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Resolutions for 2020: Optimizing my Ikigai and the pursuit of happiness

While reflecting on an extraordinarily busy yet rewarding career year of 2019, I thought of my resolutions for 2020. I’m exceptionally bad at keeping new year resolutions, so I only made one: to be happy.

The concept of Ikigai

Happiness can mean different things to different people, and each of us, particularly medical professionals, is on a personal journey. There is a cool Japanese concept that encompasses multiple spheres of happiness, called Ikigai. Meaning “a reason for being”, it is well-depicted at the intersection of a quintessential Venn diagram that is really doing the rounds on the internet.

The concept of Ikigai

Image: Find your Ikigai. BODETREE, ADAPTED FROM FRANCESC MIRALLES

 

Fundamentally, it encompasses aligning one’s personal and career goals by combining the things one loves, is good at, what the world needs and what one is/could be paid for.1 Applied to physicians, it’s essentially the pinnacle of work-life balance.

While much is being discussed about physician wellness and work-life balance in recent times, for fellows in training and early career physicians, achieving a good work-life balance can be formidably challenging. In a formative and critical stage in your career, you want to maximize on all opportunities to learn and demonstrate competence. Given that conventional wisdom in medicine has always assumed that working harder and taking on more responsibilities is what makes one a better physician, you find yourself in a precarious position, and unable to say no, perhaps to avoid being considered “irresponsible” or “disinterested”, among others.

Thus “having it all” is way easier said than done. Thinking long and hard about this resolution, I went back to the concept of Ikigai. Seemingly, in order to discover your Ikigai, you must first find what you’re most passionate about, then find the medium through which you can express that passion.2

As cardiologists, or in fact medical professionals in general, I’d like to think that we’re already halfway there, having discovered our passion for the work we do. This got me thinking that a great part of my sense of happiness and fulfillment, my ikigai, could actually be achieved simply by getting better, more competent and efficient at my job, thus paving the way (and time) for doing the other things I also wanted to do.

While cardiology can be one of the most rewarding and emotionally fulfilling careers, it does come with significant sacrifices. In my sometimes unrealistic attempts to maintain a social life and achieve the so-called “work-life balance”, I recall doing exam revisions with my study buddy until midnight, forcibly satisfying a respectable quota of daily reading and “rewarding“ myself with a game of Settlers of Catan with my non-doctor friends late into the night, only to have to be present at rounds by eight the next morning. Especially during my initial years of training, in a pursuit to achieve work-life balance, I struggled trying to exclusively “slot out” time periods for work and leisure. As a result, my laptop became a mandatory accessory, finding a place at hangouts, parties and even vacations, where I’d squeeze in that little bit of work if I found the time.

P-squared: Matching passion with purpose

So, how do you effectively ensure time for other things in life, without compromising on expectations and quality at work? I found myself picking up handy tips from Morton T. Hansen’s fabulous book Great at Work: The hidden habits of top performers.3 One aspect that really resonated with me was the concept of P-squared, i.e. matching passion with a strong sense of purpose. He writes about how passion at work is not merely taking pleasure in the work itself, but can come from success, social interactions, learning and competence. In short, pursuing activities that are personally meaningful.

Working smarter over working harder

One way of ensuring one’s focus on meaningful activities is to prioritize and decide what work you will pour your heart and soul into.3 Naturally, each task is not guaranteed to trigger your interest to the maximum. While the “chores” that are one’s professional responsibility absolutely need to be done (and prioritized), it’s important to pick and prioritize ancillary projects, thus ensuring one’s full focus and ultimately better seeing it to fruition. Given professional hierarchy in medicine, it can sometimes be difficult to say no early on in one’s career. A piece of brilliant advice I’ve been given in such scenarios is: If it’s part of a project you happen to land but which can (and should) be done by someone else, delegate it smartly and oversee the work. The advantages are multiple: you facilitate an opportunity for someone else to gain that experience, you gain the experience of overseeing a job and most importantly, it reduces an unnecessary load on you, allowing you to make the time for the projects that matter.

Also, focusing on doing fewer things but doing them better, means that you have more time left over, which you can spend on your private life, effecting towards some degree of work-life balance.3

Share the load

A roster has a purpose and it’s important to share the load. Accepted that we all have our unique personal challenges, some more than others, I found myself chronically covering another person’s roster, stressing out and compromising on my own private time that I could very well have spent with family and friends. While mutual cooperation within a working unit is vital to good work-life balance, particularly in medicine, it should certainly not be at the expense of one’s happiness.

