Allison Webel, PhD – Page 2 – The Early Career Voice

Seeing and Serving Invisible Populations

May 8, 2019June 11, 2019 Allison Webel, PhD

Like many of you, I chose to be a nurse because I wanted to serve people during their most vulnerable times, knowing that this work would make a difference. Working with people at their most vulnerable has taught me a lot, including that my patients can be braver, kinder, more frightened, angrier, disappointed, lovelier, and in general more surprising than I expect when I walk in the door.

A growing and perhaps surprising population at disproportionally high risk for heart attacks are individuals who identify as transgender. Transgender individuals are those whose gender identity is different from the sex they were assigned at birth. People identifying as transgender can be any age or race, from any background, and reside in all 50 states. In 2016 there were approximately 1.4 million people in the United States who identified as transgender. Given the increase in the transgender population, new initiatives are attempting to understand the unique health needs of this population in order to provide high-quality health care. Little is known about the cardiovascular health of this population, which prompted a recent study by Dr. Alzahrani from George Washington University who found that the transgender population had a higher reported history of heart attacks compared with the cisgender (those whose gender corresponds with their birth sex) population.

This first-of-its-kind study examined approximately 720,000 U.S. adults who completed the telephone-based Behavioral Risk Factor Surveillance System survey, conducted by the Centers for Disease Control and Prevention between the years of 2014-2017. Of these, 3,055 adults identified as transgender. In gender stratified analyses, Dr. Alzahrani and colleagues found that after adjusting for known cardiovascular risk factors transgender men had (i.e. they were told by a doctor, nurse or health care professional that they had a heart attack) compared to cisgender men and women. And transgender women had a 2-fold increase in the rate of heart attacks compared with cisgender women. Importantly, the investigators also found that transgender men and women were more likely to smoke and be sedentary, and that these and other traditional risk factors were associated with increased odds of experiencing a heart attack. This suggests that while there are about the long-term cardiovascular risk of gender affirming-hormones, mitigating these traditional risk factors are important first line targets for this and all populations.

In an accompanying editorial Dr. Paul Chan evoked Ralph Ellison’s Invisible Man, citing the narrator “I am invisible, understand, simply because people refuse to see me.” Dr. Chan states that today transgender individuals are invisible. But they don’t have to be. We have to actively reject any implicit or explicit expectations we have about this population and simply see them and treat them as they present. This sentiment is echoed by Dr. Billy Carceres, Nurse and Post-Doctoral Fellow at Columbia University Program for Study of LGBT health, “There’s this perception that we can spot transgender people; but if we don’t ask the question about gender identity we might be missing out on people who are at risk. Patients want to have conversations with health care providers about things that influence their health.”

Table 1 lists several steps that can help us start to have these conversations. Adopting such steps in our clinical practice and research are critical against the backdrop of the increased social stress, poor socioeconomic status, health disparities, violence, and a perpetuating fear of mistreatment by healthcare professionals experienced by transgender populations. These steps will help us to see this invisible population, gain their trust, and ultimately help engage them in activities to improve their cardiovascular health.

Table 1. Steps to Reducing Cardiovascular Risk in Transgender Populations

Assess the gender of all your patients or research participants on multiple levels
Ask which pronouns they would like you to use
Understand the terminology used by the trans community
Recognize that transgender people may avoid seeking out health care because of fear of discrimination and create a safe and welcoming environment
Assess all potential cardiovascular risk factors for transgender patients and work with them to collaboratively develop a plan to reduce their risk factors
Learn more about the unique health care needs of your transgender patients. Your health care institution may have good local resources and the Center of Excellence for Transgender Health at UCSF and the World Professional Association for Transgender Health have up-to-date resources.

While Dr. Alzahrani’s new article highlights a significant disparity in an often overlooked and vulnerable population, ultimately we need a lot more data before we can develop and tailor cardiovascular treatment guidelines for transgender populations. As Dr. Sangyoon Shin, Medical Director of Co-Management Service for Gender Affirmation Surgery of Mount Sinai stated, “Its important to realize that the transgender population has specialized needs because they are more marginalized and face high rates of discrimination; But the health care practices the guidelines geared towards them need to be just as evidence-based as with any other population.“ Anything less would be a disservice.

People who seek out a health care provider – a nurse, physician, physical therapist, or pharmacist – do so because they need our help. Our job is to serve them, all of them, as they are, with high quality evidence-based health care. How we treat invisible populations, no matter how different or perplexing they are to us, is the true mark of our professionalism.

