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5 Daily Struggles of an Early Career Physician

For this month’s blog entry, I’ve decided to share a more reflective piece. In now just over six months into my young career, my early morning routine is pretty set in stone. Wake up. Shower. Scrubs. Coffee. Mask. Keys. Go! But what happens from approximately 8 am – 5 pm is still evolving.

This blog will briefly go over my daily struggles, but I could just as easily share five daily rewards/positives/joys of an early career physician … and maybe next month I will.

  • I’m the attending (physician). Part of being fresh out of training is that nobody knows. Whether you stay at your home institution or move to a new setting, you’re likely the new kid on the block in the Doctors’ Lounge or the EMR’s attestation text box. Despite proudly wearing my “attending physician” ID badge, I find myself constantly having to reiterate that I’m the supervising doctor. I recently entered the room to begin time out for a transesophageal echo and was stopped by the anesthesiologist because we couldn’t begin the case without the cardiologist present. Another time, I was asked if I was the fellow doing the case with Dr. X, a well-known echocardiographer. Despite how this may sound, I quite like the shocked look on my patient’s faces when I walk in and introduce myself as the person who will be managing their complex cardiovascular disease – or my ability to walk through the medical center unbothered and largely unnoticed while taking in some much needed Miami sun.
  • One of my daily struggles is not knowing how to say “no.” As a medical trainee, you’re often the person called upon to do the tasks that no one else wants to take on. Whether it be consent for a procedure or calling the pharmacy to correct a prescription, you’re often faced with the rhetorical question of “can you please…?” or “ would you mind…?” Well, this doesn’t really stop when you’re a newly appointed faculty. I often reply to emails first or make phone calls because I’ve been there and I know that I CAN help in that way. Eventually, though, I will need to learn when this is impinging on time that could be well allocated to more important tasks.
  • To do or not to do. From the moment my first patient shares with me the reason for their visit, there is a tug-o-war in my head between doing something and doing nothing. A wise professor once told me that 70% of medical conditions resolve without the doctor doing anything. We’re tasked with identifying the 30% of the time when we can make an impactful difference in the disease course. I once read a Wall Street Journal article titled “When Doing Nothing is the Best Medicine.” This is much easier said than done, but I’ve found that many patients just want reassurance that what ails them will not lead to their untimely demise. Explaining my thought process, and clearly stating that we can always order more tests or perform more studies at a later date if things don’t get better, has served me well so far.
  • Leaving work at work. It’s not uncommon to find a trainee spending extra time in the hospital or in the clinic finishing tasks that their attending doesn’t want to find undone in the morning. When you’re the attending, the decision as to what can wait until later lies with you. When I first started my new job, I often stayed up late replying to emails or finishing notes, or making calls from home. What I’ve found is that not everything needs to be done now. I have frequently reminded myself of the following diagram, as it has helped me leave work at work and not take it home with me.

Source: https://luxafor.com/the-eisenhower-matrix/

  • Work/Life Balance. As physicians, we’re tuned to work work work until you can’t work anymore. It’s commonplace for physicians to work well past the retirement age, and sometimes until they are no longer with us. My mentors have shared with me that the decision to prioritize family, vacation, rest starts NOW. It is a lot harder to put into practice. There is always something that needs to be attended to, whether your “out of work” auto-reply is posted or not. I’ve made it a goal of mine to fully utilize the ample paid time off afforded to me by my employer, and to truly disconnect during these times. It’s still very hard, and I haven’t perfected it, but making it a priority is the first step.

Thank you for reading, and please share with me some struggles that you’re having as an early career physician. I can be reached on Twitter @DrDapo. Until next time!

 

“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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Financial Fitness in Medicine Part III – Tax Season

“The hardest thing in the world to understand is the income tax.”

– Albert Einstein

But it doesn’t have to be. As tax season nears, and we all cringe, it’s important for us healthcare professionals to understand how to optimize our tax bill. Paying taxes isn’t fun. Paying more taxes than you need to is painful. Below, I’ll share a few tips for lowering your tax burden this year:

But first, one thing to understand is how income taxes are calculated, and what tax bracket you fall into. I didn’t fully understand the tiered way in which our tax responsibilities are determined until recently. I was under the impression that if you made a certain income, the entirety of your income would be taxed at that rate. The following chart shows you how to calculate your expected tax home income.

(Source: Nerd Wallet)

Now for the good stuff.

