Elliot Howard (elliot22@gmail.com)

Graduate Program: Bioengineering
Lab PI: Dr. Jeff Omens
Undergraduate Institution: UCSD
Med-into-Grad clinical training area: Cardiovascular Diseases
Main clinical mentors:
Sam Tsimikas stsimikas@ad.ucsd.eduj
Kirk Knowlton kknowlton@ucsd.edu

Quote: “The Med-into-Grad (MIG) program provided me with a great opportunity to receive a first-hand perspective on the diagnosis, treatment, and management of patients with heart failure, coronary artery disease (CAD), and conduction disturbances. As a bioengineer I have been trained to (1) identify a problem, (2) assess the current solutions, (3) see areas of challenge and improvement, and (4) develop new solutions for the problem. However, this rational may not always be the best strategy in the diagnosis and treatment of disease in the clinic. For this reason and many more, I have decided to dedicate my time in this program in order to gain new perspectives on the challenges that arise in the management of heart disease and refocus my research in areas that are atypical for an engineer. I strongly agree with the idea that a combination of medicine and engineering is needed for the development and application of new tools for diagnostic and therapeutic purposes. As a young bioengineer, with career aspirations in entrepreneurship, innovation, and technology advancement, I saw the MIG program as a needed path towards the development of a solid foundation in cardiovascular science and engineering.”

Rational for Med-into-Grad training: 
My current research in the Cardiac Mechanics Research Group involves the use of experimental and computational models of heart failure and dyssynchrony in canines to investigate the influence of LV lead placement on regional function and global hemodynamics during single and biventricular pacing. Clinically, patients suffering from severe systolic heart failure and conduction abnormalities have been shown to benefit from Cardiac Resynchronization Therapy (CRT), in which a biventricular pacemaker is implanted with leads placed on the atrium and both ventricles in order to improve the synchrony of contraction between the right and left heart. Despite the well-established benefit from CRT, there still exists a population of patients (~30%) that fail to show an improvement in their condition after CRT. The high non-responder rate associated with CRT is most likely due to the enormous complexity of human heart disease and the high inter-patient variability. Therefore, a major theme in my current research is the use of animal-specific computation models that are individualized and tailored to measurements made in one animal as compared to those representing the mean of a population. Detailed data on the (1) surface geometry and muscle fiber orientation, (2) ventricular hemodynamics, (3) activation sequence, (4) regional cell function, and (5) material properties are used in the construction of these animal-specifc models (See Figure Below). The importance of these models is that they will allow researchers to predict the outcome of a multitude of pacing strategies on regional and global function of the heart. The methods used in developing these models and the experimental data acquisition can then be translated to the clinic in which patient-specific models can be made. These models may serve to assist the clinician to (1) identify patients that may benefit from CRT, (2) simulate the hemodynamic effect of multiple LV pacing site locations, and (3) optimize the outcome of CRT. Understanding the mechanisms that determine the outcome of CRT is not only an important question from a basic science perspective, but it is also a question that may serve to direct new therapeutic strategies in the clinic.

Figure adapted from CMRG group

The Med-into-Grad (MIG) program provided me with a great opportunity to receive a first-hand perspective on the diagnosis, treatment, and management of patients with heart failure, coronary artery disease (CAD), and conduction disturbances. As a bioengineer I have been trained to (1) identify a problem, (2) assess the current solutions, (3) see areas of challenge and improvement, and (4) develop new solutions for the problem. However, this rational may not always be the best strategy in the diagnosis and treatment of disease in the clinic. For this reason and many more, I have decided to dedicate my time in this program in order to gain new perspectives on the challenges that arise in the management of heart disease and refocus my research in areas that are atypical for an engineer. I strongly agree with the idea that a combination of medicine and engineering is needed for the development and application of new tools for diagnostic and therapeutic purposes. As a young bioengineer, with career aspirations in entrepreneurship, innovation, and technology advancement, I saw the MIG program as a needed path towards the development of a solid foundation in cardiovascular science and engineering. 

