Miguel Quintero-Consuegra, MD – The Early Career Voice

The residency MATCH: a 101 guide to understand it

February 18, 2022February 14, 2022 Miguel Quintero-Consuegra, MD

The match, residency, ERAS. These terms become part of our everyday vocabulary, either as MS4 or IMG applying into residency. A cumbersome, long application process in which oneself that is going through seems lost most of the time. It is no wonder that our family or friends who are not in the medical field get confused about how the process occurs. To alleviate my anxiousness prior to the match and help our loved ones understand better what the process of applying to residency in the USA entails, I will make this quick 101 guide to understand it. And before we start, I will address a very common preconception; passing the steps1 and 2 does not mean we got into residency.

The beginning

Hello! If you are reading this behold, as a friend or family relative is about to embark into a couple of stressful, exciting, doubtful several months starting early June/July until matchday in March, yes, it this long, so please gives us love.

The process starts earlier than you might imagine. Before applying, you should have already decided what specialty you want to go into. Specialties in medicine could be divided in 3 big groups medical specialties (internal medicine, pediatrics,dermatology), surgical (neurosurgery, ophthalmology, plastic surgery), diagnostics (radiology, pathology). Once you have decided what specialty you want to apply to, the process begins.

Around June, ERAS will become the most searched website on your applicants one’s laptops. ERAS stands for Electronic Residency Application Service. This is the website where we will have to do a lot, so I will bullet point all that we have to get done on this website that gets quite stressful even with the calming blue colors of the ERAS banner.

CV: LONG standardized CV format where we will have to write in excruciating detail all our accomplishments, education background, hobbies (yes, super important). This is an essential part of the application because we have to look attractive for programs. Your applicant will spend several hours witting, re writing, and writing again this application for several months.
Letters of recommendation (LOR): It is pretty standard to put references down for a job, right? Well, I wish this was just to put down a name. The LORs are probably one of the most stressful parts of the application since it does not depend entirely on us. Our professors write these letters, mentors that want to support our residency application, and every word they write is taken very seriously by programs one applies to. There are two ways to upload a LOR as they are so important. One is to waive the right to see the letter (which is usually preferred) so that the person can freely write about you or upload the letter yourself (not recommended). So we reach a point where many students are asking the same attendings for LOR’s, that in addition to their busy clinical schedule, they have to write and upload in a platform for which they have to create an account. So you can imagine the stress one could go under while catching our mentors and pressuring them to write the LORs and upload them. Tip for future applicants, do this early in the season if possible.
Personal statement: I think my non-medical readers might be familiar with this part, as you must have read a couple of versions of the personal statement. In less than 28’000 characters, convey who you are, why you want the specialty you are applying to, and seem interesting enough to catch the attention of the selections committee. One goes on and on, and one writes several versions (I think I did about ten versions) and gets inputs from many people. So, brace yourself as you will be receiving personal statements any time soon to revise.
Medical School Performance Evaluation (MSPE): For American graduates, you are blessed; you don’t have to do much here as your medical schools are in charged. For my fellow IMG’s, this is where we go back to our alma mater across the world to ask for our medical school performance, and we all know how slow administrative requests are. Please do so in advance as we need to request them and translate them to English. I enjoyed this part as I got the chance to remember great memories from medical school.
Programs selection: Decision burnout, yeah, it might happen. How do I choose from so many programs? Which ones to apply to? This is where applicants will go over more than > 100 programs and read what each has to offer to decide which ones they want to apply. Usually, the limitans is, yes, you guessed it: money as applications to around 100 programs could cost up to $2000.

Congratulations! Once you have gathered all items on your ERAS application and decided which programs to apply, all is left is to use that plastic to pay thousands of dollars in applications and wait for the next phase of the match season.

The interview invitation season: two rules

ALWAYS HAVE YOUR PHONE TURNED ON WITH NOTIFICATIONS ON
Have a proxy that will be receiving emails when can not

Your application rests now in the people’s computers that might decide your future career. It is only normal that your applicant seems anxious during this time and is waiting impatiently for that [email protected] email at any time for an interview invitation.

Most programs will send out interview invitations at any time during the day, hence you will see your applicant glue to their phones, with an special alarm ready to receive these emails, and in constant cycle of checking to see if the email is working. This tends to become stressful for many reasons, as sometimes programs might send more interview invites than slots to interview, or if you don’t respond fast, you might have scheduling conflicts.

You will hear funny stories such as people jumping out of the shower once they hear an email notification. Thus, having a proxy answering your emails and scheduling your interviews when you won’t be able to be on your phone, like when flying on an airplane or while you are in other interviews. In my case, the funniest story was that I received an interview invitation while in the middle of taking step3, good energy boost but terrible timing. Shout out to my proxy Sebastian Gallo for scheduling that interview for me.

This time is mixed with extreme rushes of energy and enjoyment once you get that email that says you are invited to interview, sadness when a program you liked rejected you, and uncertainty when most of the programs you will apply for will neither invite you nor reject you.

Interviews: Game ON!

While the most stressful part is the first month and a half to receive interview invitations, by this time, your applicant will most likely start to interview. We will all do our interviews virtually as we are going through the COVID-19 pandemic, which makes things somewhat more accessible. Before the pandemic, applicants had to travel all over the United States to interview their desired programs, wild, right?

Before the interview, applicants will carefully study the program, the attendings that will be interviewing them, and reviewing their own application as anything they have written could be asked whether that been a hobby or a paper. This period is full of excitement, they are interviewing for their dream job! You will probably be asked to help them with mock interviews and to practice with them for a few times to be able to shine during the interviews. So be there for them and cheer them through this interview season that will last from October until probably mid-February.

Ranking order and match day

The interviews are over, by this time you probably have a sense of which programs your applicant liked more and you have asked, so when do you get the job offer? Well unfortunately this is not a direct hiring process. After the programs have interviewed the applicants and applicants have interviewed at all of their programs, each one of them well sit down and write something called the Ranking Order List (ROL). This is a list of preferences in descending order of which one is the program they liked the best to the least, or even not rank places they did not like. Programs will do the same to rank in order of preference applicants or not rank them at all if they did not seem like a good fit. Once the lists are done, they will be submitted to the NRMP platform. On this platform, the Gale-Shapley matchmaking algorithm, which earned them the 1995 Economic Nobel Prize, will dictate where you will spend the next 3 to 8 years of your life and be the most crucial part of your training as a physician; an algorithm will be determining our life’s.

So, the best way to explain this is to make an analogy with Tinder or any dating app. You swipe right when you like someone, and if the other person also swipes right, you will both match! It is similar in that if the number 1 ranking in your list is a program that also ranked you first or within the number of positions available, you will have a perfect match and train in your most desired program.

But if that program ranks you in a lower position than there are available slots, things get a bit complicated. So let’s set a fictional hospital, Greys Sloan Memorial, and our two dear applicants, Derek and Meredith.

