Faculty Spotlight: Erin Goerlich, MD

 

When Form Meets Function

“I have a passion for understanding how the structure of things in the body makes sense with how they work,” said echocardiographer Erin Goerlich, MD, who recently joined the UCSF Cardiology faculty.

Born and raised in San Antonio, Tx., Dr. Goerlich always loved science. Her mother was a nurse, which helped inspire her interest in medicine. She earned her bachelor’s degree in biology from the University of Texas at San Antonio, then completed her medical degree from McGovern Medical School at the University of Texas Health Science Center in Houston. She especially enjoyed anatomy lab, learning about the body from the inside out and later becoming an anatomy tutor. She then completed her internal medicine residency and cardiovascular disease fellowship at Johns Hopkins Hospital.

She gradually came to love cardiology. “The more I understood how the heart worked, the more it made sense and the more fun it was,” said Dr. Goerlich. “As I learned how to read EKGs and interpret other kinds of cardiac imaging, I realized cardiology was a great mix of clinical medicine, procedural skills and really interesting pathophysiology.”

Inspiring Mentors

She had multiple great mentors at Johns Hopkins who fostered her interest in cardiology. Steven Schulman, MD, was a master clinician, medical educator, and director of the cardiac ICU and cardiology fellowship program at Johns Hopkins. “He was so passionate about teaching all levels of students, from medical students all the way to advanced fellows,” said Dr. Goerlich. “He knew how to engage a group of overworked residents at 7 a.m. who were half-asleep because they were working 28-hour shifts. Rather than pointing at a PowerPoint slide, he’d toss you printouts from the best clinical trials, ask directive questions, get feedback, and keep it fun. He taught me that if you show people the primary data or key graph from a trial and put it into clinical context, you can really get that knowledge into people’s heads.”

Dr. Schulman’s dedication to both his patients and his trainees was legendary. “His patients loved him, and he could take people from death’s door to walking out of the hospital,” said Dr. Goerlich. “He was well-known to stay in the CCU (Coronary Care Unit) until after midnight and to send his fellow home before him. His fellows were like his children. He was great at guiding us to beneficial career pathways, pairing us up with other great mentors, and helping people get jobs and fellowships.”

Another key mentor was Allison Hays, MD, medical director of echocardiography at Johns Hopkins. “She found opportunities for her mentees, pushed me to present my abstracts at conferences and submit papers to journals I’d never heard of, and encouraged me to apply for awards that I was too busy to search for myself,” said Dr. Goerlich. “She was also so kind, warm and welcoming.”

Dr. Hays was also her research mentor, helping her pursue clinical investigations using cardiac magnetic resonance imaging (MRI) and echocardiography. Many of these projects focused on vascular reactivity – the ability of arteries to dilate or widen in response to stress or exercise, allowing them to increase blood flow and supply more oxygen and nutrients to the body. “Patients who later develop heart disease or have undiagnosed heart disease often have impaired arterial dilation,” said Dr. Goerlich. “It’s one of the hallmarks of early vascular disease.”

Conducting Clinical Research

One subtype of this condition affects the pulmonary artery, which carries deoxygenated blood from the heart to the lungs to release carbon dioxide and replenish with oxygen. If the pulmonary artery has difficulty dilating, it can lead to pulmonary hypertension, a condition characterized by high blood pressure in the pulmonary artery. Patients living with HIV are at elevated risk of hypertension, and Dr. Goerlich and her colleagues conducted a non-invasive MRI study of pulmonary artery dilation in this population.

Because patients need to lie still during an MRI, it can be difficult to measure their vascular response to exercise. Dr. Goerlich had participants squeeze a hand grip for five minutes while lying absolutely still. This isometric exercise elevated their heart rate, revealing that many of the participants with HIV had impaired vasodilation in their pulmonary artery.

She also helped lead research on hospitalized patients with COVID-19, including estimated heart filling pressures, multimodality imaging for cardiac evaluation, associations between reduced left atrial function and new cardiac arrhythmias, and novel findings of reduced function in part of the left ventricle. Dr. Goerlich also has studied cardiovascular effects of long COVID, and assessed the strengths and limitations of both invasive and non-invasive modalities of assessing endothelial function, or the inner lining of the blood vessels.

“We conducted most of this research during the peak of the pandemic,” said Dr. Goerlich. “Because the COVID patients were so sick, often they were in the ICU, flat on their backs, intubated and ventilated. That meant the quality of the echoes were not as high as we would normally have in a regular clinical trial, but we used what we had, and were excited about some interesting findings.”

Learning the Craft of Echocardiography

Under normal circumstances, sonographers often have patients roll onto their left side and take deep breaths to position the heart in the best location for capturing a clear image. Depending on each patient’s physiology, they find the best “windows” – spaces in between ribs or elsewhere in the chest that will allow the ultrasound probe obtain a good view of the heart. Lung disease can complicate this process, since conditions such as chronic obstructive pulmonary disease (COPD) or emphysema can create air pockets in the lungs that obscure the path of ultrasound waves and make it difficult to get high-quality images of the heart.

