Joseph Stephen Alpert, MD: a conversation with the editor. Interview by William Clifford Roberts.

TY - JOUR

T1 - Joseph Stephen Alpert, MD

T2 - a conversation with the editor. Interview by William Clifford Roberts.

AU - Alpert, J. S.

N1 - Funding Information: Dr. William C. Roberts interviews Dr. Joseph Stephen Alpert. Joe Alpert was born on February 1, 1942, in New Haven, Connecticut, and he grew up there. He attended college at Yale University and went to medical school at Harvard. His training in both internal medicine and in cardiology was at the Brigham and Women's Hospital in Boston, and after a 2-year stint in the Navy he returned to Brigham to head the coronary care unit. In 1978 he went to Worcester to be Chief of the Division of Cardiovascular Medicine at the University of Massachusetts Medical Center. In 1992 he moved to Tucson, Arizona, to be Chairman of the Department of Medicine at the University of Arizona Health Sciences Center. He has won outstanding teacher awards at the Brigham and Women's Hospital in Boston, the University of Massachusetts Medical Center, and at the University of Arizona Health Sciences Center. His publications are numerous and diverse. His books, entitled Manual of Coronary Care and Valvular Heart Disease, have each gone through multiple editions. He has authored or edited 32 books. William Clifford Roberts, MD 2 2 From the Baylor Cardiovascular Institute, Baylor University Medical Center, Dallas, TX 75246. (hereafter called WCR) : I am speaking with Dr. Joseph S. Alpert in my home in Dallas on September 16, 1996. Dr. Alpert arrived about 15 minutes ago from Tucson, Arizona. We have about 90 minutes before we have dinner with several members of the Baylor University Medical Center staff. Joe, let me start by asking you to speak a bit about your background, where you were born, your parents, what growing up was like in your home and in your city. What early influences shaped you? Joseph Stephen Alpert, MD 3 3 From the Department of Medicine, The University of Arizona Health Sciences Center, Tucson, Arizona 85724. (hereafter called JSA) : I was born in New Haven, Connecticut. My father was a practicing dentist, a very popular clinician in New Haven. I think that many of my clinical skills and attitudes have come from him and from his very relaxed, friendly, and folksy approach to the patients that made him extremely popular. My mother and father met at the University of Pittsburgh during the Depression when he was in dental school and she was an undergraduate. She went on to major in journalism and then worked for some years as a journalist before they were married. In those days you didn't get married right away, you had to wait until things were financially straightened out. They got married toward the end of the Depression. My mother stopped working as a journalist and eventually, when my brother and I were in junior high, went back to school and got a graduate degree in English and then taught high school English. She was an excellent writer, very articulate, very interested in books and written expression. I think I got a lot of my interest in writing, books, and reading from her. There was one other person who had a lot of influence on my early life and that was my father's sister (Aunt Eva, for whom my daughter is named). She was a very popular first grade teacher in New Haven. She taught me to read long before I went to school. I was already reading by the time I got to kindergarten and books and reading have played an important part in my life from the very earliest point. Therefore, my earliest influences were my clinician father, my journalist mother, and my first grade reading teacher aunt. I have always loved books and school. Growing up in New Haven, you grow up in the shadow of Yale University. My earliest memories are of being taken to the Yale Peabody Museum to see the dinosaurs and going to Yale football games. From my earliest school years I always wanted to go to Yale University. I think that is not an unusual feeling on the part of people who grow up in New Haven. Doing well in school was strongly emphasized in my family. I can't remember a time when it was not expected that not only would I go to college when I graduated from high school, but that I would go on to graduate school of some kind. I think my father would have loved it if I had gone to dental school and joined him in his very large and successful practice, but it did not work out that way. There were a number of teachers who influenced me along the way. There were several fine high school English teachers who saw that I liked to write and was reasonably good at it and who really pushed me hard to write as much as I could and to read as much as I could. I could give you a few of their names. There was a woman named Ms. Frazee who was very important as a sophomore English teacher. I had some very good science teachers, too. This was a time when the public school system in New Haven really was very good and we would send 20 or 25 students off to Ivy League schools from the James Hillhouse High School, which was the central high school in New Haven. When I got to Yale it was as if I had died and gone to heaven. There were so many interesting people. There were so many exciting courses. I remember freshman year thinking there was not enough time in a lifetime to participate in all the interesting things going on. I loved history, English, and various science courses. I took art history courses and psychology courses. There was almost nothing I took that I didn't say, “Oh, this is really interesting, I wish I had more time to study this.” I think I was also very fortunate in my roommates at Yale. Yale had a system at that time where nobody was allowed to Fig. 1 Photograph of Dr. Joseph Alpert at the time of the interview with WCR. live off campus unless you were married and there was hardly anyone married. Essentially, the entire student body lived on campus and lived in residential units known as colleges. Harvard has the same system where the residential units are called houses. Within these residential units there are faculty members who live there including some married faculty members and single faculty members. You ate your meals there; there was a great variety of cultural and academic activities that went on there. I had contact with just a tremendous number of very, very exciting people. I remember to this day telling my wife about things I can remember from lectures. I can remember big chunks of lectures from those first 2 or 3 years at Yale. I remember Charles Garside who taught Introductory European History and Maynard Mack who taught Shakespeare. I was fascinated and I was not alone in this. My roommate was David Gergen, who you know as a political commentator and Washington pundit who has been in 4 different White Houses. He was my roommate for 4 years at Yale and he and I had all kinds of interesting conversations. I would have to say that for me there was great value in my roommates and my friends at Yale. We would stay up until 3:00 a.m. arguing and discussing politics, religion, philosophy, literature, you name it. That to me was as valuable as the courses, even though the courses were wonderful. Dave and I took a number of courses together. I remember very well our taking Introductory European History together and really getting excited about European history, probably because the teaching was so exciting. The material was interesting, but you know medieval European history was a little bit removed from New Haven, Connecticut, in the early 1960's. Yet, the course was taught in such an exciting way that you could not help but be fascinated by what had gone on 600 or 700 years earlier. There were teachers like that throughout Yale. Of course, Yale had a fabulous library and a wonderful art gallery. The science laboratories were equally interesting. During my first 3 years at Yale, it was such a very exciting time that I actually had a very hard time deciding what my major would be. I think I changed it about 4 times. For the longest period of time I was going to be an English major, specializing in Elizabethan England. Then I thought for a while that I would be a History major. Then eventually, because of some summer work in the Bingham Marine Biological Laboratories at Yale, I really got excited about biology. I ended up in the beginning of my senior year becoming a Biology major. I took a lot of English courses, a lot of history, a very broad liberal arts education. I think that was terribly important and I feel badly for many of our current medical students who have majored in something like microbiology; not that there is anything wrong with microbiology, but I think they have missed out on a lot of very exciting material in their undergraduate years. It is unfortunate when they focus themselves that tightly, that early in their career. I agree with Lewis Thomas, if it were up to me, I would strongly discourage premed students from majoring in science. I would force people to take a much broader liberal arts background. We will talk about that again because it has continued