10-Minute Interview: Peter Spector, MD

Dr. Spector is a Professor of Medicine and Director of Cardiac Electrophysiology at the University of Vermont College of Medicine and Fletcher Allen Health Care in Burlington, Vermont. Tell us about your medical background and how you came to work in the field of electrophysiology. What interested you about this field? I came late to the idea of medicine, having started as a philosophy and religion major in college. My studies introduced me to psychology, in which we learned about the physiology of the eye and the biology of vision. I was immediately hooked on the “how things work” aspect of biology, and ultimately switched to the study of neuroscience. During my medical training, I was drawn to cardiology because of the intimate relationship between daily clinical practice and basic physiology. Eventually I discovered electrophysiology, and now I can’t imagine doing anything else with my life. EP is an interventional field that appeals to my inclination to “do something”; meanwhile, it is also tremendously intellectually engaging. In EP we have great gadgets that are indispensible, but the most important tool we use to cure patients is critical thinking. Describe your position as Director of Cardiac Electrophysiology. What is a typical day like for you? I love my job. My time is split between clinical care, research and teaching. I find that these endeavors are symbiotic. Patient care is the whole point; it provides the goal (how can we better understand and treat arrhythmias?). It also shows the way; patient care points out where we need to learn more. Teaching has a great power to focus and organize one’s ideas. Research keeps everything fresh. We always hope to be treating patients better next year. So, to (finally) answer your question, there isn’t really one typical day: some days are spent in the hospital seeing patients and doing ablations or implanting devices, others are spent doing research. Both types of days involve a lot of teaching. What is one of the more unusual EP cases that you have ever worked on? That’s a tough question, since there have been so many great cases. There are many ways that a case can be special. Sometimes they involve something we don’t see often and the challenge is to recognize the significance of an unexpected finding. Other cases teach us something fundamental about electrophysiology in general or about how to interpret EP data. My favorite cases are the ones in which the analysis of mapping data or response to pacing is critical to success. These cases affirm the importance of striving to deeply understand the art of EP. A few years ago I was doing an atrial fibrillation (AF) ablation. The AF persisted despite isolating the veins and creating both roof and mitral isthmus lines. This was before there were algorithms for automated frequency detection. The AF was fairly organized, and I wanted to find which area of the atrium was fastest. It occurred to me that we could trick the mapping system into automatically identifying local activation cycle length, thereby creating a color-coded cycle length map. We placed a jumper cable from the mapping catheter to the reference input. This made the mapping catheter its own reference and the “local activation time” actually the local cycle length. The cycle length map directed us quickly to an area in the posterior left atrium that was faster than everywhere else. A single lesion at that site terminated AF. What aspects of your work do you find most rewarding? What motivates you to continue your work in the EP lab? I love the intellectual stimulation, and I love that in the process of EP we help people to feel better. I’m frustrated that we don’t have better solutions for people with atrial fibrillation, though. As a result, my research work probably provides the greatest impetus for me to get out of bed in the morning. I feel strongly that thinking about the challenges of AF more thoroughly and critically will ultimately lead us to a safe and reliable cure. I won’t relax until that’s done…or I’m done. Tell us about your research interests. Are you currently involved in any research initiatives or clinical trials? The main focus of my research is the study of atrial fibrillation. My current work involves trying to develop the means for an electrophysiologically-guided ablation procedure. For the most part, current ablation techniques are guided by atrial anatomy and a “one size fits all” approach is used. I think the key to improving success rates will be found in tailoring our approach to each patient’s electrophysiology. Because of the complexity of fibrillation itself, standard mapping techniques are inadequate to this task. I see that you are teaching a nationally attended course on ablation and transeptal puncture, and will soon be starting a national course on the fundamental principles of cellular electrophysiology. What can you tell us about these courses? The former is really a series of different courses, all of which revolve around some aspect of ablation. We teach three-dimensional electroanatomic mapping, biophysics of radiofrequency ablation, and more recently, ablation for atrial fibrillation. These courses are attended by practicing electrophysiologists and electrophysiology fellows from around the country. They are taught at the Ethicon Institute in Ohio. The institute is a remarkable place with state-of-the-art facilities for teaching. It looks like something out of a James Bond movie. I also teach a course here at Fletcher Allen Health Care and the University of Vermont called “Foundations of Cardiac Electrophysiology.” This is a very intensive two-day course that reviews electrophysiology from ion channels and action potentials through conduction properties and arrhythmia mechanisms to how we use current tools to diagnose arrhythmias. We have developed a computer model of cardiac tissue that we use to demonstrate the fundamental EP properties that result in complex tissue behavior, such as how so-called source/sink relationships lead to unidirectional block and reentry, and why wavefront curvature slows conduction and can result in spiral waves and fibrillation. This course is given twice a year. Anyone interested in either course can feel free to contact me at peter.spector@uvm.edu. What advice would you give to others in EP who are currently at the start of their career? I would warn against the risk of using the powerful tools available in EP as a crutch. Take each piece of information in context, and understand the limitations of the equipment. Think twice and act once. Enjoy it! Has anyone in particular been helpful to you in your growth as an electrophysiologist? In addition, what medical textbooks or online EP resources have you utilized that you can recommend? I have had many influential mentors over the years to whom I owe a tremendous debt of gratitude. There is no question, however, that the person who has had the greatest impact on me is Dr. Warren “Sonny” Jackman. Dr. Jackman is one of the pioneers of modern EP. He is responsible in large part for developing RF ablation. Essentially I can be well described as a Jackman disciple; what I mean by that is that I deeply subscribe to his philosophical approach to electrophysiology. Sonny is brilliant, but there are a lot of smart people in EP. What is so special about Sonny is his relentless application of critical thinking in everything he does. He never tires of pursuing the implications of an idea or a finding. I learned a tremendous amount of specific information as junior faculty working for Dr. Jackman. However, in the sense of the saying “Give a man a fish, feed him for a day; teach a man to fish, feed him for a lifetime,” Dr. Jackman’s greatest gift to me was teaching me how to think well. There are so many good books to read, and there are no shortcuts. I remember a general cardiology fellow once asked me if there was a book called “EP for Dummies.” My response was, “EP is not for dummies!” In other words, you have to read a lot of books to be proficient in EP. Basic Cardiac Electrophysiology for the Clinician by Jalife, Delmar and Davidenko is a superb start.