  • If you have student loans, consider filing taxes separately from your spouse. Filing your taxes jointly can be a great financial perk of married life. The marriage tax credit can double your standard deduction compared to what you received as a single filer, and you get access to many other tax breaks, too. However, consider “married filing separately” this tax season. Under the right circumstances, doing so could save you hundreds of dollars on each of your monthly payments, and thousands over the life of your loans. The reason being, when filing jointly as a married couple, your spouse’s salary and debts factor into the calculations. Your minimum monthly payments on your loans could increase substantially, and you may no longer qualify for some income-based repayment plans.1
  • Take a look at which tax credits are available to you. Each year, the IRS makes a host of tax credits and deductions available to filers. Knowing which ones you’re eligible for could save you a substantial amount of money. For instance, if you own a home and you itemize on your taxes, you can deduct the interest you pay on your mortgage as well as your property taxes. If you’re paying off student debt, you may be eligible to deduct the interest on your loan. Depending on your costs, you may also be able to deduct a portion of your medical expenses.2
  • Contribute to your retirement plan (401k, 403b, IRA). Whether you’re hospital-employed, an independent contractor or operating a private practice, contributing to a tax-deductible retirement account can lower the amount of taxes you pay…and potentially drop you into a lower tax bracket (see above). The more money you put into one of these accounts, the more you stand to save. For the current year, deductible IRA contributions max out at $6,000 for savers under 50, and $7,000 for those 50 and over. For 401(k)s, these limits currently sit at $19,500 and $26,000, respectively.
  • Fund a health savings account (HSA). If your employer offers an HSA plan, definitely take advantage of it! It’s one of the best non-taxable accounts available. You can set aside pre-tax funds and carry them forward indefinitely to cover both near- and long-term medical bills. Check out this page for what you can potentially spend your HSA funds on. To qualify for a program, you’ll need to be enrolled in a high-deductible health insurance plan. If so, the IRS allows you to contribute up to $3,600 this year if you’re under 55 and have self-only coverage. If you’re under 55 with family coverage, that limit rises to $7,200. And if you’re 55 or older, you can put in an extra $1,000 on top of the limit that already applies to you.
  • Donate to charity. You should consider this regardless of the tax benefits, but it definitely sweetens the deal. As long as you donate money to a registered charity, you can claim a deduction on your taxes for that amount. I recently learned that this is not limited to cash donations. You can also donate goods and deduct their fair market value, which is the amount they’d be worth at the time of your donation. Did you know that you can even donate stocks to charity if you so choose? In prior years, only those who itemize on their returns could deduct charity donations, but there are special provisions in place for 2020-2021 that allow you to deduct $300 for charitable contributions.
  • Sell underperforming equities. This is called harvesting losses. Essentially, if you have stocks in your portfolio that are underperforming, selling them at a loss could slash your tax bill. If your net investment loss exceeds your gains, you can use it to offset some of your ordinary income (up to $3,000 in a single tax year).
  • Hire an accountant. The best place to look for one is honestly your digital Rolodex of friends. It may not seem useful to you now, but asking a friend (preferably one who works in finance or law) for a recommended CPA can help you incredibly down the line, as things tend to get more complicated once you begin taking on increasing amounts of financial responsibilities.
  • File on time and online. Filing on time will save you lots on penalties and fees associated with late processing of your returns. If you expect to miss the deadline, the best thing to do is request an extension by filing Form 4868 here. Overall, electronic filing works best if you expect a tax refund because the IRS processes electronic returns faster than paper ones. You can expect to get your refund three to six weeks earlier than those who file via snail mail. If you have your refund deposited directly into your bank account or IRA, the waiting time is even less.

I hope these tips help you this tax season! If you want to read some of my other blogs on financial fitness, visit the links below. Happy filing!

A Paycheck Away: Financial Fitness in Medicine Part I

A Paycheck Away: Financial Fitness in Medicine Part II

“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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COVID-19: Healthcare Workers vs The Vaccine

The mid-December rollout of two FDA-approved COVID-19 vaccines coincided with a surge in US infections, as we surpassed 21 million cases and 300k deaths. Amidst the hope for a recovery from the virus, that has captivated the world for the past 10 months, the vaccine rollout was met with stiff resistance from many Americans. Of these, healthcare workers comprise the largest group of those refusing vaccination (albeit, healthcare workers also comprised the majority of people offered the early doses). This theme has persisted over the past few weeks. I will review some of the ideas behind the refusal of vaccine acceptance.

First, the headlines (taken from Forbes):

  • Last week, Ohio Gov. Mike DeWine said he was “troubled” by the relatively low numbers of nursing home workers who have elected to take the vaccine, with DeWine stating that approximately 60% of nursing home staff declined the shot.
  • Joseph Varon, chief of critical care at Houston’s United Memorial Medical Center, told NPR in December more than half of the nurses in his unit informed him they would not get the vaccine.
  • Roughly 55 percent of surveyed New York Fire Department firefighters said they would not get the coronavirus vaccine, the Firefighters Association president said last month.
  • The Los Angeles Times reported that hospital and public officials in Riverside, Calif., have been forced to figure out how best to allocate unused doses after an estimated 50% of frontline workers in the county refused the vaccine.
  • Fewer than half of the hospital workers at St. Elizabeth Community Hospital in Tehama County, Calif., were willing to be vaccinated, and around 20% to 40% of L.A. County’s frontline workers have reportedly declined an opportunity to take the vaccine.
  • Nikhila Juvvadi, the chief clinical officer at Chicago’s Loretto Hospital, said that a survey was administered in December, and 40% of the hospital staff said they would not get vaccinated.

Distrust For The Government Among Black/LatinX

Frontline workers in the United States are disproportionately Black and Hispanic. It is no surprise to my readers, as mentioned briefly in my AHA recap article(s), that structural racism is (and has been) a pervasive force within healthcare. “I’ve heard Tuskegee more times than I can count in the past month — and, you know, it’s a valid, valid concern,” said Dr. Juvvadi. This forms the crux of the argument made by minority frontline workers against receiving the vaccine. A recent survey by the Kaiser Family Foundation found that 29% of healthcare workers were hesitant to receive the vaccine, citing concerns related to potential side effects and a lack of faith in the government to ensure the vaccines were safe. Furthermore, dissenters question the involvement of Black/LatinX participants in the clinical trials that led to the development and deployment of at least two FDA-approved vaccines at the time of this article. Dr. Juvvadi told NPR that “there’s no transparency between pharmaceutical companies or research companies — or the government sometimes — on how many people from.” In an op-ed published in the New York Times last week, emergency physicians Benjamin Thomas and Monique Smith wrote that “vaccine reluctance is a direct consequence of the medical system’s mistreatment of Black people,” exemplified by the unethical surgeries performed by J. Marion Sims and the Tuskegee Syphilis Study, that highlight “the culture of medical exploitation, abuse, and neglect of Black Americans.”

