Elison's Evolutions

Speaker 1: 0:01

This is Coffee in Cardiology.

Speaker 2: 0:05

In this podcast we sit down with the faculty from the University of Washington Division of Cardiology to discuss the very latest in diagnostics, therapeutics and as a special bonus, we ask what makes our cardiologists tick? John Michael, we have David Elisson with us today. He is one of our newly minted I guess not so much newly minted anymore, you've been at this for quite a while but structural interventional cardiologists here at the University of Washington. I had the privilege of working with David as he sort of came up through his training here, but I would like now if he would give us an even broader picture of his journey in medicine, because it's actually a very interesting one.

Speaker 3: 0:56

Well, thanks for having me guys. Yeah, I went. I'm from Montana and I went to college at the University of Montana fully anticipating to be a biology teacher. My father was a teacher and I just sort of always saw that as a career that I enjoyed. I was sort of part of the way through that. When one of my advisors in the biology department was like, have you ever thought about going to medical school? And I was like no, and here we are. She sort of pointed me in the right direction and really never looked back.

Speaker 3: 1:40

I did my medical schooling at the University of Colorado, so I lived in Denver for four and a half years. Then I've been here ever since I came here for residency. I really liked the University of Colorado, but I thought to myself I should experience something new and different, and so I came out here for residency in 2015 and I stayed on for cardiology fellowship. I really liked the people I worked with as a resident and, following my general fellowship, I was like you know, I really like the interventionalists here. I really like the group, I like the program. I have small children.

Speaker 3: 2:21

There's a lot of reasons to want to stay, and I stayed on for two years of interventional training. At the end of that, which was only eight months ago, the group sort of welcomed me on as the seventh member of our team. So I've actually sort of become a UW lifer minus the undergrad med school part. I really love this job. I've been really excited to transition into my attending life and it feels like a nice home for me. It's a very supportive team that the leaders of our section have created and it's been an easy and smooth transition into attending life for me. So I'm happy to be here and talk to you guys about it and let you know about me.

Speaker 2: 3:09

Well, that's fabulous. It sounds like you're not exactly the one who's being forced into all the call and doing all of that sort of early guy stuff.

Speaker 3: 3:18

No, no, I mean I think there's a certain amount of new guidance. You know I got Christmas, for example, but that's to be expected anywhere you go. It's obviously easier when you're in a seven person group than if you go somewhere and you're in a two person group. But no, I mean, everyone has been incredibly supportive.

Speaker 3: 3:40

I think what's unique about our interventional group here is we really take care of, you know kind of the broad end of spectrum in terms of structural and coronary cases, and it's a little daunting sort of day one in your attending life to be like oh, here's somebody who's having an end stemmy in Yakima and their EF is 20% and they're on a balloon pump and they're not intubated and they're in sort of borderline cartogenic shock.

Speaker 3: 4:07

Can you do their atherectomy left main tomorrow, it's like sure. So everyone has been very supportive to me and our senior members of the section are really unmatched in terms of their mentorship and care and your development, and I think that's something that's not present everywhere you go and it really, as I interviewed for jobs last year, it really stood out to me as something that was really unique and beneficial about our group and something that has been obviously a wonderful thing to have in your back pocket to go around the corner and be like hey, bill, 10 years, would you mind looking at this angiogram with me? Just to have world experts in the things that you're trying to do all day as a new person is really beneficial.

Speaker 1: 4:57

What is you kind of glossed over the jump to cardiology. What was that? Why?

Speaker 3: 5:03

You mean from internal medicine. Yeah, I think I've always been someone who struggles with the decision, which is funny now, because now my life is just split decisions all day long. But when I was in medical school I sort of liked everything. My wife always tells all her friends that I went through a six week period where I thought I was going to be an obstetrician and now I do something quite remote from that. So it's always been hard for me to align exactly my interest with where I'm headed in the moment it feels.

