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#COVID-19: Universal Mask Policy, Universally, Now.

As the COVID-19 pandemic has wrought havoc in major American cities over the past few weeks, particularly in New York City, a common refrain from health care workers (HCWs) on the front line continues to be: “Get Us Personal Protective Equipment (#GetUsPPE).” Yet intertwined in this tragedy of a gross undersupply of PPE has been the problem of mixed messages about the level of PPE that should be used by HCWs, which stemmed from dynamically changing recommendations from the Center for Disease Control (CDC).

Ultimately, the current CDC recommendations, which advise the use of surgical masks when with a symptomatic COVID-19 patient and N95 masks only during aerosolizing procedures, were borne primarily out of an anticipated shortage of PPE, and these recommendations differ from earlier ones that recommended N95-level masks whenever with a patient with suspected COVID-19. Justification for this effective reduction in PPE levels stemmed from the CDC’s thought that COVID-19 is primarily spread via droplet transmission.

In light of this CDC guidance, many hospitals implemented policies that similarly aimed to preserve PPE supply, anchoring on the notion that COVID-19 is transmitted by symptomatic patients via droplets. Many of these policies restricted hospital staff from wearing masks outside of patient rooms, and ultimately led to numerous reports of staff (including house staff trainees) being reprimanded for doing so.

Yet as hospitals in countries like Italy and Spain and in major American cities such as Boston are experiencing alarming numbers of their HCWs test positive for COVID-19, it is crucial for us to reassess whether our current PPE policies are adequate to protect HCWs from infection and to prevent nosocomial spread. Indeed, prominent academic medical centers such as Partners Healthcare, University of Pennsylvania, New York Presbyterian, and University of California San Francisco (UCSF) have already adopted a “Universal Mask Policy” to help address this vital issue.

In order for us to more effectively contain the rapid spread of COVID-19 in our communities, I strongly believe that all hospitals should adopt a Universal Mask Policy, in which hospital staff are required to wear surgical masks in all areas of the hospital. This step is crucial for the safety of our team members, our colleagues, and our patients.

My belief stems from the following:

  • Precedent from countries with effective control: On March 18th, the American College of Cardiology held a joint teleconference with the leadership from the Chinese Cardiovascular Association, which included a section on recommendations from their physician leaders on how to adequately control COVID-19 spread at our hospitals in the U.S. They strongly urged us to wear surgical masks in all areas of the hospital, and they also used N95 masks during all encounters with patients with suspected COVID-19. They felt these measures were pivotal in their ability to protect their staff members and control the rampant spread of the virus throughout their hospitals. Further, the Director of the Chinese Center for Disease Control and Prevention, Dr. George Gao, told Science that it is a “big mistake” that people in the U.S. are not wearing masks everywhere in public, let alone not wearing them everywhere in the hospital. Similar public masking policies are in place in South Korea, Japan, and Singapore, where COVID-19 disease spread has also been more effectively controlled.
  • Likelihood of asymptomatic spread among HCWs in the hospital: It is becoming increasingly clear in the literature that a large portion of the disease spread is from asymptomatic individuals (Li et al, Science, March 16, 2020; CDC MMWR March 27, 2020),  with a long incubation time of 5 days median (Lauer et al, Ann Intern Med, March 10, 2020). Hospital staff, who are only advised to stay home from work if symptomatic, may still present to work asymptomatic but infected and contagious. Without at least wearing a surgical mask throughout the hospital, we are at increased risk of spreading infection among each other.
  • Transmission by talking: By the nature of our work, we are not used to routinely standing 6 feet away from each other in the hospital as we communicate; in a small Twitter survey, >60% of respondents said that #SocialDistancing is not currently practiced in their hospital. Further, we are all touching common surfaces (e.g., keyboards, computer mice, phones) that will inevitably carry droplets that are inevitably spread from unmasked mouths when we talk. While surgical masks are not the perfect solution to filter out the droplets emitted from our mouths when we talk, cough, or sneeze, they undoubtedly reduce emission into the ambient air around us (Figure 1) and should reduce the likelihood of asymptomatic hospital staff from transmitting infection among each other and to our patients.

 

Figure 1: Two-way protection provided by masks (from Medium blog post by Sui Huang, MD, PhD at the Institute for Systems Biology)

In summary, I urge all hospitals to implement a Universal Mask Policy to account for these data and expert recommendations. As mentioned above, the lack of a clear, effective message has led to conflict between care teams, leading to discord at a time when unity is so critical. Although no randomized clinical trial has yet to show that a Universal Mask Policy is the most effective way to reduce nosocomial transmission of COVID-19, the “absence of evidence is not evidence of absence.”

When there is enough reason to believe that a Universal Mask Policy should help to protect our staff and patients, we need to err on the side of safety when the consequences are life- and livelihood-threatening. While anticipated mask shortage is clearly an issue, the remarkable resourcefulness, philanthropy, and ingenuity of our communities will come through.

In the meantime, we need a Universal Mask Policy to protect us. We need a Universal Mask Policy to unite us. We need a Universal Mask Policy now.

 

“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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Nutrition in the New Year: What is Our Role as Cardiologists?