Let’s say Greys Sloan Memorial has eight spots for General Surgery, and our imaginary applicants Derek ranked Greys Sloan as his number 1 residency program and Meredith as her 4th choice. Derek was ranked in the position 9 and Meredith was ranked as their # 1 out of the 60 people they interviewed. He was certainly ranked high, but for Derek to match in Greys Sloan Memorial, at least 1 of the other applicants that are above him must have either matched elsewhere or not have ranked Greys Sloan. Meredith on the other hand would have directly matched into Grey Sloan, right? They have 8 spots, and she was first! However, Grey Sloan wasn’t her first choice. Since the algorithm favors applicants, the system will first try to match Meredith into her other top 3 hospitals. For Meredith to match into Greys Sloan, she must not have been able to match in her top 3 choices. She would go ahead and match at Greys Sloan.

As you can see, Meredith matching into this program might mean that Derek will not be able to match into his top choice thus the outcome of the match is dependent on the ROL from each of the hundreds of applicants and the programs.

MATCH week: The reveal!

After submitting and editing the ROL endlessly, the second week of March of each year will be a life-defining week for most applicants. On Monday, we will receive an email stating if we were accepted for residency or matched into a program. If so, we will receive another email on Friday, AKA Match Day, that will tell us where we will be doing a residency for the next 3-7 years.

Of note, the match in March occurs only for most specialties, except for urology that happens in January and ophthalmology that happened this past Tuesday.

This was a brief overview of the tumultuous process of applying for residency. It goes without saying that having friends, significant others, and family through this time is paramount, and I take this opportunity to say thank you for the unwilling support anyone has brought me until this point. I want to specially thank my mentor Dr. Nestor Gonzalez, my family, and my friends (Sebastian Gallo, Sandra Saade, Andy Serrano and Juan Esteban Velez) for putting up with my anxiety through these months.

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

National and worldwide blood shortage, we need blood! But we don’t want YOUR blood!

July 19, 2021July 7, 2021 Miguel Quintero-Consuegra, MD

Back in Colombia, the minimum age to donate blood was 18 years old, coinciding with the minimum legal drinking age and attending bars. The excitement to party causes a lot of expectancy to everyone’s 18th-year-old birthday, and although I love to party, I was looking forward mostly to be able to donate blood. As I was finishing the first semester of medical school, I had wanted to be a regular blood donor. I saw it as a way of walking the talk of being a physician that wanted to advocate for healthcare beyond the mere consult room, and to be honest, how much does it cost to most of us to donate blood? A few minutes of our time. How much does it mean to someone that needs it? Everything.

On my 18th birthday, before my party, the first order of business was to donate blood as I was finally eligible! I arrived with my mom at the Red Cross, and I filled out some questionnaires and headed to see the physician for further questions. As she reviewed my questionnaire, she mentioned that I had stated that I had sex with men; thus, I was not eligible to donate blood. I was in shock; I tried to explain that I have never had any risky behavior and that, at that recently, I only had sex with a woman. She then elaborated that even if it was with one man, I could not donate blood ever, as I was at risk of transmitting HIV or hepatitis. I then told my mom that my hemoglobin levels were low, so I needed to return in a few weeks. I must admit, this was a heartbreaking moment in my life, which added another layer of burden to the journey of self-acceptance as a bisexual man because my blood was undesirable because of who I am.

The emergency of the HIV and AIDS pandemic during the ‘80s initially identified groups that had a higher risk for having HIV and potentially transmitting it with blood transfusions; these were men who have sex with men (MSM), heterosexual commercial sex workers, and intravenous drug users.¹To reduce the risk of transmissions, the FDA put a first donor deferral policy to identify if the persons were in the high-risk groups to prevent them from donating blood. Since 1985 and until December of 2015, the FDA recommended blood establishments to ban FOREVER, indefinitely, for a lifetime, male donors who had sex with another male, even if it was only a one-time encounter. The reason behind this preposterous and anachronic decision, according to the FDA, was “due to strong clustering of AIDS illness and subsequent discovery of high rates of HIV in that population (MSM).”²

In 1988 the Blood Donation Rules Opinion Study (BloodDROPS) found that the prevalence of HIV infection in men that reported male-to-male sexual contact was 0.25%, much lower than the previously thought 11-12%, which could have been a strong argument towards the discriminatory life ban of blood donation to MSM.¹

In addition to prejudice-based decisions, a question arises, even if there is a higher prevalence in MSM, doesn’t HIV exist in heterosexual people? Doesn’t their blood get screened as well? Yes, HIV also exists in heterosexual people (currently account for 23% of all HIV diagnoses)³ and yes, ALL blood gets tested. Although surveys rely on the honesty of people and serve as a first screening, according to the CDC, all blood that is collected undergoes rigorous testing for HIV, Hepatitis B virus, HCV, HTLV, syphilis, West Nile virus, and Zika virus.⁴ Additionally, modern HIV tests can identify HIV as early as ten days after infection.

In 2015 the FDA lifted the lifetime ban for homosexual, bisexual, and MSM to donate blood, if they abstained from having sexual contact with other men for 12 months. Although an improvement from the previous ban, the policy was still highly discriminatory and baseless from science, as it assumes that all homosexual sexual interactions are high-risk interactions. This new policy meant that a male, homosexual, monogamous couple that takes drugs to prevent HIV (PreP) would not be able to donate blood if they did not abstain from sex for a year. Still, a man in a heterosexual monogamous couple that does not use protection was by default consider eligible for donation. Thus, once again, attaching the label of presumptive HIV carrier to all bisexual and gay men.

The latest change on these policies was last year during the peak of the COVID-19 pandemic. Facing severe blood shortages nationwide, the FDA randomly reduced the deferral period of sexual abstinence from 12 months to 3 months; no new data was presented to suggest such changes.⁴ Agreeing with what Jon Oliveira said to the American Journal of Managed Care regarding this abrupt policy change, “The FDA’s decision to ease restrictions on blood donations from men who have sex with men proves what medical experts have been saying for decades: that this ban is not based in science but rather discriminatory politics. The FDA’s policy change is a sign of progress—even if forced by the needs of the current crisis—but we must follow the science and continue fighting for a complete end to this archaic, demeaning ban.” ²

The risk of contracting HIV and other blood-transmitted diseases is not linked to one’s sexual orientation or gender identity. They are linked to the actions we take as individuals. Individualizing high-risk behavior (multiple partners, no condom usage, IV drug use, etc.) instead of stigmatizing a particular sexual orientation would still serve its purpose of screening before blood donation. It would allow thousands of bisexual and gay man that want to donate blood. It would put an end to a discriminatory policy that perpetuates the narrative of an unequivocal link between HIV and MSM.

But there is hope after all. While researching for this blog, I found that there is a multicenter clinical trial taking place in various cities ( San Francisco, Los Angeles, New Orlean&Baton Rouge, Memphis, Atlanta, Orlando, Miami, Washington), named the ADVANCED study (Assessing Donor Variability And New Concepts in Eligibility). This pilot study is focused on the FDA’s deferral policy for MSM. The purpose of the study is to determine if different eligibility criteria for a bisexual and gay man can be used, such as an additional history questionnaire, to assess individual risk for HIV, instead of deferring our blood donation according to our last male-to-male sexual contact. The study will be groundbreaking and be the first big step towards changing blood donation eligibility criteria for bisexual and gay men.