to play a role in my career. In any case, the summer before my senior year I worked with a faculty member named Alfred Ebling who needed some extra technicians in his lab during the summer; I worked with him on deep sea fish that were dredged up from a mile down: very interesting animals with lantern lights and big teeth and telescope eyes, and all the adaptations that are required to live at that depth. Of course, almost no light gets down there, the temperature is constantly just barely above freezing, and the pressure is intense. It is a very marginal zone to survive in. Yet, there are a lot of very interesting fish that live down there and obviously do survive. I worked with Ebeling and I got so excited about what he was doing that I ended up deciding that I would be a Biology major and that I would focus on fish biology. At that time, Yale had several programs that encouraged independent study. One of them was an honors program where for 2 of your 5 course credits you did a research project. I started doing this research project with Al Ebeling for 2 of my 5 courses. After about 3 or 4 weeks of the senior year it became clear that this project, if I was going to do it right, was going to take a lot more than just 40% of my time. I was working on the physiology of air breathing fish from southeast Asia, the same family as the Siamese fight Fig. 2 Dr. Joseph Alpert (left) and Dr. Lewis Dexter (right) in 1973. ing fish. The particular fish I was working on was known as Macropodis Opercularis (this work resulted in my first publication), the paradise fish. This is a fish that actually breathes air, so it not only has gills for extracting oxygen from the water, but it also has a little specialized respiratory organ underneath its gill cover, the operculum. It can actually take bubbles of air into that specialized organ, so that during the long dry seasons in Southeast Asia when most of the ponds are dry or nearly dry and the water is very hot so there is very little oxygen in it, this fish can breathe air. Al Ebeling and I got to talking about this and to be honest with you, I can't remember whether it was his idea or my idea, but we sought to learn if changing the oxygen in the environment could speed up or slow down the development of this organ. In any case, after a few weeks of work it became clear that I could not conclude this research project in the time allotted. Fortunately, Yale had a program at that time known as the Scholar of the House in which you basically did full time research during your senior year in addition to a long reading list. In essence, it was like a little Masters' degree done as a senior student. Many other students were in the same program. People were working in English, Sociology, Anthropology, Music, and so forth. There were about 18 or 19 throughout the University. You met once a week for dinner and 1 of the scholars came with their professor and presented what they were doing with discussion afterwards. You can imagine that these were some of the 18 or 19 most interesting people intellectually in the undergraduate college, because each of them had a burning passion for some area. Normally, you were supposed to apply at the end of your junior year. Ebeling gave a very quick call to the fellow who was running the thing and said, “We have this critical situation here; either this project is only going to get done halfway or we are going to do it right, and the only way to do it right is to get into this program.” They were very good about it and took me in. I basically spent my whole senior year working very closely with Al Ebeling doing 10 to 12 hours a day of investigation on this fish project as well as a lot of reading on fish biology. By the end of that year when I took my oral exam and presented my thesis, I really felt like I had already done a Masters' degree in fish physiology. Probably, there was a lot less to know in 1963 when I did this than there is today, but nevertheless I thought it was exciting. I had always thought I would probably go on to medical school and end up being a clinician like my dad, but I got so excited about basic biology that I thought about doing a PhD in fish biology. Ebeling was a graduate of Scripps Oceanographic Institute and he was encouraging me to consider doing a PhD at Scripps. I was really very conflicted at that point. Al became a very good friend. He and his wife did not have any kids and I think I sort of became an adopted son. He said to me, “You know what you ought to do, you ought to do a year's graduate study and see how it goes. If it is interesting and excites you, you can go into the PhD program. If it doesn't excite you, keep up your applications to medical school, and they will surely accept you.” Ebeling went on: “I have a very good friend who runs the Carlsberg Oceanographic Laboratories in Copenhagen, Denmark, and I could arrange for you to do a year's research with him on deep sea fish, because I spent a year there and it was really fun. It is a wonderful place to go. The Danes are just fabulous people, and you will have a year away from New Haven where you grew up and went to college; and here is a chance to get on your own for a year and then you will see what happens. At the end of that year you will know whether you like it or not.” I applied for a Fulbright Fellowship and got one to Denmark to the Carlsberg Oceanographic Laboratories at the University of Copenhagen. That was a life changing event for me in a variety of ways. I could joke about it and say I went there and met my wife and that changed everything, and to some degree that did happen, but also I discovered that I really wanted more human contact than I would get doing fish physiology, particularly deep sea fish physiology, where much of what you do is sit alone in a laboratory working with specimens from jars. Perhaps it was my dad's clinician influence working on me. During that year a number of things happened. I ended up living in a Danish kollegium, which is sort of like a cross between an American fraternity and a dormitory. I was the only foreigner there, so it became sort of the game of the kollegium to teach me to speak Danish. About half way through the year I met my wife at the University of Copenhagen and she also thought it would be a good idea for me to learn the language, which I did. Suddenly, I found myself at the end of that year in this culture where I could not quite pass for a Dane because people could hear my accent, but where people thought I was from some other Scandinavian country. It gives you a whole different perspective on life because suddenly you are seeing things from other people's viewpoint and with other people's attitudes as opposed to the ones that you have always grown up with. It was a very maturing experience. I went home that year committed to figuring out how to get my future wife, Helle Mathiasen, over to the US so we could get married and be together. I also decided I would go to medical school and try that out, since after a year of basic biology I felt that I was not cut out for a full-time life in the laboratory. I went back to Harvard Medical School and kept corresponding with my fiancee. I went over at Christmas time and visited her, and we got married the summer of 1965. During medical school, I had a lot of help from people at Harvard Medical School, specifically Dr. Clifford Barger, Professor of Physiology, and subsequently Head of the Department of Physiology at Harvard Medical School. He had very good friends in Denmark, particularly a fellow named Niels Lassen, who is still one of the world's great clinical circulatory physiologists. Lassen was one of the first investigators to come up with a way to measure blood flow in various organs, for example, the kidney, skeletal muscle, and the heart, using radioactive tracer gases. He subsequently won many prizes for his work and is very well known. Barger had spent time in Lassen's laboratory and was able to arrange for me to get summer support from the Harvard Medical School, money that I believe originated from the National Institutes of Health (NIH) Those were the good old days of the NIH, when there was lots of money to support student projects. I went over that summer, worked with Niels Lassen, and actually wrote my first medical scientific paper with him. We used Xenon-133 gas dissolved in saline and injected it into skeletal muscle in normal people and patients with peripheral vascular disease in order to demonstrate flow deficits when they walked on a treadmill. The extent of the deficit depended on the severity of the vascular disease. This project got me absolutely excited about circulatory physiology. Basically, at that point, the rest of my life was determined. That was 1965. The die was cast: I married Helle and that has meant an ongoing and continued relationship with Danes. I have a very warm and loving relationship with my Danish family and many friends. I have a close relationship with many Danish cardiologists as well as many European cardiologists and feel like I have close to a second home in Denmark. Niels Lassen really got me excited about