Editor's Note: In this episode Dr Ohman interviews Lynne W. Stevenson, MD, who went from saying that she would never have anything to do with heart transplant to becoming a leading authority on heart failure and transplant cardiology. This interview was recorded November 8, 2015.
E. Magnus Ohman, MD: Hello. I'm Magnus Ohman from Duke University. I'm very fortunate to have with me Dr Lynne Stevenson for the series called Life and Times of Leading Cardiologists. Lynne is a professor of medicine at Brigham and Women's Hospital at Harvard Medical School. Welcome to this program.
Lynne W. Stevenson, MD: Thank you. I'm happy to be here.
Dr Ohman: So, where did you grow up? Where did your life start, so to speak?
Dr Stevenson: I was born in the Midwest and lived in Chicago until I was about 9 years old, and then my family moved out to Southern California.
Dr Ohman: Wow, you moved around quite a bit. Where exactly in the Midwest were you?
Dr Stevenson: Joplin, Missouri. Home of Mickey Mantle.
Dr Ohman: Are you a baseball fan?
Dr Stevenson: Not really.
Dr Ohman: Where did you go to high school?
Dr Stevenson: In Claremont, California, where the Claremont Colleges are. My father was a professor and that's how we ended up there.
Dr Ohman: What was he a professor of?
Dr Stevenson: He was a professor of economics and statistics, but one of his major interests was information theory.
Dr Ohman: Explain that. What is information theory?
Dr Stevenson: It's how you use information, how you present it, and how people process it. That was actually one of his real loves.
Dr Ohman: Fascinating. Of course, this might have come in handy later on in your famous career, so we'll come back to that. And your mother?
Dr Stevenson: My mother did a number of different things. She was a secretary for a while, then she was a model, then she taught high school geometry, and then she taught piano.
Dr Ohman: That's a broad array. Were you an only child or did you have siblings?
Dr Stevenson: I was an only child until I was 15 years old, and then my brother came along. That turned out to be a wonderful thing for me.
Dr Ohman: You were a teenager when she had a little baby. That works well to some extent. This is interesting. Do you have any other siblings?
Dr Stevenson: No.
Dr Ohman: Just the one brother? Is anybody in medicine in your family?
Dr Stevenson: Nobody.
Dr Ohman: You went to high school in Claremont. What were your interests when you were in high school?
Dr Stevenson: I was always interested in science. I kept this little journal where I would do things like put salt under a microscope and then add a drop of water to see what happens. I was always interested in things like that. I also really liked writing. I have things that I started to write that I put in a drawer.
Dr Ohman: How did you develop that interest in science? It doesn't come to children just out of the blue. Somewhere along the line, a middle school teacher or somebody might have stepped in.
Dr Stevenson: I'm sure that my father somehow introduced it without me really recognizing it.
Dr Ohman: That's funny.
Dr Stevenson: He still says that the reason I went into medicine is because they gave me one of those bodies that you're supposed to assemble, but I never did. He thought that maybe the guilt about that drove me into medicine.
The Formative Years
Dr Ohman: That is funny. So you completed high school in California and you were going to go to college. How was the college selection process?
Dr Stevenson: At the time, I wanted to try living in a different part of the country, so I basically looked in the East Coast for colleges. I thought I was going to major in math, so medicine was in the background. That came later. I liked the objectivity and the problem-solving nature of math.
Dr Ohman: I think your father's statistics influence here is fairly significant.
Dr Stevenson: I think so.
Dr Ohman: Which college did you end up going to?
Dr Stevenson: I was accepted to MIT and Princeton and wait-listed at Yale. I really wanted to go to Yale because I thought I wanted to write as well, but I ended up choosing Princeton. I think it was a very good choice.
Dr Ohman: You must have been really good. Were you valedictorian? Because those are some of the best schools in the country. Even when you were younger, they were still among the best schools.
Dr Stevenson: Well, you have to realize that with Princeton, I was only in the third year of women attending, so I suspect that they weren't quite as selective as they were for their male students at that time.