I enrolled for the study and will have my first appointment in 3 weeks, I’ beyond thrilled to be part of this trial, so I encourage all bisexual and gay men who reside in these cities to participate in the study. The results of this study are likely to contribute and provide yet another evidence to make the FDA eliminate this prejudice ban permanently. We must gain our dignity in every field of life, and small steps such as getting equal treatment in blood donations is the right step forward.

ADVANCE study: https://advancestudy.org

References:

https://www.fda.gov/media/92490/download
https://www.ajmc.com/view/fdas-revised-blood-donation-guidance-for-gay-men-still-courts-controversy
https://www.hiv.gov/hiv-basics/overview/data-and-trends/statistics)
https://www.cdc.gov/bloodsafety/basics.html
https://www.cnn.com/2015/12/21/health/fda-gay-men-blood-donation-changes/index.html

“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.”

Studying for Medical Boards as a Foreign International Graduate While Working: tips and experience

June 18, 2021June 11, 2021 Miguel Quintero-Consuegra, MD

When I decided I wanted to take the steps, in January of 2019, to pursue a residency in neurosurgery in the United States, I did what most of us do, I went to Youtube and saw how other people have studied. After a couple of days watching various videos, I felt overwhelmed since most of the videos entailed studying >9 hours, having a dedicated period exclusive for studying, and some of them suggested doing them during medical school.

All of those suggestions were not possible at the time for me, I had just graduated from medical school in December of 2018, and I had accepted a full-time job at Cedars-Sinai. Though I did question if I was going to be able to manage a full-time job on research and study for this life-defining exam, in the end, I pulled it off, and I took step1 in October of 2019 and step2 CK in may of 2020.

Before starting with my personal story of how I studied and managed my time to finish both USMLE while working, I just want to give you peace of mind to all of you that are not in the ideal situation of studying full time or that cant dedicate enormous time of study due to personal responsibilities. All roads lead to Rome; everyone is in a particular economic, social, and educational situation and what each one of us must do is to adapt and make the most out of our conditions!

So, let’s begin.

What was your approach to work and study at the same time?

When I faced this challenge, the first thing I did was to talk to my boss, Dr. Nestor Gonzalez, and my coworker Juan Toscano. I let them both know that while I was going to fulfill my job to the best extent of my abilities, they should know that I was also dedicating all my spare time both at work and outside from work to study.

I believe it’s crucial to the people you work with know what you are going through, and to me, this was extremely helpful, as there were times my coworker took over simple tasks and was very understandable to give me as much time as I could to study. Since my boss knew that I was taking this exam, I was able to take 2 weeks off before my exam date to dedicate 100% of my time to study.

For how long and how did you prepare for step1 and step2?

I started my step1 preparation on the third week of January 2019, when I started my job. During the first three weeks, I tried to get a sense of how my day to day was going to be at work, identify which hours would be ideal for studying either after work, before work, and also determine what the best time to do questions was, watch videos, read the first aid, etc.

After finishing the First Aid’s first pass (not extremely thorough, just a glimpse to see and get familiarized with the material), I outlined 3 phases of the study.

The first (from Feb-April) would be dedicated to learn and review the theory, so 90% of my study day was to read the first aid, watch pathoma/Kaplan/sketchy, and a 10% was to do questions from different banks.
The second (may-sept), Was dedicated 90% to Uworld and their respective review, and 10% to review the FA, pathoma, or any gap in my knowledge.
The third and last (last week of sept-first of October), I only did questions. These were the 2 weeks my boss gave me to dedicate full time to study. I was able to do during this first week > 4 blocks a day with their respective review, and the last 5 days, I did practice 7 blocks as if I were taking Step1 (based on the recommendation of my friends Sandra Saade and Andre Monteiro), which was extremely helpful to gain endurance.

Total study time for Step1: From February-October

For step2 was easier to get organized since I would follow the same schedule and balance of work/study. I took a month’s break from step1 and started to study for step2 at the end of November. I studied from November until May 28, 2020 (one day after my birthday).

The approach was pretty similar to that of step1 with the caveat that I started from day 1 to do questions, and I also took one week off from my vacations to dedicate full time to prepare step2. The pandemic changed my preparation timing since we had to deal with the Prometric cancelations due to covid.

How was a regular workday during step1 and step2 preparation?

I would wake up at 6 am in the morning, and during the first 3 months, I commuted on the bus to my workplace, which was approximately 2 hours away. During these bus rides, I would read first aid; of course, I needed some noise-canceling headphones. I would highlight or repeat the things that I thought were most important. By the time I got to work, depending on the time, I would do 10 questions from any qbank before starting to work at 9 am. Usually, I would leave work by 4-4:30 pm to head back to my place.

On the way back, the commuting was equally long, sometimes a bit longer depending on traffic, so by the time I got to my home, I would have already read first aid on average 3 hours/day from Monday-Friday. I used to get home at around 7:00-7:30, cook dinner and my lunch for the next day, and after an appropriate break watching friends (I had just started to watch it), I would start my night study routine at 9:00 pm. From 9 pm until 1 am, I would watch pathoma, Kaplan, or sketchy videos. My goal from Monday to Friday was to study at least 6 hours per day, and I usually slept from 1 to 6 am (since med school, I had slept 5 hours a day)

In March, to make my commute more manageable, I got a bicycle, so I was biking halfway to work and the other half on the bus. This allowed me to get some exercise done, which I realized I was missing, and helped me to be more relaxed during this study/work period. From March until mid-June, I followed the same routine of reading first aid or doing my Anki cards on the bus and then studying at home until 1 am (or if I felt tired before 1 am). Some days, I had some spare time at work, so I tried to get some study done either by reviewing questions or reading the first aid.

From June-September, I wanted to increase my study time and try to use any free time to study. This routine of study/work with no other activities was highly tiring and stressful, and I knew that I needed something for my mental health, so I decided to join the gym. During this period, I wanted to use my time on my bicycle rides which were more than 50 min a day, so I converted all the pathoma videos into mp3 so I could listen to pathoma while I was riding my bike. Then I would do Anki or read FA on the bus, and at work would still review any question I didn’t finish the night before. Anki became my favorite and most used application, as during any break, at lunchtime, waiting for a meeting to start, or on the bus, I would do a couple of cards, and in the end, this helped me a lot. After work, I would get home at the same time (around 7 pm), eat dinner, and study until 9 pm. Then I would go to the gym and disconnect myself from anything related to the step. After my workout, I would study again until 1 am. Since I was increasing my study time during my former free time, I was trying to aim to have more than 6 hours of study a day, even though I had added the gym to my schedule.