Take breaks

Doctor Hansen also writes about the importance of keeping one’s passion in check, and not allowing it to consume you.3 Grossly translated, it means making the time for one’s private life, be it travel, working out, reading or playing a sport. Thanks to a wonderfully supportive spouse, I might have gotten away with amalgamating work and life on most occasions, but I appreciate the necessity of making an effort to keep work passions in check, and actively make some quality time for family and friends.

“Work on how you work, not on protecting your life from work” – Morten T Hansen

All things said, I’m extremely grateful for being able to do something that I absolutely love, would hope I’m good at (!), get paid for and certainly what the world needs, neatly satisfying the central convergence of the multiple dimensions ikigai. One’s ikigai.is a deeply personal journey, and not one a mentor can spell out for you. However, actively making an effort to being efficient at work, being less stressed out and more balanced would certainly make one better at life too, translating to happier social and private lives. Achieving an Utopian level of work-life balance may not be possible, but finding happiness and fulfillment in what you do certainly is, and it’s a resolution I’m going to make an effort to keep this year. A happy new year to you all!

 

References

  1. Garcia H, Miralles F. Ikigai: The Japanese Secret to a long and happy life. New York: Penguin Books; 2016.
  2. Myers C. How To Find Your Ikigai And Transform Your Outlook On Life And Business. Feb 23, 2018. https://www.forbes.com/sites/chrismyers/2018/02/23/how-to-find-your-ikigai-and-transform-your-outlook-on-life-and-business/#6e99332a2ed4
  3. Hansen MT. Great at Work: The Hidden Habits of Top Performers. New York: Simon and Schuster paperbacks; 2018.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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Is Old Really Gold? The Case Against Aspirin

The recently concluded AHA Scientific Sessions provided for a myriad of sessions on antiplatelet therapy in cardiovascular disease (CVD).

The late-breaking TWILIGHT ACS trial reported a win for ticagrelor monotherapy among patients randomized after 3 months post-NSTE-ACS and PCI, in results consistent with the main TWILIGHT trial.1-2 TWILIGHT ACS showed a reduction of clinically significant bleeding with no increased risk of ischemic adverse events at 1 year, for those randomized to ticagrelor monotherapy versus aspirin plus ticagrelor (DAPT).1

That same day, an entire session aptly titled “Aspirin: who needs it anymore?” dedicated to the dissection of aspirin, featured a series of talks on the role for aspirin for the primary and secondary prevention of cardiovascular disease (CVD).

Questioning the potential “twilight” of aspirin therapy, Dr Roxana Mehran raised some pertinent issues particularly pertaining to bleeding risk and gastrotoxicity of aspirin, in addition to treatment failure/ “aspirin resistance” resulting from its enteric-coated preparation and potential drug-drug interactions.

Nevertheless, while aspirin may still remain in the game with respect to secondary prevention, 3 randomized clinical trials in primary prevention have ensured a “three strikes and you’re out” scenario for aspirin, culminating in a de-emphasis in the guidelines as well.

One of the best things about attending meetings is the effortless re-cap/ additional reading one does afterwards. Thus, in order to discern how such a fate befell aspirin, here’s a brief look at the “three A’s” of 2018 responsible for hitting the nail in the coffin:

 

The ARRIVE (Aspirin to Reduce Risks of Initial Vascular Events) trial

ARRIVE enrolled 12 546 patients (men ≥ 55 years with 2-4 risk factors and women ≥ 60 years with ≥risk factors for CVD) who were randomized to enteric-coated (EC) aspirin 100 mg/day versus placebo.3 ~29·5% of participants were women. Individuals with diabetes and those at high risk of bleeding were excluded. The primary endpoint was a composite outcome of time to first occurrence of CV death, MI, unstable angina, stroke, or transient ischemic attack.

After a median follow-up of 5 years, no significant differences were observed in the primary end-point between those assigned to aspirin vs placebo (4.29% vs 4.48%; p=0.6038), although the event rate was much lower than expected, thus making the study more representative of a low-risk population. The overall incidence of adverse events was similar in both groups, however, there were significantly more gastrointestinal bleeding events (predominantly mild) in the aspirin group than placebo (0.97% vs 0.46%; p=0·0007).

 

The ASPREE (Aspirin in Reducing Events in the Elderly) trial

This trial enrolled 19,114 healthy community-dwelling individuals across sites in Australia and the USA aged ≥ 70 years (or ≥ 65 years if  Black/ Hispanic in US) and devoid of CVD, dementia or disability who were randomized to 100 mg EC aspirin vs placebo.4-6

The primary end-point was a composite of death, dementia or persistent physical disability while secondary end points included major hemorrhage and cardiovascular disease (defined as any ischaemic event).4-6 At 56.4%, ASPREE enrolled the highest number of women from among the three trials.4 The median age of participants was 74 years.

