Civility in Scientific Debate

Disagreement, dissent, challenges to commonly held positions? Cool. Ad-hominum attacks, sexist language and images, name-calling? Not cool.

Critique and dissent can be eloquently expressed, and often they are. I have read thoughtful letters to the editor and received constructive, if painful, reviews of my work (side note: learn how to write constructive reviews!). There are well-established professional norms in these contexts. On social media, however, discourse is less measured and formal. A benefit of this democratization of publication means that ideas challenging power structures and status quo can propagate more easily, cross-pollination among disciplines flows naturally, and historically underrepresented voices can gain a wide audience. But a downside to this lack of gate-keeping is sometimes the deterioration of debate.

Scientists and clinicians use Twitter for education and conversation (for great examples, see #FOAMed— free open-access medical education). Many of us use the platform to communicate ideas and research findings to a wide audience, both other scientists and the public. Social media offers a channel to interact with people whose work you admire, too. It’s a great way to share your hard work, comment on debates, ask questions, and yes, disagree.

But Twitter isn’t without its downsides, one of which is immediacy: the second you hit publish, your words are out there, associated with your name. It’s too easy for something you dashed off in a fit of pique to come to represent your professional self. It’s also easy to forget that there are people behind the hashtags and handles: if you wouldn’t say something to a human in front of you, it’s likely not wise to tweet it, either— but the sense of anonymity encouraged by social media platforms can embolden some people. In combination, these factors can create conditions where bullying and other bad behavior, rather than reasoned debate, take over.

Take a recent online kerfuffle involving cardiology trainee Danielle Belardo, MD, and Jeff Nelson, who owns the website VegSource.com. Dr. Belardo recommends olive oil to her patients as part of a plant-based diet, and she shares this information on her social media channels. She bases her advice on scientific evidence and the recommendations of professional bodies such as the American College of Cardiology. There is plenty of conflicting evidence on dietary approaches to reduce risk of heart disease, and many disagree on the conclusions, including Nelson. Dietary patterns stir up lots of dissent, and that’s good. But rather than engage in conversation about the differing viewpoints on the science, Nelson posted an inflammatory meme including blatantly sexist imagery, in an apparent attempt to ridicule discredit Dr. Belardo. This behavior is, unfortunately, not unusual. People, especially women, who voice controversial ideas online are frequently subject to this kind of bullying and often to sustained harassment also. Outside of social media, a physician who promotes an evidence-based but controversial idea will likely have fans and detractors, but on twitter, she has trolls and bullies. Suddenly, rather than an intellectual back-and-forth focused on difference of opinion and evaluation of evidence, we have the digital equivalent of name-calling, schoolyard insults, and stalking.

This behavior isn’t only bad for the targets, it’s also bad for science. Unfortunately, incivility online can have a chilling effect of innovation and conversation. Afraid of triggering flame wars, some may hesitate to ask excellent probing questions. Afraid of trolls, some may hesitate to speak controversial truths. And fearing aggressive bullying, some (especially women, who are the targets of much egregious behavior) may resist speaking altogether. Diversity of methods, opinions, identities, and backgrounds should always be welcome in science, and it’s hugely detrimental to progress when brilliant people are silenced.

How can we promote civility and dissent, which are good for science? I don’t know that there’s an easy answer, but I will leave you with these words from social scientist Amy Cuddy, who has weathered her share of online incivility: “The only way to elevate the civility and quality of scientific debate is to radically depart from personal attacks and public shamings. We have to replace fear and indignation with excitement and curiosity. If there’s a genuine interest in understanding any complicated scientific phenomenon, there is a way forward. It requires openness, listening, trust, and collaboration.” (source: https://amycuddyblog.com/2017/11/29/civility-in-science-is-not-a-luxury-its-a-necessity/)

How can you contribute to openness, listening, trust, and collaboration?

#scicomm #supportwomen


“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.”




Support Your Colleagues in 2020: The Year of the Nurse

The World Health Organization (WHO) has designated 2020 The International Year of the Nurse and Midwife (coinciding with and honoring the 200th anniversary of Florence Nightingale’s birth.) “International Year of the Nurse and Midwife”

The WHO stresses that “strengthening nursing and midwifery – and ensuring that nurses and midwives are enabled to work to their full potential – is one of the most important things we can do to achieve universal health coverage and improve health globally.”  If you work in health care in a clinical, community, education, or research setting, you almost certainly work with nurses. In the U.S. alone, there are over 3 million registered nurses (via Bureau of Labor Statistics).

Do you know what roles nurses serve in in your community, and what their scopes of practice are? In many areas, nurses are not permitted to practice to the full scope of their education and training (which may include bachelors, masters, and/or doctoral degrees) due to both legal and institutional restrictions. This means we’re leaving much needed, highly skilled work on the table. Why, and how can we fix this?