I continued this pace until September before my 2 weeks of dedicated, with a few modifications. The closest I was getting to the date of my exam on October 8, I cut back even more from my free time, so once I finished listening pathoma, I transformed to Mp3 all the videos from Boards and Beyond (per Sebastian Gallo suggestion), and I would listen to them instead of listening to music, during my bike rides, while walking and even at the gym. This passive learning was a way of trying to make the most of the time during a working day.

I took 2 weeks off work, and I had the most significant visit at the worst time, from my mother Patricia, but it did give me an energy boost to finish up my studies. I stayed with my aunt Cristina and uncle mike in San Diego for the 2 most stressful weeks of my life so far, where I was studying from 9 to 11 hours a day before the test.

For step2, things were more manageable since I moved 15 min away from the hospital, and not commuting for more than 3 hours a day improved my life and study style a lot. My working schedule did not change, but my study times did. Since I was living so close to the hospital, I arrived at 6:40 am to the hospital and headed to the library to do a block of uworld and study until 9. I would work until 4:30 pm and then head to the library until 9:00 pm to keep doing questions or reviewing questions and then heading to the gym until 11-11:30. I would head back to my place and go to bed at around 12:30 to 1 am and then repeat the same schedule before the pandemic hit.

When the pandemic hit, we were sent to work from home. To adapt to working and studying in the same place as my roommates, that weren’t particularly quiet, I shifted my schedules to go to bed at 6:00 pm and wake up and begin my day at 11:00 pm. This allowed me to have enough space and time to study from 11:00 pm until my workday began at 8 am. After finishing work at around 4 pm, I would run 3 miles while listening to mp3 of MedEd, then had dinner and go to bed. After 3 cancelations from Prometric, I was able to schedule my step2 for the end of May.

How was your schedule on the weekends?

My weekends were the days that I studied the most and tried to make up for the study that I could not finish during the week and the sleep I did not get. I would do grocery shopping, take care of my place, and all the labor that entails with being an adult. I would study 8—9 hours on Saturday and Sunday. My goal per week was to study at least 42 hours. Some weeks were more brutal at work, or I was tired and couldn’t finish my 6 hours daily on the weekdays, making the weekends the perfect time to make up for the time that I did not study. The weekends were ideal for taking any assessment, whether Uworld Self-assessment or NBME.

When I joined the gym, I had another activity to do on the weekends, and I wish I had done it sooner to improve my mood at earlier stages of my study preparation.

How did you manage your time?

In the beginning, I was using just a regular clock and writing down how much I was studying per day on an excel sheet. This helped me keep track of how much I was studying, so I would stop the clock every time I grabbed my phone or took breaks. Then I found an app that changed my time management forever that is called aTimeLogger, which allowed me to set goals per day, week, and month depending on the activity that I was doing, that basically were studying, working, exercising, and wasting time (yes, to visually see how much time one wastes on Instagram, Facebook, youtube, is disturbing and helped me to reduce this screen time especially during quarantine).

As I said before, my goals were to reach a doable 6 hours per day or 42 hours of study per week and to do at least 6 hours of exercise per week for mental and physical health. Also to maintain a minumun of 5 hours of sleep per day which is used to be my normal sleeping time since medschool.

How did you balance your social life and working/studying?

Significant endeavors entail enormous sacrifices, so during this working/studying period for step1, I deleted all my social media (Facebook, Instagram, Twitter) and only kept Whats app to talk to my family and close relatives. Not having the distraction of social media on my phone helped me keep my objective clear, which was to pass with a good score step1/2, and that instead of grabbing my phone to check Instagram, I grabbed it to do Anki.

My social life was nonexistent during my study period. I did go out with my friend and coworker Juan maybe 6 times from January-December, and I saw my family a couple of times for brief moments. Since I had moved to a new country and new city, isolating myself from people was doable and extremely helpful to focus my energy only on studying and working. My first vacations during 2019 were for my dedicated 2 weeks for step1; they were not the ideal vacations but were necessary to study.

Any final suggestions for someone that is in a position similar to you?

These exams are complicated not only for the amount of time invested and information one has to learn but also the emotional pressure of having a test determining how feasible your dream of becoming a physician in the USA would be.

So, I would suggest:

Committing thoroughly to studying and working, and trying to isolate yourself from most social engagements, talk to your family and friends; they will understand your absence in social engagements and not hold a grudge.
Reducing, if possible, to zero social media from your phone and laptop. This helps you focus on the exam and not feel sad/anxious (which happened to me) because you see your friends and family partying or having fun while you are spending more time with Uworld than with another human being. Remember this is temporary; your life will get better after finishing the exams.
Surround by people that are going through the same process and by those who already took the exam, we know how it feels, and we understand what you are and will go through. I have to say that talking out loud when I felt hopeless, tired, and overwhelmed was a vital pillar of this process of studying/working. So I want to give an enormous shout-out to my very patient friends and were there for me every step (Juan Velez, Sandra Saade, Sebastian Gallo, Andre Monteiro).
Make time, even if little, to do your hobbies. In my case, it was going to the gym. It really changed my mood and gave me more mental stability, and to give yourself a break from studying.
If you feel tired or burnout (because at some point you will), don’t be hard on yourself and take a break. I used to get very mad at myself when I was trying to study but could not focus, or I was falling asleep. Taking a break is also crucial to maintain sanity during difficult and extended periods of studying/working.

Last but not least is to look at the big picture and all that is at stake. While it is thought to work and study simultaneously, it taught me a lot of things, such as resilience, pushing my boundaries, and making the most out of a not ideal situation. When situations or conditions cannot be changed, one must adapt, and I’m glad I was able to deal with long commutes, working/studying, moving to a new country, and living alone for the first time in my life at the same time. In the end, it was worth it. I passed Step1 (239) and Step2 (236), and I’m thrilled that my dream to become a neurosurgeon is still intact.

Should interventional cardiologists perform thrombectomy?

April 28, 2021April 22, 2021 Miguel Quintero-Consuegra, MD

“Sutor, ne ultra crepidam” a Latin expression for shoemakers not beyond the shoe, a common saying to warn people to avoid passing a judgment beyond their expertise.

With mechanical thrombectomy changing the management of stroke and becoming the standard of care for patients with large vessel occlusion (LVO), a new challenge has emerged, adequate access for care.

A recent cross-sectional study by Aldstadt et al.¹ aimed to determine the percentage of the US population with 60 min (ground or air) to a designated or non-designated endovascular capable stroke center, or percentage of non-designated endovascular centers that were 30 min from an endovascular capable center. They reported that overall a 49.6% of the US population is within 60 min of an endovascular capable stroke center, while 37% of the US population lacked access to endovascular capable centers within 60 min. For the non-endovascular stroke centers, 84% have access within 60 min, and 45.4% are within 30 min drive from an endovascular capable stroke center.

Since time is the brain, increasing the access to care is of paramount importance and increasing the number of well-trained physicians equipped to perform and treat stroke holistically. Since there are approximately 10 times more interventional cardiologists, radiologists, and vascular surgeons than neuro interventionalist in the USA (10.000 vs. 800-1000)², some non-endovascular capable hospitals have explored the option of incorporating some of this workforce to contribute to patient care.