Speaker 3: 5:40

And I chose internal medicine because it sort of allowed that decision to be kicked down the roadways. And when I was in internal medicine residency I liked a lot of the things that I tried and for a period of time I thought I was going to be in GI. Ultimately I settled on cardiology because I felt, of all of the systems in our body, I just often feel like we understand the heart so much more than so many other things in terms of the mechanics and the physics behind the way it works and the electrical signaling. I found all that very interesting. But then the other point of that is that there were so many things that we could do. I got very frustrated in things where it felt like, well, you have this awful disease and I'm sorry that always was a great frustration to me. And in cardiology I feel like there's so many avenues of things that we can offer patients, many of which improve not only longevity but also just the way they feel, and I found that to be incredibly fulfilling.

Speaker 3: 6:51

And I came into cardiology thinking I was going to be a heart failure doctor and people like Wayne Levy wrote my letters for fellowship shout out to Wayne and I went into fellowship thinking that that was what I was going to do and that I liked working with patients with advanced heart failure. I liked transplant and things like that. And I just sort of realized over time that I am much more of like a Mr Fixit kind of person. Is that I like sort of a problem approach, dealing with a particular issue and how are we going to fix it? What are the tools that we have to address a particular problem and what are the imaging pieces that we're going to use to try to understand the problem that we're dealing with? I worked in construction before I went to medical school and I actually feel like there is so much of my day job now that is very akin to that work.

Speaker 3: 7:50

So that's sort of how I found my way to where I am now, and it was a sort of stepwise decision where there was a lot of reroutes along the way, but I feel like I've really kind of found my home.

Speaker 2: 8:06

I think you really encapsulated a lot of the seduction, if you will, of cardiology for so many of us that we can do things that benefit people's lives in multiple different ways, that we do have answers.

Speaker 2: 8:19

We don't always have answers. Sometimes we have to have hard conversations, but at least we've almost always got something, whether it's medicines or whether it's an intervention. But the thing I just love about your story is that you're admitting to a pathway and an orientation that, let's be honest, isn't found in a lot of interventionists. I mean, a lot of interventionists were not thinking about advanced heart failure as part of their career path or biology teacher.

Speaker 3: 8:52

Or biology teacher for that matter.

Speaker 2: 8:55

Construction, yeah, definitely makes sense. But I think that's emblematic of our group here. The seven of you are not just incredible world-class technicians, but you're world-class thinkers, you're deep thinkers, you are decision makers, or deciders, if you will, in a way that is beyond just the technical aspects and I think the fact that you've and I'm assuming it feels very much at home because you've been here for a while, but also you fit in this group because this is the nature of your group. You're incredibly high volume, you're incredibly technical and yet you have that patient-oriented focus. You have that deep thinking, that integration of the imaging and the electricity and that advanced heart failure meds and all that other stuff that goes into what I think it makes you guys the best interventionists.

Speaker 3: 9:53

Well, yeah, I agree. I mean, I think the physicians that I have had the greatest respect for in my training pathway are those doctors who I feel like are actual, real people. I find that those individuals have the best bedside manner in the way that they talk to people and explain a problem, and you know, so much of what we do is really salesmanship. When you get down to it is, you're talking to somebody about something that they don't really have a lot of expertise in or understanding most of the time. You know.

Speaker 3: 10:34

This is especially fresh in my mind because my wife and I just bought a house and we did our closing this morning where you sit across the table from somebody who just hands you document after document that's 25 pages long and totally illegal ease and you're like I have no idea what any of this means, but the person across the table at the escrow office is explaining things to you and like this is why this matters, this is why this matters, and I feel a little bit like that's often what we do is somebody from you know your dad's practice in Longview gets sent up because they have aortic valve disease and they don't have any medical background and this is sort of a foreign concept to them and you're sitting across from somebody talking about how you're going to do something that is inherently surgical and can be dangerous and is ultimately really important, and I think so much of that conversation can be challenging and time-consuming, but I think it's really important and I think the reason why I have a lot of respect for my partners and the members of our group is that I think particularly Drs McCabe and Lombardi, Bill and Jamie, as our leaders, have really done a remarkable job of cultivating a team of people who are real people and can sit across from you and say you know, here's the thing that we're dealing with, these are the things that we can do about it, these are the risks.

