Elizabeth Knight, PhD, DNP (she/her/hers) is a family nurse practitioner, scientist, and educator at Oregon Health & Science University in Portland. She focuses on social justice in health care, including the role of gender in cardiovascular health. She tweets @TheKnightNurse.
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Vaping is a Public Health Problem. It’s Also an Equity Issue.

Elizabeth Knight, PhD, DNP
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.
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Get a Mentor, Be a Mentor

Elizabeth Knight, PhD, DNP

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.

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

Elizabeth Knight, PhD, DNP

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:

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

Elizabeth Knight, PhD, DNP

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.

 

Research:

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.

 

Education: 

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?

 

Resources:

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)

 

References

  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).

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

Elizabeth Knight, PhD, DNP

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?

 

References:

  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

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

Elizabeth Knight, PhD, DNP

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!

 

References:

  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!

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

Elizabeth Knight, PhD, DNP

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?

References:

  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

 
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The Clinician-Scientist-Educator: Why The “Jack of All Trades” is Viable and Valuable

Elizabeth Knight, PhD, DNP

I am a nurse practitioner, nurse scientist, and nurse educator. That means I’m typically teaching nurse practitioner students two days a week, seeing patients in family practice two days a week, and working on a clinical research project one day a week. (At least, this is the “official” breakdown. Sometimes, in the real world, these things bleed into each other, and into the rest of my life!). I am frequently asked, with some measure of incredulity, why I completed both a DNP (clinical doctorate) and PhD (research doctorate). Was I trying to delay graduation as long as possible? Am I just indecisive? There may be some truth buried in those quips, but I think there are compelling reasons to marry clinical practice, research, and teaching.

The physician-scientist is the most well-established professional role that marries science and practice (see recent popular press mentions here and here). Other clinical fields including nursing, psychology, dentistry, and physical therapy also have dual practice/research roles. Often, teaching is additionally part of an academic position, making the role even more diverse. So what’s behind the role of clinician-scientist? Why do we need these jacks-of-all trades?

I asked clinician-scientist colleagues on Twitter what the rewards are for them. Several described feelings including seeing patients is a reminder of the ultimate reason for clinical research, and seeing the ways that research findings impact patients is motivation for further discovery. One mentioned that participating in research combats the tendency to feel like a “cog in the machine” of medicine. Another noted that it keeps the day-to-day exciting to be in practice, as lab work can sometimes be lonely. And then, there’s the exposure to new ideas and methods that comes from following multiple paths.

(Thanks to @andyYchang and @AnberithaT for the feedback!)

Elizabeth teaches health professions students at the Mobile Health Program's clinic on wheels, where she practices as a family nurse practitioner

Elizabeth teaches health professions students at the Mobile Health Program’s clinic on wheels, where she practices as a family nurse practitioner

I agree, colleagues! In addition to these personal reasons, there are philosophical reasons to take this path.  One reason that speaks to me is the nature of the relationship between science and practice. The gulf between research findings and practice change is wide — some is because the research community doesn’t always do a good job disseminating findings, some is appropriate caution on the part of clinicians, and some is inertia. But part of the problem is upstream — a lot of clinical research was not designed with translation in mind, so the findings don’t seem readily applicable or there are logistical barriers to implementation. Clinician-scientists can address these problems by designing clinically relevant studies and publishing papers that speak directly to clinician’s concerns. They may also enhance research translation by serving as hubs of disseminated learning in the clinical context. (see evidence on clinician-scientists as knowledge hubs here). This brings us to the role of educator: people with research and practice expertise are excellent educators, both in clinical and academic contexts. The deep understanding that comes with immersion in both clinical and research contexts is a powerful tool for teaching. Encouraging current students to appreciate the tools of both disciplines will pay dividends in the shared future of science and healthcare.

My colleagues and I identified many reasons to pursue the clinician-scientist-educator role. Why then isn’t this the default position with everyone following this path? There are challenges. Training as a researcher and clinician takes time, and it may require intense focus in areas that are not always well aligned. The “publish or perish” mantra of academic careers is taxing to those who may dedicate a significant amount of time to clinical practice and teaching. The expected pace of productivity for a tenure-track job can seem unattainable. Likewise, the time and focus required to prepare for and lead a large research project may be out of reach for someone with an active clinical practice. While some may find it energizing to switch contexts frequently, it can be taxing for others. It can be an uphill battle, depending on your work environment, to meet the expectations of multiple roles.

On a personal note, I have faced many of these challenges myself, but I’ve found great support in places like the AHA Early Career community. While my path isn’t typical of those in my profession, I’ve been able to seek out the resources I need to succeed. While taking an unusual path isn’t always easy, it’s also deeply rewarding to be one of the only ones who does what you do.

Would you consider a career as a clinician-scientist-educator? If you’re one or the other, do you collaborate with people who have different roles and expertise?

 

Elizabeth with a team of early-career clinicians and scientists and mentor David Goff at the AHA 10-day seminar on the Epidemiology and Prevention of Cardiovascular Disease in Tahoe City, CA.

Elizabeth with a team of early-career clinicians and scientists and mentor David Goff at the AHA 10-day seminar on the Epidemiology and Prevention of Cardiovascular Disease in Tahoe City, CA.

