What Would He Do Next?

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Alfred Buxton

“What Would He Do Next?”

I met Mark Josephson in 1973 when he came to the Hospital of the University of Pennsylvania (HUP) as a cardiology fellow. He had just completed 2 years at the US Public Health Service Hospital on Staten Island where he began his career in clinical electrophysiology. I was beginning medical internship at the same time. Even though Mark was among the most junior members of the cardiopulmonary division he quickly became one of the leaders, both by force of his personality, as well as a remarkable series of observations encompassing broad areas of clinical electrophysiology, including supraventricular (SVT) and ventricular tachycardias (VT). In the 1970s at our clinical cardiology conferences, Mark and colleagues described exciting new observations almost on a weekly basis. These observations formed the basis for much of the practice of clinical electrophysiology, not only in that decade, but to the present time. For myself, as someone interested in asking questions, this was an incredibly stimulating environment, and Mark was a most exciting mentor and role model.

Subsequently, from 1979 to 1981 when I served my electrophysiology fellowship, the work of the EP lab continued to expand. During this time surgical therapy for ventricular tachycardia was growing enormously, and both patients and electrophysiologists came to HUP from all over the US and abroad. The mantra of Mark, which carried over to the entire lab, was to study everyone possible, and enroll everyone possible into a research protocol. These were times before catheter ablation existed: therapeutic efforts were aimed at appropriate drug choices, based on physiology as we then understood it. Direct EP therapy was limited to the operating room for patients with VT as well as SVT – we routinely operated on patients with Wolff- Parkinson-White syndrome. Mark loved studying patients with SVT, and used these cases to expand and refine our understanding of the underlying physiology.

Two major changes took place in clinical electrophysiology in the 1980s: the introduction of the implantable cardioverter-defibrillator (ICD) and the introduction of catheter ablation (initially using direct current shock, then radiofrequency energy). Characteristically, Mark was initially skeptical of each, before embracing them, and utilising them fully and skillfully. Nevertheless, a common theme drove him crazy about each of these therapeutic modalities: indiscriminate, unphysiological use. Regarding the ICD, he felt that it is often used inappropriately, without regard to the individual patient’s overall clinical situation – he was staunchly against blind adherence to practice guidelines, without attempts to comprehend individual patients’ arrhythmic tendencies and mechanisms (i.e., underutilisation of diagnostic electrophysiological studies). Second, he both practiced and preached against empiric catheter ablation without first exploring a patient’s physiology. That is, he did not believe in “Learning While Burning”. Rather, his philosophy could probably be expressed as “Learn Before You Burn”.

I spent about 22 years training under, and then working alongside, Mark. I also spent 18 years working at institutions separate from Mark. I think his influence on me (and I suspect this is true for most of the many others who trained under him) can best be summed up in this way: regardless of his physical presence, I have never done an EP study or ablation without him at my side, thinking, “What would he do next?” Almost every time I care for a patient, I think, “What would he do?” For me, this will never end. What greater tribute could there be for a physician, electrophysiologist and teacher. I am extremely grateful for the time we had together. I will miss him sorely.