As we embark on this new year, we are bound to field questions from our patients (and likely, family members) centered around the most popular new year’s resolution: Eating healthier. Reflecting upon my own answers to these questions in clinic over the years, I realize they have been some combination of:

“Eat smaller portions.” “Eat less meat.” “Cut out soda or juice.” “Don’t eat for 3 hours before going to bed.” “Have you heard of the Mediterranean diet?”

And the basis for my recommendations? While I’m sure my years of medical training were factored in somewhere, I feel like these suggestions were largely based on a combination of my own experiences with managing my nutrition, anecdotes from colleagues and friends, and quite possibly my favorite podcasts.

Upon further reflection, though, this is not all too surprising. For all the years that we spend in medical school, residency, and fellowship learning about pathophysiology and pharmacology, we receive much less structured education on nutrition.1 In four years of medical school, one study estimates that the average medical student receives approximately only 19 hours of didactic lectures in total on nutrition, with most of this education focusing on the manifestations of nutritional deficiencies (thiamine, vitamin C, etc.).2 If your recollection is like mine though, 19 hours seems like an overestimation, and it only declines in post-graduate medical training. In a recent study published in the American Journal of Medicine, 31% of cardiologists reported receiving no nutrition education in medical school, 59% reported none during residency, and 90% reported receiving no or minimal nutrition education during fellowship.3

Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

Figure 1: Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

“But we are cardiologists, not nutritionists,” one might say. Yet in the same study, 95% of cardiologists believed that their role is to provide their patients at least basic nutrition information (68.6% believed they should personally provide detailed nutrition information to patients).3 While many of our cardiovascular care teams include dieticians specifically trained to counsel our patients on their nutrition habits, we as cardiologists often find ourselves directly answering these questions from our patients.

Indeed, some physicians have made names for themselves by proselytizing specific diets for their patients. Yet what I find a bit unsettling is the variability of the messages we deliver to our patients when it comes to nutrition. While the AHA provides dietary recommendations we can share with our patients, new diets continue to pop up and gain traction in the headlines, inevitably leading to questions from our patients about whether it is safe for them to adhere to these diets. Notably, (1) intermittent fasting, (2) plant-based or vegan, and (3) ketogenic or “keto” appear to be the diets du jour.

While I personally have experimented with intermittent fasting and a plant-based diet, I am a bit uncomfortable fully endorsing one or the other to my patients, each with his or her own metabolic profile and potential list of glucose-lowering medications. When it comes to diet, more than anything, individualization is key. More so than exercise and medications, diet has deeper roots in the cultural, financial and societal environments in which our patients live. Helping them navigate a healthy lifestyle through these obstacles requires not only more time in clinic but also a deeper, more evidence-based foundation in cardiovascular nutrition.

Fortunately, we are entering an era in which we are gathering more evidence in nutrition science. A recent study published earlier this month in Cell Metabolism studied “time-restricted eating” (AKA intermittent fasting with a 10-hour eating window) in patients with metabolic syndrome,4 finding that it had beneficial effects on weight loss and metabolic profile in its albeit small sample size. (Figure 2) Additionally, a New England Journal of Medicine review article published over the holidays highlighted the existing evidence we have, both in animals and in humans, of intermittent fasting on health, longevity, and various disease states (including cardiovascular disease and cancer).5 Importantly, these recent publications and the responses they have elicited in the news and on social media have called attention to the need for more dedicated studies to address the safety and efficacy of specific diets and dietary patterns in our patients with metabolic and/or cardiovascular diseases. Indeed, more clinical trials are underway: a quick search on ClinicalTrials.gov shows that 24 registered clinical trials with an “intermittent fasting” intervention are actively recruiting participants, including the LIFE AS IF trial from the University of Chicago.

Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

Figure 2: Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

In a prior blog post on “Wearables in Medicine,” I recommended that we consider trialing wearable devices ourselves before counseling patients based on data obtained from them. While I do think our own experiences with diets and dietary patterns may be informative, our personal experiences should not be the sole pillar upon which we base our nutritional recommendations to our patients. Again, individualization is key, and a nuanced approach, factoring in living environments, medications, and metabolic profiles, is necessary.

So what should we do as members of cardiovascular care teams? Well, to provide basic nutrition recommendations to our patients, we can use the AHA Diet & Lifestyle Recommendations. However, we must acknowledge our own limitations regarding the lack of formal training on nutrition during our medical education. As such, my resolution this year is to further my education on nutritional science and attempt to understand how these popular diets may fit within modern cardiovascular disease management. To achieve these goals, I will:

  • Read: Some books recommended by my attendings that I plan to read include The Obesity Code by Jason Fung, MD and The Plant Paradox by Steven Gundry, MD. Additionally, for those interested in learning more about the role of a “keto” diet in cardiology, the ACC.org Sports and Exercise Cardiology section recently published a series of high-yield, informative articles (Link 1 and Link 2).
  • Collaborate: We have a dietician in our cardiovascular care team with whom I regrettably had not spoken directly with until recently. I previously had just referred patients to her, but I did not necessarily know exactly what advice she was giving to our shared patients. Opening and maintaining this channel of communication is essential to delivering a consistent message from our team.
  • Ask: I am now making it a habit to include a simple question in my clinic encounters: “How’s your diet?” I have found the open-endedness of the question to be quite enlightening, often helping me to uncover a new aspect of the world my patient lives in and their own perspective on how their nutrition impacts their health.