A Tale of Two Heart Attacks

April 16, 2019June 11, 2019 Allison Webel, PhD

Differentiation between Type 1 and Type 2 heart attack according to the condition of the coronary arteries (Thygesen, et al., 2012, Circulation)

Crushing. Stabbing. Gut-wrenching, knock the wind right out of you sort of pain in your chest, arms, neck, jaw or back. This is how we commonly think of heart attacks and for patients and their loved ones – it is the worst of times. But just before the pain or discomfort starts, your body is adjusting to the cause of the heart attack and those causes can be classified as either Type 1 or Type 2 heart attacks. There are actually 6 types of heart attacks, but the vast majority of heart attacks, including those experienced by people living with HIV, are either Type 1 or Type 2.

A Type 1 heart attack is when a person has a sudden block in their blood flow, usually related to a blood clot that has broken off from a plaque, resulting in reduced oxygen going to the heart and death of heart muscle cells. Whereas a Type 2 heart attack is when the heart needs more oxygen than it gets, due a number of potential causes including a spasm of the heart vessels, critical illness (including sepsis, very low blood pressure, and respiratory failure), or those undergoing surgery.

As I’ve previously written, HIV doubles the risk of heart disease and doubles the risk of having a heart attack. But in order to understand how to reduce this risk, we need to better understand what causes heart attacks in people living with HIV. Building on previous work demonstrating that half of the heart attacks in people living with HIV are Type 2 heart attacks, Crane and colleagues recently presented new research on the differences in types of heart attacks among people aging with HIV. In over 27,000 adults living with HIV, the investigators determined the type of heart attack, probable cause of all Type 2 heart attacks, and looked at the rates of heart attack by age.

causes of type 2 myocardial infarction among people living with HIV They identified over 1,000 Type 1 and 2 heart attacks and found that age was a primary predictor of the incidence and type of heart attack. Younger people with HIV had 10-fold more Type 2 than Type 1 heart attacks (although rates were low – only 22 heart attacks in this age group). Starting in their 50’s, people living with HIV experienced significantly more Type 1 heart attacks than Type 2. Most interestingly were the heterogeneous causes of the Type 2 heart attacks including sepsis, respiratory failure, pneumonia, hypertensive emergency, and GI bleeds (Figure 1).

When asked what initially prompted this work, Dr. Heidi Crane from the University of Washington Center for AIDS Research states, “As an awareness of the importance of Type 2 heart attacks has grown in the general population, we were struck that there was so little data in people living with HIV- a population which has twice the rate of heart attacks as the general population.” This new study demonstrates that younger adults living with HIV are more likely to have Type 2 heart attacks from heterogeneous causes, which change the prevention strategies needed for this group. While prevention strategies for Type 1 and 2 heart attacks require attention to traditional risk factors, we also need to pay attention to other non-traditional causes that may put someone with HIV at risk for heart attack due to supply-demand mismatch. Ultimately, these prevention strategies will need to be as heterogeneous as the causes. Dr. Crane continues, “There’s not going to be an easy fix for Type 2 heart attacks, there’s a lot going on and we will need to dive deeper to understand how to best tailor strategies to the individual patient.”

And yet, we’re often told that we need to treat the patient, not the disease. But in order to treat the patient, we have to know them, listen to them and understand the risk factors that they face as individuals for heart attacks. Whether it is a chronic disease like HIV infection or some other inflammatory condition, we will need to avoid the temptation to apply blunt prevention strategies, and favor the more challenging personalized solutions.

What are your experiences diagnosing and treating Type 2 Heart Attacks? How can we do a better job preventing them in people living with HIV and others at high risk? Tweet at me at @AllisonWebelPhD to follow the conversation.

Thumbnail photo credit: Photo by Kelly Sikkema on Unsplash

A Profile in Mentorship: Dr. Thomas Pearson

April 1, 2019April 1, 2019 Allison Webel, PhD

Every scientist, even those who are particularly good at hiding away in their offices, will have an impact on others. Most of the time, this impact is a byproduct of our everyday work. We don’t give it much thought – it just happens. But what if that impact was not accidental, and instead was a deliberate, strategic path of choices that build up those around us – even those who disagree with us, compete with us, and threaten us? That is the path that has been trodden by Dr. Thomas Pearson who was awarded the 2019 AHA Council on Epidemiology and Prevention Mentoring Award.

Dr. Pearson has an impeccable academic pedigree and an enviable career. After an early start at the University of Wisconsin, he earned his Bachelor of Arts, MD, MPH, and PhD all from the Johns Hopkins University. He has achieved the goal of every early career scientist – over 35 years of continuous NIH support and is a Fellow of the American Heart Association, American College of Cardiology, the American College of Preventive Medicine, and the American College of Physicians. But the degrees, grants, and accolades are a byproduct of a man driven to service for the love of science.

