Chris Gregg (cgregg@ucsd.edu)

Lab PI: Ajit Varki, M.D., Ph.D.
Undergraduate Institution: The Johns Hopkins University
Med-into-Grad clinical training area: Cardiovascular Diseases (CVD)
Main clinical mentors: Kirk Knowlton, M.D., kknowlton@ucsd.edu
Sotirios Tsimikas, M.D., stsimikas@ucsd.edu

Quote:  “Honestly there is too much to say to sum up this jam-packed 3 month experience.  I was learning more and more throughout the whole experience and never got bored. Taking 3 months off to pursue this opportunity full time, I was able to indulge myself and learn more about those issues in clinic that intrigued me.  I am continuing minimal activities to maintain and use these skills I have acquired.  I would recommend this experience to anyone interested in cardiovascular diseases (CVD) and hope that it teaches them as much as it has taught me.  Without the fulltime immersion, the reality of disease and the behaviors/variables that affect life would still be foreign”.

Rational for Med-into-Grad training:  From my introduction to the cardiovascular system during undergraduate education, I was fascinated like never before.  I have continually learned more about this system, through both its homeostatic and pathologic mechanisms.  However this learning has been mostly book based with peripheral laboratory experiences.  The chance to touch, to see, and to hear the human cardiovascular system everyday for 3 months was too irresistible to pass up.  A simple scan of the details of the CVD MSP show that almost anything is on the menu for HHMI Med-into-Grad fellows. For someone truly interested in research of a particular disease or organ system, this type or experience is a no-brainer.

Medical training and identification of medically-relevant research issues: 
I found this program to be a non-stop learning experience.  Taking 3 months off to pursue this opportunity full time, I was able to indulge myself and learn more about those issues in clinic that intrigued me.  The program provided me with funding for textbooks that I was able to use to help with this learning process. 
The CVD MSP was organized very well and gave me so much to see & do.  I did three one-month rotations at the UCSD hospitals, both Thornton La Jolla and Hillcrest.  I spent time rounding on the Cardiac Care Unit and time in clinic with both interventional and electro-cardiologists, which allowed me to see both inpatient and outpatient care, respectively.  Understanding everything that goes on in these sessions was  somewhat overwhelming at first, however getting immersed in these environments day after day helped and I was acclimated in a bout a week.  While there were always new things to learn throughout the program, I was able to understand what people were talking about around me and even participate.  The clinic environment was easier than hospital rounds to interact with both patient and physician, but the clinic wasn’t usually where the interesting stuff was.  I spent time learning about the diagnostic techniques available to cardiologists, specifically echo and the angiogram.  I spent enough time in the echo lab that I have a fairly advanced understanding of what to look for in a cardiac echo.  I even got to give a few echo’s on willing patients and found that my pictures were pretty bad, but usable.  Regardless I very much enjoyed this section of my time.  Both the staff and attending physicians welcomed my questions and were very eager to teach.  They enjoyed that I was “actively observing”.  As mention above, I saw many angiograms and percutaneous coronary (cerebrovascular & peripheral) interventions.  I was very impressed with the tools that are available to cardiologists to treat atherosclerosis and other pathologies.  For example, the intravascular ultrasound places a catheter-sized ultrasound probe into the coronaries to visualize vascular occlusions from the vessel lumen.  Some of the interventions were quite amazing and I leaned a lot about the pace of human atherosclerosis what to what degree the disease can progress without manifesting in angina that requires these sorts of procedures.  I become quite comfortable with the coronary circulation by angiogram and can diagnose significant occlusions well.  I also spent time at various meetings that physicians attend weekly for both teaching and learning purposes.
I learned an absurd amount about the cardiovascular system and the diseases to which it is susceptible.  I believe that a comprehensive understanding of any system is necessary to really expect to treat a problem.  I gained significant information in non-invasive imaging of the heart, the electrical function of the heart as an organ, peripheral artery disease.  I gained more understanding about the interdependence of the cardiovascular system and every other system in the human body.  I got to see more congenital CVD disease that help elucidate gene function and also see the wild extent to which a congenital disease can cause wild perturbations in normal anatomy/physiology and still yield a live birth.  I learned how medicine works and got to see the built-in redundancy of health care at university hospitals.  From a knowledge standpoint I was surprised to learn how similar I was to interns and residents in training and now understand that physician training continues throughout an entire career.  The emphasis of the attending physician as a teacher and leader indicates that learning is quite important for patient care.
I was able to consult residents and interns easily for basic questions about jargon, drugs, etc.  I was able to ask more complicated questions about disease mechanisms and procedures of both fellows and attending physicians.  Almost nothing went incomprehensible.