clinical physiology, and I went back to Harvard Medical School in the second year determined to be a circulatory clinical physiologist. Of course in the USA that means you are going to be a cardiologist. After my second year in medical school, my attitude about clinical research was totally different. Two or 3 times each semester, the Dean of Students would come into our class both during the first and second year and say things like, “I have money for every single one of you students to spend the summer in somebody's laboratory.” Can you imagine anyone saying that today? During the second year he came and said, “I have a substantial amount of money to send a large number of you to somebody's laboratory for a whole year between the second and third years, and I really want to see a lot of you come to my office and tell me you want to do that.” These days we have to scrounge to find a pittance for someone to do research. In those days they were literally twisting everybody's arm, “Come talk about this.” There were probably 16 or 18 of our class of 100 that did do that. I went back to Niels Lassen's laboratory for a year, where I published a number of papers and actually wrote a gold medal thesis, which is a competition that the University of Copenhagen has every year in a number of different areas. I was fortunate that year since the question fell in the area of circulatory physiology and actually related to some of the studies I was already doing. I wrote a thesis on that and was awarded a gold medal from the University of Copenhagen for that year's work. Basically, my career was established by the time I started my third year in medical school. Our first child, a daughter, Eva, was born at the end of that year, 1967, and we returned to the USA to do the third and fourth years of medical school. My wife, an English major and Master's Degree recipient at the University of Copenhagen, entered Tuft's University to do a PhD in English. Again, the influence that I had had from Yale, a strong liberal arts influence, continued right throughout my medical school career, because my wife was coming home talking about Kafka, Shakespeare, Chaucer and so forth, some of which I had read, some of which I had not, and when I found a little time I would try to read and talk to her. I had saved some of my notes from some of my best Yale English classes and we would get those out and look at them and talk about them. I was able to maintain at least a little bit of contact with the world of literature, literary criticism, and philosophy. Our son, Niels, was born one and half years after our daughter. Meanwhile, Helle finished her PhD and I finished my MD, and then we stayed on in Boston because I stayed at Brigham to do internal medicine residency. During my medical student years I met 2 more people who had particular influence. My first attending, when I did third year medicine, was Lewis Dexter, one of the first people to do a cardiac catheterization, and perhaps the first person to put a catheter in the pulmonary artery, which he did by accident. It is a wonderful story. His laboratory was where the pulmonary wedge pressure was first worked on and where Dick Gorlin was a fellow. Gorlin, of course, also worked out the Gorlin formula for valve area calculations. Many other developments also came out of that laboratory. In any case, Lew was my attending the first month I did medicine at Brigham, which would have been February 1968. Within a few days, it was clear to me that this was the kind of doctor I wanted to be. This was a man who was both a circulatory physiologist, a fine clinician, a wonderful teacher, and a fabulous human being. Literally, one of the nicest people I had ever met. He died in December 1995 and was widely mourned by the cardiology community. Subsequently, I took a fourth year elective in Dexter's laboratory and met Lew's first lieutenant, Jim Dalen, a very young faculty member at that time. He had been an Assistant Professor for a couple of years when he and I met and there was just a definite “click.” Even though I was still a medical student and he was a junior faculty member, there was a sense of meeting somebody you immediately like and they immediately like you. You just know you are on the same wave length. We started working together on some projects, so that when I graduated from medical school it was clear I was going to be a cardiology fellow in Lew and Jim's laboratory as soon as I finished internal medicine training. In those days internal medicine was only 2 years, so you had to make up your mind reasonably quickly because by the middle of internship you had to apply for cardiology fellowship. I only applied to Dexter's program and, of course, they took me. That was also a very exciting time at Brigham in cardiology. I don't know if we will ever come to a time when one has as much going on in a single institution. WCR: You started your cardiology fellowship July 1971? JSA: Right. I was an intern in 1969 to 1970 and a junior resident in 1970 to 1971. Beginning July 1, 1971, I was a cardiology fellow with Dexter and Dalen. The exciting thing at Brigham at that time was that there were 4 separate cardiology fellowships, 4 separate groups in this 320-bed hospital. You might say that does not make any sense at all: people must have torn each others throats out, but somehow though there was competition, everybody got along with everybody else. Dexter was a special person. When Dick Gorlin finished training with Lew, Dexter went to George Thorn, the Chief of Medicine, and said, “Hey, this guy Gorlin is too good to lose. He is interested in things like the coronary circulation that I am not interested in.” (Dexter was interested in valves, congenital heart disease, pulmonary embolism, right ventricular function.) “Why don't you give him his own cath lab and let him go after the coronary circulation.” Remember, this was a time when cath labs were very different from what they are today. They were basically clinical physiology laboratories and you did few “studies” for clinical purposes. Almost every patient was studied to learn something about circulatory physiology. No one anticipated the huge growth in coronary arteriography and percutaneous transluminal coronary angioplasty (PTCA). Remember, Sones started to do coronary angiography in the 1960s, and Favaloro did the first saphenous vein bypass only a few years before I became a fellow. It was not yet clear whether any of that was going to turn out to be important. In any case, Gorlin had his own lab and he had his own fellows, and they mainly focused on patients with chronic coronary disease. Now, you might think they also ran the coronary care unit since they were interested in coronary disease, but that was not the case. Dr. Bernard Lown ran the coronary care unit. He also had his own fellowship program and his own people, and they were totally separate. Lown had a very noninvasive approach; he was generally opposed to cardiac catheterization and surgery. Edmund Sonenblick also had a basic science laboratory that was very loosely affiliated with Gorlin, but basically he ran his own show as well. Thus, there were 4 different groups. Sonnenblick's group consisted of fellows who had already finished their clinical fellowship and wanted to spend a couple of years in the lab. At the time, Bill Parmeley, Michael Lesch, and Michael Herman were also there, and Lown had interesting people in his group as well. Many of the people that were fellows or junior faculty when I was there have ended up as chiefs of cardiology or chiefs of medicine. It was a very interesting and exciting time, because these 4 cardiology groups would compete to have papers at the meetings and articles in the New England Journal of Medicine. It was a golden era. Of course, the NIH was supporting the training grants and research for all 4 of these programs. It was just a remarkably fruitful and exciting time for cardiology, and many people launched their careers at that time. I did 2 years of cardiology fellowship. I had a Navy deferral on the old Berry plan, named after Dean Berry of the Harvard Medical School who devised this plan. The Vietnam War was going on then and I had friends who actually were drafted out of fellowship and internship and were sent to Vietnam. I had a full 5-year deferment just by the luck of the draw. At the end of 4 years I had to choose what to do with that fifth year, whether I should think about trying to be a chief resident in medicine or whether to stay in Dexter's lab. Lew and Jim came to me and said, “Why don't you be our junior associate in the lab?” Jim was the 1st lieutenant and Dexter was the General; then I became the corporal. I accepted their offer and published a number of papers. I was involved in a lot of exciting projects and was not anxious to leave, but I knew I had this 2-year commitment to the military. Then, another fortunate thing happened. During my second year of cardiology fellowship, George Thorn retired after 25 years as Chief of Medicine at Brigham. The new Chief of Medicine was a cardiologist, Eugene Braunwald. Braunwald took an