Standing against the stream: Dr Renu Virmani

Washington, DC - World-renowned cardiovascular pathologist Dr William Roberts (Baylor College of Medicine, Houston, TX) still remembers the day he got a call from Dayton, OH cardiologist Dr Sylvan Weinberg asking if he could take in a foreign doctor looking for work before writing her federal licensure examination to have her medical degree recognized in the US.

"At the time, I was chief of the pathology branch at the [National Heart, Lung, and Blood Institute (NHLBI)]," Roberts recalls. "He called me up and said there's this lady from India, a pathologist, and she just moved with her husband to Bethesda. How about giving her some projects to do? So she came in, and she was very good, and she worked for free for two years."

Thirty years later, Dr Renu Virmani has her own international reputation and calls herself "lucky in her life" for having met Roberts when she did. "I would never be where I am now if I hadn't trained under him. He was very instrumental in my becoming what I've become. If I'm aggressive, if I demand perfection, it's his fault. He taught me everything, and I couldn't be more grateful."

Roberts impishly admits that he enjoys teasing Virmani, because "she can take it," but he's thoughtful and serious about his former fellow and long-time friend. "It's not easy for a woman from India to come over here, obtain a residency, marry an American who's busy, bring up two kids, and work like hell at the same time. And she's done all of that. I have high regard for her, and I'm fond of her, too."

Working like hell

Born before India's partition in what is now Pakistan, Virmani was the youngest girl in a family of nine daughters and one son. Virmani grew up in Delhi, where she did her medical training, and she still returns to India roughly once a year to visit friends and familytwo of her older sisters are also physicians, and a third is a dentist.

"I always knew I wanted to be a physician, and I had role models to follow," she says.

Virmani moved to the US after meeting her husband, Chester Finn, who was serving as an assistant to the late Daniel Patrick Moynihan when he was US ambassador to India. Finn went on to work as a staff assistant to Pres Ronald Reagan, assistant secretary for research and improvement at the US Department of Education, and founder and president of the Thomas B Fordham Institute for education standards and reform.

Virmani credits a mutual love of travel for helping two people very dedicated to their own demanding and distinct careers stay supportive of one another. "I think most of the time we don't see each other, and maybe that's the secret to making a marriage last," she quips. "But we take vacations together and we relax on vacation." Both enjoy visiting obscure holiday destinations, most recently, the Sea of Okhotsk separating Northern Japan from Siberia. Virmani and Finn have also recently become grandparents for the first time. An effusively proud grandmother, Virmani managed to work a picture of her granddaughter into a recent presentation on the future of vulnerable plaques.

After writing her licensure exams in July 1975, Virmani did her residency in pathology at George Washington University in DC, then returned to the NHLBI as a staff fellow until being hired as staff pathologist at the Armed Forces Institute of Pathology (AFIP), Washington, DC. When her husband was hired by Vanderbilt University in Nashville, TN, Virmani took a position as director of the autopsy service at Vanderbilt but returned to AFIP in 1984 when she was offered the chair of the department of cardiovascular pathology.

It was an offer too good to pass up, she says, although it did have strings attached. "When I came back to the AFIP, they said you have to join the military," Virmani recalls. "I said, only on one condition: that I don't have to go for basic training." In fact, Virmani did end up going for basic training when she served in the reserves until 1989, based at Walter Reed Army Medical Center.

"I am actually proud of having served in the US military," she recalls. "There aren't many physicians in the US who could say that they've served in the army. There were difficulties, obviously. I don't conform that well to discipline. But you can't make it as a researcher if you conform too easily, you wouldn't be imaginative enough."

Standing against the stream

Dr Ron Waksman (Washington Hospital Center, DC) met Virmani in 1995 when she was evaluating tissue responses to radioactive stents at the same time that Waksman was caught up in the early studies of vascular brachytherapy. He speaks of her with a mix of fondness, admiration, and exasperation.

"She's dynamic, she's opinionated, and she's not afraid to give her opinion, even if it's not going to be very popular," Waksman says. "She stands against the stream, brave enough to take a very aggressive, critical opinion that may not always be right at the end of the day. We interventional cardiologists don't have a short memory, so we tend to remember her predictions! She's been right about many things, but the jury is still out for some of her predictions."

Dr David Holmes (Mayo Clinic, Rochester, MN), who has worked with Virmani on and off for 15 years, says it would be wrong to paint Virmani as a black-and-white antagonist. Rather, he says, she offers an understanding of tissue effects that predate the interventional-cardiology era. "She has brought to the table her wealth of experience in cardiac pathology and animal cardiac pathology, and in vitro, post mortem, and in vivo animal models of interventional cardiology and healing responses. I think she has been able to lend an opinion over time based on science and data that we sometimes don't have because our horizon has been shorter than hers."