Research collaborations: I am planning to test chimpanzee plasma cholesterol levels and do full lipoprotein profiles to understand if chimps do indeed have a proatherogenic lipoprotein profile, as their published total cholesterol levels would indicate.  Also, I am attempting to look at atherosclerotic lesions for the presence of non-human sialic acids that our hypotheses suggests play a role in initiation of these lesions.  This second point was a suggestion by my clinical mentor after learning some more about my basic research.

Long term impact: My MIG experience has opened my eyes about the scope of the field and should obviously help me direct my future research paths. MIG gave me a strong desire to maintain interaction with cardiovascular physician groups, and I am now trying to have a physician scientist on my thesis committee to maintain a clinical point of view on my work and to assess the relevance of my ideas, and aims as they develop.  Also, the broadly applicable knowledge I gained in MIG has helped me understand both life and death (by disease) more fully.  I feel that I understand more of how the human body functions to maintain homeostasis and am sure that all my decisions, statements, and hypotheses are more informed, reasonable, and reliable, respectively.

Training in diagnostics & therapeutics, and identification of unmet diagnostic & therapeutic needs:   Diagnostics:  I took special interest in two major diagnostic methods for CVD diagnosis.  First, being completely ignorant of the diagnostic power of EKGs, it was difficult to understand the course of action chosen by an attending given a patient’s info.  I took advantage of the HHMI money set aside for text book purchase and purchased two books on EKG, the seminal Interpretation of EKGs by Dale Dubin and a higher level workbook to practice diagnosis based on EKG alone.  I am still working on the workbook and can now correctly interpret often.  Second, I took interest in trans-thoracic echocardiography.  I have already had experience with echo and found it easy to understand advanced topics, such as diastolic dysfunction, flow Doppler, and tissue Doppler.
Therapeutics:  Understanding patient management required copious knowledge of drugs and their actions.  Initially, while on rounds, I was playing catch up because I had to ask about drug names thrown around during rounds.  Moreover, after learning about a drug I often had to do research on that drug to understand its molecular mechanism because the knowledge required for a clinician to use a drug safely did not satisfy my thirst for knowledge about the subject.  Time spent in interventions were extremely useful for understanding the extent of man’s power to heal.  I now understand that advances in cardiovascular medicine over the past decade or two has been half due to drugs and have due to catheter-based medicine.  I was lucky enough to view many angiograms (coronary & pulmonary), ablations, percutaneous coronary (peripheral & cerebrovascular too) interventions.  Because my clinical mentor was an interventional cardiologist, I spent much time understanding the vanguard of stenting and angioplasty and now am extremely comfortable reading angiograms and diagnosing vascular occlusions.  Also I was able to spend some time with company reps who were more than happy to teach me about their devices and products.

Advice for new trainees--Autumn preparatory quarter:  For the CVD MSP it is necessary to be able to listen to heart & lung sounds (stethoscope), read chest x-ray, read & interpret EKGs, read CT scans.  These basics are used all the time mostly for diagnostic purposes.  So, attempt to understand these concepts before you enter the clinic.

Take home perspective on Med-into-Grad at UCSD: Honestly there is too much to say to sum up this jam-packed 3 month experience.  I was learning more and more throughout the whole experience and never got bored.  I am continuing minimal activities to maintain and use these skills I have acquired.  I would recommend this experience to anyone interested in CVD and hope that it teaches them as much as it has taught me.  Without the fulltime immersion, the reality of disease and the behaviors/variables that affect life would still be foreign.