Nov 18, 2015 | Ankur Kalra, MD and Jill B. Whelan, MD
Career Development

Mark E. Josephson, MD, FACC, is the chief emeritus of the division of cardiovascular medicine at the Beth Israel Deaconess Medical Center, Herman Dana Professor of Medicine at Harvard Medical School, and director of the Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service at the Beth Israel Deaconess Medical Center in Boston, MA.

Kalra: Five years ago, I had the opportunity to visit Beth Israel Deaconess Medical Center as a visiting resident, and one of my most impressionable memories was your Thursday morning electrocardiography teaching conference that you conducted (and still do) with the cardiovascular medicine fellows. What is your inspiration for your dedication to teaching basic and advance electrocardiographic interpretation?

Josephson: I have been teaching electrocardiograms with Hein J.J. Wellens, MD, FACC, for the past 33 years around the globe, and have the good fortune to influence approximately 8,000 individuals now. It is amazing how little attention has been paid to the electrocardiogram as a chief physiological tool that is cheap, readily accessible and provides pivotal information about our patients. I think our electrocardiogram teaching, aimed at the electrophysiology and cardiovascular disease fellows, should be extended to the general medical residents. I see too many inappropriate cardiac interventions being done because physicians reading and interpreting the electrocardiograms have little understanding about the culprit versus the non-culprit lesion, and many physicians manage arrhythmias inappropriately because of an incorrect diagnosis. There are a lot of signals in the electrocardiogram that can inform us about the structure and function of the heart. Therefore, I think it is a very useful knowledge base that everyone should possess, and hence the inspiration behind the Thursday morning conferences.

Whelan: I completely agree; the rigor with which the electrocardiograms are taught to fellows at the Beth Israel Deaconess Medical Center is exemplary. How do you recommend incorporating this electrocardiography educational experience into other cardiovascular disease fellowship training programs nationwide?

Josephson: Programs need to identify physicians who are dedicated to education and have the wisdom on how to use electrocardiograms. That's usually not a young faculty member, but maybe. There are some (physician educators) out there that might like to do that, if given the opportunity.

I also think as I look at my future, which is winding down to its end, that it might be a good idea to take one Morning Report session in the residents' curriculum, and make that an electrocardiography session. We need to get the young house staff involved too, because they are dealing with patients on a day-to-day basis, and many things are missed. Many of the problems in the heart failure area are arrhythmias, which are not clear at first to most heart failure cardiologists. One needs to know what's the chicken and what's the egg. The first time I did an ablation was in a patient with incessant atrial tachycardia who was on a transplant list, and the patient had normal ejection fraction three months later. This is just an example of how far down the track patients get lost, if you don't have someone who can point them the right way.

Kalra: What you bring up is very important. Electrocardiography, in-and-of-itself, does not typically exist as a didactic session in many residency programs' curricula. Even in fellowships, many programs organize monthly electrocardiography sessions, but these sessions do not equate to what you do with the fellows here on a weekly basis, which includes an intensive dissection of the electrocardiogram, and differential diagnosis of the clinical scenario.

Josephson: No one reads electrocardiograms the same way, and most (electrocardiography teaching) sessions are not geared toward trying to understand physiology. I try to make my electrocardiography sessions living sessions, so that every electrocardiogram is a case, and (our focus is on) what the findings infer with regard to the case, and the patient one is caring for. And that isn't like going over a set of electrocardiograms in a monthly session; that's what most programs usually do. A fellow has to read a certain number of electrocardiograms as part of electrophysiology fellowship, but there is no data on whether they have been read and interpreted correctly, or whether it was a learning experience for the fellows, other than commenting "this is an infarct." I have always found the physiological approach, the clinically-relevant approach more important for the house staff and the fellows, than just reading the electrocardiogram as a piece of paper.

Jill B. Whelan: That's extremely important. You alluded to the course you have been teaching with Dr. Wellens for over 30 years now. Tell us more about the genesis of that course, and how it still continues to be one of the most popular courses in all of cardiology, let alone electrophysiology.

Mark E. Josephson: Wellens had just moved to Maastricht from Amsterdam and had a new program there. He always liked electrocardiograms, and I had been asked to put a session together by the ACC about the electrocardiograms, so I asked him to do that session with me. We did a similar session in Nice, France), maybe in 1978 or 1980. And then we thought on the plane trip to Nice that may be it will be a good idea to have a course. The formal course began in September 1982, after spending a week in a living room going over electrocardiograms and putting them together. The workbook for the first course wasn't even ready until we got to Monte Carlo in the French Riviera, where the first course was. Each day had a different workbook, and gradually it became more professional, and everything was done beforehand. But that's how it started. And then in 1985, we moved the course to the U.S. Gradually, we extended the European course to the spring and September courses, and the U.S. course to the July and winter courses. The courses are purely educational for cardiac clinicians to develop deeper understanding of their patients from the electrocardiograms. Almost 8,000 individuals have benefited from these courses. In the last year, the courses in Europe have been discontinued.

Kalra: Like electrophysiology, interventional cardiology, because of its changing landscape, has also begun its extension to a two-year fellowship, but the big question is funding. Industry funding is not looked upon favorably and graduate medical education funding is getting cut.

Josephson: The funding is getting cut, while at the same time, the training requirements are increasing. I do not understand how this is sustainable.

Whelan: Tell us more about that the "Elio Fine Electrocardiography Conference".

Josephson: This was done to pay tribute to Elio Fine, who ran the electrocardiography laboratory here for more than 50 years, who has now retired. It's a tribute to her hard work, and she is proud to have her name attached to the conference. Actually, she could read electrocardiograms better than most of our cardiology physicians, and would come to me with mistakes. She was a special person here. The conference is open to anyone who wants to come and learn, and not limited to the fellows at Beth Israel Deaconess Medical Center.

Kalra: The art of interpreting electrocardiograms is dwindling, and talking to fellows across the board, it is hard to get top-quality electrocardiography education in programs. The fellows here are very fortunate to have you and learn from you. As a conclusion to this wonderful interview, what would be your final recommendation to cardiology fellowship training program directors on how to better incorporate electrocardiography education into their didactic curriculum for fellows?

Josephson: Try and look for people who have been inspired by courses like the one we do and incorporate them in leadership positions in the division, for education. In addition, have mandatory electrocardiography teaching for all fellows. This is important because not everyone will become an interventionalist or an imaging expert or an electrophysiologist. But everyone will be a cardiologist, and every cardiologist must know how to read an electrocardiogram.

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This article was authored by Ankur Kalra, MD, and Jill B. Whelan, MD, both clinical and research fellows in training at the Beth Israel Deaconess Medical Center and Harvard Medical School in Boston, MA.