I would love to hear your input on this topic. What do you feel our roles are in nutrition counseling for our patients? What are reliable resources to learn more about this topic? How can we be better at delivering appropriate nutrition information to our patients? Please reach out to me on Twitter (@JeffHsuMD) with your thoughts and ideas.

References:

  1. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321:1351–1352.
  2. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. Journal of Biomedical Education. 2015;2015:357627.
  3. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130:1298–1305.
  4. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, Wang X, Fleischer JG, Navlakha S, Panda S, Taub PR. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020;31:92-104.e5.
  5. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381:2541–2551.

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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#AHA19: Why Choose Heart Failure?

“Skate to where the puck is going, not where it has been.” -Wayne Gretzky, Hall of Fame Hockey Player

I heard this quote a few times at #AHA19, most relevantly during a special interest “breakout” session for Advanced Heart Failure & Transplant Cardiology held in the AHA Early Career / FIT Lounge. In reflecting on the hot topics of the meeting, as well as the landmark clinical trials that have been published over the course of my training, I couldn’t help but agree with the following notion discussed in the breakout session:

Heart Failure is where the puck is going.

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Dr. Tariq Ahmad, Dr. Eric Adler, and Dr. Sophia Airhart serving as expert faculty panelists for the Advanced Heart Failure & Transplant Cardiology breakout session in the AHA Early Career / FIT Lounge at #AHA19.

As a current Advanced Heart Failure fellow, I am clearly biased here. But after the field experienced a decade-long drought absent of new effective therapies to improve the outcomes of patients with heart failure, the landscape changed in 2014 with the publication of the PARADIGM-HF trial and its effect of adding angiotensin receptor-neprilysin inhibitor (ARNI) therapy to the armamentarium of cardiologists treating patients with heart failure with reduced ejection fraction (HFrEF).

Fortunately, since PARADIGM-HF, the momentum has continued to build. The addition of effective new therapies for patients with heart failure has not stopped with ARNI. In 2015, with the EMPA-REG OUTCOME trial, we began to see the signal for improved heart failure outcomes (reduced heart failure hospitalizations), with the use of a sodium glucose-cotransporter 2 inhibitor (SGLT2i) in patients with diabetes, generating excitement for the potential for SGLT2i therapy in heart failure. In 2018, we learned of our first effective treatment for transthyretin amyloid cardiomyopathy, which is now FDA-approved and quickly making its way to our patients.

Presentations at #AHA19 kept this wheel turning, as there were key studies presented that continue to shape the new frontier of therapies for heart failure.

  • DAPA-HF: The DAPA-HF trial was the first to study the efficacy of SGLT2i as a heart failure therapy, even in patients without diabetes. While initial results were presented at the European Society of Cardiology (ESC) Congress in September 2019, further insights from the DAPA-HF trial were presented at #AHA19, demonstrating that the significant effects of the SGLT2i, dapagliflozin, on reducing the risk of death and improving heart failure outcomes in HFrEF spanned across the spectrum of ages studied, demonstrating efficacy even in the elderly. Further, dapagliflozin improved the health status in patients with HFrEF, based on the Kansas City Cardiomyopathy Questionnaire.
  • PARADIGM-HF + PARAGON-HF: The results of the PARAGON-HF trial, presented earlier this year, did not show significant added benefit of sacubitril/valsartan therapy in reducing adverse events in patients with heart failure with preserved ejection fraction (HFpEF) compared to valsartan therapy alone. However, a pooled analysis of the PARADIGM-HF & PARAGON-HF trials was presented at #AHA19 by Dr. Muthu Vaduganathan from Brigham & Women’s Hospital. This analysis suggested that the therapeutic effect of sacubitril/valsartan may extend into the heart failure with mid-range ejection fraction (HFmrEF; LVEF 40-49%) range. Interestingly, there appears to also be differential response between men and women to sacubitril/valsartan. The HFmrEF category has been garnering more interest lately, and this study points to a potential benefit of ARNi therapy in this group.
  • VICTORIA: While not presented at #AHA19, the announcement of positive results for the VICTORIA trial was made shortly after the conclusion of the conference. The VICTORIA trial studied the soluble guanylate cyclase inhibitor, vericiguat, in patients with HFrEF, and per the press release, “reduced the risk of the composite endpoint of heart failure hospitalization or cardiovascular death.” This class of medications is most well-known for riociguat’s use in chronic thromboembolic pulmonary hypertension, but, depending on the results of VICTORIA, which will be presented in 2020, it may constitute yet another class of effective medications in the heart failure toolkit.

With new, effective medical therapies continuing to emerge for patients with heart failure, the field is making progress at chipping away at the high mortality rates that still plague our patients with heart failure. With the impending approval of SGLT2i for patients with HFrEF, we are now entering an era of “quadruple therapy” for HFrEF, with significant efficacy if adequately implemented.

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Combine these exciting developments with the concurrent advances in structural therapies (i.e., percutaneous valve repair/replacement) and eventual development of a fully implantable left ventricular assist device (LVAD), I believe that heart failure is a cardiology subspecialty on the rise and that undifferentiated trainees should do one simple thing: Skate to where the puck is going.