Speaker 3: 12:12

This is how I see you and I see your problem, and I think that conversation is intrinsically much easier to have if you yourself are a person and sit across and have an actual conversation. That becomes increasingly less technical when you're just meeting with somebody. I have always found that the people in our section as a former trainee in our section and I was a member of it are a truly remarkable group of people with a really broad array of skills that I just have a great deal of respect for it's sort of like a big family. I hope they don't feel like that's dorky for me to say, but that's always how I felt about it and it makes it easy to feel at home.

Speaker 2: 13:01

That's good, and I know that your family is one of those non-dysfunctional families too. They're very supportive and even though you get stuck on Christmas, they're always there for you.

Speaker 3: 13:10

Yeah, I mean I think you know my immediate family, like my parents, we have a very blended family. My parents are long-sense divorced and got remarried and so in that setting I have a number of steps of things that it made for an interesting growing up experience. And my father, he got remarried almost 20 years ago now and so you know, my stepbrothers and sisters are really like my brothers and sisters and we all live like tremendously different lives. And he refers to us as the village people like the YMCA, because I, you know, I do this. I'm the oldest.

Speaker 3: 13:51

My closest brother after me is he's 6'6" and has hair to his shoulders and full beard and works at a nice restaurant, lake Tahoe, and is mostly like an outdoor ski bum. And my brother after him was in Catholic Seminary School to be a priest and then was like, well, you know, I don't know that that's actually for me and now he's an attorney in Montana. And my closest sister after him flies. She's a first lieutenant in the military and she flies Apache helicopters and she's currently I think it's okay to say this she's currently deployed in Romania. And my youngest sister was like a cheerleader in Louisiana and now she's married and has two kids and I think that background really shaped kind of who I am.

Speaker 3: 14:46

You know, my dad's very fond of saying that there are two types of parents. There are carpenter parents and there are gardener parents. And carpenter parents sort of construct their child in the way that they see them being, and a gardener parent just sort of makes the soil for your child to become whoever they might be and my parents were very much hippies from the 70s. Gardener parents.

Speaker 3: 15:10

And that's raised me to be who I feel like I am and my own immediate family, my wife. We met in college, actually, and we've been together for this will be 15 years coming up this year and she's a wonderful person. She's incredibly supportive. I don't actually think I could do this job without her being the sort of independent, individual, supportive spouse that she is. We have two little girls.

Speaker 3: 15:47

Our life has been a little tumultuous in the last six months with our second daughter, but we have two wonderfully sweet little girls and parenting and being a new, attending and moving and I think all of those things add stressors that are just made easier by a family that you can rely on and trust. And really I really count my blessings for the way that my wife is when it comes to supporting this line of work, because there's nothing quite like being like just one more case I'll be home in 20 minutes and then it's like 945, because the last case took three and a half hours and I think there's something to be said about how that's not an easy role for a spouse to play and she really does have a lot of grace and I'm very thankful for that.

Speaker 2: 16:40

That is phenomenal. That is really, really neat. I'm assuming that, despite your carpenter background, you're planning to be a gardener parent.

Speaker 3: 16:47

I am very much a carpenter parent. My first daughter is just stubborn, as the day is long and I don't know exactly what sort of person she's going to grow up to be. But I'm excited to see how that develops and I don't actually really know how to be a carpenter parent. I just sort of want my children to know that I love them and care about them and I want them to succeed in whatever it is that they're interested in and find their own way in life, because that's really what I did and it's worked out in a way that I'm very grateful for.

Speaker 1: 17:27

How about, as a student, to now teach your parent to our fellows and be supporting them? Do you also kind of bring that mentality to how you support them?