Dr Ohman: How was it to go to Princeton as a very strong minority of women? How many were there? Maybe 5%?
Dr Stevenson: I was about one in nine when we started.
Dr Ohman: About 10%.
Dr Stevenson: It was interesting because I went to a public high school in California where we were with boys all day long, and that was normal. It was very different when I went to Princeton because many of the boys had only gone to school with boys, so they didn't know how to interact with women except on the weekends. It was a curious environment.
Dr Ohman: This could be really bad or really good. Was it "weekend" all the time or...?
Dr Stevenson: Frankly, it was a bit difficult in the beginning. By the end of my college career, it felt much more natural. But the beginning was very odd.
Dr Ohman: Did it feel competitive?
Dr Stevenson: Not really. I just wanted to survive. It was a pretty tough academic environment, so I just wanted to stay above the watermark.
Dr Ohman: Yes, because so many bright people go there. Were you very studious?
Dr Stevenson: I was after my first semester. During the first semester, I had my high school habits and I thought that that might get me by, but it didn't. When I think back on it, one of the science teachers at Princeton was incredibly influential because he didn't teach us any facts. He just taught us the experiments that were done, and then all our tests and all our assignments were to describe an experiment that you would do to look at something. I thought that was most fascinating.
Dr Ohman: What area of science was this?
Dr Stevenson: It was cell biology.
Dr Ohman: That requires a lot of theory, so it's interesting how he could pull that off.
Dr Stevenson: I don't remember the details. I just remember thinking that this is how I want to learn.
Dr Ohman: It's almost Socratic teaching.
Dr Stevenson: Yes. Another thing that was very formative for me in college is that I switched from math and decided to go into biochemistry. In your junior year, you sign up with your mentor to do your thesis within your senior year, so I quickly got with the best-known person to do my junior work. At the end of my junior year, he said, "I have too many people in my lab, so you're going to have to find someplace else." It was at the end of the year.
Dr Ohman: How did you take that? That's insulting.
Dr Stevenson: I was very wounded. I literally had to go knocking on the doors of all the other faculty and say, "I know it's late in the year, but I don't have a place."
A wonderful man named Harold Weintraub (Editor's Note: Dr Stevenson misspoke when she said her mentor was named Irv Weissman; it was Harold Weintraub), "I'll just stick you someplace. It'll be fine." And he gave me a project. As it happened, I couldn't do what it was that he wanted me to do. It just didn't work out, but I found something interesting along the way from my own error. I was not very good at cell culture and I always got things dirty. His cultures didn't survive very long. But I put them in different incubators and found that at different temperatures, the cultures would be more or less vulnerable to getting infected. We came up with some very interesting information that was totally not what we were looking for.
That was probably the best experience I had, the fact that you've got to pay attention because, often, what looks like a mistake turns out to be part of the answer.
Dr Ohman: This serendipity in research is fascinating. So you've been a believer ever since.
Dr Stevenson: Absolutely.
Dr Ohman: Was this all with Dr Weintraub?
Dr Stevenson: Yes. I wrote to thank him several years later, only to find that he'd died of lymphoma prematurely, which was very tragic.
Heart Transplant? Never!
Dr Ohman: This is an incredible undergraduate experience at Princeton. Where did you go from there? At some point, you turned to medicine.
Dr Stevenson: Somehow I always pictured myself being in medicine. When I was little, I would line up my stuffed animals and put vital-sign charts in front of each of them, so it was always there. But I never quite knew how I was going to get there. And then I applied to medical school.
Dr Ohman: Straight from Princeton?
Dr Stevenson: Yes, straight from Princeton.
Dr Ohman: Where did you apply and where did you finally go?
Dr Stevenson: I applied to Duke University and Stanford University and ended up going to Stanford. I also applied to the University of California in San Diego.
Dr Ohman: Back to the West Coast.
Dr Stevenson: Yes, but Duke was also in there.
Dr Ohman: Interesting.