 

 
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Why & How To Talk About Your Research: Tips From Science Writers

Elizabeth Knight, PhD, DNP

I’m a researcher, but I’m also a nurse. Nurses are used to talking to people about complex health topics in plain language. We are often the ones helping patients wade through jargon, numbers, and data they don’t have the experience to interpret otherwise. Many nurses can do this brilliantly on the individual level – nurse to patient. As scientists, though, we have a responsibility to translate specialized knowledge on a larger scale, and most of us are ill prepared to take on this task. In graduate school, we are taught how to present our findings to other scientists, but many of us are at a loss as to how to talk to people without a science background about our work.

In health-related sciences our research findings are often relevant to the general public. Sometimes, there are enormous public health implications. An example from my field of study is the identification of women’s symptom characteristics when they have acute coronary syndrome (ACS). Communicating common symptom patterns to women can help them to recognize ACS and seek treatment quickly, which in turn can lower their morbidity and mortality rates. Research findings like this need to reach a wide audience! But translating nuanced and complex findings into meaningful information for a general audience is challenging. The public is interested in health news, yet often research findings are stripped of context and misconstrued when they’re reported outside of the academic literature. The pitfalls of poor communication include not only obscurity, but also dangerous misinformation (see an interesting take on this at the New York Times).

Still, the general public doesn’t read the New England Journal, so how do we bridge the gap between the academic press and the popular press? How can we as scientists and health care professionals communicate effectively to the public? We don’t have to go it alone – science journalists are professional communicators. It’s their job to craft science-based stories that are both accurate and compelling.

Melissa Weber, the news editor for the American Heart Association News, talks to scientists frequently when she’s developing stories. We as early career scientists should seek out these opportunities to publicize our work. It doesn’t need to be intimidating!

“Making things simple doesn’t mean you’re making them inaccurate,” Weber says. “A good story is a good story, whether it’s about science or a football game. It’s all storytelling.”

When journalists talk to scientists, they want to hear us talk about our findings in our own words. Science journalist Flora Lichtman told the AAAS that enthusiasm from the scientist is one of the best ways to generate an interesting story, and it’s okay to be informal. One rule of thumb, suggests Weber, is to try to explain your findings like you would to a fifth-grader. And “avoid medical jargon like the plague,” she adds. Other tips for good communication include thinking about who the audience for the piece will be and thinking of metaphors to explain tricky concepts. And Weber and Lichtman both stressed that being interviewed doesn’t need to be nerve-wracking – silence is okay while you’re thinking, and you can always ask to re-state something if it didn’t come out right.

 

Are you talking about your work to people outside your field? If not, start now!

 

References: https://www.aaas.org/resources/communication-toolkit

 

 
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3 Key Reasons to Attend Scientific Sessions Early in Your Career

Elizabeth Knight, PhD, DNP

What is the value of traveling to a large cardiovascular meeting, when the information communicated in the sessions will be available via Live Streaming and the major news will be published immediately? Why go through the expense and the hassle of time away from work? Attending an event like Scientific Sessions is not easy for most of us — especially Early Career professionals who experience high demands on our time and limitations on our resources. So what makes it worthwhile? Of course this depends on your career type and your goals, but I believe the following three reasons are important for everyone in academia:

  1. Hearing and learning things you would not have sought out. When you’re at a professional conference, you have set aside time for learning. You are less likely to be squeezing learning in between other tightly scheduled commitments at home. This time allows for serendipitous exposure to new areas. For example, even though my research focuses on symptoms, risk, and communication, I heard some very interesting sessions about the microbiome. Similarly, this kind of broad exposure enables cross-pollination among disciplines that share common goals but diverse methods. What can basic scientists learn from nurses? What can interventional cardiologists learn from computer programmers?
  2. Personal connections. The power of small interactions— a chat in the coffee line, a well-put question during a session— is undeniable. The opportunity to make such connections with people at all levels in your field and related fields is one of the major benefits of attending a conference. Certainly this includes people who are “big names,” but also people whose work you might now take an interest in since you’ve met them (and vice versa). When I attended a 10-day seminar in Tahoe last year, I sat around the campfire with Dr. David Goff, director of an NIH division, and I was also the roommate of Dr. Sherry-Ann Brown, a junior scientist whose work I’ve since cited. I was able to reconnect with them and other old connections from the seminar at Scientific Sessions this year, and was genuinely interested in their work on a new level because I knew them.
  3. Momentum and enthusiasm. I always come home from events like this brimming with ideas. Science is a highly creative endeavor, and anything that sparks creativity is good for science. To make the most of this aspect, I keep good notes and make a priority list, including names, references, and contact information if applicable. I review my list on the plane ride home and identify “action items” for follow up. An event like Scientific Sessions also gives you a great feel for the overall state of cardiovascular research, and for the current priorities of different stakeholders. Using this information in long-range planning is smart and increases changes of successful projects going forward.

While it’s not feasible to attend every event that interests you, I highly recommend making an event like Scientific Sessions a priority, especially early in your career.

Why do you go to Scientific Sessions?

AHA Early Career Bloggers had the opportunity to get to know one another during Scientific Sessions 2018