Speaker 3: 17:38

Yeah, I mean I think I would like to. Ultimately, there is a realism to the fact that you're dealing with things that are inherently life-threatening and, when done improperly, can cause harm, and so, especially as a newer person, I gravitate towards being a little bit more hands-on and making sure that each patient is cared for in a way that I would want my own family member to be cared for, and so to that end, I guide the fellows a little bit more in a carpenter sort of way than perhaps just sort of like laying the foundations for them to grow. But I do think where I really see this playing out is I want our fellows to. Our field is just ever-expanding in terms of what we can do and what we can offer, and even in interventional cardiology there are increasingly finite subsets where people focus on one thing, and our fellows come in sort of undifferentiated for the most part, and I have appreciated that our faculty have been very supportive to that. They were very supportive to me in my process of doing that, and I think, as you find your way through the interventional landscape, finding the things that you like doing or you feel fulfilled in doing is really important, and so I have had several conversations with our fellows about how to explore those things that you're interested in and how to gravitate yourself towards one particular thing or not.

Speaker 3: 19:20

It's been very interesting to me as a newer attending working with our current structural fellows, particularly one structural fellow who was a first-year interventional fellow while I was the structural fellow just last year, and so obviously there's a new team dynamic there.

Speaker 3: 19:41

That's very different, but Greg has actually been very supportive to me in my newness, which I really appreciate him for. Our other structural fellow, christina, came from outside so I didn't know her as well prior to this process in transition, but it's been an interesting change in roles, sort of the way that the staff sees you, the way that people interface with you on the day-to-day, and one of the things that I thought a lot about was how I would interact with fellows that I knew personally when I was a fellow, because I think there's a certain familiarity that can sort of change the dynamic in a way. That is not always perfect, but our fellows have really embraced me and I think they're a solid and important part of our team and when I say our team, I include them in that and our team has really welcomed me and made this process pretty seamless.

Speaker 2: 20:46

I wonder if you could explain a little bit the difference between interventional and structural and how that works in the training process and also how that works from the attending level.

Speaker 3: 20:56

Yeah, so it's a good question. So you finish General Cardiology Fellowship, which takes three years, and then you can go into interventional fellowship. Previously in decades past, to become an interventionalist took about a year that was before the advent of most trans-catheter heart valves, things like that and so you were really learning how to do coronary interventions on patients having heart attacks or with stable heart disease. So that was a process that for most took a year. I don't know exactly the time course in which this has happened, but I'll just say over the last decade there has been a emphasis placed on continuing the development of that skill set, and so for the first year you really spend your time dealing with coronary artery disease stent procedures.

Speaker 3: 21:55

And once you have solidified that skill set, there is an opportunity now increasingly across the country not just in our program to enter a second year of training in which you specialize either in very complex coronary artery disease interventions or you enter a space called structural heart disease, which is what I do and primarily focuses on the interventional side.

Speaker 3: 22:20

That does not include coronaries, so valve interventions, replacements and repairs, closing of holes in the heart, things of that nature, and so that's how I spend my time now. I mean all of us who work in intervention have a component of your life that's made up coronary interventions, as that is far and away the most common thing. But increasingly people are doing a second year specializing in structural intervention to get that particular skill set related to primarily valve procedures, and that's how I spent the entire last year working with Dr McCabe and Dr Chung, as well as Dr Don, who are my structural trainees over the course of the last year, which was a unique experience for me and was really enjoyed that time a lot and learned a lot, and that is now how I spend the other bulk of my time, and so the section that we have here is kind of divided into those two separate areas of focus right.

Speaker 3: 23:29

Yeah, that's correct. So I don't know exactly how they might think about it. But how I think about it is that there are two silos and we all intermingle to some degree. But the complex coronary team Bill Lombardi and Kate Carney and Lorenzo Asilini, who's the newest member of their team, and then Jamie McCabe, christine and myself on the structural side, and then Zach Steinberg is our guy who does adult congenital heart disease interventions, which is like a totally different thing out in left field. So the seven of us make up this section and yeah, we're sort of subdivided along specialty lines.