Some retrospective studies³ with low sample sizes have described that their interventional cardiologist team was able to perform a thrombectomy safely, with the guidance of a stroke neurologist. Nonetheless, they are not clear on the prior training these cardiologists have had regarding neurovasculature, the nuances of the procedure, critical care, and stroke neurology.

Endovascular Neurosurgery and Interventional Neuroradiology is a field shared by physicians with different backgrounds in training, such as neurosurgeons, neurologists, and interventional radiologists. Regardless of their background or training, they are all required to complete an additional 1-2 years of training exclusively for neurointervention. Endovascular physicians trained rigorously per ACGME⁴ requirements were most of the physicians involved in the clinical trials (ESCAPE and DAWN) and maintained a high caseload volume of thrombectomy. The cumulative case volume is crucial since it has been associated independently for obtaining good recanalization and outcomes.⁵

Even if the technical aspects have various similarities between the endovascular fields, shoemakers not beyond the shoe, cannot be translated from one field to another without proper training. To adduce that interventionalist cardiologist can inherently treat intracranial diseases would be, in my opinion, not in benefit of the care of the patient, even if they are the only option nearby where no endovascular treating center can be reached, the patient outcome of patients is directly correlated with the expertise of the treating physician.

Nonetheless, interventional cardiologists should only be allowed to perform thrombectomies if they complete a full endovascular fellowship with the requirements established by the ACGME and as the other specialties go through (interventional radiology, neurosurgery, and neurology). This formal training could contribute to those rural areas where there is no possibility to access an endovascular center. More efforts should be made to increase access to endovascular capable stroke centers, to continue training neurosurgeons, radiologists, and neurologists to meet patients’ demands requiring this life-saving treatment. But I don’t consider converting specialists in treating myocardial infarctions to stroke being a priority in the US.

REFERENCE

Aldstadt J, Waqas M, Yasumiishi M, et al. Mapping access to endovascular stroke care in the USA and implications for transport models. Journal of NeuroInterventional Surgery. 2021:neurintsurg-2020-016942.
Hopkins LN, Holmes DR. Public Health Urgency Created by the Success of Mechanical Thrombectomy Studies in Stroke. Circulation. 2017;135(13):1188-1190.
Hornung M, Bertog SC, Grunwald I, et al. Acute Stroke Interventions Performed by Cardiologists: Initial Experience in a Single Center. JACC Cardiovasc Interv. 2019;12(17):1703-1710.
Hussain S, Fiorella D, Mocco J, et al. In defense of our patients. J Neurointerv Surg. 2017;9(6):525-526.
Kim BM, Baek J-H, Heo JH, Kim DJ, Nam HS, Kim YD. Effect of Cumulative Case Volume on Procedural and Clinical Outcomes in Endovascular Thrombectomy. Stroke. 2019;50(5):1178-1183.

The Great Terror of Oral Anticoagulant Use: Intracerebral hemorrhage

March 15, 2021March 12, 2021 Miguel Quintero-Consuegra, MD

I am pleased to summarize a recent paper published by Dr. Xian Et.al on the clinical characteristics and outcomes associated with oral anticoagulants (OAC) use among patients hospitalized with intracerebral hemorrhage (ICH)¹.

Major question addressed in the paper:

What is the association between prior oral anticoagulant use (FXa inhibitor, Warfarin or none) and in-hospital outcomes among patients with nontraumatic ICH?

Approach:

The investigators used the American Heart Association Stroke Association Get with The Guidelines-Stroke (GWTG-Stroke) registry to evaluate patients between October 2013 and May 2018, that had experience non-traumatic ICH with preceding use of FXa inhibitor compared with warfarin or none. Patients with subarachnoid hemorrhage, subdural hematoma, or taking dabigatran were excluded. Included patients were defined by documentation ICH and use for at least 7 days of OAC, in three different groups: FXa inhibitor (rivaroxaban, apixaban, edoxaban); warfarin, or no use of OAC prior to hospital arrival and ICH.

Main outcomes and measures:

Primary outcome: In-hospital mortality
Secondary outcome: Composite of in-hospital mortality or discharge to hospice, discharge home, independent ambulation, and modified Rankin Scale (mRS) score at discharge.

Results:

Generals

Of 219,701 patients in the study, 104,940 were women (47.8%), 189,069 were not taking any OAC prior to ICH (86%), 9202 were taking FXa Inhibitors (4.2%), and 21,430 (9.8%) were taking warfarin.
One third of patients were taking concomitant antiplatelet therapy. This was more prevalent amongst patients taking FXa inhibitor (27%) and warfarin (30.1%) than those without taking OAC (24.8%).
NIHSS median score was 9 amongst the three groups. Patients taking warfarin had a higher mean NIHSS (12.5 {SD:11.3}).

Major results

FXa inhibitors (aOR: 1.27; p<0.001) and warfarin (aOR: 1.67; p<0.001) were associated with greater odds of in-hospital mortality compared with no OAC.
FXa inhibitors (aOR: 1.19; p<0.001) and warfarin (aOR: 1.50; p<0.001) were associated with greater odds of death or discharge to hospice compared with no OAC.
Patients with FXa were less likely to die (aOR 0.76; p<0.001) or be discharged to hospice (0.79; p<0.001) compared to those taking Warfarin.
Patients taking FXa were more likely to be discharged at home (aOR1.18; p<0.001) and have better mRS scores at discharge (aOR 1.24; p<0.001).
No statistical difference was found amongst the three groups regarding rates of discharge home, independent ambulation, or mRS score.
The use of single or dual antiplatelet, in patients taking warfarin was associated with higher odds of in-hospital mortality (aOR 2.07; p<0.001), and dead or discharge to hospice (aOR 1.86; p<0.001).

Major study limitations:

The use of OAC use was defined as patients taking them 7 days prior to ICH, however the timing of the last doses of the OAC was not document, and it is possible that some patients might have not taken it or received a lower dose.
Data regarding platelet transfusion was not recorded on the registry, and this might have influenced outcomes.

Key take-home message:

One of the most devastating complications of the use of FXa inhibitors is ICH, and although its prevalence is low (<0.5%), the in-hospital mortality can be as high as 27% as it was found on this study. Although its high, when compared with prior use of warfarin, taking FXa inhibitors has a lower risk of mortality and dead or discharge to a hospice in the setting of ICH.

Potential future research:

Develop prospective studies that compare the available treatments for spontaneous ICH bleeding, four-factor prothrombin complexes concentrate vs. reverse factor Xa inhibitors (Andexanet). An underpowered retrospective study by Ammar et. Al,² found no difference between these treatments due to the low number of patients analyzed in this study. Due to the burden of this complication we must find the most adequate treatment for non-traumatic ICH in the setting of FXa inhibitor use.

References:

Xian Y, Zhang S, Inohara T, et al. Clinical Characteristics and Outcomes Associated With Oral Anticoagulant Use Among Patients Hospitalized With Intracerebral Hemorrhage. JAMA Network Open. 2021;4(2):e2037438-e2037438.
Ammar AA, Ammar MA, Owusu KA, et al. Andexanet Alfa Versus 4-Factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors in Intracranial Hemorrhage. Neurocrit Care. 2021.