The trial was terminated early at a median of 4.7 years of follow-up, as it was determined that no benefit would be derived with continued aspirin use in terms of primary end point. Accordingly, there were no significant differences in the primary composite outcomes (21.5 vs. 21.2 events per 1000 person-years; p = 0.79 ).4 However, rates of major bleeding were significantly higher in the aspirin group (8.6 vs. 6.2 events per 1000 person-years; p < 0.001),  with a progressive increase in the cumulative incidence of major hemorrhage across the follow-up period.5 The majority of these episodes were gastrointestinal bleeds, with the higher risk of upper GI bleeds being particularly more pronounced with aspirin (hazard ratio, 1.87; 95% CI, 1.32 to 2.66).5

There was also an increased risk of all-cause mortality in the aspirin group versus placebo (12.7 vs 11.1 events per 1000 person-years; HR, 1.14; 95% CI, 1.01 to 1.29) with cancer being the major contributor to the higher mortality seen with aspirin.6 Thus, ASPREE concluded that the daily use of low-dose aspirin did not prolong disability-free survival among the elderly.6

 

The ASCEND (A Study of Cardiovascular Events in Diabetes) trial

A trial specifically designed to investigate the effects of aspirin in primary prevention among diabetics, ASCEND enrolled 15,480 individuals (~37. 5% women) in the United Kingdom with diabetes but no evident CVD who were randomized to 100 mg of aspirin daily versus placebo.7

During a mean follow-up of 7.4 years, those randomized to aspirin had a significantly lower percentage of serious vascular events in comparison to placebo (8.5% vs. 9.6%; P=0.01). However, this benefit was offset by significantly higher major bleeding events seen in the aspirin arm (4.1% vs. 3.2%, p=0.003), with no attenuation of the effect on bleeding over time. As with ARRIVE, the majority (41.3%) of major bleeding events were gastrointestinal, of which close to two thirds were in the upper GI tract. Thus, the trial concluded that the absolute benefits of aspirin in preventing CVD among diabetics were largely counterbalanced by the hazards of bleeding.

These trials formed the basis for the de-emphasis of aspirin in the 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease, which recommended against the prophylactic use of aspirin among elderly (>70 years) and those at high bleeding risk. There was also a downgrade in class of recommendation for low dose aspirin for primary prevention in select 40 to 70 year-old adults at higher ASCVD risk but lower bleeding risk (Class II b).8

To add to this, a comprehensive meta-analysis of 13 trials comprising of 164 225 participants without cardiovascular disease by Zheng et al., found that aspirin use was associated with a significant reduction of cardiovascular events but also an increased risk of major bleeding events compared with no aspirin.9

As Dr Erin Michos, one of the co-authors of the Primary Prevention guidelines pointed out in her talk at AHA 2019, this poor performance of aspirin in terms of risk-benefit could be attributed to the improved adherence to other primary prevention methods, such a reduction of smoking, better control of blood pressure and importantly more aggressive lipids control by virtue of statins.

With the much-needed emphasis on bleeding and its detrimental effects, “less is more” has been the focus in recent times, at least for antiplatelet and antithrombotic drugs, with recognition of trials that withdraw rather than add to current drug treatments. Furthermore, the appropriate prescription of drugs and increased emphasis on lifestyle modification for primary prevention cannot be understated. The onus is on physicians to keep up to date and tailor drug prescriptions to the individual patient.

Also, in keeping with the spirit of on post-conference re-caps, highly recommend the following as additional reading:

  1. Marquis-Gravel G, Roe MT, Harrington RA, et al. Revisiting the Role of Aspirin for the Primary Prevention of Cardiovascular Disease. Circulation 2019;140(13):1115-1124.
  2. Ridker PM. Should Aspirin Be Used for Primary Prevention in the Post-Statin Era? N Engl J Med 2018;379(16):1572-1574.
  3. Antithrombotic Trialists’ (ATT) Collaboration, Baigent C, Blackwell L, et al. Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 2009;373:1849-60.

References:

  1. Presented by Dr. Usman Baber at the American Heart Association Annual Scientific Sessions (AHA 2019), Philadelphia, PA, November 17, 2019.
  2. Mehran R, Baber U, Sharma SK, et al. Ticagrelor With or Without Aspirin in High-Risk Patients After PCI. N Engl J Med2019;381:2032-42
  3. Gaziano JM, Brotons C, Coppolecchia R, et al. Use of aspirin to reduce risk of initial vascular events in patients at moderate risk of cardiovascular disease (ARRIVE): a randomised, double-blind, placebo-controlled trial. Lancet2018;392:1036-46.
  4. McNeil JJ, Woods RL, Nelson MR, et al. Effect of Aspirin on Disability-free Survival in the Healthy Elderly. N Engl J Med 2018;379:1499-1508.
  5. McNeil JJ, Wolfe R, Woods RL, et al. Effect of Aspirin on Cardiovascular Events and Bleeding in the Healthy Elderly. N Engl J Med 2018;379:1509-18.
  6. McNeil JJ, Nelson MR, Woods RL, et al. Effect of Aspirin on All-Cause Mortality in the Healthy Elderly. N Engl J Med 2018;379:1519-28.
  7. ASCEND Study Collaborative Group, Bowman L, Mafham M, et al. Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus. N Engl J Med 2018;379:1529-39.
  8. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019;140(11):e596-e646.
  9. Zheng SL, Roddick AJ. Association of Aspirin Use for Primary Prevention With Cardiovascular Events and Bleeding Events: A Systematic Review and Meta-analysis. JAMA 2019;321(3):277-287.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

 

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From across the Atlantic: making the most of your conference trip as an international delegate

Approximately 30-40% of AHA Scientific session attendees are from outside of the United States. Taking a couple (or more!) of flights, landing in a new city after a 23-hour trip from across the Atlantic and functioning at optimum levels during a meeting of such magnitude may well be a formidable task, particularly when it’s a short trip and you want to get the most of it.

While each person has their own mechanisms of adapting, here’s some derived from my relatively short experience:

Optimize the long flight hours: I personally feel that sleep makes for the finest use of flight time, particularly on long-haul flights and red-eyes. There are others, however, who might opt to use this time to fine-tune presentations and prepare points for posters. A good rest in flight also helps you adapt and combat jetlag optimally, allowing you to function at maximum efficiency.

Get the mundane things over with: Make sure you’ve sorted (and preferably pre-paid for) accommodation, figured out airport to hotel commutes, activated international roaming allowing for sufficient data/connectivity and downloaded offline maps of the city, just in case. Accommodation within walking distance to meeting location is convenient, allowing for a later wake-up (if you’re not an early riser like yours truly!) but most importantly obviating the need for figuring out taxis/ tube maps/traffic navigation when you’re very likely to be in a rush.

Pack light but pack smart: International transfers can be unpredictable; I always factor in lost/delayed bags and pack an entire day’s conference wardrobe into my hand luggage. The importance of comfortable shoes cannot be understated, especially if you’re trying to do a superspeed Flash act between meeting rooms. I also carry a large bag at meetings, one that would accommodate a fully-charged laptop and power banks, phone charger with universal adapter (absolute essential!) and a light jacket for a cold meeting room. Also, any additional space is more than welcome for journals and other print material you might pick up.

Plan your itinerary right: Basically, be in the room where it happens. Even with the most efficient meeting app, chances are you’ll have multiple overlapping sessions bookmarked. Keeping in mind the genre of sessions one might not always have access to back home, I would opt to attend late-breaking science, live cases and interactive sessions by experts, over, say, seminars and updates on more general topics.

Use social media: It’s a formidable accessory to derive the maximum conference experience. Apart from the obvious pluses of rapid access to scientific content and networking, a twitter update might even alert you to a session you intended on attending but somehow missed bookmarking.

Avail opportunities for networking: Most of conference science can now be accessed online post-conference but, one cannot put a price to the value of face-to-face networking or comparing notes with peers from across the globe, potentially even leading to collaborations. And let’s not forget the opportunities to literally pick on the brains of global experts at dedicated sessions, such as those offered at the FIT lounge.

It’s not all about the science: Make use of the additional programming. The Women in Science mentor-mentee session I had Saturday morning with Dr Noel Bairey Merz, even before I attended my first scientific session, provided a wonderful opportunity to discuss research and career with a prominent woman in cardiology (WIC).

Take breaks: Go to exhibition halls and training pavilions; If you’re super-saturated with all the scientific content, visiting booths at exhibit halls are actually a great way to take a breather, caffeinate, pick-up some new literature or check out the new tech.

Get involved: At various levels in one’s career, there are many ways international members can get involved, perhaps by joining one of the AHA’s 16 scientific councils, for a start. The Early Career Blogging program is a fantastic project: apart from the remarkable learning and networking opportunities it affords, you can’t beat the incredible perks of front row seats at the Presidential Session, including a performance by the cast of Hamilton!!

Embrace the different perspectives but apply them locally: While these meetings provide the international attendee a much-needed global perspective on a variety of aspects pertaining to cardiology, it’s also equally important to appropriately apply what you learn, taking into account local culture and tailoring it to the norms of practice back home.

Enjoy the break from work: Last but not least, even with the busiest of itineraries, international meetings offer what can sometimes be much-needed downtime and a break from work. There is no joy like that of exploring a new city, so even if it means taking an extra half day, use that “me” time to good effect. Carpe diem!

 

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.