Altruism and Others More Deserving

Medicine is an inherently altruistic field, one that requires a dedication to the service and betterment of others. This theme has largely affected the sentiment concerning the acceptance of the COVID-19 vaccines. In an op-ed published earlier this week by Marty Makary MD MPH, a professor of surgery and health policy at the Johns Hopkins University School of Medicine, the case for delaying vaccination is made. Dr. Makary states:

“After a summer of corporate statements pledging that Black Lives Matter, America’s vaccine rollout is creating inequities stemming from a ruling class making rules to favor themselves. In the first two weeks after the FDA authorized the life-saving vaccine, hospital board members, spouses of physicians, cosmetic surgery receptionists, and young firefighters have been getting the vaccine ahead of our society’s most vulnerable. Low-risk Americans with access and power are cutting in the vaccine line and, by doing so, are essentially telling our society’s most vulnerable members ‘your life matters less.’”

Dr. Makary shares his experience as a physician who performs surgeries on COVID-negative patients in a sterile environment with the highest infection control precautions accounted for. Furthermore, he weighs his personal risk of having a complicated course of COVID-19 infection versus that of his elderly patients, many of whom have multiple comorbid medical conditions. He argues that low-risk healthcare workers, including those who have already been infected, defer their vaccination in order to allow for higher-risk individuals to receive a potentially life-saving intervention. This highlights the chasm in Medicine between altruism and self-preservation. Is it possible to do both?

I end with a quote from Dr. Makary, expressing his views on the matter:

“I’m not criticizing clinicians who get the vaccine — my personal decision might be different if I spent more time in the ICU, took more ER calls, or was at high risk of being a silent carrier of the virus, putting my patients at risk. But that’s not me. Given my very low personal risk of mortality and my very low risk of getting the virus in my clinical work, I have joined a growing chorus of healthcare workers who have taken a pledge to not get the vaccine until every high-risk American has been offered it first.”

Thank you for reading, and please feel free to reach out to me with comments or questions on Twitter @DrDapo.

 

“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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AHA 2020 Delivers on Virtual Conference Experience

As we near the close of the American Heart Association’s 2020 Scientific Sessions, I’d like to reflect on the virtual conference experience. I must admit, despite the high quality research and programming schedule, I was skeptical going into this year’s virtual conference. It was my first (of many?), and I had reservations about the ability of any organization to recreate the live experience that we all love so dearly. Looking back, the AHA put on a phenomenal show, filled with groundbreaking research, high profile panelists and even networking. For this blog, I’m going to focus on the networking, as this was the area that I was most skeptical of. How can you provide ample networking opportunities for clinicians, trainees and vendors when they’re all at home watching? Well, first, let me share the AHA’s plan to tackle this, then I’ll share some examples.

VIDEO: Networking Opportunities at AHA (Don Lloyd-Jones MD and Manesh Patel MD)

The AHA successfully delivered on their promise to fulfill the networking needs of its attendees in the following ways:

  1. AI-powered networking. The AHA brilliantly utilized burgeoning artificial intelligence technology to match like-minded individuals to each other as well as to programming that matched their interests. The AI then facilitated the organization of virtual meetings amongst interest-matched attendees. Wow!

  1. Fireside chats and FIT Virtual Lounge. The AHA continued its focus on providing mentorship to early career cardiologists and trainees. The experience was as engaging, and some would argue more engaging, than the live sessions. The democratization of commentary afforded by virtual communication was evident, as even the most reserved participants were able to ask questions and exchange ideas with established leaders in the field.

 

 

 

 

 

 

 

 

 

  1. Scavenger Hunt. Even the scavenger hunt was preserved! The AHA managed to provide a scavenger hunt experience via QR codes hidden throughout the conference programs for attendees to scan and WIN. This also further cultivated the relationship between the AHA and its industry partners.
  2. In line with its commitment to foster group wellness and health activities, the AHA organized morning yoga, exercise, and mental health sessions for attendees to virtually participate in together. This is a trend that has been popular since the start of the pandemic and hopefully will continue long after COVID-19 is gone.

In conclusion, my AHA 2020 experience has been rewarding in many ways. With quality education and networking opportunities, this year’s conference proved that the AHA is prepared to weather the challenges brought on by the COVID-19 pandemic. I look forward to future programming, and will certainly be an active participant.

 

“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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Quotes from AHA 2020: Structural Racism in Healthcare

In a year wrought with challenges spanning social, political, and healthcare spheres, one issue has risen to the forefront of our collective consciousness. Structural racism.

What is structural racism? A recently published presidential advisory from the American Heart Association states that “structural racism refers to the normalization and legitimization of an array of dynamics–historical, cultural, institutional and interpersonal–that routinely advantage white people while producing cumulative and chronic adverse outcomes for people of color.”