Dr Stevenson: Duke didn't want me, but Stanford did.
Dr Ohman: Well, our loss, their gain. You picked Duke and Stanford. At the time, these were two very different schools. It's hard to see the difference now, but back then they were very different. What attracted you to Stanford and what attracted you to Duke?
Dr Stevenson: At that age, we really didn't know much about it. People came to the campus and gave a little spiel, and you thought, "Well, that sounds like a nice place to go." I really had no idea what either place would be like.
Dr Ohman: And you ended up at Stanford. Tell us a little bit about Stanford. Beautiful location.
Dr Stevenson: Beautiful location. I actually don't picture my years there as formative as my time before and after.
Dr Ohman: Interesting.
Dr Stevenson: I enjoyed my colleagues. I found that I really enjoyed clinical medicine. I did a summer internship with a geriatrician, which I really enjoyed as well, but I wasn't thinking that much about long-term plans at that time. I was enjoying the weather and the curriculum.
Dr Ohman: So you passed and obviously got through medical school. You had to go for residency. Did you stay on the West Coast or go back East?
Dr Stevenson: I ended up going down to [the University of California, Los Angeles] UCLA for personal reasons that did not pan out. Another serendipity. When I think back, one thing that's interesting is that when I was at Stanford, I was a blood gas technician to help pay for my expenses. On nights and weekends, I worked in a blood gas lab and we used to do blood gases on heart-transplant donors.
Dr Ohman: When was this, roughly?
Dr Stevenson: This was during my freshman, sophomore, and junior years.
Dr Ohman: This would have been in the '70s, '80s?
Dr Stevenson: Late '70s. And I thought that it was the most macabre thing in the world, to have a dead person be a heart donor. I told all my friends, "I'll tell you one thing that I will never do. I will never have anything to do with heart transplant." That was the one thing I was sure that I didn't want to do when I left Stanford.
Dr Ohman: Life is funny like that, isn't it? So, you worked your way through medical school with a little side trip further south—I presume it might have been related to a boyfriend.
Dr Stevenson: Yes, it was.
Dr Ohman: And then what happened?
The Early Days of Heart Transplant
Dr Stevenson: Well, I was at UCLA for quite a while. I was a fellow there and met my husband there. We were both on the faculty and felt very fortunate as a young career couple to both have jobs in the same place. I would have done almost anything to stay there and that's how I got into transplant, because that was the "anything."
Dr Ohman: Let's go back a little bit here. This is a fascinating story. Essentially, you did your fellowship at UCLA and the thing there was transplant. Now we're looking at the '80s. It was really taking off and had a lot of early challenges, of course. How did you meet [your husband] Bill Stevenson? We should point out that he's also a cardiologist.
Dr Stevenson: Yes. We had met before, but we really got to know each other at one of the house staff retreats up in the mountains.
Dr Ohman: That's great. You were both on faculty. How were you able to manage it? It's stressful, to have two young faculty members in academics and, in your case, doing transplant medicine. That's a very stressful job. How were you able to juggle all of that?
Dr Stevenson: At that time, there were just the two of us, and Bill always worked harder than I did. It was probably one of the reasons that I became as diligent as I am, because we would go home together at the end of the day. It would be 10 o'clock and he was still working, so I would keep working, too.
Dr Ohman: Wow. You commuted together?
Dr Stevenson: He set a very good example.
Dr Ohman: I guess that's important in Los Angeles, where the commute is very long, right? What happened next? You're now in transplant, which you said you would never do.
Dr Stevenson: Well, as it turned out, this was fairly early days in transplant medicine. Cyclosporine was just approved and there weren't many transplant programs, so there weren't many transplant cardiologists. I became interested in heart failure. What really piqued my interest was the physiology of heart failure. I began to spend a fair amount of energy learning about that. I was told at that point by a senior faculty member that there was no point in doing heart failure because transplant would make it obsolete. That's the era in which I began. But I really loved it. I had always liked exercise physiology and circulatory physiology, and heart failure was just full of it.