 

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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Why Get Involved with the AHA as a Trainee?

Keeping tradition with Dr. Ivor Benjamin’s visit to the AHA FIT & Early Career Lounge last year, current AHA President Dr. Bob Harrington came by the Lounge today to engage and interact with FITs and research trainees alike. He expounded on his own journey towards the AHA Presidency, from getting involved with the AHA as a cardiology fellow to volunteering on many councils within the organization.

His path was one filled with persistence and hard work, yet he emphasized the importance of mentorship in his career trajectory. At Duke University, Dr. Robert Califf served as an early mentor of his, and Dr. Harrington continues to collaborate with Dr. Califf on research projects, he said that he still views him as a career mentor. Yes, even while holding arguably the peak leadership role within American cardiology, the President of the AHA still has mentors who advise him.

At another FIT/Early Career session, Dr. Jared Magnani, Chair of the FIT Programming Committee, emphasized the role of knocking on doors, seeking out opportunities, and seeking out mentors. While we may feel like we have wonderful mentors at our home institutions, it is crucial to broaden your horizon and learn about the breadth of career paths that have been tread elsewhere.

So, why get involved with the AHA as a trainee? Mentorship. Opportunities. And the opportunities to meet mentors.

For a more detailed list of the opportunities that exist for AHA FITs to get involved, see the AHA FIT Newsletter published earlier this year.

But by getting involved with the AHA as a trainee, whether it be through applying for research funding or volunteering for committees within your council, allows you the unique opportunity to network with mentors (faculty & peer) from across the country. These people can become invaluable resources as you progress in your career, and as Dr. Harrington reiterated, it is crucial to find mentors in all aspects – research, clinical, leadership, work-life balance, etc.

Dr. Harrington’s Q&A session in the FIT Lounge today demonstrated the AHA leadership’s willingness and readiness to be available to mentor trainees. As a trainee, getting involved with the AHA demonstrates your willingness and readiness to be mentored by them.

To learn more about mentorship opportunities through the AHA as a FIT/Trainee, please email ahafellows@heart.org.

And to learn about how to Cultivate a Successful Mentor/Mentee Relationship, stop by the AHA FIT & Early Career Lounge tomorrow at 10am to hear tips from our faculty panelists.

The AHA FIT Programming Subcommittee with AHA President, Dr. Bob Harrington.

The AHA FIT Programming Subcommittee with AHA President, Dr. Bob Harrington.

 

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

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How To Train Your Leader?

Last month, I attended a meeting held by HFSA, entitled “Future Leaders in Heart Failure Symposia.” The meeting gathered together a multi-disciplinary team of trainees – cardiology fellows, nurses, pharmacists, post-doctoral researchers – to immerse them in discussions with current leaders in the world of heart failure. Session topics centered on themes such as having conversations with division chairs and effectively building and running a subspecialty clinic.

The HFSA Future Leaders program provided a venue for participants to actively engage in discussions with prominent faculty members (the current leaders in heart failure), as well as meet each other (our future, fellow leaders in heart failure). While the goal of the program was not necessarily designed to “train” us on how to be leaders per se, I could not help but think about the following:

  1. What are the qualities of an effective leader?
  2. Can you actually train someone to be a leader, or is leadership ability an innate quality one is simply born with or without?

I’m still trying to sort out my own answer to Question #2, but from my training experience thus far and after some fun discussions with colleagues, I’ve tried to distill my answer to Question #1 into 3 common qualities I have found in effective leaders in medicine and medical research:

  • Treat their team members with respect. When I was a medical student, the CEO of our hospital system spoke to our class as we were about to start our first clinical rotation. While the practice of a CEO speaking to medical students (infamously the lowest position on the totem pole in the hospital patient care setting) may potentially be a common practice, the CEO uncommonly spoke to us as peers, teammates in the collective mission to improve our patients’ health. At the end of his talk, he asked each of us to take our cell phones out of our pockets, and he gave us his personal cell phone number to enter into our Contacts directory. He urged us to call him with any issues we thought could help improve our patient care. Ten years later, I still have his number on my phone, and while I have never called him, this gesture had a tremendous impact on me as a trainee. The CEO was widely considered to be an outstanding leader for our hospital, and I’ve found that effective leaders similarly seek out opportunities to meet with their team members and earnestly listen to their stories. Great leaders know and respect the individuals of their teams.
  • Know their material. It is difficult to ascend into a leadership position without having demonstrated a superior grasp of the pertinent material in your field. Yet leaders actively find ways to demonstrate their knowledge of the field, whether it be through peer-reviewed publications, through presentations at local or national conferences, or even through small group discussions with their team members. This demonstration of knowledge elicits trust from their team members – trust that they “know their stuff” well enough to make appropriate, well informed decisions going forward and move their teams in the right direction.
  • Speak publicly with passion and clarity. Public speaking is a challenge for most people, and some may argue that being an excellent public speaker is not a requirement for being a great leader. But in my experience, I have found that the leaders whom I admire are those who can not only demonstrate their deep knowledge of a topic (e.g., the urgent need to improve our delivery of optimal HF therapy to our patients) during a public presentation, but can also excite the audience to go out and uptitrate their patients’ beta-blocker doses right away. A famous quote from President Dwight Eisenhower goes: “Leadership is the art of getting someone else to do something you want done because [they] want to do it.” Leaders who are engaging, eloquent speakers tend to be the ones who can convince you of the importance of achieving your collective goal and clearly articulate their vision for the team.