The planning committee for this year’s AHA Scientific Sessions took it upon themselves to address the presence of structural racism in Cardiology with a comprehensive series of lectures and discussions on the topic. The sessions kicked off on Friday, November 13th with an awe-inspiring fireside chat featuring legends in the education and treatment of cardiovascular disease, Drs. Eugene Braunwald and Nanette Wenger. The discussion was moderated by legends in their own right, Drs. Clyde Yancy and Robert Harrington.

“When I arrived in Atlanta in the early 1960s, racism was prevalent…and sadly, it continues more than half a century later” – Dr. Nanette Wenger

The morning continued with the main event session, “How to Use Behavioral Interventions to Advance Equity in Cardiovascular Health.” Drs. Keith Norris, Eberechukwu Onukwugha, and LaPrincess Brewer eloquently proposed solutions for tackling disparities in hypertension management and post-discharge care, as well as shared a bold new vision for cardiovascular health interventions to address disparities across the board.

“I am issuing a call for us, as an American Heart Association, community to integrate community-based interventions to promote cardiovascular health […] First, we must recognize the historical improprieties and wrongs in research, from events such as the Tuskegee syphilis study and the Henrietta Lacks cell line, which have led to a lingering mistrust of scientists and clinicians among racial and ethnic minority groups.” – Dr. LaPrincess Brewer

Arguably the main highlight of the morning was the AHA Fellows-in-Training session, titled “Racism in Medicine: What Medical Centers & Training Programs Can Do to be Antiracist.” This program sought to implore early career cardiologists to engage in the fight against structural racism, as well as provide trainees with a forum to learn more about racism in Medicine. The esteemed panelists, Drs. Clyde Yancy, Ileana Pina, and Michelle Albert led an incredible discussion with plenty of teaching points and actionable items to strengthen and support diversity, equity, and inclusion in medical training.

“It’s not about the number of people in the room or what they look like […] it’s about the diversity of thoughts in the room” – Dr. Clyde Yancy

This year’s AHA Scientific Sessions is off to a great start! Judging by the quality of programming on Day 1, there will be plenty more to write home about after this weekend.

 

“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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The Clock is Ticking: Door-to-Needle Time in Acute Ischemic Stroke

Lay of the Land

In 2008, after years of being the third-leading cause of death in the United States, stroke dropped to fourth. In part, this reflected the results of a commitment made by the American Heart Association/American Stroke Association (AHA/ASA) more than a decade prior to reduce stroke, coronary heart disease, and cardiovascular risk by 25% by the year 2010 (a goal met a year early in 2009). The reason for the success, although multifactorial, can largely be attributed to improved prevention and improved care within the first hours of acute strokes.1 As early as 2000, the benefits of time-dependent administration of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke were well supported (Figure 1).2

Figure 1. Graph of model estimating OR for favorable outcome at 3 months in recombinant tissue-type plasminogen activator (rt-PA) treated patients compared to placebo treated patients by time from stroke onset to treatment (onset-to-treatment time [OTT]) with 95% confidence intervals, adjusting for the baseline NIH Stroke Scale. OR > 1 indicates greater odds that rt-PA treated patients will have a favorable outcome at 3 months compared to the placebo treated patients. Range of OTT was 58 to 180 minutes with mean (μ) of 119.7 minutes.2

Guidelines began recommending a door-to-needle time for tPA administration of 60 minutes or less, however, studies found that less than 30% of US patients were treated within this time window. The Target: Stroke initiative was launched in 2010 to assist hospitals in providing timely tPA. As a result, the proportion of tPA administered within 60 minutes increased from 26.5% during the preintervention period to 41.3% after implementation. Despite national initiatives, shorter door-to-needle times have not been as quickly adopted as door-to-balloon times for percutaneous coronary intervention in acute coronary syndromes (Figure 2).4 Part of the problem is a lack of robust mortality outcomes data to support trends observed in the (only) two randomized trials conducted to assess long term outcomes with tPA in acute ischemic stroke; neither of which was powered to probe for mortality effects.

Figure 2. Trend in percentage of patients with door-to-balloon (D2B) time <90 minutes over 6 years.4

This brings us to the study published earlier this week in JAMA Man S et al. (corresponding author Fonarow GC) titled “Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke.” This nationwide study of US patients treated with intravenous tPA for acute ischemic stroke demonstrated that shorter door-to-needle times were significantly associated with better long-term outcomes, including lower 1-year all-cause mortality, 1-year all-cause readmission, and the composite of all-cause mortality or readmission at 1 year.5

Study Design

This US cohort included Medicare beneficiaries aged 65 years or older who were treated with intravenous tPA for acute ischemic stroke at Get With The Guidelines (GWTG)–Stroke participating hospitals between January 1, 2006, and December 31, 2016, with 1-year follow-up through December 31, 2017. Patient clinical data were obtained from the GWTG-Stroke database. Study entry criteria required patients to (1) have been aged 65 years or older; (2) have a discharge diagnosis of acute ischemic stroke; (3) have been treated with intravenous tPA within 4.5 hours of the time they were last known to be well; (4) have had a documented door-to-needle time; (5) not have been treated with a concomitant therapy with intra-arterial reperfusion techniques; (6) have had the admission be the first for stroke during the study period; and (7) not have been transferred to another acute care hospital, left against medical advice, or without a documented site of discharge disposition.5 Overall, 61426 participants met the inclusion criteria for the study.