The December 2019 issue of the Lancet includes an editorial about the value and potential of nursing. The authors note that “…for all its importance, nursing remains underappreciated. Perhaps the biggest barrier that continues to stifle the profession concerns gender and stereotypes. Most nurses are women, and nursing is still viewed by many as women’s work and as a soft science, rather than as the highly skilled profession it really is.” Though most readers likely feel they do not value women less than men, the institutions we work within demonstrably do. What are the gender and educational preparation of the president of the university, the CEO of the health system, the PI of the big grant? How many full professors in your department are women? What salaries do nurses make, what salaries do women make, and how do they stack up against others in an organization? If your organization is typical, you might be surprised at the disparities. AHA pledged to have no all-male panels (#nomanels!) at Scientific Sessions this past November— is that true of other events you’ve attended?

Understandably, some nurses have met the WHO’s announcement with skepticism. We’ve heard calls for recognizing and honoring nurses before, without much substantive change following. Can this time be different? I believe we can work to address the undervaluing of nursing as a profession and women as professionals, which is hindering improvement in global health. Institutions can support nursing— and I don’t mean with a pizza party during nurses’ week (although I do love pizza, so please don’t stop doing this). I mean with safe staffing, respect, leadership roles and adequate compensation. With decision-making power. With professional autonomy. This is easier said than done.

Providing this support means developing a better understanding of the breadth and depth of nursing expertise. As early career professionals, we are poised to set priorities for the coming decades of healthcare, research, and education. When it comes supporting nurses and nursing, ask yourself if you are truly walking the walk, and look for ways to do more.

Here are some ways to increase your awareness of the actual and potential impact of nursing:

  • Read the Journal of Cardiovascular Nursing or other nursing research journals. Learn what kinds of research nurses are doing and how it might impact your work.
  • Invite nurses to present at grand rounds. Their clinical expertise is often vast.
  • Invite nurses to be part of your research team— not only as staff to do your data collection, but as co-investigators. Doctorally-prepared nurses work as researchers, teachers, and advanced practice clinicians, and they are likely to have invaluable insights into aspects of science and health that others may not have.
  • Look at your citations when you write: are you including diversity, including professional role, gender, race, and nationality?
  • For nurses and those interested in nursing, have you affiliated with the Council on Cardiovascular and Stroke Nursing? Get involved, fill out a science volunteer form (committee assignments are made in April), and get in touch with the leadership.
  • Consider joining other professional organizations and getting involved with political causes— scope of practice and reimbursement issues are often hashed out by legislators, and voices supporting nursing are sorely needed. This includes from physicians!

What will you do to support nursing this year?

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)



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.


Climate Change & Cardiovascular Health: New Perspectives

I have always advocated making time to attend a talk that’s outside of your area of focus when attending a big conference. It’s a powerful way to experience new perspectives. On Monday, the last day of Sessions, there was a panel held in Main Event I— the grand stage, where the presidential session and the big-news late breakers are held— about climate change. That definitely qualifies as outside of my area. Climate change, at a cardiovascular health conference? Yes, the panelists argued, climate change is a dire threat to cardiovascular health, and we need our scientists and clinicians to address it.

Dr. John Balbus suggested several avenues through which climate impacts health, including air pollution, thermal stress and migration and conflict. These problems create cumulative physiological stress, which is a major driver of cardiovascular disease. Direct evidence of health impact can be seen. For example, during severe wildfires in California, Dr. John Balmes noted, not only did lung-related illness increase, but so did myocardial infarction.

Photo: Marcus Kauffman via Unsplash

Photo: Marcus Kauffman via Unsplash

AHA took a great step towards raising the profile of the climate problem by hosting this panel, and by doing it as a Main Event. I was dismayed, though, to see the room mostly empty.  Why does this issue not have traction? Is it “too big”— leaving folks feeling like they can’t make an impact, or any impact would be too distant to feel? Is it a question of importance vs. urgency— we see people dying vaping-related lung injuries right now, and we are facing the specter of climate-related illness less immediately? Is it that the clear lines of causation between human activity, climate change, and health problems aren’t yet clearly visible to all? I don’t know, but it is up to us as the next generation of health and science professionals to insist.

So here we are, as early career scientists and clinicians. We know there’s a problem, and we know it’s a big one. But what can we do, as busy, ambitious, career-focused young(ish) people, working in universities and healthcare organizations? Get ready to channel your inner Greta Thunberg and speak truth to power!

During the climate panel at sessions, Dr. Caren Solomon presented a framework for action with six ideas. Here’s how we can apply them to professional meetings and conferences, and maybe this will help you think about how to apply them at your home institution, as well.