Dr Ohman: Who were your mentors at UCLA who really got you interested in this piece?
Dr Stevenson: Well, you have to realize that nobody did heart failure at that point. That wasn't a specialty, and none of the faculty wanted to do heart transplant. That's why they had me do it. They brought me on when I was still a fellow because no one else would do it. So, I didn't actually have any mentors in the sense of doing exactly what I had done. Jan Tillisch was there. He was the head of the CCU and was one of the early people who became interested in using Swan-Ganz catheters to understand hemodynamics. I would say that he was my mentor just by getting me interested in the circulatory physiology of heart failure.
Harvard and Fame With Physical Diagnosis
Dr Ohman: You and Bill were there together, but you must have been attracted to somewhere else because you eventually ended up at Harvard. How did you get to there?
Dr Stevenson: At that point, we seemed to be a fairly attractive combination for people. I don't think either Bill or I would have made it to Harvard if they didn't need the set. It's so much more efficient to recruit a couple than to recruit somebody and then have to figure out what to do with their spouse.
Dr Ohman: Interesting.
Dr Stevenson: I think the fact that we came as a matched set fit into a hole that they had there.
Dr Ohman: When did you actually come to Brigham?
Dr Stevenson: 1993.
Dr Ohman: Part of your fame rests with the fact that you brought physical diagnosis back into the picture. I remember rounding with Rob Califf and he would say, "Why are you listening to the patient?" Why would we even bother? We have echocardiography and all these other things. But the reality is that physical diagnosis has always been important. What made you take that step and look at that? That's a very unusual part of your career.
Dr Stevenson: First of all, you have to realize that Joe Perloff was at UCLA working in adult congenital heart disease. Almost everyone who was exposed to Joe came to appreciate what you could learn if you just really look at the patient. All of us who trained and had the privilege of seeing Joe learned that there's a lot to be seen at the bedside. From the beginning, as I was dealing with people who are very sick with heart failure, I was impressed by how different every patient was. They had the same disease, therefore the same therapy, but they were so different. What has always fascinated me is trying to figure out what the differences are between patients who superficially looked the same with physical diagnosis. I also think that the history is way underemphasized. You ask a patient what really limits them and when and how, and you learn a tremendous amount about their physiology. So much more than you can learn by just doing an exercise stress test.
Dr Ohman: It's important because some of this art is getting lost in the bigger picture, which is sad.
The ESCAPE Trial
How did you get involved with the ESCAPE trial? The ESCAPE trial, as I'm sure you'll tell us, was a randomized trial of Swan-Ganz catheterization vs continued medical management based on physical diagnosis. You'd been trained to use Swan-Ganz, I presume.
Dr Stevenson: At UCLA, we developed what we called tailored therapy, which basically said that when someone comes in with congestive heart failure, it's a combination of high filling pressures and high systemic vascular systems. In order to sort those two out hemodynamically and treat them, you need to know the relative contribution of each one. That's why we put in Swan-Ganz catheters in over 1000 people at UCLA, to sort this out. We used nitroprusside and adjusted things, and it was quite clinically effective in a very gratifyingly short period of time for the patients. So, that became what I did.
When I got to Brigham and Women's Hospital, I was challenged by Marc Pfeffer and others who said, "How do you know that this really works?" And it happened that at that time, the National Institutes of Health [NIH] was concerned about how the Swan-Ganz catheters might be hurting people. Through various steps, the ESCAPE trial request for proposal came out and we answered it. The ESCAPE trial was designed to compare our clinical impressions with what we learned with the hemodynamic catheter. As you know well, it turned out that it didn't make a difference to outcomes at 6 months.
I've learned a tremendous amount from that trial. The first thing I learned is that these were not the same patients that I had developed tailored therapy for. By the time we got to 10 years, most patients didn't have a high systemic vascular resistance (SVR) anymore.
Dr Ohman: Because we had medications for them.