Dr. Pearson’s own mentors reflected his insatiable curiosity. As a student, he drew from a broad mentoring team that left lifelong impressions of the qualities of good mentor. While excellent teaching was important, more so was the “utterly frank” assessment and advice they provided him. He states, “from them I learned that the primary role of a mentor is to provide an honest, encouraging perspective on the mentee’s ideas, plans and experiences. While some mentors may be tempted to acquiesce or tell mentees what they want to hear- that is abrogation of their responsibility of a mentor.” Such frankness can be tough in today’s academic environment, so to help cultivate this skill, Dr. Pearson’s University of Florida developed the Mentorship Academy. Equally important to learning how to deliver a frank assessment of the mentee is helping the mentee learn how to receive and act upon such advice without taking umbrage to it.

Additionally, Dr. Pearson offered this advice on how early stage professionals can intentionally become effective mentors, including:

Be a good communicator. Communication is the basis of mentoring. Good communication should include developing shared expectations of the goals, responsibilities, and processes of the mentor-mentee relationship. Many of the problems that occur in the mentoring relationship result from a misalignment of expectations and reality. An honest conversation, with both parties being active listeners, about the mentor and mentee’s strengths, weaknesses and goals early on in the relationship can set both parties up for success.
Broaden your network. Every day we hear about new grants, interesting conferences, and visiting professors. Yet because they are just starting their career, mentees may not hear about the same opportunities. Part of being a good mentor, Dr. Pearson suggests, “is to continually be looking out for opportunities for your mentee and actively encouraging them to pursue them”. This includes inviting a mentee to a lecture and offering to introduce her to the speaker. Opening this door can help a mentee broaden her professional network and embolden her to pursue new opportunities.

Focus on the mentee. The mentor must recognize the mentee is not “hers.” Rather the mentor should focus on the mentee’s needs and goals and, if she finds another investigator can provide a better opportunity for the mentee, help to arrange it. Dr. Pearson states, “Mentoring and selfishness are like oil and water- they don’t mix.”
Stay curious. In his acceptance speech, Dr. Pearson talked about how much he learned from each of his mentees. They taught and inspired him as much as he did them. But that can only happen by accepting that mentoring is a partnership in which each person has a lot to offer. Good mentors need to be curious about their mentees and excited about learning from them.

Dr. Pearson has mentored over 60 people during his career. Many have gone to have equally enviable careers where their impact reverberates into every corner of our profession. He told me, “You never really stop mentoring a mentee. People I mentored still call me and talk about their career, their family. At some point, they start being friends.”

Mentors – true mentors – view their work not as a requisite service but as a thread that weaves together the knowledge of the current and past generations to the next. Mentors are the foundation upon which scientific progress is made; and their impact is the greatest when their mentoring is done with humility, enthusiasm, compassion, curiosity, and an infallible sense of optimism. These are the traits Dr. Pearson embodies; and are the ones that all who seek to see further should strive to emulate.

Engaging in the Conversation of Science: Its Time for You to Take an Active Role

March 13, 2019March 28, 2019 Allison Webel, PhD

Every day, headlines scream about cures, causes of disease, and questionable scientific advances. While many health reporters work hard to get the science right and translate it into something digestible for the public, they are still subject to pressures that can lead to less than precise articles. And once a scientific paper or abstract finds its way on to social media, the “facts” can be distorted into something barely resembling the original results, leaving scientists and the authors of the paper cringing. Given the speed of information-sharing today and the resulting imprecision, NOW is the time for all scientists (including early career scientists) to actively engage the lay public in the conversation of science through all means possible – even social media.

This was the topic of the early morning, early career presentation Bailey DeBarmore and I gave at the 2019 AHA EPI Lifestyle Scientific Sessions. To be honest, using social media to disseminate my science was definitely not something I learned in graduate school. In fact, my first exposure to blogging was through the TV character Barney Stinson, and for most of the past 15 years, I thought blogging was typically superficial and shameless. However, recently I have seen (and used) its immense power to share my own science. These experiences convinced me that social media may be one of the powerful tools we have to actively engaging and shaping in the conversation of science.