Speaker 2: 24:09

Yeah, and that makes sense from the academic standpoint, but that's not the way it is everywhere. A lot of times there's a fair amount of overlap where there's just focus on the coronary aspects but not necessarily the complex coronary aspects.

Speaker 3: 24:23

Yeah, I would say a lot of my sense of the structural landscape is that there are a lot of people who do TAVR or trans-catheteria aortic valve replacement or close simple holes in the heart, simple connections in the heart, like a patent for Immunovalli PFO. That level of training seems to be relatively common across the country. I think when you're getting into the things that we do here that are more complicated, involve other valves, involve more complex lesions, subsets, patient complexity, that is something that is much less common and is particularly reserved for people who have had dedicated training in structural heart disease.

Speaker 2: 25:16

I know even within the structural component we have sort of areas of specialization.

Speaker 3: 25:24

Yeah, I mean, I think maybe that isn't necessarily the way that I would think about it. I think on the structural side we have a team lead. Jamie is my personal mentor and husband for several years and he's remarkably gifted and a world's expert in a lot of what we do and he certainly does the most complex stuff in our group, including the fully percutaneous electrosurgical things and interventions in the mitral and tricuspid space. Christine is several years ahead of me and has started to move into some of that as well. Right now I'm doing primarily aortic valve interventions, closing some simple lesions, things like that to get.

Speaker 3: 26:12

It's not to say that I didn't train in all of those things, but I think there's a hierarchical approach to some degree of the most experienced person doing the most complicated things Kind of just makes sense, and so I wouldn't say that Jamie does this, christine does this, I do this. It's more that he leads our team and through his guidance we all are learning and getting better and approaching new problems in new ways. And yeah, I guess that is the way that I would think about it.

Speaker 2: 26:52

Yeah, that makes a lot of sense, this stuff. If you end up doing most of the tavers at this point because Jamie is doing a lot of the other stuff, it's more that great responsibility and great complexity.

Speaker 3: 27:03

Yeah, and I think that's, as I was saying earlier. One of the great benefits of our team is that if I'm referred a patient who is particularly complicated for one reason or another, there is no closed door. I just would walk around the corner and say, hey, what do you think about this? And it's a remarkably positive experience to have that in your back pocket and I don't.

Speaker 3: 27:33

In speaking with other people who have been along my training pathway and now work at other places that's not always the case and having the support of people who, first and foremost, want every patient to have a good outcome, but also want you to continue to develop the skill sets that you've worked hard and trained to make and want to be a resource to you in your continued development. I mean, we are all continuing to develop always. There is no point at which you sort of stop, particularly in this field, and having a team of people where you can say this is a circumstance that I've not exactly encountered before. What would you think about this? This is what I was thinking about. How would you approach this? That's a gift and I really value that.

Speaker 1: 28:29

When the field and everything's evolving very quickly in structural heart, a lot of clinical trials. What excites you most about that future and what you really want to be involved in?

Speaker 3: 28:39

Yeah, I mean, I think the things that are most interesting to me are the dedicated valve prostheses. Right now a lot of the work that's done in the mitral space, for example, is done by the пригeremos queideexecuto's districts that are I don't want to use the word gerry-rigged, but it's a little bit gerry-rigged from pieces of equipment that are not designed for that valve. You know, using a prosthesis that's made for the aortic position, off-label in the mitral position, for example. A lot of the clinical trials we participate in are in dedicated valve prosthesis and the results from those have been very interesting. You know I don't know if you saw just last week the FDA approved the evoke valve, which is a dedicated tricuspid valve prosthesis which we had the privilege of participating in a few of those implants with Dr McKabe last year and the results were really remarkable in treating a valve lesion that we previously had.

Speaker 3: 29:45

No, I shouldn't say no, that we previously did not have great management strategies, for there were valve repair options that would work but were challenging and difficult, and this is sort of the first dedicated device made for this problem and it just got FDA approved. And so I think seeing those things come down the pipeline, participating in that research process is really what kind of gets me out of bed in the morning. Those are the things that I think in 10 years, looking back and being like can you believe that we used to solve this problem with this equipment is going to be sort of an interesting path. You know, jamie is, I think, about 10 years out of practice now and it's interesting to hear him talk about even the way they did TAVR 10 years ago, in which they would do a small surgical cut down at the groin to get the sheath in and just things like that that were made. What is now, you know, approaching an outpatient procedure sort of thing, is really remarkable to reflect on just the expansive growth of the space in the last decade.