interest in me. He came to Brigham in 1972 or 1973. (He retired this year after more than 20 years as the Hersey Professor at Brigham.) Braunwald found out that I owed time in the Navy. You may remember that Braunwald had been Chief of Medicine at the University of California, San Diego, before coming to Brigham. He had worked on clinical research projects with the Balboa Navy Hospital in San Diego, which was one of the premier hospitals in the Navy. They had very good people on staff, and a lot of fellows would have given anything to get there. It was about a 1,200-bed hospital, so it had a lot of clinical material. We had about 15 cardiologists there and a good cardiac surgery program. We basically did all complex cardiology for all the services from the western United States and the Pacific. You can imagine how many patients we saw: one fascinating patient after another, plus the connection to the University meant that we were doing a lot of teaching and were heavily involved with the University. Braunwald did me a tremendous favor by recommending me to the Head of Cardiology at Balboa, a fellow named Art Hagan, who was a superb cardiologist and one of the pioneers of 2-dimensional echocardiography. I came as a hemodynamic cardiologist, but after arriving they told me they had lots of people in the cath lab, but needed someone to run the coronary care unit. I quickly went to the library and read everything I could find on coronary care. Of course, I had had some time with Bernard Lown in the coronary care unit at Brigham. During the next 2 years I did a lot of work in coronary care. There were more than 800 patients per year with acute myocardial infarction going through that coronary care unit. At the time there were almost a million people in San Diego County eligible for care at the Naval Hospital. In addition, we were involved in some of the early myocardial infarction (MI) intervention trials that were going on. Just as I was concluding my service with the Navy, Michael Lesch, the person who had been running the coronary care unit at Brigham, (the Samuel A. Levine Cardiac Unit) left to go to Northwestern to be Chief of Cardiology. I got a phone call from Tom Smith, who was the Chief of Cardiology at Brigham, and he said, “I understand you have been doing a lot of coronary care. Would you like to come back to Brigham to run the coronary care unit?” For me that was just a dream come true. Jim Dalen, Dexter's lieutenant with whom I had a very close personal relationship, had just moved to the new University of Massachusetts Medical School in Worcester to be its Chief of Cardiology and he wanted me to join him. But the chance to run the Levine Cardiac Unit, or “the LCU” as we called it, was just more fun than I could have thought possible. I accepted the job at Brigham and went back to Boston. That was the year (1976) when we were just starting up the Milis Trial. Again, there were a lot of exciting people at Brigham. Tom Smith was a wonderful person to work for, a superb academic cardiologist, and a great human being as well. Braunwald, of course, knew more cardiology than almost anybody I had ever met. It was another exciting time. I would have been perfectly happy to stay there for the rest of my career. However, an interesting thing happened at that point as so often occurred in my career: suddenly a door opens and somebody says “here is an opportunity for you, would you like to do this?” The opportunity that happened then was that Jim Dalen became Chief of Medicine at the University of Massachusetts Medical School and that left the job of Chief of Cardiology open. He called me up at Brigham where I was running the CCU and said, “Why don't you come here to be Chief of Cardiology?” I did that and it led to many events in my life. The University of Massachusetts hospital had opened only about 18 months earlier. Things were just starting up, and I got to be involved with Jim Dalen in building the Department of Medicine and the Division of Cardiovascular Medicine nearly from its inception to where it is today, one of the better cardiology sections in the country. Then, about 7 years ago, Jim, who is an excellent investigator, a very good clinician, a superb teacher, and an outstanding administrator (perhaps one of the best physician/administrators in the country) was offered several deanships of medical schools. He accepted the job at the University of Arizona, which he thought would be the most exciting and interesting. He went there approximately 7 years ago. About 4 years ago, the Chief of Medicine at Arizona, who had been there for a long time, retired, and Jim asked me to apply for his position. I went there as Chief of Medicine and continued our working relationship that had begun when I was a medical student. I would have to say that the most important factors influencing my career besides my childhood and early schooling and the influence of my wife, have been a number of outstanding people in academic circles in high school, college, and medical school. Influential people who said to me, “I like you and I can see that you like working with me and let's work on some things together.” Each time that happened it has been a very positive experience for me and has influenced the direction in which I have gone. WCR: What were you most pleased with as your accomplishments as Chief of Cardiology at the University of Massachusetts in Worcester, looking back on it? JSA: The thing I'm most proud of is my mentoring of young physicians. I have written a lot of papers and done a lot of research but I don't think any of that is going to win the Nobel Prize. Perhaps 100 years from now some of my contributions will be mentioned in various footnotes along with a lot of other people. I have done some good solid work, but if you ask me what was the most important thing I have done, I would say it was mentoring and developing the careers of young people: medical students, house officers, cardiology fellows, and junior faculty members. What I am most proud of at Worcester is that when I first went there there we were only 4 faculty, all trained in the Dexter lab and all picked by Jim Dalen to start off his cardiology program. We went from that faculty of 4 people to a total of 16 or 17 faculty members by the time I left in 1992. When I went to Worcester they were doing essentially no research and the quality of the fellows was not great. Yet, over that period of 15 years we ended up getting wonderful cardiology fellows and house officers. The internal medicine program took off and really became one of the most competitive in the Northeast. The faculty blossomed. Many faculty members who are there now were trained at the University of Massachusetts as fellows. They have been able to get grants; they have published articles in first rate journals. My greatest satisfaction was mentoring and developing these young people, many of whom have become senior faculty members and have developed substantial and solid careers. WCR: Was it hard for you when you became Chairman of Medicine in Tucson to give up exclusive cardiology? When you had this opportunity to be Chairman of Medicine at the University of Arizona was that a difficult decision? Had you always wanted to be a Chairman of Medicine somewhere? JSA: I considered all of that, but what went through my mind was “wouldn't it be wonderful to work with Jim Dalen again, because so many of the good things that had happened in my professional life had happened when we had been working together.” When I thought about giving up cardiology and going to be Chief of Medicine, I said, “Well I'll still be a cardiologist.” I could still attend in the coronary care unit, which I do. I can still see a lot of cardiology patients, which I do. I had always liked internal medicine. In fact, I remember during my first year as a fellow when I used to do consults, Jim Dalen used to say to me, “There is too much internal medicine in this consult. Just give me the cardiology. They are not asking us to manage the electrolytes and the acid base. They just want to know how to deal with the heart problem here.” In fact, it was pleasant for me going back to part-time internal medicine. What has been less than pleasant is the current environment in which one is a Chief of Medicine. I thought Chiefs of Medicine were people like Braunwald, George Thorn, etc. When I got to Tucson, managed care was galloping along in Arizona, and it was an extraordinarily tough first year because of the impact of managed care. We really had to completely redesign how the faculty did medicine with the amount of protected time markedly reduced and the amount of clinical time increased, because we had to compete with the community for managed care contracts. I know this is an issue that is going on throughout the country. It was not difficult for me to decide to be a Chief of Medicine, but once I became one, I had the difficult challenge of dealing with an academic department of medicine in the midst of this managed care revolution. That was, and still is, a major challenge. I spend a lot of time thinking about and dealing with economic