Whether or not scientists should blog has been hotly debated. In 2018, Eryn Brown and Chris Woolston published a persuasive article on why science blogging matters in Nature. They list a number of benefits to blogging including furthering one’s career, recruiting more bright minds to science, creating a new community of scientists, and it can further the reach and understanding of science (by both the public and often by the scientist herself). Those are significant reasons to write a science blog. But, if you’re someone like me and didn’t really understand what blogging was, you may be wondering how to start. There are several ways to get started writing science blogs:

Write your own. Brown and Woolston mention a several blogs started by scientists including Small Pond Science. This is a viable option, and there are a number of books and companies ready to help anyone start to blog for a fee. However, it can be a lot of work. Not only will you have to create the content, you will need to create and maintain the website, as well. Depending on your experience with website creation, you may not want this to be your first foray into science blogging.
Work with your professional organization. Many professional organizations including the American Heart Association, The American College of Sports Medicine, and the American Society for Nutrition have active blogs. And all blogs need one thing to stay relevant – content. As professional organizations have recognized the power of social media and blogging to advance their noble goals, they have increasingly worked with their members to help develop and promote accurate, timely, and engaging blogs. Some, like the American Heart Association and the American Society for Nutrition, have formal programs that provide both the blogging platform and training to help improve the quality and reach of the blog. (See links above to learn more about these great programs)
Collaborate with your journal editors. Increasingly, journals are offering authors the opportunity to create video abstracts, blogs, and podcasts on their accepted manuscripts. While it may seem like one more tedious or abstract thing to do, these can be highly engaging mediums on which to share your work. After all, if you’ve just spent years working on a research study that has somehow been condensed to 8 single-spaced pages, don’t you want that paper to have the maximal amount of impact?

Hopefully by now you’re convinced that that science blogging can be a helpful tool and want to see how you can test it out yourself. But science bloggers are [often] not paid, and if something is going to take away from your teaching, patient care, grant writing and manuscript writing time, then there needs to be a way to derive academic benefit from it. We need metrics – specifically metrics that your promotion and tenure committee can appreciate. So I’ll conclude with a couple of tips for benefiting from blog writing.

Put your blogs on your CV. Edge for Scholars has great advice for how to cite a blog post on your CV (note they also publish some great early career academic blogs, as well).
Get your analytics (page views, geographic reach of your blog, number of times shared) and use them. You can include your analytics in your CV and also use them to highlight the reach of your science and your national and international impact on your 3- and 5- reviews.

If you like this blog or have any questions, let me know. I’d also love for you to share some of your science blogs with me on twitter at @AllisonWebelPhD and tell me how they helped you better engage in the conversation of science. Happy Writing!

Red Dresses & Red Ribbons: What Every Health Care Provider Needs to Know about Cardiovascular Disease and HIV in Women

February 8, 2019March 28, 2019 Allison Webel, PhD

Lead Image (created by Cynthia Rentrope):

Each February, we celebrate Go Red for Women – a time for healthcare providers to reacquaint ourselves with the shocking fact that on average one woman dies from cardiovascular disease (CVD) every minute – and recommit to doing better. In the United States and the around the globe, women living with HIV are at higher risk for developing cardiovascular disease, yet not all women are affected equally. There are disparities in the quality of cardiovascular care in women, especially younger women, compared to men. Simultaneously, women living with HIV are at increased risk for cardiovascular disease than HIV uninfected women and receive less guideline-based cardiovascular care. In order to provide better preventative, diagnostic, and curative care we have to understand why women living with HIV are at higher risk for cardiovascular disease and stroke and what we can do about it.

Women living with HIV are at higher risk for CVD and stroke

The reasons why women living with HIV are at higher risk for CVD and stroke are not entirely understood. However, scientists have described several likely reasons. HIV is an inflammatory disease and women infected with HIV have higher levels of inflammatory cytokines and markers of immune activation. In turn, this inflammation may increase the risk of CVD by accelerating development of atherosclerotic plaques and making these plaques more ‘vulnerable’ to rupture, causing more heart attacks and strokes. Additionally, we recently reported that inflammation was also associated with reduced cardiorespiratory fitness in adults living with HIV, which may help explain this increased risk. Women living with HIV have elevated rates of depression, obesity, stigma, and homelessness, also associated with increased CVD.

However, there are also unique biological factors that increase the risk for CVD in women living with HIV, particularly with aging. According to Dr. Sara Looby RN, PhD, Assistant Professor of Medicine at Harvard Medical School and Massachusetts General Hospital, hormone changes experienced during menopause such as estrogen loss and reduced ovarian reserve may negatively influence immune activation and the development of subclinical CVD in women living with HIV. Her current study funded by the National Institute of Allergy and Infectious Disease is exploring this and the results are expected in the next 4 years.

Strategies to Reduce the risk of CVD in Women Living with HIV

Yet it is not enough to know there is a risk and even to partially understand why; health care providers- cardiologists, nurses, primary care providers, and HIV and emergency room physicians -chose their profession because they wanted to improve health. And all of us have an important role in helping women living with HIV accomplish this goal. There are several evidence-based strategies we can use to improve cardiovascular health in this population.