  • Personal Behaviors: Traveling to a meeting is resource-intensive. For the trip to Philly this year, I tried to mitigate my impact by using public transit instead of taxis or Lyft, bringing a reusable mug/water bottle, skipping daily linen changes and housekeeping at my hotel, turning down the lights and heat when I left the room, forgoing items like bags, straws, and lids that I didn’t need, and eating plant-based (that’s a topic for another post!). These changes aren’t hard, but they do require paying attention. What else could you change to reduce your impact?
  • Institutional Decarbonization- Hosting organizations could focus on providing sustainable food and food packaging, reducing waste (think of all the printed papers and giveaways that wind up in the trash), or purchasing carbon offsets for meeting travel (organizations like Terrapass make this easy).
  • Education: The public views physicians and nurses as trusted sources. When we are knowledgable, the potential impact is high. Professional organizations like AHA can therefore facilitate the flow of information. AHA is on the right track, including a climate panel at scientific sessions. Maybe next year, we can work to increase exposure around this issue and boost uptake: promote the issue in conference materials, schedule it at a high-visibility time, and minimize conflicting sessions.
  • Advocacy: AHA recently joined a consortium of medical organizations focused on education and advocacy around climate issues https://medsocietiesforclimatehealth.org/ and @DocsForClimate). This is a great step! This group provides organization and resources to help health professionals educate local lawmakers, the press, and community groups. I’d like to see organizations do more to take up the link between climate and cardiovascular health directly, consistently, and visibly. That’s a great way to be a relentless force for a world of longer, healthier lives.
  • Nonprofits and public institutions generally have their financial information available, including financial relationships with companies and other organizations. Advocating for divestment can make some waves in an organization because it’s so closely tied to the bottom line, and it often requires a very compelling case to make change. Financial relationships can conceal conflicts between an organization’s stated values and its actions effectively— and it often takes guts to challenge the apparatus. But you have guts, right?
  • Protest & Non-violent direct action. We can be visible, as scientists, clinicians, and members of our professional organizations (including AHA). Speak out in public, wear your lab coat or your “Go Red” gear. Write letters to the editor. Attend a demonstration. We can leverage the respect our society affords us as health experts to encourage societal change.


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.


Vaping is a Public Health Problem. It’s Also an Equity Issue.

Image: Angus Maguire, via http://interactioninstitute.org/illustrating-equality-vs-equity/

Image: Angus Maguire, via http://interactioninstitute.org/illustrating-equality-vs-equity/

Vaping is a massive public health issue— and history shows us that public health issues often disproportionally affect vulnerable populations. While there has been some push-back from the vaping public about the scientific community’s alarm— focusing on the fact that the evidence of harm attributable to vaping isn’t yet fully developed— scientists and clinicians agree that the emerging pattern is deeply concerning, especially as it relates to children and adolescents. There are well-established theoretical and evidence-based reasons to associate vaping with cardiovascular disease and even death, but that’s beyond the scope of this discussion. What I will address is this: failing to address an imminent public health crisis early and aggressively can lead to real harm for vulnerable populations. Waiting for a preponderance of incontrovertible evidence before acting means that significant harm has already occurred. Intervening now is a chance to promote health equity.

We know there are disparities in tobacco use among populations. There is higher prevalence in the LGBT community, those living in poverty, those with mental health disorders, those with substance use disorders, and those living in South and Midwest , an those living in rural areas (CDC, 2015). Some evidence suggests that disparities in the use and promotion of other tobacco products and e-cigarettes mirror trends in cigarette use and marketing. In a session at #AHA19 today, Dr. Michael Blaha (@MichaelJBlaha on Twitter) noted that vaping specifically is more common among men, LGBTQ people, unemployed people, and people with less than a college education. We also know that data may hide some populations, especially homeless, incarcerated, marginalized, non-English-speaking people. So yes, this an equity issue. As we in the health community face the specter of vaping-related health crises, we must look at the impact through an equity lens.

As recently announced, the AHA is pledging $20 million to fund research on youth vaping. This is part of a program including a public information campaign (#QuitLying and #EndTheLies) and policy initiatives. Priority research areas, per the AHA’s statement, include nicotine’s impact on adolescent brain development, the impact of nicotine and other compounds in e-cigarettes on the cardiovascular system, how devices, flavors and other chemicals influence addiction, how to treat nicotine addition in youth, whether e-cigarettes are effective for smoking cessation, and what the impact of regulation is. As we scientists and clinicians proceed, we must design our research to address:

  • Racial, ethnic, gender, & socioeconomic factors
  • Comorbidities, including mental health disorders, substance use disorders, and disability
  • Whether proposed policy and information/communication solutions are effectively reaching those with the highest need

Some healthcare practitioners and researchers didn’t get the tools during their education to design equitable research and programs. If this is you, check out the resources below. Then, get your voice out— participate in research design and policy initiatives, communicate to the public and your professional community, and remember to put health equity at the top of the agenda.

Resources & References:

-Centers for Disease Control (2015). Best Practices for Health Equity in Tobacco Prevention and Control.  Available at: https://www.cdc.gov/tobacco/stateandcommunity/best-practices-health-equity/pdfs/bp-health-equity.pdf  (much of this information is applicable to vaping, as well as other public health concerns).

-MPH@GW: Milken Institute School of Public Health at the George Washington University. What’s the diffrence between equity and equality? Available at: https://publichealthonline.gwu.edu/blog/equity-vs-equality/

-Research presented at #AHA19 about vaping: https://newsroom.heart.org/news/e-cigarettes-take-serious-toll-on-heart-health-not-safer-than-traditional-cigarettes



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.