and organizational problems. We are completely revamping the way the hospital and the group practice work together. Therefore, a lot of time has to be spent with these issues and a lot of time is spent supporting the faculty and reassuring them about the outcome of all of these changes. This is a revolutionary time. The faculty grew up as did I in what I call “the golden era,” the era when there was lots of NIH and American Heart Association support. If you wanted a grant there was probably a 40% chance you were going to get it. If you got turned down the first time, you kept at it and if you were persistent and people saw you were serious, there was a very good chance that you would get funded. The NIH pay line now is no more than 10% and in some instances less. This is discouraging for both junior and senior faculty members. The amount of money we are being reimbursed for our clinical activity is also markedly less than formerly. The profit, if you will, in our enterprise has essentially vanished. We used to use that profit to cover people's free time so you could do half-time clinical, or sometimes even less if you had a grant, and have a lot of protected time paid for by the department to do investigation and to teach. There is much less of that free time now. People have to do academic activity on weekends and evenings and steal a little time here and a little time there. It is a lot tougher than it used to be. WCR: How many faculty members do you have in medicine? JSA: We have 76 or 77 full-time faculty members in the Department of Medicine at the University Hospital, and then at the Veterans Administration Medical Center, which is part of our system, there are about another 20. We have about 100 full-time faculty members. WCR: How many house officers, interns, residents, fellows, in the various divisions? JSA: The total number of house officers is 52. There is a far smaller number of fellows, probably 23 or 24. WCR: When you add up secretaries, lab technicians, and other personnel, the total number of people in your department of medicine is approximately what? JSA: There are over 400 people that I am, in a sense, ultimately responsible for. Of course, I can't possibly micromanage all the daily routines of those 400. There are a number of section heads who are involved and a number of laboratories with heads and so forth, but ultimately I am responsible for a little over 400 people. WCR: As a cardiologist who is chairman of a department of medicine, could you sort of go through your typical day? What time do you get up in the morning? What do you do first during the day? How does your day go? What time usually each day do you leave the hospital? What are your evenings at home like? What time do you go to bed? JSA: I was expecting this question because you asked Eric Topol the same question. It was interesting how much my life resembles Bruce Fye's life and Eric's life in terms of sleep. I don't get a lot of sleep. Maybe that is what is going to come out of this whole series, Bill, is how little sleep your interviewees get. I usually get up about 5:00 a.m. , I go out and run or run/walk, depending on how sleepy I am, for about 60 to 70 minutes. It is almost a 5 mile hilly route. I have been doing that for years, although not necessarily in the mornings. Sometimes, if I have a day where I have some time at noon, I will go out and run instead of eating lunch. I call it “the negative calorie lunch.” I have been doing this for about 10 years. In the late 80s and early 90s I ran the Boston Marathon 5 times, which was an instructive event, an experience. The first twenty miles were great and the last 6 miles were pure pain. Not that I was very fast, but it was fun and we had a group I would run with. After exercise, I come in, have a little breakfast, shower, dress, and get to the hospital about 8:00 a.m. When I am on the Coronary Care Unit, where rounds start at 7:00, then I get up about 4:15 or 4:30 so I can get my exercise in before getting to work at 7:00. I do 3 months of attending a year, 2 months of medicine, and 1 month of coronary care. Three months is actually a lot, but, as I told you, we are going through this managed care revolution and I felt like I could not just sit in my office and tell everybody else to increase their clinical load, I had to increase mine, too. I am doing more clinical work now than I have ever done, because I also have 3 half afternoons a week when I see outpatients, so I carry a pretty heavy clinical load. I believe in the Patton theory of leadership: “if you are not in the front tank that is heading towards the enemy, then you have not earned the responsibility or the right to lead the people.” Sitting back behind the lines and telling other people what they ought to be doing somehow never appealed to me. Besides those 3 months when I have to be there at 7:00 a.m. and when I am up at 4:00 to 4:30 a.m. to get my run in, most days I get to work about 8:00 a.m. Then, I will look at the mail that comes in or answer the phone calls from the East coast (Arizona is Pacific time in the summer and Mountain time in the winter). We don't do daylight savings time so we are either 2 or 3 hours behind the East coast depending on the time of year. Then, I go to morning report many mornings which is 9:00 to 10:00 a.m. , unless there is some meeting with the head of the hospital or the head of the group practice to deal with urgent or emerging economic or administrative issues. That probably happens 40% of the time, so 60% percent of the time I get to morning report. That ends at 10:00 a.m. Then, from 10:00 a.m. until noon I will again go back to my office. There will be a huge stack of mail to answer, and there are always people that just have to see me right away. It could be from our cancer center, or the arthritis center, or the cardiologists. The latter are pretty easy to work with because they know that somehow they can get to me at one point or another, and I usually go to their section meeting on Tuesdays at noon. Most of the other sections want to talk to me as well. These days, the Head of Infectious Disease is one of my major clinical right-hand people and so he often comes by to talk about how we are reorganizing. The office for our house staff program is right next to mine and the Head of the House Staff program and his associate director may want to grab me about an issue. Administrative activity usually will wind down about noon time. Then, there are noon conferences. Wednesday from 12:00 to 1:00 is grand rounds; Tuesday is the cardiology section meeting. There are often a variety of administrative conferences at noon. Thursday, for example, is the medical group practice executive committee, of which I am a member. From 1:00 to 2:00 p.m. I usually do paperwork, see people, make decisions, phone calls, etc. I go to the clinic from 2:00 to about 4:30 on Tuesdays, Wednesdays, and Thursdays. Mondays and Fridays I have appointments: any student, any house officer, any fellow, any faculty member that wants to talk to me. My door is always open. In general, I prefer that people make appointments; otherwise it gets unmanageable. I have superb secretarial and executive assistants who help in terms of the business aspects, the paperwork, and the phone calls. I have built this team over the 4 years that I have been in Tucson. Many of them are new people who have come on board to be with me, and we work very well together. Generally, when I come back from the clinic, there will be people waiting to see me or I will have other appointments. Starting at 5:00 p.m. , there are either group practice meetings or other administrative meetings. Then, I am involved in 2 courses that meet in the late afternoon. One I have been teaching with my wife for almost 20 years. I call it “Medicine and Literature.” She calls it “Literature and Medicine.” As I mentioned earlier, she has a PhD in English literature. She teaches on the main campus at the University of Arizona. She taught for many years at Boston College. We started back in 1978 to teach this seminar called “Literature and Medicine.” The course picks works of literature that relate to medicine in some way. We might do a Camus novel, The Plague, in which the main character is a physician, Dr. Rieux, or we might do Graham Greene's novel A Burnt Out Case, which takes place in a leper colony and also has a prominent physician in it. We might read Chekhov, the famous Russian author of short stories, plays, and so forth, who was a physician. Many of his stories have a lot of medical material in them. We might talk about the Pulitzer Prize winning poet, William Carlos Williams, who was a practicing pediatrician and a writer of poems, novels, and short stories or Simone deBeauvoir's recollection of her mother's death from cancer, A Very Easy Death. The course runs in the fall semester for undergraduates on the main campus from 5:00 to 7:15 p.m. on Wednesdays, and in the spring semester we run it for medical students and that generally runs from 4:00 to 6:30 p.m. twice a week for 6 weeks. In addition, this year the Chief of Surgery, Bruce Jarrell, and