Take HIV medications. This strategy is well known among HIV nurses and physicians but those not trained in HIV may not realize the significance of HIV medications to reducing CVD in this population. Having a suppressed HIV viral load, obtained through adherence to effective HIV medicines, is consistently associated with reduced CVD.
Recognize and treat the cluster of traditional cardiovascular risk factors in HIV. Increased traditional cardiovascular risk factors in women living with HIV, including hypertension, dyslipidemia, diabetes, and obesity, need to be effectively addressed using guideline-based care. For a good resource on how to do this, check out the American Heart Association’s Life Simple 7
Assess sex-specific risk factors in women including menopause history. This may not be routine for HIV, cardiovascular or family health providers but it is important for understanding cardiovascular risk. Increasing evidence indicates we should use a woman’s menopause history to improve understanding of her risk of CVD and provide good cardiovascular treatment. Other health conditions unique to women, such as a history of pre-eclampsia, can also influence risk and are recommended as “risk enhancers” in the most recent AHA Cholesterol Practice Guidelines.
Engage women in their cardiovascular health. While this may be the hardest strategy to implement, it is the most important because for so long, women living with HIV have focused on surviving HIV that they do not perceive they are at elevated CVD risk. Dr. Looby acknowledges, “It can be difficult to find time to do this given the competing demands of clinical care, but education is essential to empowering women living with HIV to become active participants in their care. Delivering education in plain language that is easily understood by patients. Asking patients basic questions like, “Do you know what heart disease is?” or “Do you know your cholesterol levels and what they mean?” can provide simple snap shots of important information that can be built upon at subsequent visits, or followed up by providing supplemental educational materials.” Through this patient-focused engagement women living with HIV will be able to take charge and reduce their blood pressure, cholesterol, weight, and smoking resulting in improved cardiovascular health.

Almost every minute a woman dies from heart disease. But they don’t have to. We are privileged to serve in a profession dedicated to improving the health of our fellow humans. But human health is complex and, for women living with HIV, we cannot just treat their HIV or their CVD or their depression or their symptoms of menopause- we have to treat these intertwining conditions together. There are countless barriers to doing this well, and as new models of delivering cardiovascular care in HIV are under investigation, I am confident we will learn how to do this better. In the meantime, we have start today and commit to implementing strategies in our own practice to improve the heart health of women living with HIV.

A New Year, A New Story: Tips for a Healthy Lifestyle in 2019

January 9, 2019March 28, 2019 Allison Webel, PhD

A new year presents a new opportunity for improvement. Each year, thousands of advertisements beckon us to join or buy the most recent fitness and wellness craze – wearable technologies, personal coaching, pea protein and oat milk. However, if trends are not your thing, you may find it reassuring that “traditional” fitness and wellness strategies (e.g., training for a 5K walk/run, taking the stairs instead of the elevator, and reducing your sugar intake) can also be re-imagined and integrated into your daily routine leading to a healthier, and likely happier you.

Perhaps contrary to the many images trying to sell wellness products, adopting fitness and wellness strategies are equally if not more important for those who are living with a chronic disease. In November 2018 at the American Heart Association Scientific Sessions, the Physical Activity Guidelines were updated and, for the first time, specified that physical activity can help to manage chronic conditions including decreasing pain, reducing the rate of progression for high blood pressure and diabetes, reducing anxiety and depression, and improving cognition in those with chronic comorbidities. These critical health outcomes symptoms are particularly important for adults living with HIV, who tend to experience worse symptoms than many living with other chronic illnesses – and consequently, they may stand to benefit the most from increased and improved physical activity.

Figure 1 Photo by Christine Schmitt via flickr (http://bit.ly/2LZufoz)

However, in addition to physical activity, nutritional intake is a critical part of improving health and wellness among adults living with HIV. A recent practice paper of the Academy of Nutrition and Dietetics found that nutritional status affects the overall health and longevity of this population. They suggest that improved diet can lead to reduced blood pressure, obesity, and diabetes, which will result in improved cardiovascular health. Lead author of the report, Amanda Willig, RD, PhD, from the University of Alabama at Birmingham, suggests that when anyone (especially someone with a chronic disease such as HIV) is starting to adopt a new diet to “Remember, the enemy of good is perfect. A perfect diet is not needed to see big changes in your health.”

So what are the good diet changes needed to improve health? Regardless of one’s HIV status, Dr. Willig’s recommendations on healthier eating are the same: “Watch your portion sizes, try to eat vegetables every day / fill ½ of your plate with vegetables at meals, limit the amount of sugar in your diet, and choose water over sugar sweetened beverages like soda, sports drinks or sweet tea.”

