Robert Battle, MD: Treating Hypertrophic Cardiomyopathy as a Sports Cardiologist
OCTOBER 25, 2018
Cecilia Pessoa Gingerich
Robert Battle, MDRobert Battle, MD, is a professor of medicine and pediatrics at the University of Virginia Health Systems and serves as a cardiologist for the University of Virginia, James Madison University, and other schools in the area. He is also co-director of the Hypertrophic Cardiomyopathy Center of Excellence and director of sports cardiology there.
He began his career working with adults with congenital heart disease, but has expanded to work in pediatric cardiology, sports cardiology, and cardiovascular structural genetics.
Do you have a personal background in sports and athletics?There aren’t many sports I haven’t done. I was the most valuable player on my college lacrosse team, I played football, baseball, and soccer in high school. I’m now a cyclist, snowboarder, cross country skier, and a swimmer. I swim 3 miles a day, typically. Staying fit for me has been what’s kept me in the game. It’s kept me happy in life and balanced in life, so that when I got to my clinic and I’m working late I’m okay and feel good.
It’s amazing what can happen in medicine when people lose that balance, you don’t get enough sunlight, you’re sitting under an incandescent light all day long, you’re sitting around reading x-rays and it can lead to an unhealthy lifestyle. So, I practice what I preach and having played all those sports I can question athletes right down to the nitty gritty.
What is hypertrophic cardiomyopathy?Hypertrophic cardiomyopathy is the most common genetic cardiovascular disorder affecting probably more than 1 in 500, so there are literally 750,000 to 1 million Americans affected by this. It’s an abnormality that’s a little bit unique, the heart muscle is thicker than normal and it’s genetic, so the genetics of it are such that if you have a child and you have the gene you give your child a 50% chance of getting that. The heart muscle is unusually hypertrophied and thickened and it usually functions very well, but it can lead to heart failure and sudden death.
I have a genetics counselor and we’re very active in that area and we take care of families. So, I have a joint appointment in pediatric and adult medicine, so we can actually bridge the gap and see families.
Do you see patients with hypertrophic cardiomyopathy long-term?Absolutely. It’s longitudinal care, so that’s what I do basically. So, the younger patients—I’ll see some of them for years and continue to see them as long as I practice. So, you’re talking about decades of care and one of the things that’s interesting is you see a teenager turn into an adult, turn into a professional, to have a family, to get married. It’s really interesting to see people transition as they grow older, because in standard adult cardiology you’ll see older patients with coronary disease and to me this is far more interesting, far more fluid, far more dynamic, and there are a lot of issues I have to deal with. I have to deal with pregnancy, we do fetal echocardiographs to make sure the child’s not affected, you have to deal with dental hygiene because these hearts can get infected. We cross disciplines because many of them have liver disease and issues with employability or insurability, and we try to help with those issues.
Communicating with patients is important for any provider. As someone who sometimes works with patients from childhood through to adulthood, how do you manage that relationship?As they say in medicine, 90% of the time the answer is lying in a very careful history, and I consider that a conversation with the patient. Let them articulate what they want to say. Say for instance you have a young patient with hypertrophic cardiomyopathy like an elementary school kid. What happens with those children as they get older, many times their parents have done all the talking and many times the providers are used to talking to the parents and not talking to the children. And so, as they get older if you continue with that pattern you make a big mistake.
I had a young adolescent many years ago who was very volatile, very reactive, very hard to manage, and he had something called coarctation of the aorta and he wouldn’t go to doctor’s appointments and his mother brought him in once, and she just looked at me and she said, “you know Dr. Battle you’re the only doctor he’ll see.” And I asked why is that, and she said I’m the only one who talks to him, and that was a really interesting lesson for me. It’s interesting because parents that have been put through the ringer with a young child with really complicated congenital heart disease—in fairness to them they’ve been through hell and high water for years to get that child into adulthood, so it’s natural that they would go to doctor’s appointments and try to figure out what’s going on and talk about what their child is experiencing and all that kind of stuff. So, there’s a normal dynamic there, but the parents who can let their children grow and enter the discussion—they’re usually the ones you get the best results for.
What is the value of experience when it comes to caring for patients with a rare genetic condition?In the old days, doctors would see patients with these conditions—maybe 2 or 3 a year and maybe even fewer than that. They had very little experience with the conditions. People now want to see providers that are experienced and see a significant volume of these conditions to get the best possible care rather than just going to any doctor that views it as unique and different but may not have very much experience in it.
I’m 62 years old now and the single most important teacher in medicine is experience and it’s not even close. I don’t care how much you read and study, or how much literature you peruse, if you don’t see patients and you’re not exposed, you’re not going to know what to do under certain situations. So, to me things are changing now with medical education there’s lots of limitations, your access can be limited by the amount of time you’re allowed to work or all these sorts of things, and that’s why I believe in being really busy clinically. It’s really important for physicians to have those at-bats. As I look back on my career, you didn’t know as much as you thought you did when you were younger, there’s no doubt about that. It’s like that old-line form Ron Stewart, “I wish I knew what I know now when I was younger.”
How are you, as a specialist in hypertrophic cardiomyopathy even within the specialty of cardiology, able to help patients live to their fullest potential? Can you share an example of working with a patient?I saw a patient this week with hypertrophic cardiomyopathy and he’s a risky genotype, he’s got things that worry me, and he knows that. He’s been seeing doctors and he’s getting progressively more frightened and progressively more depressed and he’s profoundly symptomatic, because his muscle is so thick his heart is obstructing as he’s ejecting blood, making him profoundly short of breath. He can’t hardly walk across a field.
But it turns out there’s a surgical procedure where you can go in and get that muscle that’s obstructing flow and improve his functional capacity dramatically. So, there’s a chance we can change this guy from suicidal to almost fatalistic to having a good quality of life and being happy again. You know those decisions were reached after I had a really in-depth discussion with him about what his life was like.
What is it like working with medical students or residents who are interested in sports cardiology?I have a lot of undergraduates that come and shadow the clinic or cardiology fellows come and we’re trying to teach them these things that are not typically part of the standard curriculum. It’s new enough that it’s just not part of the standard curriculum. We’re so inundated with the usual things in cardiology like electrophysiology, heart failure, valvular heart disease, and coronary heart disease—those things are so overwhelming in terms of how much attention they get that the nuance in these areas is often lost on most people when they come out of their training.
It’s also interesting when people come to interview for their training program they already know what they want to be, and I don’t understand how they know that. Part of it is they have so much pressure to decide who they are and what they want to do, and I love it in an interview when they say they don’t know what they want to do yet.
And my daughter’s pre-med, she’s an athlete. She played on the Virginia basketball team her first year, but it was just too much so she’s focusing on her studies and I said you’ve got to find your passion and be patient, you’re not in a rush. It’s like if you’re going to marry somebody you have to make sure you get it right, because if you wake up and you’re 60 years old like I am, and you don’t love what you’re doing—I don’t know if I could survive that. I don’t know if I could continue to practice if I didn’t love what I was doing.