I am confident that this list will dynamically evolve over the course of my career, as I continue to be privileged to meet my professional heroes. But as trainees interested in becoming future leaders in cardiovascular medicine, I believe it is important for us to reflect on the important qualities of the leaders we follow and admire. Can we be trained, or even train ourselves, to cultivate these qualities in own leadership practice? Entire books and TED Talk series are devoted to these questions, and I hope to reflect further on these questions in future posts. But if your goal is to become a leader in medicine, perhaps the first step is to recognize these common characteristics of leaders you personally admire and find ways to incorporate these habits into your own routine.

 

What do you think are qualities of effective leaders? Do you think these qualities can be taught? I would love to hear your thoughts via Twitter (@JeffHsuMD).

 

 

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Why We Sleep, and Why Don’t We Let Hospitalized Patients Sleep?

Last month, I wrote about my newfound fascination with wearables and the physiological parameters I now measure on myself. One of these metrics is my “recovery score,” (Figure 1) which is heavily determined by the quantity, quality, and consistency (the regularity of the times at which I go to sleep each night and wake up each morning) of my sleep. Now that I wake up each morning being graded by my wearable on how well I slept, I have implemented strategies to improve my scores: wearing an eye mask, using blue light-blocking glasses at night, using my phone in bed, going to sleep at a regular time. These indeed have improved my recovery scores, and I honestly feel I sleep more efficiently as a result – I feel just as rested after 6 hours of sleep now as I previously did only with 7-8 hours of sleep.

Figure 1: Sample recovery score from my wearable device (Whoop strap).

Figure 1: Sample recovery score from my wearable device (Whoop strap).

My focus on my own sleeping habits led me to start reading the book, “Why We Sleep” by Dr. Matthew Walker. It is a fascinating review of the physiological role of sleep (or at least, the best knowledge we have of it), and I recommend it to anyone interested in the topic. While sleep has been studied intensely for decades, there still is much we do not know about how it benefits our bodies and minds. Some recent high-profile studies on sleep caught my attention though, including one published in Science that implicates the sleep-wake cycle in the regulation of the Alzheimer’s Disease-related tau protein in the brain.1,2 Another recent study suggests that when we cannot repay accrued “sleep debt” over the course of a week, at least with regards to its effects on metabolic dysregulation.3 However, as I continued to read about the importance of sleep and its health benefits, I could not help but think about some of the most sleep-deprived people we encounter regularly – our own patients.

Anyone who has worked in the inpatient hospital setting knows that admitted patients are regularly disrupted throughout the evenings in the hospital, and it is a rare evening they can get a full, restful night’s sleep. Indeed, one study showed that inpatients on average get 83 fewer minutes of sleep compared to their sleep duration at home.4 Some factors preventing sleep are related to the nature of their hospitalization and are difficult to circumvent – severe pain, hemodynamic instability, infections that produce significant discomfort (e.g., fever, cough).

Yet many factors are systematic and iatrogenic. Often, nurses receive orders to check vital signs every 4 hours, and thus are required to check in on patients in the middle of the night to measure blood pressures. Intravenous medication infusion pumps alarm seemingly every 5 minutes. Daily lab work is ordered to be performed early in the mornings, so that results will be ready by the time physician teams begin their rounds. And in teaching institutions, medical students and housestaff “pre-round” in the early hours (sometimes as early as 5:00am), waking their patients to briefly interview and examine them (Figure 2).

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Figure 2: Depiction of early morning “pre-rounding.”

While clearly many hospitalized patients are in the hospital precisely because they need close monitoring, there is a large subset of admitted patients who, despite the need to be hospitalized, could be provided an environment in which they can get a full night’s rest. Many hospital systems are attuned to these issues, and I am proud to say that mine is as well, but many of the systematic factors that interfere with sleep are unfortunately just part of the rounding culture at academic hospital centers (early labs, pre-rounding, etc.).

A recent Twitter thread from a former co-resident of mine, Dr. Dan Wheeler (@WheelerMed), made me reflect on the purpose of morning rounds. Dr. Wheeler’s thread highlighted the heterogeneity in how different teams rounded and the challenges this may pose to trainees. Yet I could not help but think that the major problem with rounds is that, in my opinion at least, it is not patient-centered. In fact, given that many features of rounds interfere with an inpatient’s ability to obtain adequate sleep, rounds actually impede patient recovery.

Isn’t patient recovery our ultimate goal? When I spend so much time trying to improve my own “recovery score,” shouldn’t I also focus energy to improve the recovery scores of those who need it much more than I do?

As trainees, we arguably do not have much control of the rounding schedule and culture. But, my goal in writing this post is to challenge us to be mindful of these factors when we eventually do have the capacity to restructure the inpatient hospital routine, to focus appropriate attention and efforts to allow for adequate patient sleep and recovery. This field may actually be an exciting avenue for research, particularly in wearables that can appropriately monitor inpatients’ physiological parameters during sleep without disturbing them.

