In this interview, we speak with Dr. Edward Walsh, Chief of the Division of Cardiac Electrophysiology at Boston Children’s Hospital, and Professor of Pediatrics at Harvard Medical School.
Tell us about your medical background and how you came to work in the field of pediatric electrophysiology. What interested you about this field?
I attended the University of Pennsylvania School of Medicine, and then was a resident at Children’s Hospital in Philadelphia. I later came to Boston for my cardiology fellowship, and I’ve stayed at this hospital ever since. What got me interested in EP? To me, life is a series of accidents — it’s who you meet and when you meet them. I met a person who had a big impact on my life when I was a resident, and that was a cardiologist in Philadelphia by the name of Dr. William Rashkind. He was a wonderful man — he was my advisor and a great mentor to me. He got me interested in cardiology, and was the one who persuaded me to go to Boston for a fellowship since it was the best place to train at the time. My intention was always to go back to Philadelphia to work with him, but unfortunately he passed away when I was a fellow. Dr. Rashkind was a great influence on my life. Another person that greatly influenced me was Dr. Barry Keane, who was one of the senior people in our cath lab in Boston. He taught me a lot about electrocardiograms and arrhythmias, and later helped me get additional fellowship training at Mass General Hospital to study electrophysiology. Back in the early 1980s, there were not many places to go as a pediatrician to learn electrophysiology — if you wanted to learn the ropes, you had to train at an institution that by and large treated adult patients, and there were few exceptions to that. I was very lucky that Dr. Jeremy Ruskin and his group at Mass General took me on, even though I was a pediatrician. That was a wonderful year of training, and fortunately, there was a staff job waiting for me at Boston Children’s when I finished up.
Describe your work as Chief of the Cardiac EP Service at Boston Children's Hospital. What is a typical day or week like for you?
It has definitely evolved over the years. When I first started in 1985, it was pretty easy to be chief, because I was the only one! We now have 5 full-time EPs here, along with EP nurses, techs, and fellows. A typical week for me would break down as follows: one day a week seeing outpatients, about two and half days a week doing procedures, one half day of doing consults and rounds on inpatients, and one day doing research/teaching/administration.
Describe one of the more memorable EP cases that you have been involved in.
The type of cases I like the most are performing ablations (e.g., for ventricular tachycardias and atrial tachycardias) in patients with complex congenital heart disease. My expertise is in abnormal anatomy and congenital heart disease — I find those cases to be challenging and interesting.
If I had to focus on one case in particular, it was ablation of WPW in one of conjoined twins; both twins had congenital heart disease, and the hearts were joined, so when one would go into tachycardia, it would drive the other one’s heart, and both twins got very ill. This was before they were successfully separated; before separation surgery could be done, we had to calm down the arrhythmias, so we were forced to do an ablation when the twins were just a couple of months old, and thankfully it worked well. That was about 2 years ago. We wrote the case up in the HeartRhythm journal.
What aspects of your work do you find most rewarding? What motivates you to continue your work in the EP lab?
I like patient continuity — taking on a patient as a baby or young child, and continuing to see them through the years. At this hospital, we follow a lot of adults with congenital heart disease, so I still get to see a lot of the patients that I treated early on in my career when they were babies, and now they’ve grown to have children of their own. I also like the procedures and problem solving that goes on in an EP study — performing the manual skills just appeals to me. We’ve also trained a lot of fellows in pediatric EP, and I love taking this young talent and molding them into the type of electrophysiologist that we think they should be.
Tell us about the clinical research you’re involved in.
We do a lot of clinical outcomes research on the procedures that we perform, and we always try to look at this prospectively. We also look in-depth at arrhythmias in patients who were born with congenital heart disease, who now have post-operative arrhythmias.
What advancements do you think will be seen in the pediatric cardiac electrophysiology field in 2015?
In our field in particular, there are two major areas of advancement. The first is managing adults with congenital heart disease, because it’s a novel population — you have to remember that two generations ago, these patients didn’t survive to adulthood; now they do, and they have a lot of late arrhythmias. We’re just feeling our way on how to manage and prevent these arrhythmias, and what we can do differently with surgery. One area that we’re working on now that is going to need more attention is dealing with atrial fibrillation (AF) in this population, because as these patients get to be middle aged, a lot of them are having AF. We didn’t use to think this was going to be a big problem, but that might have been because there were not enough people surviving to middle age. If you try to perform pulmonary vein isolation, catheter manipulation may not be straightforward. You can’t always get there from here, if you know what I mean, because of surgical patches and various vascular connections, so sometimes you have to innovate depending upon the underlying anatomy. There is a member of my team who has done a lot of AF ablation in adults in his prior job in London, and he has started up an AF program here, so we’re learning as we go, but it remains challenging.
The other advancing area in pediatric EP is in hereditary arrhythmias and channelopathies. The progress in this field is really dramatic, both at a molecular and clinical level.
What advice would you give to others in EP who are currently at the start of their medical career?
First, be a good general cardiologist. You’re a cardiologist first and an electrophysiologist second, and I think people make much better EP decisions when they can view the whole heart disease picture. This includes being good at mundane things such as EKG readings, running clinics, and going to rounds — even though that might not be the most exciting thing you do as an electrophysiologist, it’s still critical. I don’t think people should only focus on complex procedures — I think they should do as much broad picture cardiology as possible.
My other advice is to always be available. If you’re just starting out in the field and you want to get people to trust you, rely on you, and refer you patients, you have to be available for them. Don’t think they are going to come knocking on your door — you have to be standing at their door and telling them you’re ready.
What medical textbooks or online EP resources do you recommend?
It’s hard to go wrong with any textbook by Dr. Mark Josephson. All of his writing is clear, practical, and comprehensive. I think when you’re starting out, it’s good to get a basic textbook like this and go through it carefully. However, once you’re established in the field, I’d recommend going to PubMed and keeping up with what’s new. If somebody has written a good paper, there will likely be a few references to good reviews if you need background information, but new journal articles are the best way of keeping up to date in my opinion.
Is there anything else you’d like to add?
It’s a very tough job market right now in EP. It used to be that people would call me 2 or 3 years in advance asking, Can you train me someone in EP for our department? The jobs were lined up before trainees even started their EP fellowship — those days are certainly gone. People coming out of training now really have to shake the bushes to see what’s available — both in adult and pediatric EP. It’s a great field to be in, it’s a lot of fun to do this stuff, and a lot of people want to do it. However, it’s not as easy to find the ideal job as when I was going through my own training. Still, my bottom line to young people is: talent always rises to the top and finds a job. Work hard, and you’ll ultimately succeed in finding a good position.