I have been running a course in intensive care medicine, surgery, and pathophysiology for fourth year medical students, which meets on Mondays from 3:00 to 5:00 p.m. . I get back to my office after that and I finish the day's paperwork, letters, and so forth. Generally, I finish work between 6:30 and 7:00 p.m. , except when I am on the clinical service. If I am on the coronary care unit or the ward service, then I have to go back and see the residents and patients. Those days I might not leave the hospital until about 7:30 p.m. On weekends during the 3 months I am on a clinical service, I do rounds on both Saturdays and Sundays. When I am not on service, I may have meetings on Saturday mornings. I try and keep as much as possible of the weekends free for my wife. We travel a fair amount when we can. I also try to take a month's vacation every summer. We usually try to take a substantial trip. When we left Massachusetts we had a small house on Cape Cod, which we still keep. We try to get back to that periodically and it is very curative and restorative. The long trip this past summer was to Alaska and western Canada. WCR: What do you do on your vacations? Is that when you and your wife have more time to develop new material for your course the following year or how does that work out? JSA: We are always talking about our course. One of the nice things about living in Arizona is that the weather is always good, so we talk about the course when we go for a walk together or over dinner, now that our kids are grown. Besides our 2 cats, there is just my wife and I at home, and the cats are not big conversationalists, so we might discuss topics from the course over dinner. When we take a vacation, we are always talking about things that come up in the course as well as new books we run across. We tend to be energetic tourists. We are often out hiking or roaming around. In Alaska, we were doing a lot of hiking and touring, looking at the animals, and seeing the wonderful natural environment there is up there. My wife says, “Medical issues are life issues, every person on this planet at some time or another has a medical issue.” For example, recently we discussed assisted suicide. That is the sort of issue that comes up in our class. Often Helle and I have a dialog going on, which continues in the classroom when we teach the class. WCR: When you get home on weekdays, what are your evenings like? JSA: My wife and I will have dinner together. Usually the Wednesday night in the fall when we are teaching the Med Lit class we don't finish until 7:30, then we usually will not cook. At that point we have both been going for about 12 plus hours. We might order food in or we might stop at a restaurant on the way home. Sometimes we prepare food on the weekends that we will just heat up in the microwave. On the days when we get home at reasonable times, my wife still likes to cook and I occasionally cook. Most nights she cooks, although I like to cook. We have a fairly simple meal together, and a glass of wine. If we have work to do, then we will work for 1 or 2 hours or so. Occasionally, we watch TV or a VCR movie. Last night, for example, we watched Ken Burn's new series, The West, which was excellent. Some nights we go to the movies when we need to relax. Most weekday nights and on the weekends we will do some work. We try to get together with friends, often for dinner, or go hiking with friends or to the movies on weekends. My wife is on the board of the Tucson Symphony, so we have a certain number of nights when we go to the symphony or the Chamber Concert series or the theater. WCR: So you do it all? What time do you go to bed? JSA: It depends on how exhausting the day has been. When I am on the wards and up at 4:00 in the morning, usually I will try to get to bed by 9:00 or 9:30 p.m. , otherwise 10:00 or 10:30 p.m. WCR: So you can go pretty well on 6 hours sleep? JSA: Yes, 6 hours is fine. WCR: People are pulling at you all the time. With this number of people on your house staff, your full-time faculty, it must be a real pleasure to get away sometime. You are 54 years old now? Do you want to continue being Chairman of Medicine for another 11 years or what do you see on the horizon? JSA: I think the days of trying to be Chief of Medicine for 20 or so years, as was common in the past, would not be realistic in the current environment. Today, in order to stay that long in this position would require someone made not of iron, but made of diamond to withstand the constant problems. The house officer problems are the least difficult. The economic problems, the constant pressure from the business side are, however, energy draining. I believe these days that 10 to 12 years would be a reasonable term of office for a chairman of medicine in a university setting. That should be more than enough. Maybe when I get to 10 to 12 years I will change my mind, but at least from this vantage point, 4 years in, it seems to me that 10 to 12 years would be more than reasonable. By then, I would be over 60 years of age and I would like to go back into the section of cardiology and continue to teach, write, and see patients. I would be more than happy to continue the level of clinical activity I have now, more than happy to continue to teach, do my books, be involved in clinical research projects the way I have been; in other words, continue to do everything, except the heavy administrative load. I would perhaps even be willing to take a small administrative load. I don't think I want to be a Dean, at least not as seen from this vantage point. If there is any job that is more political, more administrative than the Chief of Medicine, it is the Dean. The Dean's job is very difficult. I see how beautifully Jim Dalen does it, and he is a superb administrator with just the right sense of where people are coming from and what his vision is and where he wants to go. At least at this vantage point, I don't think I would like to do that. I think I would like to stay in an arena where I am heavily involved in clinical medicine, teaching, clinical investigation, and my books. WCR: You obviously are a wonderful teacher. You have won a number of awards while at Worcester, San Diego, and Tucson. You obviously work hard at that. It takes a lot of energy to be a really good teacher. You must be worn out when you get home at night. Does the running give you more energy or less energy? JSA: I have always been a high energy person. You know some people are born with high energy and some people are not. I have always been a high energy person and I have always had a lot of enthusiasm for things. Somebody comes to me and tells me something new and different and I am always interested in that. I can pick up a National Geographic or another magazine, open any issue, and say “Oh, that is interesting” and get myself engrossed in it. I think that is just something I am genetically endowed with—high energy. However, I do think the running helps. For many years when I was in Worcester and did not have such a heavy administrative load, I tried to keep the 12:00 to 1:30 p.m. period open and run 5 miles. In those days, I ran with friends. I found that I came back and had more energy in the afternoon having done that. These days, because of the administrative load, my 12:00 noon to 2:00 p.m. period gets eaten up, so I generally run in the morning, but I think it still helps increase my energy. WCR: You grew up in the Northeast corridor, namely New Haven, had Ivy school college and medical and postgraduate training there, and then all of a sudden you are in Tucson, Arizona, a striking contrast. How did you adjust to the new environs? JSA: It was, of course, a major cultural change. Probably you would have a hard time finding a greater cultural difference in the USA than the Boston area versus southern Arizona. The Boston area is Anglo, New England, long tradition, Ivy League, and the Southwest is Hispanic, Native American, and more of a sun culture. On the other hand, the patients' illnesses are the same. The medical students are just as bright in Arizona and just as interested. The house officers are just as involved. The faculty members are the same. At least within my work environment it is not much different. It is when I leave work that suddenly things are different. That is why my wife and I have built up around us a lot of the cultural things that we did in Boston, the symphony, concerts, theater. Our Lit Med course continues. We still get the Sunday New York Times each week. We maintain a number of our Northeastern habits. But remember, we lived in San Diego from 1974 to 1976, and I have always taken that 1 month summer vacation (a Lew Dexter tradition). He always insisted that everyone have a 1 month vacation in the summer and I think it is a good idea. When we lived in Boston, my wife and I spent a lot of time in the West, hiking, white water rafting, being out in the environment. We spent a couple of summers on the Zuni Indian reservation as volunteers. I was a volunteer physician and my wife was involved in the hospital and also in some of the other community activities. So