The prespecified primary outcomes included 1-year all-cause mortality, 1-year all-cause readmission, and the composite of all-cause mortality or readmission at 1 year. One-year cardiovascular readmission was a prespecified secondary outcome and was defined as a readmission with a primary discharge diagnosis of hypertension, coronary artery disease, myocardial infarction, heart failure, abdominal or aortic aneurysm, valvular disease, and cardiac arrhythmia. Recurrent stroke readmission, a post hoc secondary outcome, was defined as a readmission for transient ischemic attack, ischemic and hemorrhagic stroke, carotid endarterectomy or stenting, but not for direct complications of index stroke.5

Door-to-needle time was first analyzed using the prespecified times of within 45 minutes and within 60 minutes versus longer than those targets, in line with prior studies on this topic. The authors also ingeniously also evaluated time as a continuous variable, as a categorical variable in 15-minute increments using within 30 minutes as the reference group, and in 45-minute and 60-minute increments. Cox proportional hazards models were used to examine the associations of door-to-needle timeliness and each 1-year outcome with robust variance estimation to ac- count for the clustering of patients within hospitals.5 On hours were defined as 7:00 AM to 6:00 PM on any weekday. Off hours were defined as any other time, including evenings, nights, weekends, and national holidays. The authors did this because prior studies using this prespecified time cutoff have shown that presenting during off hours was associated with inferior quality of care, inferior intravenous thrombolytic treatment, and in-hospital mortality.5

Results

Among the 61426 Medicare beneficiaries treated with intravenous tPA within 4.5 hours of the time they were last known to be well at the 1651 GWTG-Stroke participating hospitals, the median age was 80 years, 43.5% were male, 82.0% were non-Hispanic white, 8.7% were non-Hispanic black, 4.0% were Hispanic, and 5.3% were of other race/ethnicity. More patients that arrived during off hours were treated within longer door-to-needle times (40.7% for ≤30 minutes, 45.6% for 31-45 minutes, 50.6% for 46-60 minutes, 53.5% for 61-75 minutes, and 56.3% for >75 minutes; P < .001). Despite having longer onset-to-arrival times, some patients had shorter onset-to-needle and door-to-needle times.5

Most patients were treated at teaching hospitals (77.7%) and primary stroke centers (73.2%); 3% were treated at rural hospitals. More patients who were treated at teaching hospitals, but not at primary stroke centers, were treated within shorter door-to-needle times. The median door-to-needle time was 65 minutes, with 5.6% of patients treated with tPA within 30 minutes of hospital arrival, 20.8% within 45 minutes, and 44.1% within 60 minutes.5

Patients who received tPA after 45 minutes of hospital arrival had worse long-term outcomes than those treated within 45 minutes of hospital arrival, including significantly higher all-cause mortality (35.0% vs 30.8%, respectively; adjusted hazard ratio [HR], 1.13 [95% CI, 1.09- 1.18]), higher all-cause readmission (40.8% vs 38.4%; ad- justed HR, 1.08 [95% CI, 1.05-1.12]), higher all-cause mortality or readmission (56.0% vs 52.1%; adjusted HR, 1.09 [95% CI, 1.06-1.12]), and higher cardiovascular readmission (secondary outcome) (19.8% vs 18.4%; adjusted HR, 1.05 [95% CI, 1.00- 1.10]), but not significantly higher recurrent stroke readmission (a post hoc secondary outcome) (9.3% vs 8.8%; adjusted HR, 1.05 [95% CI, 0.98-1.12]).

Patients who received tPA after 60 minutes of hospital arrival vs within 60 minutes of hospital arrival had significantly higher adjusted all-cause mortality (35.8% vs 32.1%, respectively; adjusted HR, 1.11 [95% CI, 1.07-1.14]), higher all-cause readmission (41.3% vs 39.1%; adjusted HR, 1.07 [95% CI, 1.04-1.10]), higher all-cause mortality or readmission (56.8% vs 53.1%; adjusted HR, 1.08 [95% CI, 1.05-1.10]), and higher cardiovascular readmission (secondary outcome) (20.2% vs 18.6%; adjusted HR, 1.06 [95% CI, 1.01-1.10]), but not significantly higher recurrent stroke readmission (a post hoc secondary outcome) (9.3% vs 8.9%; adjusted HR, 1.03 [95% CI, 0.97-1.09]).

The absolute differences in outcomes increased with longer door-to-needle times. The cumulative incidence curves showed that approximately 42% of the deaths or readmissions occurred within 30 days.

Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause mortality (adjusted HR, 1.04 [95% CI, 1.02-1.05] for door-to-needle time within 90 minutes of arrival. However, this association did not persist beyond 90 minutes of hospital arrival. Every 15-minute increase in door-to-needle times was significantly associated with higher all-cause readmission (adjusted HR, 1.02 [95% CI, 1.01- 1.03]) and higher all-cause mortality or readmission (adjusted HR, 1.02 [95% CI, 1.01-1.03]). Every 15-minute increase in door-to-needle times after 60 minutes of hospital arrival was significantly associated with higher cardiovascular readmission (secondary outcome) (adjusted HR, 1.02 [95% CI, 1.01- 1.04]) and higher stroke readmission (a post hoc secondary out- come) (adjusted HR, 1.02 [95% CI, 1.00-1.04]); however, these associations were not statistically significant for the door-to-needle times within 60 minutes of hospital arrival.

