structural heart
disease space, we would seethese patients who have been
living with tricuspidregurgitation for many, many
years and it had really startedto impact their lives, and I
think our understanding ofcertain things is just changing
as there is increasingavailability of things to do.
(33:22):
You know, it's always easier, Ithink, to approach a problem
when you have a solution in yourback pocket, and this is the
thing that we can, you know, tryto work on, as opposed to a
problem.
For us, there is no obviousanswer, and so that's the sort
of thing that I find veryexciting is that, over the
course of just in the time thatI've been in training, we've
(33:42):
gone from, you know, maybe thisis not as important of a
valvulation to well, actually,it really is just something that
takes longer to present itself,and now that we have ways of
dealing with it.
We really probably should bemore attention to it and that's
an interesting you know, that'sjust one example of something
that's interesting.
That's changed over the courseof even my time in training.
Speaker 2 (34:03):
Yeah, but you know it is fascinating how that has
made us delve deeper into thesethings.
Clearly, tricuspidregurgitation is much more
multifactorial than most of theother valvulations.
It's much less primary, if youwill.
It's not really a leafletproblem with such an anesthetist
or a personoid or you knowsomething like that.
But that doesn't mean that itshouldn't be treated.
(34:26):
It doesn't mean that it's goingto cause a problem and it
doesn't mean that using atreatment which may not be a
primary treatment modality cannonetheless dramatically affect
something that is secondary ortertiary or whatever.
Speaker 3 (34:39):
Yeah, exactly I think I agree with what you said
completely.
I just think that just becausethe problem is secondary doesn't
mean you can't address it.
Speaker 2 (34:48):
I guess is the way that I would say it.
That's a good way to put it.
That's a better way to put it.
Speaker 3 (34:54):
So those are the things that I find most
interesting is there's clearly alot of attention on the
industry side for thedevelopment of products to
address problems like this, andthat participating in that
science, the development of thisfield, is really what I find
most interesting.
Speaker 1 (35:13):
And who knows, GI might have a solution for some
things to address.
Speaker 2 (35:18):
Eventually they'll spill over.
Speaker 1 (35:22):
So, as a Montanite, montanian, montanin, yep,
montanin, what's a good story of?
Maybe the who is Dave Elison,as a Montanin, now Seattleite.
Speaker 3 (35:34):
Oh man, okay, let me think about this for a second,
maybe bow hunting a bear orsomething.
Speaker 1 (35:42):
We all do that in Montanis, yeah, right.
Speaker 3 (35:45):
It's sort of when you leave the hospital with a
handgun and your hunter safetypermit, I really love the
outdoors.
One of the things that I grew updoing a lot is skiing and one
(36:12):
of the things that I find mostcalming I guess in a job that
often feels very chaotic andstressful and busy and all the
things is just being outside,and my wife and I used to hike
(36:38):
all the time, go on runs, andthat we really started that when
we lived in Missoula together.
It's easier in Montana and Ithink kind of to give you an
emblematic view of the big skystate, we used to just walk out
(36:59):
her door to the end of her blockand we're in the woods, and
that's not present in Seattlebut it is.
It's truly an escape that Ivalue and I find that being able
(37:22):
to turn your brain off issomething that I really
cultivated in the woods, and Istill have very fond memories of
camping with my dad and mybrothers.
My dad liked to go wintercamping, which in Montana is
(37:45):
really awful, as you mightimagine, but there's something
about the stillness of the snowin the winter, in the cold, that
I crave, and I think in theplaces that I go now in
Washington, getting out into thesilence of nature is something
(38:08):
that I find incrediblymeaningful and tranquil, and I
think if there was somethingabout Montanans that I would
want people to know is that wedon't ride a horse to work.
There is electricity.
Where I went to high school,it's that there is a society of
(38:29):
people that live in the outdoorsand, um… you know, my father is
a geologist by training and heworks for the Bureau of Land
Management in Montana and heworks particularly on farming,
water rights.
How are you going to irrigatesaid quadrant of land?
(38:49):
I'll call him in the middle ofDecember, you know, and he's
like standing in the river andhe's like it's cold today.
Yeah, I can believe it, and Ireally think that that is just
something that is impacted who Iam and what I like to do and
(39:11):
where I find peace, and though Ilove this job, I think getting
away from it is important, andfinding something like that that
quiets your brain, allows youto recenter, is something that
I've always found incrediblymeaningful and important.
Speaker 2 (39:28):
That's fabulous.
Oh sorry, Go for it.
Are you still remodeling thingsas a carpenter?
Speaker 1 (39:35):
Oh.
Speaker 2 (39:35):
I just remember you came over.
We had you over for dinnersomething during your training
and you were remodeling thisincredible, amazing thing in one
of your.
Speaker 3 (39:47):
Yeah, in our old home , the upstairs was sort of a
bunch of unfinished space, avery livable area, and I would
have needed about six months tofix it myself, to turn it into a
bed, bath, master, which iswhat we had envisioned.
So we had it quoted out.
(40:08):
Well, maybe here's a good storyabout being a Montana.
We had it quoted out a coupletimes and they were quoting me
like $90,000 to have five or 600square feet remodeled.
And I called my dad.
I called my father and he waslike you told them they're not
building the whole house, right?
(40:29):
So, anyway, I ended up.
You know, my wife and I sat downand we're like well, this is
what we'd have to do.
This would be a lot of work.
We would need a lot of nightsat home with nowhere to go, and
that was like March of 2020.
And so, all of a sudden, therewas nowhere to go and nothing to
(40:49):
do.
And so we took on this projectof remodeling our upstairs and I
was really happy with the waythat it turned out.
But I do, I like building.
I like the process of thecreative thinking behind how you
envision something's going tolook.