Get a Mentor, Be a Mentor

mentorship bubbleEarly in our careers, academics are encouraged to find good mentors. You need an advisor to get a doctorate, and this person is a mentor. You might be working in someone’s lab as a grad student or post-doc, and that person can be a mentor. You might be junior faculty and have a senior mentor to show you the ropes. There are formal mentorship relationships and informal mentoring relationships, and you’ve likely had both in your career. They’re a key part of professional development.

But what about being a mentor? The other day, a colleague came into my office and asked me to mentor her. My first response was to say “no, I can’t, I’m really new, we’re the same age, I don’t know anything you don’t know, you’re smarter than me. . .” But I paused. What made her ask for a mentor? What made her ask me? What can I offer this person to help her thrive professionally, so we don’t lose a much needed person in the field?

On reflection, I considered what mentorship means. Having a senior, accomplished mentor is a gift, especially if that person also works as a sponsor for you. Yet it’s also valuable to have a mentor who’s closer to where you are— someone whose life and struggle more closely resemble yours. A young(-ish) woman in academia can mentor another young woman in academia. Non-hierarchical and team models of mentorship also hold enormous promise. I attended a great session on this at #AHA18 in Chicago — I hadn’t thought of that before. Mentorship as a tool to encourage success is much broader than the classic senior-junior one-way relationship. My mentor-seeking colleague and I could certainly benefit from this kind of arrangement.

It’s also easy to forget that as early career scientists, clinicians, and educators, we are already accomplished. A grad student, an undergraduate student, a high schooler, or a middle schooler who’s interested in your field could benefit from your guidance and experience right now. Also at #AHA2018, AHA president Dr. Ivor Benjamin spoke about mentoring young black doctors. He then dug deeper, urging us to mentor young people earlier, before there’s a leak in the pipeline. This is such a crucial idea— the value of mentoring people from underrepresented groups in your profession is enormous. Science and medicine desperately need diversity, but this diversity cannot grow and flourish without the attention of dedicated mentors. Support is especially crucial for racial and ethnic minorities, LGBTQ people, and women, who remain underrepresented in many areas of STEM, including crucial leadership roles. In addition to perpetuating oppression by limiting access to career paths for individuals and groups, the downstream effects of this underrepresentation undermine equity in our science and clinical care. We can’t ignore the need for diversity and the crucial role for mentorship in building it.


So, early career scientists, educators, and clinicians, will you take up the challenge of mentorship?


Need a resource or want some further reading?

Check out this discussion of The Mentorship Guide.



Public Speaking: How (and why) to give a killer talk.

When my sister was in law school, I visited a class with her— not on torts or contracts, but on public speaking. They practiced things like improv games and role playing. They videotaped themselves speaking and did self-critiques. Now, persuasive public speaking is obviously a skill that lawyers need, but we science folks need it to. Do we not regularly need to convince people of the value of our work? We do. And many of us never get very good at it.

Why Should You Bother With Presenting, When It’s So Nerve Wracking?

Here’s a short list of reasons why you might give a talk: Disseminate science. Make a name for yourself. Defend your dissertation. Get hired in an academic position. Get things on your CV that look good when you’re chasing tenure. Educate the public (I want to put in a plug for this one— speak to a general audience sometimes! Science is for everyone). Teach students. Share clinical knowledge— think grand rounds. Persuade colleagues to adopt better practices. Make something complex and specialized more accessible to a wider audience. Get free or discounted conference fees (maybe!). Get paid (maybe!). Get your travel paid for (maybe!).

author at Disney world

The author presented at a conference held at Disneyland– who says work can’t be fun?

How Can you Hone Your Speaking Skills? 

If I’ve done my job so far, you’re convinced that giving a talk can help your career. But not all talks are created equal! We’ve all sat through terrible talks, shifting in our seats and surreptitiously checking twitter. Conversely, a truly excellent talk can be inspiring. How do you set yourself up to give one of those?

My suggestions:

  • Practice often. Give your talk to a colleague who will be honest with you. Give your talk to a friend who’s not in your field to judge clarity.
  • Time yourself until you know you have it down to the required length— and give yourself a buffer (plan to talk for 20 minutes if the slot is for 25).
  • Use visuals thoughtfully & be sure they help you make your key points. Never say “I know you can’t see this but,” or, “I’m sorry this is such a busy slide.” If you see those issues, fix them.
  • Don’t read your slides. They’re there to help the audience follow along, not to serve as cue cards. Remember that what you write in your paper isn’t exactly the same what you say in your talk— keep the ideas, but spoken language is often less formal and less complex. Also when someone is reading a script, it’s clear to the audience. So get used to speaking from key points rather than scripted sentences.
  • Tell stories. This is a universally engaging technique. Whether this means including a personal anecdote or a real-world application related to your subject, it helps make you interesting and memorable.
  • Know your audience.  How much background do you need to give? What terms do you need to define? Are they interested in the fine points of your data, or just the take-home message?
  • Pay attention to great (and awful) talks you attend. What made it good, or bad?
  • Consider inclusivity. Are you speaking at an event that represents varied races, genders, fields, and ages? NIH head Francis Collins recently committed to saying “yes” only to events with a diverse makeup. You can do this too. Second, consider the images and references in your materials. Are they culturally inclusive? If not, fix it.