My Take

I would first like to commend the authors on this undertaking. The fact that early door-to-balloon time is still questionable seems contrary to our understanding of ischemic events and time to cell necrosis. This high-quality study further supports the notion that “time is muscle,” as seen in other ischemic events such as acute myocardial infarction and acute limb ischemia. However, the limitations of the study affects its generalizability and application to real world scenarios. The patients in this study are all over the age of 65, largely non-Hispanic whites, all with recorded times of last seen normal and mostly treated in academic centers with stroke units. Nonetheless, the authors have certainly progressed the field of stroke treatment, if even incrementally, in the right direction.

References:

  1. Jauch EC, Saver  JL, Adams  HP  Jr,  et al; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology.  Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.  Stroke. 2013;44(3):870-947.
  2. Marler JR, Tilley  BC, Lu  M,  et al.  Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study.  Neurology. 2000;55(11):1649-1655.
  3. Fonarow GC, Zhao X, Smith EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311(16):1632- 1640. doi:10.1001/jama.2014.3203
  4. Krumholz HM, et al. Improvements in door-to-balloon time in the United States, 2005-2010. Circulation 2011;124:1038-45.
  5. Man S, Xian Y, Holmes DN, et al. Association Between Thrombolytic Door-to-Needle Time and 1-Year Mortality and Readmission in Patients With Acute Ischemic Stroke. JAMA. 2020;323(21):1-15. doi:10.1001/jama.2020.5697

“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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How a Pandemic Worsens Overall Cardiovascular Health in the U.S.

The novel coronavirus pandemic, currently holding the global population hostage in their homes, has killed over 150,000 people and infected over 2 million. The US leads all nations in both categories. One only needs to look out the window, or visit the local grocery store, to understand the overwhelming sentiment amongst the people.

Afraid.

Lonely.

Stressed.

In a pre-COVID blog post, I reviewed a paper by Brewer et al. that investigates the deleterious affects of chronic stress, minor stresses and major life events on one´s overall cardiovascular health, as determined by the AHA´s Life´s Simple 7 initiative.1 In summary, the authors found that the study participants performed worst in diet, BMI, physical activity and smoking metrics. They reference research studies of depression, CVH and smoking when proposing a theory as to why this profound correlation exists. The studies identify binge eating and smoking to be adverse behavioral responses to psychosocial stress, as well as decrease in physical activity.

The current pandemic is an acute stressor, and major life event, for us all. Unemployment claims in the U.S. have topped 20 million, stock prices are 40% lower than their 2019 highs, one third of the world´s school-aged children are home, local and international businesses are closed, flights are grounded and this graduation/wedding season will be like none we´ve ever witnessed. Psychiatric telehealth consultations are at an all-time high because this is not our steady state; we are social by nature. The current pandemic´s acute stress on our society will inevitably affect its overall cardiovascular health.

I like this illustration of the effects of psychosocial stress on the hypothalamic-pituitary-adrenal axis, and how that translates to increased cortisol level and the subsequent worsening of many cardiovascular risk factors.2

When juxtaposed with the graphic below, illustrating AHA´s Life´s Simple 7, it is quite clear that our current state of stress is antithetic to our goals of reducing cardiovascular death and improving cardiovascular health by 20% by the end of 2020.

With no clear end in sight, but promising figures showing flattening of the disease curve, we must begin tackle the deleterious effects of this acute but soon to be chronic stress on our patient population. Otherwise, we will awake from this pandemic with clinics full of less healthy patients at higher risk of succumbing to an already deadly disease.

At home strategies for exercising, healthy eating, meditation etc will be discussed in my next blog post. For now, be safe, stay home and keep hope alive!

References:

1) Brewer LC, Redmond N, Slusser JP, Scott CG, Chamberlain AM, Djousse L, Patten CA, Roger VL, Sims M. Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Lifes Simple 7 in Blacks of the Jackson Heart Study. Journal of the American Heart Association, 7(11). doi:10.1161/jaha.118.008855

2) Iob, Eleonora & Steptoe, Andrew. (2019). Cardiovascular Disease and Hair Cortisol: a Novel Biomarker of Chronic Stress. Current Cardiology Reports. 21. 10.1007/s11886-019-1208-7.

“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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A Paycheck Away: Financial Fitness in Medicine Part II

In the first installment of this three-part series, I summarized the current state of financial fitness among early-career medical professionals in the United States. I also reviewed a few general changes in philosophy that can help you begin to improve your financial health starting today. The response to that blog has been largely positive; and in the days after its posting, I received text messages from friends/colleagues expressing their desire for specific measures to take in the last year of fellowship — or first few years of independent practice. This blog post will, therefore, focus on specifics.

LAST YEAR OF TRAINING: “FINISH STRONG”

(Image: ESPN)