I enjoy that a lot where, aswe're moving into our new house,
(41:10):
my wife's already like I wantyou to build this over here and
then build that over here.
Speaker 1 (41:16):
Okay, it just takes a little while YouTube or actual
experience.
Speaker 3 (41:19):
Well, I worked in contracting for about eight
months, which is a wonderfulcareer actually.
I really liked it.
But now plug for YouTube.
Like you can figure out how todo literally anything on YouTube
if you just like.
Look up the specific thing thatyou're trying to do, and then
(41:42):
you have to bust out thebuilding code and you have to do
a little bit of research beforeyou start into something.
But it's not altogether thatdifficult to figure out what you
want to do.
I'm sure every contractor outthere listening is like rolling
over in their grave, but I dofind some interest in that
process and figuring out howyou're going to deal with this
(42:08):
little thing.
You know, remodeling my housethat was built in 1947, I think
you know you take it down to thestuds and you're like oh, it's
four inches shorter at the otherend of the room.
That's going to be weird todrywall.
That sort of thing is aninteresting represents an
interesting problem to me that Ithink is fun to work through.
So, yes, I'm still building,though at a considerably slower
(42:32):
pace.
It's harder with two children,but yeah, I love that work.
Speaker 1 (42:41):
How about you just entered his faculty?
Maybe something you wish youhad known or would tell someone
exiting fellowship, or evenmaybe entering fellowship.
Speaker 3 (42:54):
Yeah, I think that, boy, if I had a perfect answer I
would give it to you.
I guess the thing I would tellsomebody who is entering
practice, particularly as aninterventionist, is, I would say
, think really hard about whoyou're going to work with.
I feel like people enter thepractice of interventional
(43:22):
cardiology with a set of skillsand I hope I don't offend
anybody by saying that we're ingeneral a confident, type A, you
know successful bunch, and Ithink it is very humbling to
work in our field.
And when you are entering a newgroup, I think who you spend
(43:45):
your time with and who you workwith and who you work for makes
all the difference.
I mean, I think if I had tocome to work every day and deal
with every single complicatedthing that I wasn't exactly sure
on by myself, I don't thinkthat's an environment that I
would feel very great about.
(44:05):
And I think all of thechallenges of transitioning from
training to attending life aremade better by your mentorship
experience.
And those can be the clinicalthings you know, like how am I
(44:29):
going to deal with thisparticular patient problem.
But it's also there's so manythings about the medical complex
, the administrative complex ofworking in like a huge
institution that you don't,you're sort of sheltered from as
a fellow, as a trainee, ingeneral, that as you enter
practice, it's criticallyimportant to have people that
(44:52):
you can trust and rely on toprovide you sound advice about,
you know, navigating the nextcouple of years.
Particularly people who havelived through that pathway and
have done some of the thingsthat you're talking about doing
and you know can provide you thefeedback like that is not worth
(45:13):
your time.
That's something that's goingto be a lot of time invested and
not a particularly good returnon that investment.
Those sorts of things are reallywhat make the transition smooth
, and I think it really boilsdown to who you work with, and
so it's my very rambling way ofsaying that you should trust
(45:34):
who's hiring you and if you goto groups that can't give you a
real solid description of whatit is that your day job's going
to look like and who you'regoing to reach out to if you
have a problem and what yourinterface with your surgical
partners is going to be like, Imean, I think that should be a
(45:56):
major red flag and it's one ofthe primary reasons why I wanted
to stay.
But I'll let you know when Iget it all figured out.
It should be in the next weekor so.
I would think so.
Speaker 2 (46:12):
Now that really brings it full circle.
You know, it's really amazing tohave you stay on with your
experience and obviously justjumping right into this
attending role.
It's not as new as it could havebeen if you were coming from
outside but to be known to know,to know what you're getting
into and then just to kind ofplop right in there and start it
(46:35):
up has just been a tremendousasset, I think, for us, and
hopefully it's going toincreasingly prove so for you as
well, going forward.
But I think that's really goodadvice.
I think that, as we all do that, as we all think about the work
environments that we're in andto what extent we get to choose
those or to what extent we getto shape them, if we can make
(47:00):
that kind of environment that'ssupportive, that family-like
environment in which the doorsalways open, as you said, and
there's greater responsibilityand there's, I think, here
particularly this idea of apatient first attitude.
That's our primary goal, ourprimary duty.
That will create something thatwill attract the best and
(47:21):
brightest, particularly thosewho've seen it, want to stay
like you and will also do thebest thing and allow us to have
the most fulfilling careers.
Speaker 3 (47:31):
Well, I think particularly yeah, I think it's
well said in a climate whereincreasingly you hear about
things like physician burnoutand the increasing
administrative burdens ofmedicine and how those
contribute.
I think what stands out to mein the things that I focus on as
(47:56):
means to avoid burnout arereally cultivating those
relationships and I think youstated it nicely how you're
going to craft that environmentsuch that you attract people who
are the best and brightest andwant to work in this space, in
this field, in this place,because it can be daunting and I
(48:19):
think, as I've moved from myfellowship to my attending life,
particularly I would like tosay thank you to Jamie and
Christine, who have reallywelcomed me into our group and
are my proverbial shoulder tocry on.
You know that is having peoplein your corner, I think, is
(48:44):
truly the best.
Speaker 2 (48:48):
Yeah, well, maybe that may that be true for all of
us.
Absolutely Great.
Speaker 1 (48:54):
Well, thank you, Dave , so much.
Yeah, thanks for having meGreat conversation.
Speaker 2 (48:57):
Yeah, absolutely, I really appreciate it.
Speaker 3 (49:00):
Yeah, of course, happy to do it, thank you.
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