What Can I Speak About, and Where Can I Do It?

Say yes a lot when you’re new— both the exposure and the practice are valuable. When you’re more established, you have to learn to say no to things, but when you’re finding your way, every time you say yes, you are honing your skills.

The author presenting at a national conference

Here are a few talks I’ve given recently:

  • Cardiovascular Physical assessment skills 101 (to NP students).
  • Women’s heart health: Know your risk and live your life (to retirement community residents)
  • Symptom trajectories after an emergency department visit for acute coronary syndrome (to a research regional conference audience)
  • Simulation in nurse practitioner education (to an education-based national conference audience)
  • Education strategies to expand access to care in rural and underserved communities (for a job talk)
  • Technology innovations to engage online NP students (to a national practice-based conference audience)

Note that they’re all to different audiences, and while the content overlaps in two of my main focus areas (women’s cardiovascular health and nurse practitioner education), I didn’t try to give the same talk to every group I spoke to.

Consider asking a senior scientist or mentor to throw things your way— they are likely turning down invitations that they’re too busy to accept. Submit abstracts to local, regional, and national conferences. Volunteer to give guest lectures to students. With this kind of exposure, you can really build your reputation as an expert on your area. Break a leg!


Public speaking resources:



Gender-Inclusive Research, Clinical Practice, and Education: Where to Start?

A person who has a scary symptom like chest pain is probably worried and stressed. For some people, their worry includes not only their health, but also whether they will be refused treatment, called by a name and pronouns that don’t reflect their identify, laughed or gawked at, assumed to have behavioral or sexual health issues, or offered treatments that have not been assessed in people like them. This is the reality that many transgender people face.

image via https://broadlygenderphotos.vice.com/, shared under a creative commons license

image via https://broadlygenderphotos.vice.com/, shared under a creative commons license

Fellow AHA Early Career Blogger, Allison Webel, PhD, recently wrote about cardiovascular disease in the transgender population. Please check out her post— it’s excellent. Some key background to remember is that transgender people live in all 50 states and over 1.4 million Americans identify as transgender1. This means that no matter where you work and what your specialty is, you are likely to encounter transgender and other gender non-conforming folks (including people who identify as genderqueer, non-binary, or other designations). It is up to you to decide to meet their needs— the systems currently in place will not ensure this. For the medical community to effectively reach transgender people, we must address their needs through research, clinical practice and education. Early career professionals need to be leaders in this effort — changing long-established ideas and practices is not easy.



Historically, the research community hasn’t done a great job of ensuring gender equity in science. As Dr. Paul Chan notes in a recent editorial, gender disparity research has picked up in recent years, but very little of it explicitly includes transgender people2. We are only beginning to generate evidence to direct our care of transgender people, and much of that evidence focuses on sexual or behavioral health. Thanks to a recent article by Dr. Talal Alzarhani and colleagues, however, we now know that the transgender population has a higher incidence of myocardial infarction than the cisgender population3. This finding is not surprising, but it is a clear sign that we must do better designing research to advance understanding the unique health needs of transgender people. But how?

  • Don’t make excuses. Women were excluded from medical research for a long time because of concerns about hormonal cycling and pregnancy. This choice has created persistent disparities4. Don’t perpetuate such inequality with the transgender population. Develop research and analysis strategies to deal with the diversity that exists rather than collapsing it or ignoring it for the sake of convenience or cost.
  • Use inclusive language to capture accurate data about gender. Dr. Chan suggests gender categories that include at a minimum cisgender male, cisgender female, transgender male, transgender female, and other2. Importantly, this strategy removes assumption that cisgender is normal and expected and allows people of all gender identities to respond authentically.


Clinical Practice: 

Much as women’s health isn’t limited to OB/GYN care, trans health is not limited to hormone therapy. Transgender people need the full spectrum of health care that cisgender people do, but many have been refused care or felt unwelcomed and mistreated in medical settings5. Primary care providers, behavioral health providers, and endocrinologists are likely to encounter transgender patients, but so are cardiologists, oncologists, surgeons, and others. Culturally and medically competent care is imperative in all of these contexts. Provider discomfort should not be a barrier. Here’s what you can do to improve:

  • Educate yourself about gender diversity. Remember that it is not your patient’s job to teach you the basics. Go to sessions at conferences, seek out knowledgeable colleagues, and read up.(Resources are listed at the end of this post to get you started).
  • Be welcoming: ask your patients what their pronouns are, and train staff to do this also. Don’t avoid addressing people because you are unsure or uncomfortable. Make sure your forms allow people to self-identify their gender with inclusive options. If you make a mistake, apologize and move on.
  • Practice with a trauma-informed approach (read an introduction to the topic here. Recognize that trust must be built. Transgender people are more likely to face significant psychosocial stressors and discrimination, including in health care. This will affect their experience.



Though health professions students report a high level of comfort with lesbian, gay, bisexual, and transgender health, they receive little formal training6. Educators in the health professions can explicitly include transgender people across curriculums to improve this perception. Here are some strategies:

  • Use gender diverse images in your education materials. Find some here.
  • Create cases and content including trans people when teaching about common health concerns.
  • Invite an expert. Find someone who cares for transgender people in your community to speak to your students.