Dr Stevenson: Because they had been on chronic ACE inhibitors, which helped prevent vasoconstriction. When they decompensated, in fact, most of it was the filling pressures, not the SVR, so the Swan-Ganz catheter was somewhat less important. Part of what I learned (and it's so important for young people to realize) is that the patients keep changing. As the therapies change, the patients change.
Dr Ohman: The disease changes.
Dr Stevenson: The disease changes, so you have to keep up with that. You can't be using the lessons from 30 years ago. We also learned something that has propelled the current level of my career, which is that when they went home, they were better if they had the catheter because they had less mitral regurgitation and smaller left atrial size. They really did look better, but at 6 months, they didn't look better. When we teased out what happened, we found that it was because they got wet again. We could make them perfect in the hospital, but we couldn't keep them perfect at home. That's really where my interest grew. Maybe we can track their congestion before it becomes symptomatic when they go home. We should be focusing on that to keep people out of the hospital and worry a little less about what you do in the hospital, and make sure that whatever that is, it is continued when they go home. That's what I'm currently most interested in.
A New Family Dynamic and a Social Mission
Dr Ohman: There's a great story in this. And now you had a daughter along the way?
Dr Stevenson: Yes.
Dr Ohman: How do you juggle that?
Dr Stevenson: At the time, it seemed unfortunate, but now, from a career standpoint, it was fortunate that it took quite a while to have a child, as it often happens for women who wait. Both of us were able to get quite a bit of momentum in our career before we had a child to add to both our joy.
Dr Ohman: And stress.
Dr Ohman: And our stress. From that standpoint, it's a little easier for me. I would still recommend for women to have their children early, because then you'll have them. Having a child changes everything in terms of your priorities. I think one of the best lessons was from Nanette Wenger, who said, "When you're a mother and a doctor, you have to hire the world. Whatever it is that you can pay somebody to do, do it. Don't rake your leaves, don't do your laundry, don't clean your house. If you can pay someone to do it, do that." And then you have to spend a lot of time finding the right person to take care of your child while you're at work. We had a lot of people who came and, frankly, a fair number of them weren't the right person for one reason or another. One of the things that made our daughter so resilient is that she learned how to deal with a lot of different people. She had to basically be her own referee because I wasn't there; she really learned some extraordinary people skills.
Dr Ohman: And she's also an only child, right?
Dr Stevenson: Yes.
Dr Ohman: So, the story continues in that sense. Where do we go from here?
Dr Stevenson: Well, I've always been very much a creature of serendipity. Some of the things I've become most interested in were not things that were intellectually interesting to me in the past, but they were things that I felt very strongly needed to be addressed or corrected in terms of misconceptions or trends. I have social missions as well as intellectual issues, so I will follow both of those. Bill, on the other hand, always knew that he wanted to be an electrophysiologist, always knew that he wanted to treat ventricular arrhythmias. I think we're the opposite extremes. I'm serendipity-driven and he's goal-driven, and the styles worked for each of us.
Dr Ohman: It has worked well for both of you. I have to ask. What is the social mission that you are on now?
Dr Stevenson: There are a couple of them. One is because I'm very distressed about what has happened to cardiac transplant. We're listing almost three times as many people as we can transplant every year, so the waiting list has become completely unmanageable. Perhaps the most distressing factor is that people who are affluent can afford to go places where the waiting list is shorter, and I think that this is a terrible travesty of what is supposed to be equal access. There is no intellectual physiologic challenge there, but it's something that I'm really striving to bring home to the community so that we start listing more responsibly.
Dr Ohman: That's laudable. For someone who started in medical school and said she will never work on transplants to have this as a mission for the future is terrific. I want to thank you for participating with us today.
Dr Stevenson: It's been a real pleasure.
Dr Ohman: Thank you, Lynne.
Disclosures: Lynne W. Stevenson, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Medtronics; St Jude Medical
Received research grant from: St Jude Medical
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: E. Magnus Ohman. Life and Times of Leading Cardiologists: Lynne Stevenson - Medscape - Mar 21, 2016.