Faculty Spotlight: Dr. Kirsten Fleischmann
"There are often many options in medicine," said Dr. Kirsten Fleischmann. "We usually ask, 'What can we do?' but the more difficult question is sometimes, 'What should we do?"
Dr. Fleischmann has devoted much of her career to finding answers to these questions. "We're lucky in cardiology that we have many good ways to investigate the heart," she said, noting that today's tools include echocardiography, which is ultrasound of the heart; computed tomography (CT) and magnetic resonance imaging (MRI); various forms of stress testing; and angiography and catheter-based testing, which involves inserting flexible tubes called catheters through the blood vessels to the heart.
"But with all these options, it becomes critical to understand the pros and cons of each test and how they can best be used to optimize outcomes important to our patients, be that minimizing the risk of another heart attack or preserving quality of life," said Dr. Fleischmann. "And since all tests come with costs, whether they are risks to the patient, potential side effects, or money, it's important to understand how we can use our arsenal of tests most effectively and efficiently. This has become a growing emphasis in medicine – to do the right thing as efficiently as possible."
One of her interests as a cardiovascular outcomes researcher has been evaluating different types of non-invasive cardiology tests and their relationship to patient outcomes. She and her colleagues have studied how each type of test measures up, their relative strengths and limitations, and patients' long-term outcomes. "Some of the questions we tried to answer were, if a certain type of stress test comes back as normal, what's the 'warranty period' on that test?" asked Dr. Fleischmann. "Who develops a cardiac event in the future? These are very practical, important issues to help us use tests most effectively." Their research has produced a number of high-profile publications that measure the utility and cost-effectiveness of such tests, and can help clinicians select which tests are best equipped to assess a specific patient's heart health.
Building on this work, Dr. Fleischmann and her collaborators are investigating the optimal ways to identify patients in the asymptomatic population who are most at risk for developing heart disease. "How do we best decide who benefits from interventions, such as taking a daily aspirin or lowering their cholesterol with medications?" she said. "Who can forego these measures safely? How can testing help? In general, we match the intensity of medical therapy to risk, and I hope to identify better ways to stratify patients' risk."
One patient population that is at increased risk of developing heart disease is people with diabetes. Currently, most diabetic patients are treated as if they have atherosclerosis, or plaque buildup in the arteries which narrows these blood vessels. "More and more, however, we're coming to understand that there is a spectrum in that risk," said Dr. Fleischmann. "Some patients with diabetes are at exceptionally high risk and some at relatively low risk."
The amount of calcium deposited in the blood vessels which supply the heart roughly correlates with the severity of atherosclerosis. Dr. Fleischmann and her colleagues are investigating whether using a CT scan to measure a patient's calcium score can help cardiologists make better decisions about treatment of patients with type 2 diabetes.
Improving Hospital Care
In addition to learning how non-invasive cardiology tests can best support preventive care, Dr. Fleischmann is also interested in how they can best help patients in the hospital.
"Chest pain and shortness of breath are so common, and they drive many emergency department visits and hospitalizations," she said. "But those symptoms have many different causes. Some cases are quite serious and, in fact, heart-related. Others are benign." Among other findings, her research suggests that patients with left ventricular dysfunction or mitral valve regurgitation are most likely to have short-term complications in the hospital, as well as poorer long-term outcomes. Her team also found that slightly increased levels of a protein called troponin, even outside the context of clear-cut heart-related symptoms, were associated with increased risk of death or heart attack within one year.
Dr. Fleischmann also collaborated with Dr. Barbara Drew in the School of Nursing to study whether using enhanced electrocardiograms – which collect more comprehensive data than standard electrocardiograms – can improve evaluation of patients in the emergency department who complain of chest pain. "One of the joys of my research career is having my own focus and programs, but also collaborating across disciplines and schools," she said. "UCSF's depth and breadth allows me to develop projects where my colleagues' interests overlap with mine." She also collaborates internationally with investigators at Erasmus Medical Center in Rotterdam, the Netherlands, in work that has been supported by the US National Institutes of Health.
Yet another area of interest is improving the cardiac management of surgical patients. "Even noncardiac surgery can be a stress on the cardiovascular system," said Dr. Fleischmann. "How do we minimize cardiac complications around noncardiac surgery? It's a fascinating area." Years ago, she was asked to serve on a committee charged with developing guidelines in this area. The group sifts through the best evidence, weighs sometimes conflicting studies carefully, and has developed nuanced recommendations based on the estimated risk of a particular patient. She has continued to serve in leadership positions with updates of those guidelines, and has also worked with hospitalist Dr. Andrew Auerbach to improve the use of medications to prevent cardiac complications in surgical patients.