Medical training and identification of medically-relevant research issues: 
My clinical training through the MIG program was done at Hillcrest and Thornton hospital. Some of the daily activities included rounding with cardiology fellows, residents, and attending physicians on the Cardiac Care Unit (CCU), review and discussions on patients’ medical history and current treatments, review of diagnostic test results (e.g. cardiac biomarkers, stress tests, ECG’s, right and left heart catheterizations, ect…), and observation of a multitude of diagnostic imaging techniques (Echocardiography, MRI, angiography) and interventional procedures (cardioversions, atrial ablations, angioplasty, and electrophysiology (EP) studies). In addition to my time spent in the clinic, I also attended weekly conferences such as the Cardiology Grand Rounds, Interventional Cardiology Conference, and the Cardiac Catherization Conference. I gained a tremendous amount of knowledge during the daily morning rounds on the CCU. There I was able to interact with both the physician and the patients and receive insight into the management of heart failure and many cardiomyopathies. I found it most excited when I was allowed, in some instances, to use my stethoscope and listen to the patient’s heart sounds. On one particular day, I can remember listening for a mid-systolic murmur present in a patient suffering from aortic stenosis. From my daily observations in the clinic I soon began to identify areas in my research and engineering expertise that could be applied towards the current challenges in diagnosis and treatment of cardiovascular disease. Specifically, I started envisioning modeling scenarios in which certain devices and new therapeutics could be tested in a virtual environment of a patient’s heart to access the benefit of such treatments. One particular area of research that interested me was valvular disease and aortic stenosis (AS). Through my observations of patients with AS, I began to formulate ideas on how to incorporate this condition in my current models of the heart in order to gain further insight into the electromechanical triggers that can lead to arrhythmia and sudden cardiac death. Overall, my clinical experience expanded my knowledge of the current state of medical treatment of heart disease and cultivated a desire to discover new and challenging applications of my research.

Potential Research collaborations:  Valvular heart disease is a disease that affects the integrity and function of one or more of the heart’s valves. In my time spent in the clinic, many of the patients that were treated for heart failure had a valvular dysfunction. In my research, which focuses on the use of CRT in patients with heart failure and conduction abnormalities, I began to discover the complexity and diversity of disease among heart failure patients. Specifically, I learned that patients with AS can develop conduction disturbances that can lead to some form of a heart block. I presented my findings to members in my research group and we begin to discuss the possibility of using a computation model to determine the link between mechanical dysfunction and electrical events that can lead to heart block, syncope, and asystole. The role of mechano-electric feedback in the development and progression of certain cardiac diseases is a developing theme in our laboratory, in which a partnership between bioengineering and clinical medicine is a vital component of many of our current and planned research projects. 

Training in diagnostics & therapeutics, and identification of unmet diagnostic & therapeutic needs: Throughout my clinical experience, I was exposed to many diagnostic and therapeutic tools used in cardiology. These included advanced imaging modalities (MRI, nuclear stress tests, echocardiography, electrocardiography, and angiography), cardiac biomarker panels for diagnosis, and interventional procedures (cardioversions, atrial ablations, and angioplasty). All of these tools represent the state-of-the-art in cardiology. One major challenge that I observed was that of the cost associated with many of the diagnostic imaging tools used. With the current state of the heath care system in the U.S. and the challenges faced by many third world countries, new strategies in cost effectiveness are needed. For example, an echocardiogram (Echo) is useful in determining the extent of viable tissue remaining in a region of poor blood flow (ischemia) after a patient has suffered an acute heart attack and often are necessary before further invasive treatments are to be performed. The cost associated with the use of Echo and the amount of training and expertise of personnel needed to perform and analyze the test may lead to the reduction of its use, especially in areas (i.e. less developed countries) that are not economically founded. Engineers and scientists at General Electric and physicians at UCSD are currently developing a pocket echo scanner that will significantly lower the cost and simplify the procedure allowing for cardiologists to perform exams without the need of a specialized technician. This example represents a common theme towards meeting the challenges currently facing cardiologists in disease diagnosis: develop tools that are (1) minimally invasive,  (2) reduce cost, and (3) streamline the procedure.