So, early career professionals, the ball is in your court. What are you doing to enhance gender inclusivity in your work?



National LGBT Health Education Center (lgbthealtheducation.org)

UCSF center of excellence for transgender health (http://transhealth.ucsf.edu/)

GLMA (http://www.glma.org/index.cfm?fuseaction=Page.viewPage&pageId=1025&grandparentID=534&parentID=940&nodeID=1)



  1. Flores, A.R, Herman, J.L., Gates, G.J. & Brown, T.N.T. (2016). How Many Adults Identify as Transgender in the United States? Los Angeles, CA: The Williams Institute.
  2. Chan, P. (2019). Invisible gender in medical research. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
  3. Alzahrani, T. et al. (2019). Cardiovascular disease risk factors and myocardial infarction in the transgender population. Circulation: Cardiovascular Quality & Outcomes, 2019(12).
  4. Shansky, R. (2019). Are hormones a “female problem” for animal research? Science, 364(6442),.
  5. Liszewski, W., Peebles, J., Yeung, H., & Arron, S. (2018). Persons of nonbinary gender— Awareness, visibility, and health disparities. The New England Journal of Medicine, 379(25).
  6. Greene, M., France, K., Kreider, E., Wolfe-Roubatis, E.,, Chen, K., & Yehla, B. (2018). Comparing medical, dental, and nursing students’ preparedness to address lesbian, gay, bisexual, transgender, and queer health. PLoS One, 13(9).



Equal Gender Representation in the News Media: How You Can Help

Last month, I wrote about gender representation in the scientific literature. This time, I’m taking a look at the popular press. Rather than look just at gender, I’m looking how nurses are represented (or not represented) as expert sources. I’m choosing to do this for several reasons; First, the public’s perception of nursing as a profession matters both to the future of nursing (who will pursue the profession?) and to the care we provide now (how do patients and other members of the health care team respond to us?). Second, there is an inherent gender bias in the under-representation of nurses as experts, since 90% of RNs are female1. Finally, the practice and science of nursing are distinct from other fields and are valuable to health – including cardiovascular health. (If you aren’t familiar with nursing research, there’s a list of nursing journals at the end of this post – have a look at what’s getting published). Increased public visibility is a gateway to broader funding, adoption of nursing-generated evidence, and professional respect.  This isn’t just good for nurses, it’s good for the health of the population.

Photo by Sam McGhee on Unsplash

Photo by Sam McGhee on Unsplash

Nursing has matured enormously as a profession and an academic field, but the public’s perception of nursing has not kept up. A seminal 1997 report, known as the Woodhull Study of Nursing in the Media2, found that nurses were identified as sources in only 4% of health news stories in national and regional newspapers, and even fewer in industry publications. Over 20 years later, we see some increased awareness, but not enough. A team at George Washington University recently investigated the current state of women and nursing in the media. They found that many journalists don’t have a clear idea of the scope of nursing expertise, and that news organizations are infrequently reaching out to nurses. Additionally, the authors reported that journalists don’t know how to find nurses, healthcare organizations aren’t offering them as experts, and nursing professional organizations aren’t effectively engaging the media. Women remain underrepresented as expert sources in news stories at just 36%3. That’s a lot of barriers to effective representation. Yet the public trusts nurses more than any other profession, including physicians4. The valuable voices of nurses represent a huge opportunity for health and science communication, if we can learn how to effectively promote them. This will take dedicated work and attention from all sides.

Photo by Matt Botsford on Unsplash

Photo by Matt Botsford on Unsplash


Here are some ways to work on this problem:

  • Women, recognize that your contributions are needed. Women will never be treated with full fairness and equality unless our voices are audible– this is as true in science and academia as it is in politics. Cultivate expertise and believe in your own status as an expert. (Fellow early career blogger Alison Webel shared some strategies to combat self-doubt.)
  • Nurses, engage with the media. Write letters to the editor. Tweet. Promote your work, both clinical and research. Talk to journalists when the opportunity arises (see my tips here). Find out if your organization has a blog, and offer to write a post. Often, PR folks run these blogs and are delighted to have volunteer contributors.
  • Leaders in adjacent professions, seek out and recommend nurses as experts. If you’re asked to provide a quote, or background, consider whether the best person for the job might actually be a nurse– don’t assume the interviewer will know that.
  • Writers, aim for balance. Are you quoting and citing diverse sources? Think about profession, age, gender, race, rank, and nationality when you’re evaluating your sources.


Can you choose a strategy to focus on for your next project?