So before you go entering your patients’ rooms at 5:30am in the morning to pre-round, I encourage you to take an extra moment to ask yourself whether it’s truly necessary to wake them, or whether you can allow them the chance to improve their recovery score just a bit more.

 

References:

  1. Holth JK, Fritschi SK, Wang C, Pedersen NP, Cirrito JR, Mahan TE, Finn MB, Manis M, Geerling JC, Fuller PM, Lucey BP, Holtzman DM. The sleep-wake cycle regulates brain interstitial fluid tau in mice and CSF tau in humans. Science. 2019;363:880–884.
  2. Noble W, Spires-Jones TL. Sleep well to slow Alzheimer’s progression? Science. 2019;363:813–814.
  3. Depner CM, Melanson EL, Eckel RH, Snell-Bergeon JK, Perreault L, Bergman BC, Higgins JA, Guerin MK, Stothard ER, Morton SJ, Wright KP. Ad libitum Weekend Recovery Sleep Fails to Prevent Metabolic Dysregulation during a Repeating Pattern of Insufficient Sleep and Weekend Recovery Sleep. Curr Biol. 2019;29:957-967.e4.
  4. Wesselius HM, van den Ende ES, Alsma J, Ter Maaten JC, Schuit SCE, Stassen PM, de Vries OJ, Kaasjager KHAH, Haak HR, van Doormaal FF, Hoogerwerf JJ, Terwee CB, van de Ven PM, Bosch FH, van Someren EJW, Nanayakkara PWB, “Onderzoeks Consortium Acute Geneeskunde” Acute Medicine Research Consortium. Quality and Quantity of Sleep and Factors Associated With Sleep Disturbance in Hospitalized Patients. JAMA Intern Med. 2018;178:1201–1208.

 

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Wearables in Medicine: Try It Before You Prescribe It?

Much of the “buzz” in the air among ACC19 attendees revolved around the Apple Heart Study. There was a wide variety in reactions to the study results – from underwhelmed to measured to overzealous.  After some reflection, my personal reaction is that I’m just glad this study was performed – now we have some data for one of the most widely used wearable devices by our patients. Patients will, and already have, come to me with questions about the Apple Watch and its heart rhythm monitoring capabilities, and now I have some numbers available to help me address their concerns.

As the Apple Heart Study is likely just the beginning of an impending flood of wearable and virtual enrollment studies, physicians will undoubtedly be asked more and more questions about data collected by our patients’ devices. Just the other week in clinic, I had one new patient present with concerns about his cycling performance over the past few months. I fortunately noticed he was wearing an Oura ring device, and I asked him if he wore the ring during his cycling rides. He was shocked – he had yet to encounter a physician who knew what the Oura ring was, let alone be comfortable with analyzing the variety of data it measured. Fortunately, I had just chatted at length with a colleague who uses the Oura ring, as I was in the market for a wearable fitness monitor at the time. Yet even my cursory knowledge of the device seemed to deepen the patient-physician relationship in that first clinic visit.

The primary objective of the Apple Heart Study was to test the ability of the Apple Watch and its rhythm analysis algorithm to accurately detect atrial fibrillation. While atrial fibrillation detection is clearly an important tool, as recently described by AHA blogger, Dr. Christa Trexler, there are a variety of data being collected by wearables that may have tremendous value for our ability to optimally care for our patients, as these measurements lend insight into the 99+% of the time our patients spend outside of our clinic room with us. These include routinely measured factors (such as heart rate, step counts, and even blood pressure), but they are also measuring parameters and providing assessments of factors we do not routinely use in clinical practice, such as heart rate variability (HRV), “sleep quality,” and recovery/readiness indices. So, should we start incorporating these latter measurements in our patient care?

Figure: (Left) Apple Watch Series 4. (Right) Whoop Strap 2.0, demonstrating my Recovery Score for the day (based on my recent sleep patterns and recent cardiovascular workloads). (Both) Demonstration of probably wearing too many wearable devices.

 

As I mentioned, I was in the market for a wearable device, and somehow I now have two: the Apple Watch Series 4 and the Whoop Strap 2.0 (Figure 1). Overkill? Absolutely. But in experimenting with these devices, I’ve become incredibly fascinated with the HRV, sleep quality scores, and recovery. These are metrics that counterbalance our typical recommendations of increased physical activity with adequate rest and recovery. However, while parameters such as HRV were heavily studied in the 1990s and remain very much present in the current literature (search for “heart rate variability” on Pubmed yields 1665 publications), we have not routinely interfaced with these parameters in modern cardiology practice.

Yet I’ve found myself poring over my own device-measured physiological data and have already used it to plan my days. For instance, when my Whoop strap notifies me that I’m “in the green” and adequately recovered (as in Figure 1), I plan a more intense workout. Conversely, when I haven’t had adequate sleep for consecutive nights, I will be reminded by the Whoop app that my body is not primed for significant strain, and I will focus my efforts on restorative exercises, such as stretching and an early bedtime. While it seems silly to rely on a device to tell me how my body should feel, it has at the very least strengthened my own practice of reflecting on my health daily, a practice that can easily be forgotten amid busy clinical and research training.