From the Lab to Clinical Research
Dr. Fleischmann was born near Akron, Ohio, and earned degrees in both chemistry and music at Case Western Reserve University in Cleveland. She thought she would pursue a doctorate in chemistry, but worked a summer job at University Hospitals of Cleveland. "I became immediately fascinated by all the intellectually stimulating aspects of medicine, as well as the way it stretched you emotionally and had an immediate impact on people's lives," she said. "Just sitting across from a patient makes it important."
She decided to become a doctor, earning her medical degree from Washington University School of Medicine in St. Louis, where she also did her internal medicine residency. She became fascinated by the pathophysiology of cardiology – the underlying physical mechanisms causing various disorders of the heart – and found the large array of cardiac procedures and interventions appealing. "In cardiology, there's a lot you can do for the patient," said Dr. Fleischmann. "I like the process of thinking through problems to get to the right diagnosis, and then having effective treatments to offer."
Dr. Fleischmann continued her interest in basic science, and worked in a molecular biology laboratory at the Max Planck Institute in Bad Nauheim, Germany after residency. She returned to the U.S., where she did her cardiology fellowship at Brigham and Women's Hospital in Boston.
"I had not been exposed to much clinical research, so I decided to seek out clinical research experiences and get some training in research methods by participating in the summer-long Clinical Effectiveness Program at the Harvard School of Public Health," said Dr. Fleischmann. She enjoyed the experience so much that she decided to become a clinical researcher focused on understanding what tests and treatments improve outcomes for patients with heart disease.
She also earned a Master's in Public Health degree from the Harvard School of Public Health while she worked her day jobs as a fellow and later an associate physician at the Brigham. "It helped that the School of Public Health is essentially just across a courtyard from the hospital," said Dr. Fleischmann.
She joined the UCSF faculty in 1998, recruited by Dr. Lee Goldman, a cardiologist and clinical effectiveness pioneer who was then Chair of the Department of Medicine and Dr. William Grossman, Chief of the Division of Cardiology. "Dr. Goldman and Dr. Grossman were interested in supporting cardiovascular outcomes research at UCSF, and the opportunity to build a program here was very attractive," said Dr. Fleischmann. "The weather didn't hurt either."
Being Wholly Present for Patients
In addition to her research on clinical outcomes and cost-effectiveness, Dr. Fleischmann has a busy clinical schedule. She sees patients in the Mission Bay clinic, performs and interprets echocardiograms, supervises stress tests in the Non-Invasive Stress Laboratory, and oversees the care of hospitalized patients in the Intensive Cardiac Care Unit as well as serving on the inpatient cardiac consult service. She also serves as Medical Director for the Cardiac Stress Laboratory.
"I find restoring someone to health and supporting them in their efforts to live a healthy life is very satisfying," said Dr. Fleischmann. "I also love seeing my long-term patients in the clinic with their family and friends, and learning about their home life, goals and aspirations. Part of my job as a physician is to educate, support and help my patients. As a doctor, I am a trusted source of information. I make sure that patients are aware of risk factors and what they can do about them. I let them know about proven treatments and therapies. It's a partnership between doctor and patient."
As a specialist in non-invasive cardiology testing, she spends a lot of time in the Echocardiography Lab. "Even after all these years, I love looking at the heart," said Dr. Fleischmann. "It's endlessly fascinating. We can get so much information from non-invasive tests, which are relatively low-risk to the patient. Those tests can tell us about the structure and function of the heart, how well it works as a pump, whether it can relax normally, how the valves are working, and whether there is fluid buildup around the heart. Our cardiology fellows tease me because I still get so excited when I see something interesting. I'll say, 'Wow, look at that!' or 'That's gorgeous!'"
Dr. Fleischmann teaches throughout everything she does, whether in formal lectures, in the Echocardiography Lab, or at the bedside. "We are very lucky to have amazing trainees here," she said. "It's a privilege to work with them and pass on what I've learned. It's also very rewarding when trainees think through a problem and figure it out on their own. To see the light go on for them is very satisfying."
She advises trainees to find something they love to do, and to take good care of themselves. "Training is a marathon, not a sprint," said Dr. Fleischmann. "It's only by taking care of ourselves that we can be there wholly for our patients."
Outside of medicine, Dr. Fleischmann enjoys spending time with her family and all styles of music. A mezzo-soprano, she has been a church singer for many years, and loves singing Lieder, oratorio and opera.