  1. National Council of State Boards of Nursing (2017). National Nursing Workforce Study. https://www.ncsbn.org/workforce.htm
  2. University of Rochester (1997). The Woodhull Study of Nursing in the Media. Indianapolis, IN: Sigma Theta Tau.
  3. Mason, D., Glickstein, B., Nixon, L., Westphaln, K., Han, S., & Acquaviva, K. (2018). Research Brief: The Woodhull Study Revisited: Nurses’ Representation in Health News Media. George Washington University. https://nursing.gwu.edu/woodhull-study-revisited
  4. Brenan, M. (2018). Nurses again outpace other professions for honesty, ethics. Gallup News. https://news.gallup.com/poll/245597/nurses-again-outpace-professions-honesty-ethics.aspx?g_source=link_NEWSV9&g_medium=NEWSFEED&g_campaign=item_&g_content=Nurses%2520Again%2520Outpace%2520Other%2520Professions%2520for%2520Honesty,%2520Ethics


Resources for nursing research:

Journal of Cardiovascular Nursing: https://journals.lww.com/jcnjournal/pages/default.aspx

Nursing Research:  https://journals.lww.com/nursingresearchonline/pages/currenttoc.aspx

Journal of Nursing Scholarship: https://sigmapubs.onlinelibrary.wiley.com/journal/15475069



Anxiety, Food Security, & Beyoncé: Addressing Young Women’s Cardiovascular Health

What can you do to address gender disparities in health and health care? In my last post, I suggested working to identify your own bias by increasing your awareness. I’m walking this path, too. A few years ago, I made a concerted effort to diversity my reading habits after I noticed that a huge percentage of the work I was consuming was produced by white men. I spent a year choosing to read only books by women and people of color instead. I learned that it was not hard to do this, but it required that I pay attention. I read a lot of wonderful work that I might have otherwise overlooked, and I was exposed to much more diverse viewpoints. I continue to seek out broad representation, and I suggest a similar approach to reading scientific literature.

Start by paying attention to 1) study populations, and 2) authorship. Are you reading articles about (and by) underrepresented populations? In cardiovascular health, this includes women, who remain underrepresented in clinical trials (estimates as low as 34% of participants in trials supporting drugs for some CV conditions1), clinical practice (just 20% of cardiology fellow are women2), and academia (check out the #nomanels hashtag on Twitter).

Clearly, we need more cardiovascular research by and about women. In this post, I want to highlight some exciting research by and about women.

Evidence of the pervasive male bias: we've programmed our machines to assume patients are male.

Evidence of the pervasive male bias: we’ve programmed our machines to assume patients are male.

At the recent American Heart Association EPI/Lifestyle conference, a woman-led team from Boston Children’s Hospital presented their work on perceptions of cardiovascular risk among adolescent and young adult (AYA) women. The team recognized that young women didn’t seem particularly informed about or interested in their heart health. Based on this clinical insight, they designed a study to identify barriers to awareness and preventive behaviors among AYA women. I spoke with Courtney Brown, an early-career professional herself and the first author of the abstract3, who explained the team’s findings. First, noted Brown, AYA women have a low baseline knowledge of their cardiovascular risk— lower than expected. They also face competing demands to focusing on their cardiovascular health, such as limited time and financial resources. One key finding was the role of mental health concerns like depression and anxiety: it’s hard to care about something that might happen to you in thirty years when you’re worried about getting through your next few days. Some participants also noted that eating healthy seems too expensive, and sometimes healthy food just isn’t available. These barriers to healthy behaviors are real! Yet behaviors established in young adulthood tend to persist as we age, so AYA women are at a crucial time in their lives for their heart health.

A key point for intervention development, says Brown, is that lifestyle behaviors (including exercise and high-quality nutrition) that are good for mood are also good for heart health. So while cardiovascular health may not be this group’s priority, they will likely benefit from risk-reducing behaviors in multiple ways.

Delivering the message in the setting of competing demands is tricky— and important.  When asked what might facilitate their adoption of heart-healthy behaviors, participants in the study indicated that family was their biggest influence, followed by their health care providers and celebrities (favorites were Drake, the Kardashians, and Beyoncé). They also talked about using Facebook, Snapchat, and Instagram to get information and communicate. This is rich data, and it suggests that a “meet them where they’re at” approach is likely to be successful. “We’d love for more people to take up this work— we have more steps to take,” Brown says. “We’d love to create and test materials.” It’s encouraging to see rigorous science targeting the needs of a group that’s often overlooked in cardiovascular research. As the body of evidence grows, perhaps some of the disparities in women’s cardiovascular health will fade.

There are also some great lessons here from a methodological standpoint. This study utilized mixed methods, including online focus groups. Courtney Brown, the researcher from the AYA study, stressed that the qualitative component of the work is highly valuable because it can help researchers develop interventions that will effectively reach the population of interest. “It lets us dig deeper into responses to find out what the unique barriers are and how to reach this population, not just what to tell them”, she says. When so much of existing clinical practice is based on research that excluded women, this approach is very relevant. In a climate where the RCT is king and the p-value determines whether or not a finding is considered significant, qualitative work is often undervalued, but these kinds of studies are crucial in understanding the needs, values, and preferences of patient populations— especially those, such as young women, that have been previously understudied and undertreated.


Have you read (or authored!) any great women’s health studies lately? Try to add some to your reading list!