Speaker 1: 31:01

What are the biggest changes there? Is it the delivery mechanism and like, being able to get the angles, or is it more the actual mechanical device?

Speaker 3: 31:10

Yeah, I mean, I didn't live through it so I don't know exactly. I never used the previous equipment, but it's just that they've. The companies who produce these valves have had iterative changes over the last several years in which they make the delivery equipment smaller, more deliverable, just easier to use. There's been stepwise iterations on just the valve itself sizing. They now treat the valves with a compound that is designed to help prevent structural valve degeneration over time, similar to what they use in the structural or in the surgical valves. So it's just these small iterative changes that make things, you know, better and better and better and better. We're actually participating in the trial right now of the most current iteration of one of our more common valves, and so I think those changes that occur over time just make things safer, more reliable and ultimately more effective and safer for patients, which is, you know, the common goal here.

Speaker 2: 32:18

Yeah, I remember when we didn't care about the tricuspid regurgitation at all and now it's. It is dramatically different, both in all the developments and the things that we can do, but just in the way we're thinking about diseases and we're thinking about improving patient's lives and the ways to do that.

Speaker 3: 32:39

Well, I mean, it's not even that far. You know, I began my fellowship in 2018. And even I remember being in the echo lab grading tricuspid regurgitation and being like, well, that's an awful lot of tricuspid regurgitation. You know, we probably are not going to pay a lot of attention to that. It's probably something that's not going to impact this person.

Speaker 3: 33:00

And then, you know, moving my life into this structural heart disease space, we would see these patients who have been living with tricuspid regurgitation for many, many years and it had really started to impact their lives, and I think our understanding of certain things is just changing as there is increasing availability of things to do.

Speaker 3: 33:22

You know, it's always easier, I think, to approach a problem when you have a solution in your back pocket, and this is the thing that we can, you know, try to work on, as opposed to a problem. For us, there is no obvious answer, and so that's the sort of thing that I find very exciting is that, over the course of just in the time that I've been in training, we've gone from, you know, maybe this is not as important of a valvulation to well, actually, it really is just something that takes longer to present itself, and now that we have ways of dealing with it. We really probably should be more attention to it and that's an interesting you know, that's just one example of something that's interesting. That's changed over the course of even my time in training.

Speaker 2: 34:03

Yeah, but you know it is fascinating how that has made us delve deeper into these things. Clearly, tricuspid regurgitation is much more multifactorial than most of the other valvulations. It's much less primary, if you will. It's not really a leaflet problem with such an anesthetist or a personoid or you know something like that. But that doesn't mean that it shouldn't be treated. It doesn't mean that it's going to cause a problem and it doesn't mean that using a treatment which may not be a primary treatment modality can nonetheless dramatically affect something that is secondary or tertiary or whatever.

Speaker 3: 34:39

Yeah, exactly I think I agree with what you said completely. I just think that just because the problem is secondary doesn't mean you can't address it.

Speaker 2: 34:48

I guess is the way that I would say it. That's a good way to put it. That's a better way to put it.

Speaker 3: 34:54

So those are the things that I find most interesting is there's clearly a lot of attention on the industry side for the development of products to address problems like this, and that participating in that science, the development of this field, is really what I find most interesting.

Speaker 1: 35:13

And who knows, GI might have a solution for some things to address.

Speaker 2: 35:18

Eventually they'll spill over.

Speaker 1: 35:22

So, as a Montanite, montanian, montanin, yep, montanin, what's a good story of? Maybe the who is Dave Elison, as a Montanin, now Seattleite.

Speaker 3: 35:34

Oh man, okay, let me think about this for a second, maybe bow hunting a bear or something.