Interview with Dr. Shlee S. Song, Director, Comprehensive Stroke Center at Cedars-Sinai

January 28, 2021January 28, 2021 Miguel Quintero-Consuegra, MD

Almost one year since COVID19 was deemed a pandemic, we are nowhere close to get it under control. Although it has affected the healthcare system in innumerable ways, stroke management has been particularly impacted. Not only by the disease itself, but also by the multidisciplinary and strictly protocols for its diagnosis and treatment that have been difficult to maintain for the past year. To understand the impact of COVID19 on stroke management, Dr. Shlee S. Song, the Director of the Comprehensive Stroke Center at Cedars-Sinai shared with me her experiences, and learnings through these unprecedented times.

Dr. Shlee S. Song, Director of is a board-certified vascular neurologist who completed her clinical and research fellowship at the National Institutes of Health. She has worked on steering committees and served as PI on multiple national and international multicenter stroke clinical trials. She serves as Medical Director of Stroke Programs at Cedars Sinai, Torrance Memorial, and Marina del Rey hospital, affiliate sites of Cedars-Sinai, and has developed a telemedicine network that delivers acute stroke care, oversees stroke quality improvement, and clinical trials enrollment across network hospitals. As the previous program director for the vascular neurology fellowship program at Cedars-Sinai, she has trained many stroke neurologists that practice across the country.

MDQC: Dr. Song, what is the association between COVID19 and Stroke?

Dr. Song: So far, we know that COVID has been associated with an inflammatory state and hypercoagulable state. Patients with more severe COVID symptoms also develop cloths in both lungs and other end organs. When we had our initial surge in the spring months in 2020, we had avoided what our NY colleagues have seen, like large vessel occlusion (LVO) in young patients. However, we did see a surge since the end of November. We have had a case series of patients where they were young, without many comorbidities, but had large cloths in large vessels like the ICA and carotid.

MDQC: So, is there an association between COVID severity and stroke?

SS: Right, what I have seen so far is that patients may have one risk factor or a couple, whether it is on birth control, having hypertension, or diabetes, even if they are managing their risk factors well, a COVID infection tips the scale toward clotting. Maybe a 2 or 3 hit hypothesis, where if you have the individual risk factors you are not in an inflammatory state, you can manage them, but when the infection occurs, the other diseases set off this cascade of injury that we see.

MDQC: Has the standard of care for management for patients with stroke has changed during the pandemic?

SS: We have seen that during the pandemic, that we have to be flexible. With the demand so high for stabilization, the surge in patients to the ICU, and hospital systems being stressed, our usual stroke pathways are not available. The patients are spread out all over the hospital because the beds are hard to come by. We have to be able to train a lot of our other service line team members to be able to deliver emergency care and monitoring.

For example, sometimes, the patients cannot go to the Neuro ICU, our usual pathway. Sometimes they are going to the PACU, where the personnel might not have received that training to get the NIH stroke scale done. However, we are focusing on the things we can monitor in more severe COVID. ICU patients that require high ventilation settings have to be paralyzed, so it doesn’t make sense to do no an usual neuromonitoring ( antigravitational strength, speech, etc.), but we can do other things like checking the pupils. We have had to shift our thinking and pivot to tailor to our situation.

Right now, we are in the “stabilization mode.” We are no trying to plan a 3-6 12 follow-up because, before the pandemic, we were able to stabilize our patients quickly. However, right now, it takes longer to stabilize these patients because of the injury to their lungs. We are just trying to get patients through to the first one or two weeks and then talk about lipid-lowering and secondary prevention that can be addressed later on. Right now, we want them to survive this cascade and storm that is going on.

MDQC: Would you consider changing the mindset of strict diagnostic and treatment protocols for stroke has been the most significant challenge during the pandemic?

SS: I think there is an acknowledgment from our specialist, that are in the frontline, that we have to be flexible because we are all operating in the dark, but we are realizing collectively that we are dealing with such limited data, this is so new in terms of what we are experiencing.

Acknowledging that there is limited data allows us to focus right now on acute stabilization and realize that somethings can be done down the road. We are working on that standardized protocol to promote this mindset to streamline the process, so during night calls, there would be some guidance focused on stabilizing the patients when there is a limited team.

MDQC: Since stroke is an acute event, what has the hospital done to procure the healthcare personnel’s safety when a patient comes to the ER with an acute stroke regarding their COVID19 status?

SS: We are minimizing the amount of exposure to our team members. Since we are a small team, we want to preserve everyone’s safety. We have incorporated our telestroke robot in our emergency department (ED). Our stroke team nurses’ expertise is well-versed in maneuvering and is quick at getting their images done and answering the inclusion/exclusion criteria for thrombolytic criteria. We can see the ER with the robot’s camera. Although we agree that is this is not equivalent to see the patient at the bedside, we are aware that we oversee a system where our stroke neurologist covers multiple hospitals, not only Cedars-Sinai.

Everyone has the personal protective equipment (PPE) ready in their backpacks, our gown, N95 masks. In the setting of a stroke code, anything can happen, sometimes the patients’ airway gets compromised or has a seizure; while this happens, we can quickly gear up since we have it with us. Our pharmacies will now have 24-hour coverage as an additional help to stabilize these patients.

The rapid COVID19 test is available. We try to do it as early during the code if we suspect an LVO, so that information can be available to the IR colleagues who can be prepared. They are also assuming that many of our patients are COVID positive. However, suppose we don’t have the test results. In that case, we don’t delay the emergency recanalization procedure, if the patient is eligible, so we assume they are positive or suspected for Covid, and we gear up properly.

MDQC: What is the impact telestroke has had in managing stroke during the pandemic? And how do you think It will evolve in the years to come?

SS: Telemedicine and telestroke are here to stay. It has been around for decades. We started our program of telestroke in 2016 for covering Torrance Memorial Hospital, and the demand keeps growing. Every minute counts in the setting of a stroke code. It doesn’t make sense for someone to start driving to a hospital when we have a camera that can quickly help guide our ER or ICU colleagues.

Dr. Song, pictured on the monitor, practices treating a stroke patient remotely with other members of the care team.

The technology has been around for a while. It continues to improve, like being able to see the imaging, PAC access, able to quickly document assessments, and write the recommendations that can be seen by the team members that are accepting patients in the ICU. The technology is being improved regularly, the software, and hardware, such as upgrading the camera or reducing background noise.

One thing that I have seen during the pandemic in telestroke where I would like to see some improvement in our non-speaking English patients. Especially with the pandemic and the no-visitor policy of many hospitals, out of a concern for community spread. It’s been challenging to get accurate clinical history from our patients. We rely on witnesses from the family and relatives to determine their medication, clinical history, and bleeding risk. All of that information is difficult to get, especially if we don’t get translators in the room. If Telemedicine could get paired with translator services, so they could be available during the stroke codes, I think that would help move things along from us.