we had been to the Southwest a lot before moving to Tucson and had lived there for 2 years if you count San Diego as the Southwest. After Phoenix, San Diego is the closest big city to Tucson. We sort of knew what we were getting into. Despite that, it was a cultural change. I think moving after age 50 takes a lot of strength and energy. Fortunately, our son moved to Los Angeles this year, so we can see more of him now. WCR: You have continued to write your books, several of them, but you are not working as you did when you were exclusively in cardiology on publications for peer review journals. You are an editor of a cardiology journal. Do you miss the article publishing? JSA: Absolutely, that is what I had to sacrifice, unless I did not want to sleep at all at night when I moved into the heavy administrative load that goes with being the Chief of Medicine. What I had to sacrifice was clinical investigation. I am involved in some of the clinical studies that are going on in cardiology, heart failure, and angina trials. So I keep a little finger in. I am on a couple of data safety and monitoring boards for some big trials. I would say I keep my pinky in the investigative waters. I will continue to do that because I envision at the end of my time as Chief of Medicine that I will have time to go back and be more heavily involved in those activities again. But I definitely miss that! It is exciting doing research, looking at the data. I get a little of that flavor on a data safety and monitoring board because you see the data when nobody else is seeing it and that is fun. I feel that I have to put heavy investigative involvement on hold until I am no longer Chief of Medicine. WCR: It sounds like your wife is your best friend. Is that correct? JSA: Absolutely! Even though I have many other very close friends; for example, Jim Dalen the Dean of the Medical School, is like an older brother to me. We have that kind of older brother-younger brother relationship that is very special to me. I also have other family and friends with whom I am very close, but the first 3 people on the list of most important friends are all my wife. WCR: You have 2 children? JSA: We have 2 children. I have a daughter, Eva, who is a tax attorney in Boston, which also keeps the Boston connection for us. We get back and see her periodically. I have a son, Niels, who is a film maker and lives in Hollywood. WCR: Is academic medicine going to survive as we have known it in the past? JSA: I would say, Bill, we are going through difficult times for medicine in general in the USA and for academic medicine in particular at the present time. The message I constantly repeat to younger physicians is not to get too depressed and discouraged. It is easy to get down when nothing is working right: there is no grant money, there is no money for clinical activities, people are being squeezed for time. It is a frightening era. What I keep telling everybody is that we just have to hang in there. We have to do whatever it takes, even if that means we have to write on the weekends or in the evenings, or do our research after hours. Somehow or other we have to keep the enterprise going. I am convinced that the pendulum will swing back. Things will get better, but we may have to go through a half dozen more years of difficult times to do that. I don't want to see us lose a whole generation of young, exciting academic cardiologists or gastroenterologists, rheumatologists, infectious disease people, and so forth. I don't want to see them disappear and get discouraged and depressed and leave academics. My message is it is still the best job in America. WCR: Do you think all 125 USA medical schools are going to survive? JSA: I think there will be some downsizing of faculty just as we are downsizing our fellows now. I suspect you will continue to see medical schools amalgamating, like the combining of Hahnemann and Medical College of Pennsylvania into a single medical school. New York University and Mt. Sinai have just formed a somewhat similar relationship, and one could envision that maybe they will downsize their medical school classes. Columbia and Cornell in New York City are also coming closer to a relationship. Whether that means some medical schools will totally close or whether everybody will just amalgamate and downsize, I can't say, but I think we will be training fewer medical students 10 years from now than we are training today. WCR: What excites you most right now in cardiology? JSA: There are a number of exciting things. I am going to be giving a talk next month, the Diggs lectureship at the University of Tennessee, in which they have asked me to discuss the most exciting things that are going on in cardiology. The advances in coronary care continue to be very exciting. We have had a 10-year period of tremendous advance, and I don't think we are finished there. I am very excited by some of the new heart failure research. There is a new surgical procedure that we have just started to do at the University of Arizona to try to shrink down some of these dilated huge ventricles and actually salvage them short of having to do a heart transplantation. The third area that is really exciting is what is going on in basic science, in molecular cardiology. Cardiology basic science when I was a fellow was predominantly physiology, but now basic research is mostly molecular biology. I think over the next 10 years a lot of exciting information is going to come out of the molecular biology labs. I think we'll see many more advances in our understanding of pathophysiology as well as therapeutics. WCR: How do you view cardiac surgery in the future? JSA: Coronary bypass is not going to disappear no matter how good we get at doing stents and all these little interventional tricks. There is still going to be a substantial number of patients at some point that are going to need coronary bypass. Coronary bypass will continue although perhaps not in a volume as great as today. Valve disease is not going to disappear. Mitral stenosis is disappearing, but at the same time we are getting lots of older folks with aortic stenosis. Congenital lesions are going to continue to be produced at the same rate as before. The major issue is going to be how to deal with heart failure. Can we come up with medical or surgical therapy short of heart transplantation, since it looks like we are not ever going to be able to get enough hearts? Cardiomyoplasty is one possibility. However, if I had to bet, I wouldn't bet on cardiomyoplasty. I would bet more on the new procedure, ventricular reduction surgery, the remodeling of the dilated ventricle. Perhaps we will come up with some molecular biology technique in conjunction with surgery to help the remaining heart muscle hypertrophy. I believe there is still going to be a lot that is going to have to be fixed by cardiac surgery. WCR: Do you push lipid lowering aggressively? JSA: As so many things in medicine, you are either a believer or not a believer. I am a believer in lipid lowering and I am very aggressive. I must say I have been influenced in that regard by one of my former colleagues at the Universityof Massachusetts, Dr. Ira Ockene, who received a cardiology preventive award from the NIH. He and I were fellows together in Dexter's lab and 30-year friends since then. He has convinced me with data that the cholesterol hypothesis is true and that the lower we can get people's cholesterol, the more likely it is that we will stem the huge volume of coronary artery disease that we have in the US. I think the cholesterol guidelines should be to get individual patients' cholesterol well under 200 mg/dl; closer to 150 mg/dl. WCR: You are on salary I presume? Everybody on your faculty is on salary? Do you believe in salary scales for physicians in general? JSA: I do. I think one of the problems we have had in the last 30 years has been that in some areas physicians have started to make too much money. They have gotten to the point where they are making high 6 and 7 figure incomes, and what happens then is that it is very easy to lose sight of why they went to medical school to become totally tied up with making money. I believe in the salary system. We need to have incentives and rewards for those people who are very clinically productive as opposed to those people who feel they need to spend more time contemplating or reflecting or doing research. The disparity between what people make in private practice and what people make in academics is too great. I know that this is changing rapidly. Managed care is leveling the playing field. However, I think academics will always receive a lower salary and that is fine. Many of the managed care companies put physicians either on salary or within a salary range based on incentives that seem quite reasonable to me. I bet we will see more and more of that control. Fee for service medicine is dying and may be gone in 10 more years. WCR: I understand you had an acute myocardial infarction about 3 years ago. Could you describe that? Would you mind doing that? JSA: As you know Bill, I have written about it in an