However, for those with HIV, there are some special considerations. While the evidence is still emerging, Dr. Willig indicated that those with HIV may need more Vitamin D than they did prior to their HIV infection for their overall health. And if one’s CD4+ T-cell count is less than 250, they may want to avoid eating raw or undercooked meat and seafood, as they be at higher risk for food poisoning. Additionally, for the growing number of people living with HIV who are over 50, they may need to increase their protein intake from 0.8 grams per kg per day to 1.2 grams per kg per day. This will help with maintaining muscle mass and preventing bone loss.

Yet whether you are decreasing your portion size or increasing your daily protein intake, changing behavior can be hard and as we age, it can seem complicated and sometimes discouraging. In addition to seeking help from registered dietitian or a Physician Nutrition Specialist who can help you decide which lifestyle nutrition plan is best suited to you, Dr. Willig also suggested several tips for adopting a healthy diet in 2019 (see insert).

Dr. Willig’s Tips for Adopting a Healthy Diet in 2019

Keep a food diary for 3-4 days to learn not just what you are eating but why.

Start with the small steps that can produce big changes, such as cutting out sugary drinks or not eating during the night.

Regardless of the nutrition plan, portion sizes still matter. One can eat too many of the “right” foods, so learn what a portion of the foods you eat actually looks like.

Make sure your nutrition plan fits your lifestyle. If you want to cook, you can to experiment with baking and sautéing instead of frying foods. If you travel often, learn to read nutrition labels and restaurant nutrition information to avoid eating too many calories.

Additional strategies can be found on the American Heart Association’s Healthy Living Website.

As you start to navigate how to start the year committed to becoming healthier you, there will undoubtedly be challenges – busy schedules, competing demands, mood, weather and so on. But you can overcome them and take small steps to become a healthier you in 2019. As you start this journey, consider the words of writer Alex Morritt, “New year — a new chapter, new verse, or just the same old story? Ultimately we write it. The choice is ours.” The new year has just begun, and regardless of your age, sex, health status, or neighborhood in 2019 you get to write your own story – one in which you relentlessly pursue a healthier you.

Feel Like An Imposter? Strategies For Dealing With Early Career Self-Doubt

December 11, 2018March 28, 2019 Allison Webel, PhD

As we were wrapping up our first editorial meeting for the AHA Early Career Bloggers on Saturday at Scientific Sessions 2018, the new bloggers were given this advice: “Over the next three days, do something [at Scientific Sessions] outside of your comfort zone.” This year’s Scientific Sessions offered some novel experiences – augmented reality in the Cath Lab, network analysis for high throughput data, and machine learning for dummies. But the thing that made me the most uncomfortable was having my research recognized by my council.

If you have read my World AIDS Day blog, you know that most of my research and clinical work has been in the field of HIV. I came to the cardiovascular space out of necessity because my patients living with HIV were developing cardiovascular disease at higher rates than those without HIV. I never worked as a CICU nurse or in cardiac rehabilitation, and I still get confused about the many different types of antihypertensive medications. I could reasonably be considered a cardiovascular carpetbagger. Yet I work hard to understand cardiovascular science and practice guidelines because I know it is important to helping people living with HIV enjoy the healthiest life possible. Knowing this, about five years ago, my mentors pushed me to get more involved with the American Heart Association which has led me attend various AHA conferences, review abstracts, and apply for (and receive) AHA Research funding.

This year at Scientific Sessions, I was honored with the Council on Cardiovascular and Stroke Nursing (CVSN) Research Article of the Year Award. It is an incredible honor recognizing work that I am proud of. And while I am grateful to the CVSN and the sponsor for this award, my first thoughts after receiving the notification of award were, “Wow, this is amazing,” quickly followed by, “Why me? Why an article on improving cardiovascular health in people living with HIV? Maybe they didn’t get other nominations.” I felt undeserving and uncomfortable being honored for work I invested the last three years of my life in and I could not understand why.

Imposter Phenomenon, or Imposter Syndrome, first defined in 1979 by Clance and Imes, are feelings of fraudulence by high achievers who “do not attribute their success to their own abilities despite their many achievements and accolades.” Recent research suggests most professionals can relate to these feelings, but it can be especially prevalent as new roles are taken on, especially in first jobs or new challenges. While Impostor Syndrome is associated with academic success, it is also associated with poor mental health outcomes including anxiety, depression, psychological distress, and minority student status stress. There is also evidence that Imposter Syndrome can make one reluctant to seek out new professional opportunities. Thus, Imposter Syndrome may be especially stunting to early career scientists and clinicians.

