Bhavya Varma, MD – The Early Career Voice

The Power of Mentorship

June 17, 2022June 14, 2022 Bhavya Varma, MD

As many of us are finalizing our application for fellowship this summer, it’s also a wonderful time to reflect on the journeys that brought us here. It’s no small feat to complete undergraduate training, medical school, and internal medicine residency and have all of that hard work culminate in this application for cardiovascular fellowship training. I’m excited and often blown away by the creativity and successes of my fellow applicants.

One aspect of this journey I’ve reflected on most deeply has been mentorship. I cannot state how important it is to find the right mentors in a process like this one. There is no one-size-fits-all, as we are all unique personalities with individual interests and aspirations. For those hoping to apply in the future, what I found to be most important is finding people you want to model yourself after.

A difficult part of this process can be the first step! How do you approach those you might be interested in working with? I met my research mentor prior to starting my residency, via Twitter. I was looking up people involved in women’s cardiovascular disease at my new institution, and a few names quickly rose on the list. My mentor had posted on Twitter recently about the importance of women in cardiology and creating an inclusive and equitable environment moving forward. Her studies span women’s cardiovascular disease but also advocate for women in research and the academic sphere. I knew this was someone I wanted to work with. I messaged her on Twitter and was met with the warmest welcome. I share this story to encourage young trainees to be proactive in searching for mentors. Take that first step, send that email, and explain why you want to work with them. My research mentor is a fierce advocate for young women trainees. At a recent CV conference in Chicago, I experienced first-hand how she uplifted medical students, residents, postdocs and made us all feel like we belonged in this space. I’m certainly grateful for trailblazers like her who are changing the face of cardiology.

You will also find wonderful mentors via clinical rotations! As an intern in the CCU, I was blown away by our CCU director. He is the kind of teacher you want to show up for. It’s not out of fear but out of respect that you want to be overly prepared for rounds in the morning, so you don’t disappoint. Together, we talked to patients about their pacemaker settings and their heart transplant status, and I found my joy for interpreting swan numbers every morning. Once again, I found someone I wanted to be like one day. He brought so much energy and enthusiasm that the whole team was excited to learn. He created a learning environment that encouraged us to ask questions and never be afraid. Most of all, he reminded us that everything is in the service of our patients. You want to seek out those invested in your growth as a trainee and those who excite you about a future in cardiovascular medicine.

Each mentor can bring something very different in shaping you and influencing the physician you will become one day. I encourage all young trainees and medical students to find people in their field who keep them excited, humble, and always striving for growth. Don’t be afraid to ask these teachers about their journeys and advice regarding your own career trajectories. In my experience, they are usually more than happy to help. From a practical standpoint, talk to residents and fellows in your program about who may be a good fit based on your interests and goals. Medical training is a long journey with many phases, and I have found most of us are very happy to pay it forward.

There have been countless mentors who have brought me to this point and I could write a novel about each of them and what they mean to me. For now I will say, if you are early in your career don’t underestimate the importance and impact of finding the right mentors. Doing so intentionally and thoughtfully both as a mentor and mentee can create environments that encourage people to reach their full potential. If you’re a young trainee reading this, be mindful about finding your village. They will shape who you become one day, don’t be afraid to reach out and introduce yourselves. You can find mentors in non-traditional settings as well in the era of digital education and MedTwitter. Create a network, talk to people at large conferences, and reach out to those you have worked with clinically. If you’re in the position to uplift others, investing in those who will come after you means everything to us. We are so grateful for all you do.

“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 health matters. If you think you are having a heart attack, stroke, or another emergency, please call 911 immediately.”

It is Time to Try Something New!

March 4, 2022February 22, 2022 Bhavya Varma, MD

The internet has revolutionized medical education. Going through medical school– the resources are endless! It’s fun trying to figure out what’s best for your learning style but given the sheer volume of all the great content it can also be overwhelming.

Podcasts became one of my favorite ways to learn while in medical school. The internist in me craves the part of the day when I can listen to the attending think out loud. It’s all about understanding an expert’s thought process so you can begin to develop your own when it comes to cool and complex pathophysiology. Podcasts allow accessibility on demand. What a gift – and there are so many fantastic medical podcasts in production today. I couldn’t be more thankful to the doctors and educators who put their time and energy into providing free and fantastic education for so many of us.

