December 19, 2016 | Peter M. Flueckiger, MD
Education

W. Gregory Hundley, MD, FACC, is a professor of cardiology and radiology at Wake Forest Baptist Medical Center. He received his medical degree from Medical College of Virginia, VCU, and completed his internal medicine internship, residency, and cardiovascular fellowship at University of Texas, Southwestern (UTSW). Dr. Hundley is the program director for the Cardiovascular Imaging Training Program at Wake Forest Baptist Medical Center and a member of the COCATS 4 writing group for training in cardiovascular magnetic resonance imaging (CMR). He is involved in numerous nationally sponsored grants and research projects related to CMR.

What is your training background and how did you choose a career in imaging/CMR?

I initially went to UTSW for cardiology fellowship with plans to pursue an interventional fellowship. However, as a general fellow I remember going to see a patient scheduled for catheterization who had also undergone a CMR scan. I was amazed at the clarity and image quality of the CMR images. At that time – more than 25 years ago – there were only a few places in the country doing CMR. I became involved in research using coronary angiographic findings to validate findings on CMR and designed CMR protocols to create specific images addressing specific clinical questions. It was at this time that I realized I wanted to pursue a career as a clinician investigator, and the infancy of CMR provided a wealth of opportunities to pursue academic research.

After UTSW, I began working at Wake Forest Baptist Medical Center. I focused on stress testing with CMR. Since coming to Wake Forest, I’ve been involved in numerous grant funded research, clinical trials, as well as directing the CMR program here. Some of the early advice I received as a general fellow was that if I was interested in academic research, that CMR and non-invasive imaging was a field in an infancy of growth which afforded many opportunities for investigative research.

As part of the writing committee for COCATS 4 training document on cardiac MRI, what do you think was the biggest change or emphasis compared to prior versions?

Initially, the problem with CMR training was the few number of sites and institutions that had the clinical CMR volume to provide adequate training. Trainees had difficulty getting the number of scans to be clinically competent. Today, CMR is more widely available, but there are still many training institutions that do not have the volume to train clinicians or researchers to be competent in reading and interpreting these exams. Additionally, the myriad etiologies and clinical conditions in which to order a CMR and in which CMR is beneficial, from stress perfusion, infiltrative diseases, aortopathies, congenital disease, etc., means that the clinician/researcher needs to be familiar with not only the findings of each exam but also the necessary protocols to obtain accurate and required information and the clinical background to order the appropriate test. 

Finally, there are multiple different national organizations overseeing cardiovascular training, imaging training, and specifically, CMR training. This makes defining clinical competencies more complicated. There is movement towards a standardized Board exam similar to what is seen in echocardiography and nuclear medicine. I have personally been involved on the Board preparation side of this via teaching Board preparation courses in conjunction with the ACC.

What do you think will be the most important developments in CMR in the next three to five years?

I think there are three major developments that we will see in the next three to five years.  The first is faster technologies. As scanners, computer processing and imaging software continue to advance, I think that we’ll see a significant decline in the time to complete a scan and acquire the necessary images. Currently many of our CMR scans run approximately 45 minutes, but I think this will decrease to 10 – 15 minutes with improved technologies. The second is mapping of myocardial perfusion that will greatly decrease the need for using gadolinium based contrast. The third is that MR imaging will include cardiac scans and other organs in the body within one protocol.

What advice do you have for first year fellows interested in a career in non-invasive imaging, specifically cardiac MRI?

If you are interested in CMR, be involved in the scans for your patients. When on inpatient or consult rotations, be involved with the planning and interpretation of the scans. A large part of being successful with CMR is having the baseline cardiovascular knowledge to plan a study based on the clinical setting. If you don’t know the characteristics of different infiltrative diseases or the nuances of valvular pathologies, you are not going to choose the correct sequences or images to answer the clinical questions. Finally, be involved in clinical and translational research related to CMR. Not only will this provide valuable experience as a clinical investigator, but it will involve you in the reading and analysis of CMR scans and images, and improve your knowledge and competencies related to CMR interpretation. 

Who have been your mentors and what did you learn from them?

Two of the biggest mentors in my early career were Ron Peshock, MD, FACC, and David Hillis, MD, at UTSW. Both Drs. Peshock and Hillis mentored me in my early career of academic research. Dr. Hillis taught me how to write; one thing that I would stress to FITs, and to early career clinician researchers, is the importance of learning how to write. Trainees and early career professionals need to ask themselves if they want to write. If you can’t write well, or don’t have a desire to improve your writing, you potentially face a major barrier to being an effective clinician researcher. If you want to go into meaningful academic research, you need to be able to express your ideas and thoughts in a clear and straightforward way. Writing is a critical skill for grant development and manuscript production.

At Wake Forest, Bill Little, MD, FACC, and David Herrington, MD, MHS, FACC, taught me how to write grants. Dr. Little created an outstanding environment for the pursuit of clinical investigation. He also helped me feel comfortable in my desire to pursue an academic career. He told me “if you wake up in the morning thinking about how to solve scientific questions, academic research is the career for you. If this is what drives you, you will never be bored with your work as there will be new discoveries every day.” Dr. Herrington was instrumental in teaching me the skills of grant writing and how to convey thoughts in a succinct manner. 

This article was authored by Peter M. Flueckiger, MD, a Fellow in Training (FIT) at Wake Forest Baptist Medical Center.