Strategies for Managing Imposter Syndrome

Recognize that many people have the same feelings of self-doubt at some point in their career

Talk about it and ask your trusted mentors and colleagues about their own feelings of being an imposter

Write down your strengths and how those led to your accomplishments

Develop a strong, safe social support network to share your feelings of self-doubt

Read about/listen to others talking about imposter syndrome, there are many great resources available which can help you contextualize your experiences

Be present for others who are going through similar experiences

The strategies for managing Imposter Syndrome are timeless but seem hard to achieve. A recent paper by Dr. LaDonna and colleagues in Academic Medicine suggests that having senior colleagues speak openly about their own experiences with self-doubt can have a positive effect. In addition to open discussion about self-doubt, is the importance of a strong support network the importance of perspective and reflection on their own strengths in order to expel “negative views of their own flaws”.

While such strategies may seem contradictory to social media which often highlights success but rarely failures, a recent twitter discussion on Imposter Syndrome (hosted by Emma Clayton of NHS Women Leaders) did just that. This discussion reveled many useful strategies and resources and created a space for people to share their experiences with imposter syndrome with others who had similar struggles. Emma is currently building a website designed to serve as a hub for women to come together and mentor each other as they seek new leadership roles, which should be up later this month. In reading through her thread, I realized that my feelings of unworthiness can be a double-edged sword and that in the end I just need own it. I need to let my discomfort with my success drive me, not distress or diminish me; motivate, not isolate, me; and above all else, never let it hold me back from confidently, passionately, pursuing my goals.

As you reflect back upon your accomplishments in 2018, I hope that you have not feelings of being an imposter stop you from enjoying those successes or thwart progress toward your own goals. But if you are one of the many of us who have, this new year resolve to lessen the negative impact of the imposter and advance confidently in the direction of your dreams.

Photo by Paul Joyce on flikr

Heart Health and HIV: An Opportunity for Global Health Partnership

November 29, 2018March 28, 2019 Allison Webel, PhD

Slightly over five years ago, I immersed myself in a growing literature that documented the increase in heart disease in people living with HIV (PLHIV). While almost of all of these studies were in well-developed “high income” countries, the conclusion was always the same. The HIV medications worked, and those who had access to them were aging and developing conditions associated with aging including, prominently, cardiovascular disease (CVD). People living with HIV seemed to be developing these conditions more frequently than those who were not living with HIV, and no one was able to tease apart the myriad reasons why this was happening.

Global Burden of Atherosclerotic Cardiovascular Disease in People Living With HIV
DOI: (10.1161/CIRCULATIONAHA.117.033369

Others had the same realization and earlier this year. Anoop Shah, MD, from the University of Edinburgh, conducted the first meta-analysis examining the global burden of CVD in PLHIV. Pooling data from almost 800,000 PLHIV with 3.5 million person years of follow up, they found that the global burden of HIV-Associated CVD has tripled in the past 20 years, especially in low and middle-income nations.

Specifically, Dr. Shah and his team measured the population attributable fraction of CVD in PLHIV. This metric combines the risk associated with CVD with the prevalence of HIV- an approach that can quantify the actual impact of risk on a population. This is important because in low and middle-income countries where the HIV prevalence is high and resources are scarce, interventions to reduce the risk of CVD will likely have a bigger impact. Dr. Shah’s work revealed that those in sub-Saharan Africa experience a “double hit” of both HIV and CVD, with higher rates of traditional risk factors such as high blood pressure, and context-specific risk factors including air pollution.

To address these risk factors, Dr. Shah suggests that while there are studies leveraging cutting edge science to help us identify those living with or at risk for CVD (e.g. biomarkers), we need more research testing evidence-based strategies to improve cardiovascular outcomes in PLHIV in low and middle-income countries. This includes testing traditional pharmacological (e.g., antihypertensive and dyslipidemia) and non-pharmacological (e.g., diet, exercise and smoking cessation) strategies tailored to the setting and the population. Critically, this research must also account for the pivotal role health systems have in delivering these interventions.

This year the theme of World AIDS Day is “Building Partnerships through Leadership” and Dr. Shah captured this promise when discussing how to improve health systems to reduce CVD. “Based on my experience, in Sub-Saharan Africa HIV clinics are incredibly well run and effective, but they only do one thing- treat HIV; but what if we could partner with this HIV clinics across Africa [and other low and middle income settings] to start to provide better CVD prevention and treatment? By building on the existing systems, and expanding to other populations, we could deliver the change that is needed to improve cardiovascular health to PLHIV and beyond”.