As my career develops and I focus my interests, CardioNerds has become one of my of favorites. They take this concept of listening to experts think out loud to another level. I recently listened to a “CardioNerds Rounds” episode which involved an expert, Dr. Kittleson, sharing her thoughts on challenging hypertrophic cardiomyopathy cases. It was riveting in the way that she laid out a wonderful foundation for those still learning and at the same time discussed nuanced management that doesn’t always follow a script. Now that is cool.

Another aspect of the CardioNerds platform that has been admittedly less approachable for me is the Twitter Journal Club. As a resident, learning about cutting edge research and practice changing guidelines is not only rewarding because it delights my academic curiosity but its crucial in improving patient care. With an unending repository of gigantic new trials that continues to grow every single day, it is difficult to decipher these alone. That it where #CardsJC¹ (the CardioNerds Twitter journal club) is magic.

I strongly believe the power of medicine specialties lies within the team aspect. I know our reputation has humorously involved discussing hyponatremia for an hour on rounds, but truly when the whole team is invested in discussing something new or controversial it is so much fun! That is what #CardsJC can provide, experts dissecting and explaining the meaning of a trial so it’s not just taken at face value but what it means for advancing patient care. This is how you learn in medicine, not just by memorizing, but by deepening your understanding; wrapping your head around how something came to be and where it is going. As a second year resident, I found the best teachers are usually masters of their content. This is especially highlighted when your own interns and med students want to learn more about a topic – I’m usually most successful when I take the time to prepare and be intentional.

#CardsJC gives us access to this. CardioNerds is a multimodality digital education platform with a mission to democratize cardiovascular education^1,2. They held their first Twitter journal club about a year ago in February 2021. They are thoughtful in involving leading experts, trial authors, guidelines authors, and society leaders in the conversation². Twitter’s unique platform allows for this innovative new approach to journal club. Additionally, for young learners it can be intimidating to speak up in traditional journal club settings where you barely grasp the basics much less feel comfortable challenging methodology or ideas. Twitter once again allows for anyone to engage on their own terms without the terror of having to raise your hand in a room full of highly accomplished people – we’ve all been there!

In addition to the nuanced conversations, #CardsJC comes with detailed trail summaries, infographics, and carefully crafted tweets¹. This is an effective, practical, and revolutionary way for busy participants in all stages of their careers to engage with new data and integrate this into their practice. It’s a way for us to engage in rich discussion with those who may not have been accessible to us in the past. It’s also a way to create great archives of information you can refer to later, especially the trial summaries.

If you were like me and hesitant to engage with this platform in the past because it was unfamiliar – there’s even a video tutorial¹! I really enjoyed this because it makes the process simple and approachable. This main #CardsJC page also includes trial summaries from past journal club discussions. Overall, I highly recommend joining the next #CardsJC on March 29^th to get your feet wet! It’s sure to be a fantastic discussion about an important upcoming topic – but I won’t give away any clues just yet.

References:

Cardionerds Journal Club – join the conversation on #cardiotwitter! Cardionerds. (2022, January 18). https://www.cardionerds.com/cardsjc/
Dugan, E., Ferraro, R., Hamo, C., Ambinder, D., & Goyal, A. (2021). The cardionerds #cardsjc: How twitter journal clubs elevate the scientific discourse. Journal of Cardiac Failure, 27(9), 1034–1036. https://doi.org/10.1016/j.cardfail.2021.04.012

The Needle Moves Slowly on MINOCA

January 18, 2022January 11, 2022 Bhavya Varma, MD

I remember being a medical student and listening to a podcast where I first heard the term MINOCA (myocardial infarction with nonobstructive coronary arteries) in 2019. I was deciding between internal medicine and OBGYN at this time, and learning about heart disease specific to and common in women naturally grasped my attention. Dr. Bairey Merz from Cedars-Sinai provides a fantastic overview of the disease process and evaluation. I kept thinking about all the ways we’ve made incredible strides in heart disease over the years. Now, I was thinking they were unequal.