  • Buy individual disability insurance before June 30th. Health is wealth, and you should protect your most valuable financial asset (as a resident/fellow, this is plainly your future earning potential) in the event that you’re incapacitated in any way. Disability insurance essentially pays you a set amount of income per month while you are unable to work. This set amount depends on the plan you choose – typically expect to spend 2-4% of the income insured. Premiums depend on your current age, health, income, etc. This is why it’s important for you to lock yourself into a plan now, while you’re making significantly less income and still exercising 4 times a week. Most university-based hospitals offer group policies that are essentially generic plans from one insurer for all employees who opt-in as part of their compensation plan. I advise you, however, to find an insurance agent on your own. This individual will find provide you with all the options on the marketplace, with specialty-specific plans that can travel with you if you leave your current/future employer. You can also increase your policy (i.e. the monthly payout) as your income increases throughout your career without having to repeat a medical exam or questionnaire. (further reading)
  • Have a lawyer review your contract/offer. One way to really start off on the wrong foot is to have a contract that limits your earning potential and adversely affects your work-life balance. Have a legal professional who deals specifically with physician contracts in your state, and better yet in your county/region of the state. Some employers, for instance, will offer an attractive base pay with an unattainable RVU requirement in order to receive that shiny new base pay. Things to ask about: fairness of non-compete clause, stipulations regarding with/without cause termination, work RVU requirement, bonus structure, and feasibility, 401k match, tuition/education benefits. Things to look up: MGMA DataDive survey results for your specialty and city, AMA Physician Practice Benchmark survey results for your specialty and city.
  • Open a low fee, high-interest checking/savings account. If you’re like me and you’ve had the same checking account since you were a freshman in college, it may be time to reevaluate if that’s the best option for you. There are so many great low/no-fee options out there for you to direct deposit your new paychecks into. There are also options that allow you to invest in the market easily, or offer credits for doing so. Ultimately, what you want is for your bank accounts to protect and grow your money rather than slowly bleed you of it. I personally recommend taking a look at Charles Schwab but here are some other outstanding options for you to consider.

FIRST YEAR AS ATTENDING: “GET YOUR LEGS UNDER YOU”

(Image: Attack of the Cute)

  • Enjoy it. You’ve put in years and years of tireless effort to finally get to this point. While your college roommates were buying homes, cars and building investment portfolios, you were spending endless nights in the library or on the wards. Make a bucket list today, and make an effort to check one of those things off each year. Maybe it’s a safari in Tanzania, or it’s the Rolex that your grandpa/grandma always wore. Go for it. You deserve it.
  • Physician mortgage loan. Most people want to own a home eventually. It’s part of the American dream. It also makes sense financially (let’s play a game: calculate the total amount of rent you’ve paid from age 18 until now…then keep track of that number each month until it stops growing). So what exactly is a physician mortgage loan? It’s a special benefit provided by banks across the country that allows early-career physicians (usually < 5 years out of training) to secure mortgages of up to ~$900k with 0-5% down payment. In any other situation, with such a low down payment, the borrower would pay a fee to the bank to ensure that they won’t default on the loan; this is called a PMI (Private Mortgage Insurance). In order to secure one of these mortgages, you need to typically have a credit score of 700 and a signed contract showing your anticipated salary. That’s right, NO PAY STUBS. Many physicians actually close on their home before they even begin working. With the 15-20% that you’re saving on a down payment, go ahead and pay down those student loans.
  • If married with loans, file taxes as separate. It always comes up during tax season whether married couples should file jointly or separately. For most couples reading this, one or both partners is a physician. The average physician income in somewhere around $200,000 per year. The average physician’s student loan debt is also somewhere around $200,000. Assuming that your situation is somewhere around the average, it usually makes sense to file separately. The main downside to filing separately is that the current tax code includes credits that are only available to couples filing jointly. However, most or all of these credits only pertain to household incomes well below that of even a single income physician household. The benefits of filing separately pertain to income-driven loan repayment programs and other income-based plans you may have. If you file your taxes separately, your lender will consider only your income (not your spouse’s) in calculating your monthly payments. This can significantly reduce your monthly payments!

It’s important for physicians to tend to our financial fitness as we tend to our physical fitness. Just like everything in life, practice makes perfect. Try saving 20% of your resident/fellow salary this month. Practice trading stocks using a simulator like Investopedia’s.

If you’re going to be an attending in July 2020, plan out how the rest of the year looks for you financially, so it won’t be such a surprise when you get there. Lastly, read about the mistakes that these financially savvy physicians made here. Learning from others’ mistakes is just as good as learning from your own.

That’s all for now! Please feel free to tweet me or email me any particular questions you have, and I’ll try to answer right away as well as incorporate them into future posts.

 

“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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A Paycheck Away: Financial Fitness in Medicine Part I

Piggy bank with bandages

(source: flickr/teegardin)

Picture this. You’re an established cardiologist practicing in the city of your dreams. You have the car, the house, the second car, the country club membership, and a few luxury items in your wardrobe. Life is good. But it throws you a curveball, as it has the tendency to. You injure yourself while skiing in Aspen, and after a few painful operations, have to complete an intense rehabilitation program before returning to work. Can you afford to take a month off? How about two weeks?

A recent survey found that 69% of Americans have less than $1000 in savings, and one in three have $0 saved for retirement. I know what you may be thinking – these data primarily represent lower-income households. True. But that same survey found that 23% of respondents making greater than $150,000 had less than $1000 in emergency funds (6% had nothing set aside). A 2015 Nielsen study found that 25% of Americans earning more than $150,000 per year lived paycheck to paycheck. Couple that with this story of a physician-physician couple with a household income of $750,000 but a net worth of $0. This is the plight of many high earning but not rich yet Americans (or HENRYs as they’re referred to in financial circles).

How can you prevent yourself from becoming a perpetual HENRY? How can you break the Work = Income redundancy? If you’re reading this, it’s now. And it begins with changing your mindset towards money/finances. We, as physicians weren’t exposed to much of the finance world as we spent our income-free 20s buried in textbooks and Prometric centers. In fact, many of us resent money, we ignore money and whenever someone talks too much about money it makes us cringe (re: contract negotiations). Then, we received a few short years of lower-middle-class income before being thrust into the top 1% of earners. Like a first-round draft pick, we rush to the local dealerships and realtors with our big smiles and our big checks ready to make up for the lost time.