Today is World AIDS Day and I am part of the first generation where AIDS has always existed. I was born a week after the MMRW report documented the first case of what would become known as AIDS. Since then we have made so much progress, and continue to make strides in preventing, treating, and eventually curing HIV. I look forward to the day when HIV will no longer be a part of anyone’s life. But until that happens, my work, and the work of many scientists, clinicians, advocates and allies will continue to build a better understanding of how to help all PLHIV enjoy the healthiest life possible, with less risk for cardiovascular diseases and stroke. By working with HIV organizations there are incredible opportunities for innovative and exciting partnerships to improve cardiovascular health in PLHIV, and millions of others around the globe. The American Heart Association can and should have an important role in this quest for longer, healthier lives.

Over the next year, I will explore what is known about the various causes of cardiovascular disease in this population in this series on Heart Health and HIV. I will work to incorporate high quality science with the perspectives of the both clinicians caring for PLHIV and the voices of the patients themselves. I look forward to engaging with all of you and, together, trying to solve these important issues.

Funding the Business of Science: Strategies for Early Career Scientists

November 12, 2018March 28, 2019 Allison Webel, PhD

During my graduate training, I learned how to write research proposals and manuscript, battle with the IRB, collect and analyze data, present my research in various settings, and handle regular (sometimes daily) rejection like a champ. I received excellent training from mentors who will always be my giants. However, as I have progressed through the early stages of my academic career, I have come to realize there are so many things about being an academic scientist that I never learned in graduate school.

The first thing is that, while science is (sometimes) a noble pursuit of generating new knowledge that will advance the human condition, it is also a business. I’ve never started a business nor have I considered myself entrepreneurial, but I believe in order to have a viable business model, one needs money to turn a great idea into something someone will pay for. It turns out that entrepreneurs and scientists have that common – this is why I was excited to attend the early career session on Sunday morning humorously titled, “WTF: Where’s the Funding?”

Even before we graduate with what we all hope is our terminal degree, we are primed by the academic enterprise to fund our work, and ultimately ourselves. For most of us it’s written into our first contracts. But after the glow of actually having a paying job wears off, we are left to agonize over the question, “How do we break into a system that is seemingly impenetrable to newcomers?” This was the very question this session addressed in an early career panel covering governmental, foundation, and industry-supported funding for early career scientists.

The panel started out acknowledging that the goal of every early stage investigator is R-level NIH funding, with its generous indirects and fabled prestige; however, it can be difficult for most of us to achieve this goal soon after completing our training. Against that backdrop this frank panel discussed how to navigate two alternative funding sources industry funding and foundation funding. Jarett Barry, MD of UT Southwestern summarized these opportunities as “I think of industry, and even American Heart Association [foundation] funding as a pop off valve– a strategy used to complement traditional funding.” For many of us, a pop off valve is exactly what we need to keep our science going during the early, lean years. Further, these types of funding streams can help establish us as experts in our field and provide data needed to publish good papers and serve as preliminary data in future grants.

However, industry and foundation grants are not without their downsides. The panel agreed with Majken Jensen, PhD of the Harvard T.H. Chan School of Public Health, who said these grants are often smaller than federal grants, tend to favor academic celebrities, have low/no indirect rates and can be more heavily taxed by academic institutions, and (in the case of industry funding) can open us up to potential conflicts of interest. But science is a business and early career scientists need money to do their work, so with the limitations acknowledged the panel started to share strategies for obtaining foundation and industry funding.

Develop a wide network and deftly use it. In addition to academic celebrities, science peers, and mentors, this needs to include industry and grant officials. The panel’s suggestions on how to accomplish this were fundamental: present at meetings and engage with people at the posters; strategically serve on panels and committees; and ask your mentors to introduce you to key people in funding organizations.
Build a team of people at your institution who are supportive of your success. This team can include those academic celebrities who can open new opportunities for you. The committee acknowledged that while it can be intimidating to approach seasoned investigators and seek out their advice and mentorship, you need to do it. They will not come to you. You need to be prepared and persistent when asking for assistance, but it is worth it as having these allies can open amazing new doors.
Write. Potential funders will look at your previous publications when determining whether or not to fund you. You need to have enough of a track record of high quality papers that will give them confidence that you will use their funding to do good science and improve the human condition.

In the end, all panelists had a common theme: if we boldly and strategically pursue all relevant funding opportunities, we can be successful.

This session left me optimistic about the future of not just funding my own research, but much of the incredible research of early career scientists. While securing funding is an exercise in endurance and humility, we don’t have to bang our head against the wall forever. If we learn from each critique, persevere, revise and repackage our ideas, and surround ourselves with an amazing team of our own choosing, eventually we will prevail.