Speaker 1: 35:42

We all do that in Montanis, yeah, right.

Speaker 3: 35:45

It's sort of when you leave the hospital with a handgun and your hunter safety permit, I really love the outdoors.

Speaker 3: 36:00

One of the things that I grew up doing a lot is skiing and one of the things that I find most calming I guess in a job that often feels very chaotic and stressful and busy and all the things is just being outside, and my wife and I used to hike all the time, go on runs, and that we really started that when we lived in Missoula together. It's easier in Montana and I think kind of to give you an emblematic view of the big sky state, we used to just walk out her door to the end of her block and we're in the woods, and that's not present in Seattle but it is.

Speaker 3: 37:12

It's truly an escape that I value and I find that being able to turn your brain off is something that I really cultivated in the woods, and I still have very fond memories of camping with my dad and my brothers. My dad liked to go winter camping, which in Montana is really awful, as you might imagine, but there's something about the stillness of the snow in the winter, in the cold, that I crave, and I think in the places that I go now in Washington, getting out into the silence of nature is something that I find incredibly meaningful and tranquil, and I think if there was something about Montanans that I would want people to know is that we don't ride a horse to work. There is electricity.

Speaker 3: 38:22

Where I went to high school, it's that there is a society of people that live in the outdoors and, um… you know, my father is a geologist by training and he works for the Bureau of Land Management in Montana and he works particularly on farming, water rights. How are you going to irrigate said quadrant of land? I'll call him in the middle of December, you know, and he's like standing in the river and he's like it's cold today. Yeah, I can believe it, and I really think that that is just something that is impacted who I am and what I like to do and where I find peace, and though I love this job, I think getting away from it is important, and finding something like that that quiets your brain, allows you to recenter, is something that I've always found incredibly meaningful and important.

Speaker 2: 39:28

That's fabulous. Oh sorry, Go for it. Are you still remodeling things as a carpenter?

Speaker 1: 39:35

Oh.

Speaker 2: 39:35

I just remember you came over. We had you over for dinner something during your training and you were remodeling this incredible, amazing thing in one of your.

Speaker 3: 39:47

Yeah, in our old home, the upstairs was sort of a bunch of unfinished space, a very livable area, and I would have needed about six months to fix it myself, to turn it into a bed, bath, master, which is what we had envisioned. So we had it quoted out. Well, maybe here's a good story about being a Montana. We had it quoted out a couple times and they were quoting me like $90,000 to have five or 600 square feet remodeled. And I called my dad. I called my father and he was like you told them they're not building the whole house, right? So, anyway, I ended up.

Speaker 3: 40:33

You know, my wife and I sat down and we're like well, this is what we'd have to do. This would be a lot of work. We would need a lot of nights at home with nowhere to go, and that was like March of 2020. And so, all of a sudden, there was nowhere to go and nothing to do. And so we took on this project of remodeling our upstairs and I was really happy with the way that it turned out. But I do, I like building. I like the process of the creative thinking behind how you envision something's going to look. I enjoy that a lot where, as we're moving into our new house, my wife's already like I want you to build this over here and then build that over here.

Speaker 1: 41:16

Okay, it just takes a little while YouTube or actual experience.

Speaker 3: 41:19

Well, I worked in contracting for about eight months, which is a wonderful career actually. I really liked it. But now plug for YouTube. Like you can figure out how to do literally anything on YouTube if you just like. Look up the specific thing that you're trying to do, and then you have to bust out the building code and you have to do a little bit of research before you start into something. But it's not altogether that difficult to figure out what you want to do.

Speaker 3: 41:53

I'm sure every contractor out there listening is like rolling over in their grave, but I do find some interest in that process and figuring out how you're going to deal with this little thing. You know, remodeling my house that was built in 1947, I think you know you take it down to the studs and you're like oh, it's four inches shorter at the other end of the room. That's going to be weird to drywall. That sort of thing is an interesting represents an interesting problem to me that I think is fun to work through. So, yes, I'm still building, though at a considerably slower pace. It's harder with two children, but yeah, I love that work.