Dr. Brent Gudenkauf, a PGY-2 at the Johns Hopkins Hospital, et al. recently published a review in the Journal of the American Heart Association entitled “Role of Multimodality Imaging in the Assessment of Myocardial Infarction with Nonobstructive Coronary Arteries: Beyond Conventional Coronary Angiography”¹. They do a wonderful job of taking us through diagnostic criteria, preferred imaging modalities, and guideline recommendations regarding MINOCA. This term is still not commonplace outside of cardiology, and in the early days some thought these patients were having “false positive MIs” as they outline in the paper. This led to mostly women missing out on necessary diagnostic work up and targeted therapies. Today we have specific diagnostic criteria from the AHA and ESC including positive serum myocardial biomarkers and clinical evidence of MI (which can include ischemic symptoms, new ST segment changes, new LBBB, new pathologic Q waves among others) and no epicardial coronary lesions >50% stenosis on angiography.^2,3

What I find disheartening is how slowly our needle has moved in terms of therapies. As they highlight in this paper, even after diagnosis of MINOCA 25% of patients continue to experience angina⁵ and experience worse quality of life compared with MI-CAD (MI associated with obstructive coronary artery disease) due to persistent anginal symptoms and inadequate treatment with existing antianginal therapies. They were less often treated with beta blockers and less often referred to cardiac rehab⁵. It is clear that this patient population of majority young women is faring worse than its traditional myocardial infarction counterpart in terms of therapies and quality of life.

For these reasons, we should all develop a good understanding of diagnostic pathways and targeted treatments. The recommended imaging modality is IVUS (intravascular ultrasound) or OCT (optical coherence tomography) ^2,4. As a young trainee myself, I am not familiar with either of these modalities and was introduced to these concepts via #AHA21. OCT is an optical analogue of IVUS and can “differentiate tissue characteristics such as fibrous, calcified, or lipid-rich plaque and identify thin-cap fibroatheroma”⁶. During PCI, OCT can also provide information about dissection, tissue prolapse, and thrombi⁶; this is significant given SCAD (spontaneous coronary artery dissection), in situ thrombosis, and epicardial and microvascular spasms are all causes that can lead to MINOCA¹. Cardiac MR is also useful when MINOCA is suspected as it will show late gadolinium enhancement and can also uncover mimics like myocarditis and Takotsubo cardiomyopathy. Additionally, if embolism to coronary arteries is suspected then thrombophilia workup is recommended. They do a wonderful job outlining this algorithm in Figure 2 in the paper by Gudenkauf et al.¹We should all be working to familiarize ourselves with this figure and its recommendations and integrating this into our evaluation for chest pain.

Although the advancements in diagnosis and evaluation are exciting and important, there are no randomized clinical trials evaluating treatments for patients with MINOCA. The MINCOA-BAT trial is an upcoming randomized multi-center study which will hopefully help to move the needle forward in evidence-based targeted therapies (clinicaltrials.gov, NCT 03686696). This excellent review by Gudenkauf et al should be shared widely as this is an important and still too often underdiagnosed and undertreated condition among our patients.

References

Gudenkauf, B., Hays, A. G., Tamis‐Holland, J., Trost, J., Ambinder, D. I., Wu, K. C., Arbab‐Zadeh, A., Blumenthal, R. S., & Sharma, G. (2021). Role of multimodality imaging in the assessment of myocardial infarction with nonobstructive coronary arteries: Beyond conventional coronary angiography. Journal of the American Heart Association. https://doi.org/10.1161/jaha.121.022787
Tamis‐Holland JE, Jneid H, Reynolds HR, Agewall S, Brilakis ES, Brown TM, Lerman A, Cushman M, Kumbhani DJ, Arslanian‐Engoren C, et al. Contemporary diagnosis and management of patients with myocardial infarction in the absence of obstructive coronary artery disease: a scientific statement from the American Heart Association. Circulation. 2019; 139:e891–e908. doi: 10.1161/CIR.0000000000000670
Ibanez B, James S, Agewall S, Antunes MJ, Bucciarelli‐Ducci C, Bueno H, Caforio ALP, Crea F, Goudevenos JA, Halvorsen S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST‐segment elevation: the Task Force for the management of acute myocardial infarction in patients presenting with ST‐segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018; 39:119–177. doi: 10.1093/eurheartj/ehx393
Agewall S, Beltrame JF, Reynolds HR, Niessner A, Rosano G, Caforio AL, De Caterina R, Zimarino M, Roffi M, Kjeldsen K, et al. ESC working group position paper on myocardial infarction with non‐obstructive coronary arteries. Eur Heart J. 2017; 38:143–153. doi: 10.1093/eurheartj/ehw149
Grodzinsky A, Arnold SV, Gosch K, Spertus JA, Foody JM, Beltrame J, Maddox TM, Parashar S, Kosiborod M. Angina frequency after acute myocardial infarction in patients without obstructive coronary artery disease. Eur Heart J Qual Care Clin Outcomes. 2015; 1:92–99. doi: 10.1093/ehjqcco/qcv014
Terashima, M., Kaneda, H., & Suzuki, T. (2012). The role of optical coherence tomography in coronary intervention. The Korean journal of internal medicine, 27(1), 1–12. https://doi.org/10.3904/kjim.2012.27.1.1.