“A huge part of learning to read echoes is training your eyes what to focus on and what to ignore,” said Dr. Goerlich. “With medical students, residents and fellows who are just learning this skill, I’ll say, ‘Don’t pay attention to that – that’s just artifact,’” she said, referring to distortions that can be related to the ultrasound technology. “Eventually you train your eyes to screen out ‘noise’ from ‘signal,’ or actual information.”

A deep knowledge of cardiac physiology is essential. “Knowing exactly what’s going on during the cardiac cycle is important,” said Dr. Goerlich. “Almost every echo has an EKG tracing at the bottom of the screen. Based on that EKG, you should know when the valves are opening and closing, or when the heart is squeezing and relaxing. Knowing your anatomy and physiology helps you track the movements, and can help you know what you’re supposed to be looking at.”

Repetition is key. A general cardiology fellow is required to read hundreds of transthoracic echoes, and an advanced echocardiology fellow reads even more. “You want to see ‘normal’ over and over again to solidify that in your mind, which helps you recognize abnormal when you see it,” said Dr. Goerlich.

As a trainee, she studied online tutorials that helped her visualize 3D images of the heart, used a physical model of the heart in front of her to help her visualize a 3D heart from a 2D image, and also dissected an animal model heart to better understand how all the different parts fit together. “That was a very valuable experience, related back to my time in the anatomy lab in medical school, and it all came full circle,” said Dr. Goerlich.

In addition to conducting and interpreting transthoracic echocardiograms (TTEs), in which the probe is placed on the chest, Dr. Goerlich also conducts and reads transesophageal echocardiograms (TEEs). These involve sedating the patient and inserting the ultrasound probe through the mouth into the esophagus, where it can transmit more detailed images of the heart. This can be especially useful for imaging the heart valves in 3D. “With TEE, we can see how all the leaflets of a valve are opening,” she said. “If there’s valve regurgitation or leaking, we can get a much better sense of its severity and how to classify it for our report.”

TEE can be more challenging to conduct if a patient has certain conditions, such as obstructive sleep apnea, low blood pressure, or morbidly obesity. Dr. Goerlich works closely with the anesthesiologist to ensure that the procedure is conducted safely, and may need to finish sooner than anticipated if the patient’s blood pressure drops or they develop respiratory distress.

“I always tell trainees, ‘Answer the clinical question first,’” said Dr. Goerlich. “From residency and fellowship, I learned how to be fast, efficient and decisive, and now I love thinking on my feet. There’s a saying in medicine, ‘Take your own pulse first.’ That requires you to focus, get what you need, and maintain your composure, especially when you’re the leader – because your mood trickles down to everyone else.”

The Joy of Patient Care and Teaching

Dr. Goerlich appreciates the variety of her work, which includes caring for patients in the clinic and hospital, seeing patients who need an urgent cardiology appointment, and reading echoes in the UCSF Echocardiography Lab. “I love interacting with patients, hearing their stories, teaching them about their disease, and forming a plan together to improve their health,” she said. “It’s also incredibly rewarding to care for patients who are really sick, and seeing them improve to the point where they are very functional and healthy again.”

She also has a true passion for teaching. “I like seeing younger learners connect the dots,” said Dr. Goerlich. “As a trainee, cardiology became fun when I started to understand how the heart worked. If I can help things make sense for someone else, I hope I can inspire them to love cardiology, too, and to find it fun rather than intimidating. I also really enjoy working with the brilliant residents and fellows here at UCSF. They teach me things I haven’t thought about. Rather than a hierarchical relationship, we teach each other.”

When coaching trainees in the Echocardiology Lab, she gently guides them to learn by doing. “It’s a very tactile skill to learn, like playing a video game,” said Dr. Goerlich. “I work closely with the fellows, and for TEEs, it’s their hands that are on the probe the whole time. I help them find the images themselves, coaching them to turn a little clockwise, forward, or to the right. Sometimes they get frustrated, but it’s very satisfying to see them get it themselves and become the experts.”

She is very happy to have joined the UCSF faculty. “Everyone is genuinely happy and welcoming, and I love the atmosphere. There’s something special about UCSF, which prioritizes good clinical care, work/life balance, and collegiality.”

“Dr. Goerlich is top notch,” said Donald Grandis, MD, who served as co-director of the UCSF Cardiac Rehabilitation and Wellness Center for many years and recently retired from the UCSF Cardiology faculty. “She is one of the best cardiologists Johns Hopkins has ever produced, and we are fortunate to have her here. If I ever need a cardiologist, I would ask her to take care of me. She is also one of the nicest people you will ever meet.”

“Dr. Goerlich has been a wonderful colleague and addition to our Noninvasive Lab faculty and the Cardiology Division,” said Kirsten E. Fleischmann, MD, MPH, medical director of the UCSF Health Stress and Echocardiography Laboratories. “She’s also an accomplished researcher who uses advanced imaging techniques to understand diseases affecting the heart. I’m excited to see her grow her career here at UCSF.”

Dr. Goerlich is married to Corbin Goerlich, MD, PhD, a cardiothoracic surgery fellow at Stanford University. Together they enjoy hiking, trying new coffee shops, and exploring the California coast with their two young sons.

“I love being at an academic institution, and helping the next generation of internists and cardiologists gain more knowledge,” said Dr. Goerlich. “The connections I build with patients give me a lot of joy, and make this job so worthwhile.”

- Elizabeth Chur