Diagnostic & Therapeutic collaborations:  The MIG program facilitated the training necessary for the advancement of my career in bioengineering and medicine. By forming relationships with cardiology fellows and physicians at UCSD I have enabled myself to pursue research collaborations that look specifically at engineering tools used to combat heart disease by improving diagnostic capacities and therapeutic outcomes. Through my time spent in the clinic I have developed a better appreciation for the prevalence and gravity of cardiovascular disease and it’s effect on people’s daily life. That is why as a bioengineer I am passionate to pursue a career in medical devices and therapeutics that encompasses entrepreneurism, innovation, and technology advancement. As my professional life advances I will always look back on my time spent as a MIG trainee and recognize the profound effect in had in shaping my research interests and career motivations.

Long term impact:  This program has given me a greater understanding of infectious and dermatological diseases.  The knowledge I gained studying the etiology and progression of these diseases has helped me to focus my research and ask clinically relevant questions.  Although my research is concerned with answering basic science questions about innate immune responses and skin homeostasis, this experience has helped me draw connections to the larger problems in these fields. 

Student-specific experiences: I found it interesting that throughout my experience in the program I often contemplated the idea of pursuing a career in clinical cardiology. While I enjoy the challenges that present me daily as an engineer and scientists, I found that the problems facing cardiologists are great and are of vital importance since they can directly affect the life of the patient. This fact alone made the idea of a career in clinical medicine very attractive.

Advice for new trainees--Autumn preparatory quarter: The biggest challenge that I had to face in my clinical activities was overcoming the technical jargon and clinical vocabulary used everyday by clinicians and trainees. That is why I highly recommend that new MIG trainees take the initiative to attend the Cardiology Grand Rounds in the Autumn and dedicate time towards reading Braunwald’s Heart Disease book as well as a basic cardiovascular physiology text. Also, I believe that it is important for students to begin to think of the types of things they want to achieve from their training and identify areas in their current research that could be translated into the clinical world. Having a good starting point for discussion about your research with physicians is important for effective communication and will help better identify yourself in the clinic

Advice for new trainees—Winter clinical training quarter:  My advice for new students entering their Winter clinical training is simple: Be confident when you speak and take interest in what is spoken to you. When starting out in a new environment your ability to effectively communicate is crucial. It is important that those around you (fellows, residents, physicians) have a good understanding of who you are, your research interests, and what you aim to achieve from your clinical training. By identifying your research interests and your goals of your training, the clinical staff will be able to better match you with activities that will give you the most from your time spent. I found it helpful to always have the following texts handy in my lab coat pockets: (1) Pocket Medicine by Pocket Notebook, (2) ECG Manual, and (3) Notebook. Many times you will encounter a term or phrase in which you are unfamiliar with. I suggest that you write it down and either look it up on the Internet later that day or use the references or similar ones that I suggested above. Pocket Medicine is great. It not only covers all of the major cardiovascular disease, but is also gives concise information of many other diseases that affect the body. You will also find that the ECG is a highly used diagnostic tool in the clinic. Become familiar with the basic ECG, how it is measured, what different leads represent, and it’s interpretation during different diseases present. By carrying a pocket ECG manual, I was able to communicate my questions and opinions in a technical manner and I believe the staff did appreciate that. Also express your interest in using your stethoscope. The MIG scholarship allows that you purchase one (I suggest the Master Cardiology by Littmann) and it is very useful in the clinic in assessing the patient’s condition. Overall, be yourself and have fun. You will quickly find that the clinical staff are happy to be helpful and enjoy having you around.

Take home perspective on Med-into-Grad at UCSD:
The Med-into-Grad program is a tremendous opportunity for anyone who is interested in discovering new ways to apply their current research tools towards the advancement of clinical medicine. The amount of clinical exposure that you will receive from the program far outweighs any textbook or Wikipedia search. Simply put, if you want to learn more about human disease and how it may relate to your current research you will want to join this program. The soul of the HHMI and the Med-into-Grad program is the development of future researchers who have a solid foundation in science, engineering, and medicine and are capable of forming interdisciplinary collaborations in their scientific endeavors. For those students, like me, who are interested in broadening their knowledge of a specific disease and are passionate in developing novel tools that can better improve the quality of life for many individuals around the world, I strongly encourage them to participate in the MIG program and begin the journey towards expanding their intellectual horizons.