With the increasing popularity and use of these wearables, and now that Apple Heart Study has paved the way for massive amounts of patients to be enrolled in studies using wearables, more of our patients will be using the Apple Watch, the Whoop strap, and other similar devices. To better prepare for this inevitable influx of personalized data, I feel that it is useful for clinicians to have our own experiences with these devices and apps. In my own experience, I’ve seen it enhance clinic encounters with patients, and by learning more about how devices monitor my own physiology, I believe it can help me better counsel my patients on how to monitor theirs.

What wearables do you use? Has your own use of wearables already impacted your management of patients? Would love to hear your thoughts via Twitter @JeffHsuMD.

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Fellow Focus: Peer Mentorship Program

During my first year of general cardiology fellowship, our program underwent an exciting transition – our incoming fellowship class increased from 6 fellows the previous year to 10 fellows in my class, nearly doubling the size of the fellowship. This growth was necessitated by the welcome addition of the West LA VA as a rotation site for house staff, which meant spreading our fellowship across 4 different clinical sites. While this gives our fellows the opportunity to train in a wide variety of clinical settings with different patient populations and pathologies, it also creates a very large fellowship program, with 30 fellows altogether. Although there are advantages to having a large program, a program this size poses the risk that fellows ultimately may not get to build the camaraderie that many acknowledge is a pivotal aspect of their medical training. Indeed, much of the education received during clinical training occurs through our peers.

At the beginning of my chief fellowship year, my co-chiefs and I chose to implement a new program within our fellowship to promote peer mentorship among our fellows. Inspired by an outstanding JACC article describing a peer mentorship program that was instituted in Columbia University’s Pediatric Cardiology fellowship,1 we created a similar program in which “Houses” were formed consisting of one fellow from each class. Each House would be led by its senior 3rd year fellow, who would also choose a faculty mentor for the group (Figure 1).

Figure 1: Schematic representation of the House system. Each pillar represents one “House” consistent of 3 fellows and 1 faculty mentor. Adapted from Reference 1.

Each House was advised to meet at least once each quarter, with each meeting organized by the senior fellow. Meetings were suggested to be informal, but discussion items, such as research opportunities, balancing family and fellowship, and exploring career paths, were recommended. Further, senior fellows were encouraged to take ownership of mentoring their respective 1st year fellows, particularly during the first half of the year.

After surveying fellows before and after the implementation of the House program, the results of the program were rather impressive. For instance, prior to the program, only 44% (4/9) first-year fellows said a senior fellow helped them during an early-year overnight call. Post-implementation, this number improved to 100% (10/10 first-year fellows from the next class). Further, first-year fellows were asked to assess their satisfaction with “Peer Mentorship” within the fellowship, and these ratings improved significantly after the House program implementation (Figure 2).

Figure 2: First-year fellow satisfaction for peer mentorship within the fellowship program.

Many more aspects were assessed in these surveys, as well as in surveys given to senior fellows and faculty members. These included measures of feedback frequency given by senior fellows and faculty on conference presentations and measures of academic productivity (abstract submissions to national meetings, peer-reviewed publications). While many other factors besides the House program may have contributed to the improved scores we observed on these surveys (perhaps even a placebo effect), the feedback we received on this program from fellows and faculty were overwhelmingly positive. As the program is far from perfect, we have found that it was easy to implement, sustainable, and effective at improving fellow satisfaction with our training program. As it continues into its second year, we hope that it will continue to improve, and more importantly, that it will further improve the fellowship experience within our program.

This past weekend, I shared our experience with this peer mentorship program with others as a moderated poster abstract at ACC.19 in New Orleans, Louisiana.2 For other large training programs looking for methods to improve peer mentorship, we believe our House system was effective and would be happy to share more details from our experience with those who are interested.

 

References:

  1. Flyer JN and Joong AN. Improving Peer Mentorship: A Novel Fellow “House” Program. J Am Coll Cardiol. 68:2907-10. 2016
  2. Hsu JJ, Flyer JN, Joong A, Small A, Vampola S, Yang EH, Watson KE. House of Cards: Implementation of a Formal Peer Mentorship System in an Adult Cardiology Fellowship Program. American College of Cardiology, Cardiovascular Training Section, New Orleans, LA. March 2019

 

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Deconstructing Habits & Engineering Good Ones

For roughly the past 15 years, I essentially have eaten the same breakfast every morning – a bowl of oatmeal with a sliced banana. And every morning, as I wait for the oatmeal to heat up in the microwave, I do push-ups and sit-ups. It has come to the point where my body reflexively moves towards the small area in my living room right after I push the “Start” button on the microwave. This activity takes all of two minutes and is often rather automated. But during busy stretches on inpatient services, these are sometimes the only two minutes of dedicated physical exercise over the course of a long day.

I just finished listening to the audiobook, “The Power of Habit” by Charles Duhigg, and while I never had put much thought into it, I realized my morning ritual is indeed a habit, and just one of many I have throughout my day. In the audiobook, Duhigg expounds on the central role that habits have in our daily lives — essentially comprising a sizeable percentage of our days and forming a large part of our identity. Habits, once formed, become automatic responses to the various triggers we encounter in our day, and often, we carry them out mindlessly. He describes the three components of the habit loop:

  1. Cue: The trigger that prompts the action. This can be a location, a time of day, a person, an emotional state, or another action.
  2. Routine: The actions or thoughts that occur in response to a given cue.
  3. Reward: The physical or emotional satisfaction that results from the habit loop.