This is precisely the moment, in the first three to five years of being an attending, that we set our financial trajectory. Here are a few tips that I’ve gathered from people much smarter than I to hopefully help you set your trajectory high.

  • Don’t fall for bad advice

Most physicians don’t know much about personal finance, and an advisor is a great idea if that’s your situation. However, choose your advisor like you to choose your barber. Don’t just jump at the first offer. Do your research, ask your attendings, ask financially responsible friends/family. And don’t be afraid to do it yourself! Here are a few sources to check out: WhiteCoatInvestor podcast, Valuetainment on youtube, RyanScribner on youtube

  • Live like a resident initially

It’s easier said than done but hold off on buying that house or that car for the first few months or years. This allows you to pay off debt, improve your credit, save/invest and settle into your new income. If you have student loans, it also allows you to refinance them and determine what your new payment structure will be. Some rules of thumb for early spending: do not spend more than 15-20% of your annual income on a car, 20% goes to savings & investments, set up an emergency fund 2-5%, give to charity (variable). Check out this Charles Schwab survey on why people live paycheck to paycheck; the responses might surprise you.

  • Retirement is closer than you think

It’s not too early to start planning for retirement. Many physicians work well into their 70s and 80s due to the reliance on an income to maintain their lifestyle. Do a simple calculation now. How much per year of income would you need to live comfortably? Multiply that by 25. That is the amount of money you need to have for retirement by age 65. Check out this tale of two doctors for more.

It’s important for physicians to tend to our financial fitness as we tend to our physical fitness. Just like everything in life, practice makes perfect. Try saving 20% of your resident/fellow salary this month. Practice trading stocks using a simulator like Investopedia’s. If you’re going to be an attending in July 2020, plan out how the rest of the year looks for you financially, so it won’t be such a surprise when you get there. I hope this post was informative and even a little entertaining. Please look out for more on this topic in the future.

Back to your regularly scheduled programming…

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.

References (embedded links):

https://content.schwab.com/web/retail/public/about-schwab/Charles-Schwab-2019-Modern-Wealth-Survey-findings-0519-9JBP.pdf

https://www.fa-mag.com/news/nielsen–even-many-high-earners-live-paycheck-to-paycheck-22704.html

https://drcorysfawcett.com/success-is-not-measured-by-income/

https://thephysicianphilosopher.com/tale-of-two-doctors/

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Doctor Knows Best? Trust and Empathy in Medicine

These American Heart Association Scientific Sessions have been a breathtaking representation of the diversity, potential and scientific progression of the greater cardiovascular diseases community. Among the flashing lights of landmark trials, late-breaking sessions and Cardiology fanfare, a small contingent gathered in room 202AB for a discussion on cardiovascular outcomes and improved quality of care. Titled “Peddling EBM in the Era of Fake News and Dr. Google,” Drs. Raina Merchant, Joseph Hill, Peter Groeneveld, Annabelle Volgman and Shannon Dunlay astutely presented the current landscape of healthcare delivery and the challenges of mending a broken doctor-patient relationship in an age of misinformation.

It is well known that an air of mistrust/distrust exists between the US population and the healthcare system. The 2019 Edelman Trust Barometer Report (www.edelman.com) showed that only 61% of Americans trust our healthcare system; a number that places us neck and neck with Turkey, and a far cry from the 83% boasted by India and Indonesia. This is due to a combination of our history of mistreating patients for the sake of scientific discovery, as in the Tuskegee Study of Untreated Syphilis in the Negro Male, as well as the greed of physicians who practice based on compensation rather than compassion. This is has led to a knowledge vacuum, as physician-led education of the population has been replaced by celebrity and influencer-led misinformation.

We have all walked into the room and had a patient expert waiting with pages of print-outs ready to educate you on their disease pathology. Or maybe you’ve walked in and had to convince the skeptic that rat poison will prevent them from having a future stroke. I’ve certainly had to talk a number of cyberchondriacs off of the ledge, as their Google search of “headache” resulted in a diagnosis of terminal cancer. We fail when we neglect the social, cultural and religious contexts within which our patients operate. The approach is the same for all three of the aforementioned personalities: 1) listen more than speak 2) validate their concerns 3) develop partnership/goals 4) make a recommendation.

Physicians are not inherently great at persuasion. We tend to believe that our patients (and friends/spouses/etc) think logically, and approach them as such. Aristotle used three terms to describe how persuasion or rhetoric works. Ethos or the ethical appeal, means to convince an audience of your credibility or character. Pathos or the emotional appeal, means to persuade an audience by appealing to their emotions. Logos or the appeal to logic, means to convince an audience by use of logic or reason. When your patient walks into the office, convincing them that you’re the one ethical doctor in town isn’t going to work, neither is describing the all cause mortality benefit of their new prescription.

The key to building and rebuilding this broken relationship, as well as combatting misinformation, is to appeal to the emotions (or pathos) of our patients. We must always remember that patients ultimately have 3 questions for us: do you know what you’re doing? Will you tell me what you’re doing? And are you doing it to help me, or to help yourself?1 If the answers to those questions are increasingly “yes, yes and yes” then we can look forward to a future where Medicine is once again regarded as the most noble of professions; and one where we deliver the best quality of care to our patient.

 

References:

  • Dhruv Khullar, MD, MPP. Do You Trust the Medical Profession? NY Times. Jan 23, 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.