  1. Scott, P, Unger, E., Jenkins, M. Southworth, M., McDowell, T., Geller, R., Elahi, M. Temple, R., & Woodcock, J. (2018). Participation of women in clinical trials supporting FDA approval of cardiovascular drugs. Journal of the American College of Cardiology, 71(18), 1960-9.
  2. Lau, E. & Wood, M. (2018). How to we attract and retain women in cardiology? Clinical Cardiology, 41(2), 264-268.
  3. Brown, C., Revette, A., de Ferranti, S., Liu, J., Stamoulis, C., & Gooding, H. (2019). Heart Healthy Behaviors in Young Women: What Prevents Teens from Going Red? Abstract presented at American Heart Association Epidemiology, Prevention, Lifestyle & Cardiometabolic Health Scientific Sessions, Houston, TX.



Who is writing what you're reading? Look at the great mix of people on the AHA early career blogging team!

Who is writing what you’re reading? Look at the great mix of people on the AHA early career blogging team!



Addressing Women’s Cardiac Risk in Primary Care: Research & Practice

Last month, I wrote about my roles in research, practice, and education. This month, I’ll delve into how research and practice interface around a critical health issue: coronary heart disease in women.

A study recently published in JAHA suggests that both delay between symptom onset and hospital presentation and post-PCI coronary blood flow are independently associated with excess mortality in women1.

A key finding for clinical practice is that if delay between symptom onset and hospital presentation is less than two hours, that sex difference in mortality is not significant. One takeaway is that though it’s not the only factor, delay matters— and it’s something we can target now, in primary care (where I work) and in public health.

A key point for research is that PCI doesn’t seem to improve coronary blood flow in women as much as it does in men. What does this mean?  Here’s the rub: the whole paradigm of coronary heart disease— from defining acute coronary syndrome to medical management and PCI— is based on the flawed assumption that men and women are essentially the same (as Pande & Jacobs discuss in an accompanying editorial2).

Recall that women have historically been drastically underrepresented in heart disease research, so the foundational assumptions are based on men. Though the evidence is mounting on some of the mechanisms of sex differences— microvascular disease, endothelial dysfunction, MINOCA— this hasn’t yet resulted in meaningful differences in approach to ACS treatment. Before this study’s publication, it had not been clear whether women didn’t do as well post-PCI simply because they were less likely to get in in a timely fashion, or because it didn’t work as well for them. Now we have data suggesting that both are true. Are we using a hammer when we really need a screwdriver? There is an enormous need for research in this area designed with sex differences as a presupposition and with establishing effective treatments as the goal. It will be a long road and we won’t have “the answer” tomorrow.

So as a clinician, knowing that the data isn’t there yet to show us how to improve women’s outcomes in PCI, one of the best tools I have is education and communication with my patients and fellow clinicians around treatment delay. We’ve made great progress educating patients and providers about women’s risks of heart disease (thanks in large part to AHA’s Go Red for Women campaign). Yet women still have longer delays in accessing treatment and worse outcomes in ACS than their male counterpoints.

Since heart disease is the number one killer of U.S. women and men3, preventing and detecting it are high priorities for PCPs like me. Even though short appointments and competing priorities mean finding time for prevention and risk assessment is tricky, we need to do better in our discussions around cardiac risk. We’re doing well at initiating discussions around statin prescriptions and, to a lesser extent, lifestyle measures. We need to work on discussions about symptoms of ACS and response to symptoms.

What are you doing now to improve women’s cardiovascular outcomes? Will you commit to taking one of these steps?


  1. Cenko E, van der Schaar M, Yoon J, Kedev S, Vavlukis M, Vasiljevic Z, Ašanin M, Miličić D, Manfrini O, Badimon L, Bugiardini R. Sex‐specific treatment effects after primary percutaneous intervention: A study on coronary blood flow and delay to hospital presentation. J Am Heart Assoc. 2019; 8:e011190. DOI: DOI: 10.1161/JAHA.118.011190.
  2. Pande, AN & Jacobs, A. Reperfusion and time to presentation in women: Too little too late. J Am Heart Assoc. 2019; 8. DOI: 10.1161/JAHA.118.011835
  3. Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, Chamberlain AM, Chang AR, Cheng S, Das SR, Delling FN, Djousse L,Elkind MSV, Ferguson JF, Fornage M, Jordan LC, Khan SS, Kissela BM, Knutson KL, Kwan TW, Lackland DT, Lewis TT, Lichtman JH, Longenecker CT, Loop MS, Lutsey PL, Martin SS, Matsushita K, Moran AE, Mussolino ME, O’Flaherty M, Pandey A, Perak AM, Rosamond WD, Roth GA, Sampson UKA, Satou GM, Schroeder EB, Shah SH, Spartano NL, Stokes A, Tirschwell DL, Tsao CW, Turakhia MP, VanWagner LB, Wilkins JT, Wong SS, Virani SS; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics – 2019 update: a report from the American Heart Association [published online ahead of print January 31, 2019]. Circulation. doi: 10.1161/CIR.0000000000000659.
  4. Greenwood B, Carnahan S., & Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. PNAS August 21, 2018 115 (34) 8569-8574; published ahead of print August 6, 2018 DOI: 10.1073/pnas.1800097115