Undoubtedly, Virmani's impact as a pathologist in the field of interventional cardiology is nonpareil. Waksman believes that his friend (and occasional foe) is somewhat unique as a pathologist in her passion not only for things dead and diseased, but also for the potential of clinical strategies to create future problems. "To her credit, I can say that she is always trying to have an impact on preventing bad things from happening in the first place," Waksman explains. "She is able to translate her interpretation of a pathology specimen into a vision of what can and cannot be done, to predict the future."

And the future is not always rosy, in Virmani's crystal ball. Her predictions based on early cellular responses to experimental stents, radiation, and most recently, drug-eluting stents (DES) have helped shaped the direction of ongoing research. "I was one of the first ones who said that brachytherapy was a bad idea," Virmani states with unabashed pride. "My predictions for DES aren't quite as bad. I think there will be problems but not they won't bad as those we saw with radiation."

In Waksman's telling, Virmani's opinion matters. In preparing to present new data at meetings or for device development, he says a standard question is always, what will Virmani say?

"One of the reasons I like to work with her is that if something will pass her criticism, that means the technology is likely going to work. It doesn't mean you have to accept everything that she says, but it gives you a new perspective," says Waksman.

"Some people in industry would view her as an enemy of new developments, but I think that's an injustice," he continues. "I think she's basically trying to bring more thinking and more attention to how things work and does not necessarily have the overt enthusiasm that companies would like their researchers to have."

What would Virmani say?

"She's not a patsy," Roberts chuckles. "There are a lot of people who call themselves cardiac pathologists, but I don't even know who they are! But Renu, she's one of the good ones. She's a good woman, she's strong, she's nice, she's a hard worker. I'm sure she expects a lot of her colleagues up there at AFIP. I expected a lot from her and she delivered."

Roberts sheepishly recalls Virmani getting very "frustrated" with him when they worked together. "She'd come to my office to work on a paper and I'd fuss at her for this and that, and she'd take it and go into her office and sob, or that's what she told me later. I would get annoyed with her for carelessness, and now I bet she gets annoyed at others for their carelessness."

Virmani can laugh at it now: "It's true! He did make me cry, but I wouldn't cry in front of him, and finally I learned how to deal with him."

Keeping up the family tradition, Virmani's son has completed medical school and is training in interventional cardiology, an irony not lost on Virmani, who acknowledges she may have her own son as her future adversary. But while she may have whittled out a role for herself as the thorn in the side of vascular innovators, Virmani herself is the first to admit that the greatest advancements in cardiology have occurred in the hands of interventional cardiologists.

Asked what she thinks her greatest personal contribution may have been, Virmani mutters in self-deprecation before singling out her work in the field of coronary thrombosis. "I proposed that coronary thrombosis occurs from more than one cause, not just plaque rupture alone, but also from some plaque erosion and calcified nodules," she says casually. She also is proud of her work on the classification of atherosclerosis and vulnerable plaques. More recently, Virmani and colleagues have put forward the notion that the accumulation of erythrocyte membranes within an atherosclerotic plaque might stimulate atherogenesis by increasing the deposition of free cholesterol, macrophage infiltration, and enlargement of the necrotic core. "And that's a totally new understanding," she states.

Others would say that her even greater contribution has been her voluble, often colorful, skepticism. At the recent EuroPCR meeting, Dr Martin B Leon (Lenox Hill Hospital, New York, NY) credited Virmani with keeping interventional cardiologists "honest" and told heartwire that "it's good to have a naysayer."

Holmes says that Virmani adds "a cautionary note" to temper the "necessary enthusiasm" of the interventional cardiologists. The sorts of questions Virmani asks, he says, are "crucial," particularly since they deal with changes occurring at a level beyond the comprehension of most clinicians. "We don't understand very much about what occurs at a cellular level, and people like Renu Virmani know more about it than we do, so they bring that added dimension to the field."

For his part, Waksman calls her "a voice of caution, a voice of reason, and a constant reminder to think through all the possibilities. Someone needs to take this role in the community and she definitely adopts it."

Virmani doesn't deny it, stating simply: "You must have some opposite views in science, otherwise things are taken for granted, and I don't think that's good for patients. For medicine as a whole to move forward, you must be questioned."

Heartwire from Medscape © 2004 

Cite this: Standing against the stream: Dr Renu Virmani - Medscape - Jun 23, 2004.