“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.”

#AHA21: Matching Into Cardiology Fellowship: The Inside Scoop from Program Directors

November 14, 2021November 14, 2021 Bhavya Varma, MD

We were lucky enough to hear from some exceptional PDs and APDs during #AHA21. The process of applying to cardiology fellowship can be daunting. These discussions provide amazing tips and insight on the process so we can best prepare.

What catches your eye on CVs?

Although this will vary by program and individual, a few themes were consistent amongst the panelists. Most programs and directors will be looking for continuation of a story and a common thread between your research, personal statement, and letters. You want to convey who you are and why you have an interest in cardiology. “It’s a two-way street” meaning fellowships also function as a part of a larger clinical and research program. They look for applicants who will fit into their culture and further the values of their program.

Additionally, PDs and APDs will look at the residency training programs, whether you are local and want to stay local, and your research. For your research projects, multiple panelists mentioned quality was more important than quality. The emphasis was showing you could follow a project to completion. “More than case reports or review articles, I look for a substantive experience in research.”

How much weight do you put on the personal statement? Should anything be avoided?

This should be used as a place to tell your story. “What attributes does this person have that will put their trajectory where we want our fellows to go? Does this person have resilience, are they able to turn disadvantages into advantages?”

The main themes that came across in the panelists answers to this question were humility, resilience, and a willingness to learn. Additionally, multiple people highlighted that this is a good place to address anything unusual that could cause confusion in your application – do you have an unusual timeline? Are there gaps in your career? Did you take breaks to do other things? They also mentioned that this would be a great place to highlight how your background prior to medicine/hobbies lend to your interest in cardiology. With this in mind, it’s important to remember this is different than a medical school application and you should be cautious with how provocative or creative you are in your writing. It was also mentioned that you can emphasize your love of a subspecialty but should also remain open-minded to the field as a whole. “The point of fellowship is to introduce you to the field so you can navigate the next steps in your career” and multiple panelists mentioned numerous fellows change their focus throughout fellowship and exploring is encouraged.

Tips for the virtual interview?

“It can be challenging to convey your narrative when you’re not in person. Find a way to project your narrative to someone who may have nothing in common with you.” Make sure you practice this with a loved one or your colleagues. Recognize your ticks, be careful when you’re reading from your screen when answering questions because interviewers notice. Applicants should also be aware that they will be asked behavioral questions (Ex. Tell me about a mistake you made when caring for a patient. Tell me about a challenging patient interaction). Practice these beforehand and think ahead about the kinds of answers you might give.

Be aware of how you look on your camera. Record a mock interview on zoom and watch it. Even small details like lighting and not have distracting objects placed in your screen can have a big impact in the age of virtual interviews. Attend the program orientation session the evening before. Do not turn off your camera, dress professionally, and don’t be late to zoom sessions. Research the program and ask the faculty about it! Show them you are invested and know about the program. It is still not clear whether interviews will be virtual or in-person for the next interview cycle.

Post-Interview Communication?

The main advice here was similar to what we heard during residency interviews: do not lie. Do not tell multiple programs they are your number one choice. Keep in mind, many people change their mind throughout the interview season and ultimately you do not want to make decisions early in the process. With this in mind, telling a program you are enthusiastic and interested can be very helpful. This is especially true during virtual interviews, where it can be difficult for programs to gauge interest and investment. If you genuinely feel you found your top choice, most programs encourage hearing from you. If you are trying to match to a different geographical location, this can also be a good opportunity to reiterate the reasons you want to move. Notably, you need to be mindful about over-communication.

Hearing from those on the other end of the interview process was an excellent opportunity to focus on what is important. Ultimately, its about your love for cardiology and passion for furthering the field! Find you network and enjoy this time as you explore and determine what you want to do in your career.

This program is part of the FIT Program at #AHA21. The panelists include Drs. Eric Yang, Salim Virani, Carlos Alfonso, Naomi Botkin, Melvin Echols and was moderated by Drs. Aubrey J Grant and Agens Koczo. All FIT program at AHA Scientific Sessions were produced and moderated by FITs for FITs.