MDQC: This is especially problematic given that the Latinx population has been affected disproportionally.

SS: Yes, we saw that in our data as well. We have a paper submitted right now (REFERENCE), looking at the nine-stroke comprehensive centers in Los Angeles. We saw a disproportional amount of Latinx community affected with LVO going to our colleague hospitals, and they have noticed a sharp increase in their thrombectomy volume during the pandemic.

MDQC: Why is the Latinx community disproportionally affected?

SS: We are trying to figure out what the patient profile looks like for that cohort. We don’t know exactly; however, some theories, such as having type 2 diabetes, maybe factor in the clotting cascade in patients with COVID. Additionally, the situation with multigenerational housing and the high prevalence of essential workers within this community don’t allow them to shelter at home because they still need to go to work. These factors have been considered to contribute to stroke, but there is no known causal relationship to date.

MDQC: Nonetheless, the social determinants play a massive role in the LatinX community.

SS: Yes, and we have been seen this in feedback from our patients. For many patients getting their health maintenance evaluation is hard since they have not had their medication for HTA, DM, etc. Chronic diseases are not being controlled. Some of them haven’t seen their doctors since most clinical visits have moved to Telemedicine, which is contingent on having a computer and Wi-Fi.

In a community with many living in multigenerational households, the computers and internet might be limited resources. Sometimes they only have one computer that must be shared, for example, with kids, for distance learning, and they don’t have other devices to schedule their appointments. COVID has highlighted the gaps between the patients with more resources and those lacking them.

MDQC: We assume that everyone has a computer and good internet access, and unfortunately, that is not the reality. A pillar of medicine is the hands-on training for medical students, residents, fellows. What changes have occurred to guarantee appropriate learning during the pandemic?

SS: We have taken this opportunity to push our trainees’ telemedicine skills in the neurology residency program. Before the pandemic, we had separated telestroke training only for the fellow because we wanted the residence to have that bedside experience first before going to the telemedicine platform. We quickly realize that this skill set needed to be incorporated into the curriculum.

We wrote a paper about that and published it in Neurology, with Dr. Alicia Zha from the University of Texas and colleagues from the University of Utah.¹ We have incorporated Telemedicine for the residency program. Using the telemedicine robot, our residents are directing the camera and maneuvering the robot. We also have the capability called multi presence where the attending and fellow can see what the resident is doing, so we can all see what the host resident is doing, and we can easily take over if we need to. Having this tool has been helpful and flexible. It allows the trainee to develop these skillsets for this technology that is here to stay. Other things that have improved since the pandemic are reimbursement since now Medicare allows the Telemedicine encounters to be equivalent to the side delivery of care. It has been helpful to continue to implement Telemedicine in our practice.

MDQC: So, is this being implemented just for acute stroke?

SS: The residents are using Telemedicine for the clinical encounters since we realize the virtual space is safer for both our patients and the provider. We moved much clinical evaluation to the iPad or evaluated with the desktop computer. It is also good to identify the gaps with Telemedicine, such as the subtle things with weakness and coordination we might not be able to pick up, which is very hard over the camera. Our residents are finding with their experience that things like visual fields cannot be done well with the equipment that we have right now. It’s important to know where our current gaps are so that this generation helps to problem-solve these issues to create apps or more tools to develop better telecare.

MDQC: Another colossal problem regarding stroke is the increase of the delay from symptom onset to arrival to the hospital. What has been your experience at Cedars-Sinai regarding this phenomenon?

SS: On the study with the nine-stroke comprehensive centers, we have seen that. Collectively we all had a decrease in our thrombolytic treatment patients, and IV tPA numbers have gone down, mostly the mild symptomatic patients. I think many patients and their family members are fearful. They have heard the system is currently overloaded and might think that their symptoms are very mild and not worth going to the hospital or are afraid of getting exposed to the virus. We have worked together with the AHA, Stroke association, and Los Angeles County to diffuse the message to tell people that if you have an emergency, a condition like a stroke, call 911.

Understanding patients and famile’ fear, we are trying to get patients home as soon as possible. In that streamlined workup, we intend to get patients out of this hospital as soon as possible. Suppose some things can be done outside of the hospital in the outpatient setting, then that is what we would like to do to reserve the hospital setting for the severe cases.

Some of our patients with mild symptoms when they get evaluated may have resolved their symptoms. We do urgent things for these high-risk TIA patients, such as the vessel evaluation of the carotids. However, maybe the Eco can be done in an outpatient setting, so we send the patient home with the Zio pad, telemonitoring, and have a home visit in 48-72 hours. We are more flexible in the way we deliver health. Not everything has to be delivered at the hospital, understanding patients’ fear and wanting to get home as soon as possible.

MDQC: Burning out syndrome has been a pressing issue in healthcare personnel even before the pandemic, how are you doing Dr. Song? and how are you and your peers coping with the stress this pandemic has caused?

SS: In terms of how we are manning with this crisis scenario is leaning on each other more. We have weekly check-ins, we called it our “stroke team huddles”, we have always had it because we have a very stressful job. We deal with patients and family members in a moment of crisis, are life and death situation during many of those codes, and now we are seen a lot more death.

Now there are lot more patients sicker, and we are seen more distress because they can’t have at the bedside their loved ones. How we have been dealing with ourselves? is giving each other the space to share that level of stress, so it is not something they are holding on to, but a shared collective, living process.

We have noticed that everyone has their highs and lows at different times, so we take advantage of that. The person who is doing well that day, really reaching out to say, “hey, unload a little bit, let me hear what is going on,” and for the person who is having a tougher day. Another really helpful thing has been laughter and sharing when we see something very funny; it has been really helpful to get us through. Sometimes we have to say what we are going through is so ridiculous, and just calling it out has relieved the tension when you share it, and I see it in the body language. It seems to lift from a burden and seems more relaxed.

We have counselors on checking areas, we have resources from Cedars, and if I see that something is helpful, I share it. I have been very open on how I’m getting through this crisis, either with therapy, with zoom check in with girlfriends, who are also experiencing high stress levels at home and work. All those coping mechanisms help and just check in with the clinic patients.

I have been writing letters and have encouraged residents and nurses to write letters to the patients and check in on them, especially those at higher risk because they live alone. You reach out to them, and they also give back to you and often ask how we are doing to the doctors, nurses. We are taking care of each other through this; the key is that we have each other, and we have a team approach.

MDQC: As the last question Dr. Song, what lesson have you learned from ongoing this pandemic?

SS: Lots of lessons. It has helped to solidify for me that we are doing meaningful work. In our team members, we are focusing more on what’s important and letting go of what is not. Our energy stores are getting depleted faster. We are learning to let go easier, focused on important things, and getting rid of the noise that doesn’t allow us to do so. Now we are getting more efficient in our work.

Also, we have all collectively seen that we need to do better, especially for our community areas where resources are lacking. There is a lot of goodwill and recognition in the stroke community. When it comes to leadership, we have to improve healthcare disparities. We are so grateful to the essential workers working delivering packages, in groceries, and getting us through the pandemic. They are the mail carriers, cashiers, all the people that have helped society keep moving during this pandemic. We need to give back to them.