The continued repetition of the habit loop leads to a craving for the Reward, which links the Cue to the Routine and promotes the automaticity of this loop.

For good habits, such as my breakfast pushup routine, this can be beneficial and can help structure physical and/or mental well-being or productivity during the day. For bad habits, however, this can clearly be troublesome.

As early career trainees, we often find ourselves complaining that we don’t have enough time in the day to do the things we want to do – exercise, read, write, cook, etc. However, while there are definitely difficult stretches, there are indeed opportunities to do all of these things. And perhaps one effective way is to incorporate them into a habit loop.

For instance, a Cue that everyone experiences daily is waking up in the morning. Consider using this opportunity to link this Cue to the Routine of going for a jog. Reward yourself with your favorite breakfast afterwards (oatmeal & banana, anyone?) or listen to the newest episode of your favorite podcast during the jog.

A particularly challenging habit to develop is giving yourself time to write about your science, as was discussed by senior AHA Early Career Blogger, Bailey DeBarmore, in a recent blog post. Find a way to schedule this Routine into your week by attaching it to a Cue (e.g., Saturday morning) and a Reward (e.g., favorite cup of coffee, checking off that box on your to-do list).

These routines are notoriously difficult to instill at first, and it takes several weeks to develop them into a true habit. But with time, as they become more automated, these good habits become easier to perform. The “Power of Habit” is rife with case examples of the role of habit in our daily lives, and the very brief overview above is just a small sliver of what was covered in the book. However, it inspired me to deconstruct the habits that form my days and encouraged me to re-engineer them into habits that can help me feel better and more productive in my busy schedule as a physician-scientist trainee.

What good habits can you cultivate in this new year?

 

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Representation Matters: How Can We Improve Equity and Diversity in Our Professional Lives?

This past August, the phrase “Representation Matters” commonly graced entertainment and popular culture headlines. Why? In what was ultimately called “Asian August,” several major movies starring Asian-American actors were appearing in theaters, led by the first American film to feature an all-Asian cast in 25 years – “Crazy Rich Asians.” This fervor was inspired by over two decades of under-representation of Asian-American culture in the entertainment industry.

As I am an Asian-American, this particular movement did indeed resonate with me in my personal life. However, I regrettably was not mindful about it in my professional life. Throughout my training, I felt that I had worked with, learned from, and/or befriended men and women of a wide variety of colors, beliefs, and socio-economic backgrounds. Perhaps it was because I was fortunate to train in programs that were diverse, but I don’t necessarily recall reflecting on the diversity nor the benefits of diversity.

In early December 2018, Dr. Hannah Valantine visited our campus at UCLA to deliver our Medicine Grand Rounds lecture, and she was kind enough to meet with many of our faculty and trainees. A renowned physician-scientist and advanced heart failure/transplant specialist, Dr. Valantine is the NIH’s first Chief Officer for Scientific Workforce Diversity. She led an outstanding, eloquent, and (of course) evidence-based discussion on the importance of improving the diversity in academic medicine. She highlighted the emphasis that the NIH is placing on this mission, and the resources her office has developed to not only educate professionals on the issues at hand, but also a toolkit they have created to help promote diversity at our institutions, including how to create a diverse talent pool and perform unbiased talent searches.

Dr. Valantine presented data showing that while there has been improvement in diversity of trainees early in their training, there remains a significant “transition barrier” for diversity upon entering the junior faculty stage of an academic career (between “Postdoc” and “Independence” in the slide below).

 

Further, she also mentioned data supporting the improved performance of more diverse groups. In an article from Nature this past year, the subjective and objective benefits of diversity were featured. Interestingly, in an analysis of over 9 million scientific articles, one group found that research “papers written by ethnically diverse groups were cited 11.2% more than were papers written by non-diverse groups.”

With clear reasons for why we should work to focus on a culture of equity and diversity in our scientific workforce, I realized that I will soon be at a stage where I will be choosing the members of my research team. In the spirit of the New Year and with the help of tools provided Dr. Valantine, I have made the following “resolutions” to myself to help prepare myself as I embark on organizing a research team in the future:

  • Discover and explore my implicit biases: There are online resources/tutorials on implicit bias, including an excellent one from my home institution, UCLA, as well as tests you can take to discover your own implicit biases. Regrettably, after my first test, I already learned that my results suggested, stereotypically, “a moderate association for ‘Male’ with ‘Career’ and ‘Female’ with ‘Family.’”
  • Be mindful of the benefits of diversity when present: Whether in a research group or the team I am rounding with in the hospital, I plan to acknowledge these benefits when present, whether aloud or to myself.
  • Follow the NIH Scientific Workforce Diversity blog: It is an excellent reminder of reasons and ways to create an effective & diverse scientific team.

 

In one of her excellent blog posts from last year, Dr. Valantine wrote:

“Our nation is presented with the unique opportunity of connecting an increasingly diverse talent pool of scientists with the full range of biomedicine careers encompassing basic discovery to health applications, a critical part of the NIH mission to advance human health.”

 

I am grateful that the NIH has placed high priority on this mission, because indeed, Representation Matters, and in the field of academic medicine, representation can lead to better science and better treatments for our patients.