Speaker 1: 42:41

How about you just entered his faculty? Maybe something you wish you had known or would tell someone exiting fellowship, or even maybe entering fellowship.

Speaker 3: 42:54

Yeah, I think that, boy, if I had a perfect answer I would give it to you. I guess the thing I would tell somebody who is entering practice, particularly as an interventionist, is, I would say, think really hard about who you're going to work with. I feel like people enter the practice of interventional cardiology with a set of skills and I hope I don't offend anybody by saying that we're in general a confident, type A, you know successful bunch, and I think it is very humbling to work in our field. And when you are entering a new group, I think who you spend your time with and who you work with and who you work for makes all the difference. I mean, I think if I had to come to work every day and deal with every single complicated thing that I wasn't exactly sure on by myself, I don't think that's an environment that I would feel very great about.

Speaker 3: 44:05

And I think all of the challenges of transitioning from training to attending life are made better by your mentorship experience. And those can be the clinical things you know, like how am I going to deal with this particular patient problem. But it's also there's so many things about the medical complex, the administrative complex of working in like a huge institution that you don't, you're sort of sheltered from as a fellow, as a trainee, in general, that as you enter practice, it's critically important to have people that you can trust and rely on to provide you sound advice about, you know, navigating the next couple of years. Particularly people who have lived through that pathway and have done some of the things that you're talking about doing and you know can provide you the feedback like that is not worth your time. That's something that's going to be a lot of time invested and not a particularly good return on that investment.

Speaker 3: 45:22

Those sorts of things are really what make the transition smooth, and I think it really boils down to who you work with, and so it's my very rambling way of saying that you should trust who's hiring you and if you go to groups that can't give you a real solid description of what it is that your day job's going to look like and who you're going to reach out to if you have a problem and what your interface with your surgical partners is going to be like, I mean, I think that should be a major red flag and it's one of the primary reasons why I wanted to stay. But I'll let you know when I get it all figured out. It should be in the next week or so. I would think so.

Speaker 2: 46:12

Now that really brings it full circle.

Speaker 2: 46:14

You know, it's really amazing to have you stay on with your experience and obviously just jumping right into this attending role.

Speaker 2: 46:24

It's not as new as it could have been if you were coming from outside but to be known to know, to know what you're getting into and then just to kind of plop right in there and start it up has just been a tremendous asset, I think, for us, and hopefully it's going to increasingly prove so for you as well, going forward. But I think that's really good advice. I think that, as we all do that, as we all think about the work environments that we're in and to what extent we get to choose those or to what extent we get to shape them, if we can make that kind of environment that's supportive, that family-like environment in which the doors always open, as you said, and there's greater responsibility and there's, I think, here particularly this idea of a patient first attitude. That's our primary goal, our primary duty. That will create something that will attract the best and brightest, particularly those who've seen it, want to stay like you and will also do the best thing and allow us to have the most fulfilling careers.

Speaker 3: 47:31

Well, I think particularly yeah, I think it's well said in a climate where increasingly you hear about things like physician burnout and the increasing administrative burdens of medicine and how those contribute. I think what stands out to me in the things that I focus on as means to avoid burnout are really cultivating those relationships and I think you stated it nicely how you're going to craft that environment such that you attract people who are the best and brightest and want to work in this space, in this field, in this place, because it can be daunting and I think, as I've moved from my fellowship to my attending life, particularly I would like to say thank you to Jamie and Christine, who have really welcomed me into our group and are my proverbial shoulder to cry on. You know that is having people in your corner, I think, is truly the best.

Speaker 2: 48:48

Yeah, well, maybe that may that be true for all of us. Absolutely Great.

Speaker 1: 48:54

Well, thank you, Dave, so much. Yeah, thanks for having me Great conversation.

Speaker 2: 48:57

Yeah, absolutely, I really appreciate it.

Speaker 3: 49:00

Yeah, of course, happy to do it, thank you.