editorial and in a review article on acute myocardial infarction with normal coronary arteries ( Archives of Internal Medicine ). Writing that piece helped me intellectually heal myself. It occurred at the end of the first year in my new job as Chief of Medicine. That was a very difficult and stressful year in large part because of managed care, but in part because it was and still is difficult to move after age 50, and to pull up stakes after 30 years in Boston. That clearly contributed to it. I was out running one day in Denmark on vacation after a very strenuous meeting, a very vigorous week, where I was doing a lot of lecturing and had received an award. It was a very emotional and exciting week. My wife and I had gone off to a Danish beach in the far north of Denmark and I was out running one morning in just a T-shirt and shorts. It was very cold and windy and I was running up a hill into the cold wind and noticed this sense of indigestion in my epigastrium. I attributed the discomfort to all the coffee and the red wine and partying that had gone on for the previous 4 or 5 days. I slowed down and walked for a while and the indigestion went away. I started to run again and the indigestion came back. I said to myself, “I don't like that symptom related to exertion.” I decided to walk. I continued to walk for a while. Then, I began to run again and the indigestion didn't come back and I completed the last 2.5 miles of the 5 mile run. I then had breakfast with my wife and after breakfast this discomfort came back again. I said to my wife, “You know I am not happy about this and I really think I should have an electrocardiogram. It is probably just hysterical on my part, but I don't like the sensation.” It was more severe than any indigestion I had ever had before. We went and found a small hospital in this resort town. They did an electrocardiogram and it was normal, but the physician on call that day said, “You are a cardiologist. You would not have come in here for nothing, and I think we should ship you down to the nearest coronary care unit and get you monitored for 24 hours.” I said, “Hey, you're the doctor. Whatever you say.” At that point I was feeling very embarrassed and very sheepish because I was sort of pulling the fire alarm for no fire. We got down to the CCU and I was put in the bed. You can imagine all the excitement in this little regional Danish coronary care unit because once they learned who I was, cardiologists started calling in from different parts of Denmark. I was really getting progressively more and more embarrassed about the whole thing when that night, about 3:00 a.m. , the indigestion came back again. I called the nurse and got an electrocardiogram and that showed ST elevations in leads 2, 3, and aVF. There was a resident on call and he came quickly. We read the electrocardiogram together and I was treated with thrombolytics, aspirin, a β blocker, and heparin. The next morning a friend of mine, Kristian Thygesen, arrived from Aarhus, the second largest city in Denmark where he is Chief of Cardiology. By now everything was fine again. The electrocardiogram showed a small myocardial infarct. An echocardiogram showed a small apical area of akinesis. My course thereafter was completely benign. About 9 days later when I got back to the University of Arizona, Sam Butman, the head of our cath lab did a coronary angiogram on me and it was normal. There was still this apical area of akinesis. In subsequent echos (I get an echo every year now), a little area of hypokinesis is still present at the apex. My electrocardiogram still shows small Q-waves in leads 2, 3, and aVF. Thus, I had a small, successfully treated acute myocardial infarct. It was probably spasm related. My total cholesterol at that time was about 200 mg/dl; now I take a statin drug and keep my cholesterol around 150 mg/dl. Today, when I go out to run I keep myself well clothed. WCR: You don't think about it anymore? JSA: Once in a while. You know it was kind of a funny thing. Even when I was in the midst of having it, I was saying to myself, “Well this can't be a big myocardial infarction because I don't have much in the way of risk factors, and really it has to be single vessel disease or distal disease or something minor. Maybe that sort of intellectualization kept me from thinking to myself, “Wow, this is a heart attack; you are liable to die from this.” Somehow that thought never crossed my mind. I was always sure I was going to survive. I knew that I just needed to get the right treatment and this was not going to be a major problem. I don't think much about it now, but when I am out running I don't push myself quite as hard as I used to. I make sure I get that 1 month's vacation every year and I'm pretty careful to take my medicines and aspirin everyday. WCR: Does your wife run with you? JSA: No, she does not run, but we often walk together on the weekends; at other times we go swimming or bicycle riding together. WCR: Do you ever talk about the myocardial infarct anymore? JSA: Once in a while. Sometimes people will bring it up and most people say we can't believe you had a heart attack. I think it proves that first of all even with minimal to no clinically evident coronary disease you can have a myocardial infarction. I believe that psychological factors, the stresses of that year, played a role as well as the cold. WCR: The angiogram was 9 days after onset. So whatever had been there could have been lysed? JSA: I am sure. I got treated with 2 thrombolytics: I got both streptokinase and tissue plasminogen activator (t-PA), as well as heparin and aspirin. Even if there had been residual clot there initially, 7 to 10 days later you could certainly dissolve it all. WCR: Do you have any thoughts about what you were feeling when you were receiving that thrombolytic therapy? JSA: I was very grateful that I was in a coronary care unit when the ST elevation was coming on, that I was actually getting thrombolytic treatment well under an hour after the onset of the symptoms. I think what probably happened was I must have had a spastic event when I was out on the cold run. That ruptured a little intramural plaque leading to coronary thrombosis, either in the distal right or the distal left anterior descending where it wraps around the apex. When I stopped running and came inside I got warm, and the artery dilated a little bit so enough blood flow was getting by for the muscle to survive. Then, later that night as I was lying quietly in bed, the flow decreased a little. Maybe the thrombus built up again because there was not such rapid flow past it. Then the thrombus eventually built up to the point where it occluded the artery. WCR: Were you on the track team in high school? Were you an athlete? At 54 years of age you run about 30 miles a week? JSA: I was a swimmer from either the eighth or ninth grade. I swam everyday, trained, and swam for the high school swim team, and swam in college. When I was in the Navy in San Diego, I was on the Navy swim team. Today, I exercise one hour everyday: running, swimming, or bicycling. WCR: You swam for Yale University? JSA: The Yale University team at that time had basically 4 teams. The first team was Olympic champions; the second team NCAA champions; the third team Ivy league champions; and the fourth team were guys who were good in high school. I was on the fourth team, but it was fun swimming with those guys anyway. WCR: What did you swim? JSA: In high school I swam freestyle and butterfly. In college I swam breast stroke. I still swim. In Arizona we have a pool and we belong to a racket and pool club and I still swim all the time. WCR: You are a pretty tall fellow. How tall are you? JSA: Six foot, three inches. WCR: Can you dunk? JSA: No, I can't jump very high. I never was very good at jumping. I started running when I got to my 40th birthday when I was starting to gain a little weight. I said to myself, “I don't like this. My clothes are tight on me.” I started running with some friends at noon time at Worcester. WCR: It is awfully cold up there in the wintertime. JSA: I wore a Gortex suit and dressed warmly. I used to run in the snow, too. When I got to Arizona I started running in quite warm weather and that felt fine. WCR: Do you ever see any snakes while you are running in Arizona? JSA: Sometimes, and actually I do a lot of hiking in the mountains where there are lots of snakes. Just this past summer a friend and I were hiking and almost stepped on a rattlesnake. Fortunately, the snake was heading uphill and we sort of froze and he kept going uphill. Most rattlesnakes are not interested in having anything to do with human beings. WCR: Joe, many thanks. 1

PY - 1997/5/1

Y1 - 1997/5/1

UR - http://www.scopus.com/inward/record.url?scp=0031136677&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=0031136677&partnerID=8YFLogxK

U2 - 10.1016/s0002-9149(97)89267-3

DO - 10.1016/s0002-9149(97)89267-3

M3 - Article

C2 - 9164887

AN - SCOPUS:0031136677

SN - 0002-9149

VL - 79

SP - 1208

EP - 1221

JO - The American Journal of Cardiology

JF - The American Journal of Cardiology

IS - 9

ER -