Dr. Shlee Song shared that the pandemic has highlighted the consequences of an unequal healthcare system. We must strive to address this pressing issue as vehemently as finding new interventions or drugs. That flexibility and adaptation have been paramount to get through the pandemic. However, most important of all is teamwork, to rely on each other to provide the best care to patients and take care of each other.

Reference

Zha AM, Chung LS, Song SS, Majersik JJ, Jagolino-Cole AL. Training in Neurology: Adoption of resident teleneurology training in the wake of COVID-19: Telemedicine crash course. Neurology. 2020;95(9):404-407.

The Inequity of the COVID19 Vaccine Distribution: The rich countries hoard vaccines while the poor countries struggle to get them

December 28, 2020December 17, 2020 Miguel Quintero-Consuegra, MD

Last week at Cedars-Sinai, we received an email asking its employees interested in getting the vaccine against COVID19. I was very excited about this since it means a lot of things at once. The development of safe mRNA vaccines in a short period shows how much technology has advanced and highlights the importance of working together as the companies that manufactured the vaccines were not in a race against each other but against the virus. On the other hand, getting a notification that I was soon going to get vaccinated against this virus that has changed our world was pure joy, that sadly faded away.

As I told my friends and family the excitement that I was having because I would be vaccinated soon, all they did was ask me, but when are we going to get the vaccination for us? For our healthcare workers, grandparents, and grandmothers? We have heard in the USA with optimism how the government has secured millions of doses for its people, and it only makes sense that a government wants to put their citizens first but, at what cost? Where does the solidarity with other nations reside? These questions made me dig deeper into an issue that gets shadow by the hype of us getting vaccinated.

The People Vaccine Alliance, an international watchdog that includes Amnesty International, has warned that some countries have bought enough COVID vaccine to immunize their populations more than once. It highlights Canada as the top country on this matter that has reported over 400.000 cases of COVID19 has secured enough vaccinations to immunize its population at least five times. In contrast, poorer countries will only be able to vaccinate one in ten people. The Alliance data also showed that the deals that have been done between the governments and the eight leading vaccine candidates’ risk of leaving behind middle-low and low-income countries, as rich nations hoard on vaccine deals.¹

A clear example of the disparity between the rich and the poor has been the Moderna and Pfizer vaccines’ inequitable deals, which have shown on their preliminary data to have the highest efficacy rate. Due to their promising results, the vaccine lots have been bought in a staggering 96% for Pfizer and 100% for Moderna by rich nations. With those impressive figures, the gap between the have and the have nots will stretch even further. The Director-General of the World Health Organization, Tedros Adhanom, warned during a press conference “Every government rightly wants to do everything to protect its people, but there is now a real risk that the poorest and most vulnerable will be trampled in the stampede for vaccines”.²

Nonetheless, international efforts have been made to achieve global vaccination, such as COVAX. This compact, composed of 189 countries, amongst which the USA and Russia resonate for their absence, has high and middle-income countries committing to provide funding to ensure access to vaccination and equitably manufacturing them. In contrast, poorer countries have signed to secure vaccines for their population. This effort will also be backed up by agencies such as the Bill and Melinda Gates Foundation.³ Efforts by the Oxford/Aztreneca are also of great importance to allow developing nations to get the vaccine, as they have pledged to five more than half of its doses to developing nations. Unfortunately, this would only reach 18% of the world’s population.⁴

I concur with Melinda Gates’s denomination of this phenomenon as vaccine nationalism, with the populist premise of “our citizens first,” that suffice its purpose of improving the polls for political gains. However, these actions go against one of the most powerful lessons this pandemic has taught us, the sense of community and working towards the benefit of all.

I firmly believe that vaccine allocation for a health crisis like this should prioritize global immunization for healthcare workers and elderly patients, rather than prioritizing country of residence or origin. It is not acceptable to have an effective vaccine, not reaching healthcare providers on the frontlines of developing countries fighting this virus without this indispensable weapon. In contrast, rich countries rely on an excess of vaccines and immunize low-risk citizens first.

This pandemic has shown us how fragile humanity. Now more than ever, the rich countries and their economic capacity must set an example of global leadership and outline a sensible policy that focuses on a global perspective rather than an exclusive, nationalistic one because this crisis won’t be over until everyone gets vaccinated.

References

The Era of Misinformation: A Constant War of Science vs. Fiction

November 17, 2020November 17, 2020 Miguel Quintero-Consuegra, MD

“Covid19 is a hoax”, “vaccines poison your body”, “the earth is flat.” Various conspiracy theories and misinformation statements have existed throughout history. Though some might seem absurd and often put into the spotlight to ridicule them as they are improbable to be accurate, like the earth being flat, this comedian aspect shifts to a sinister black connotation when the conspiracy theories, and misinformation infect the medical field.

As the first doctor of my family, it is not uncommon to get questions about a new drug that was promoted on TV, or regarding a bold scientific claim, such as someone curing cancer. However, during this year, amid the Covid19 pandemic, the spread of misinformation has been almost as incontrollable as Covid19 cases in the United States of America. With great concern, I saw that several acquaintances, friends, and family, most of them with higher education degrees, shared and contributed to spread false information on the treatment of Covid19, its origin, or questioning if this was part of a bigger plot to control humanity.

The spread of misinformation has contributed to mistrust towards medical healthcare personnel, to the point of being violent towards them,1 not following their advices, or falsely claiming overdiagnosis of Covid19 with the sole purpose of getting “more money,” claim that unfortunately gets backed up by the Highest Office in the Land.2

However, this problem isn’t new in the medical community, as Dr. Anne Marie Navar stated in her conference during the Scientific Sessions lecture “How Misinformation Steers Patients off Course.” She mentions that the Covid19 pandemic highlighted and made more evident the dire problem misinformation has brought to medical compliance with treatments. She focuses on the misinformation campaigns that have been occurring around statins, were social media personalities with doubtful medical claims such as the questionable Dr. Joseph Mercola, and unscrupulous social medial like Infowars pretend to scare and deter patients from taking statins, while promoting their products such as diets, supplements (Omega-3), that are commercialized with misleading labels, and lies about the efficacy of their products.

But how likely are statements made by doubtful doctors or non-healthcare providers likely to affect patient compliance? Would patients believe more something they read or see on social media than following the physician’s recommendations to whom they trust their health? Unfortunately, it is quite likely. Dr. Navar highlights a prospective cohort study from Denmark that included 674.900 individuals > 40 years old, that were on statin therapy ( a drug used for patients with high cholesterol levels) from 1995-2010, and followed until December 31 of 2011, to test the hypothesis if statin-related news were associated with early statin discontinuation.3

This prospective cohort showed that early statin discontinuation increased with negative-statin related news, and early discontinuation was associated with increased risk of myocardial infarction and death from cardiovascular diseases (fig 1). Also, a sensitivity analysis showed that negative statin-related news stories were associated with an odds ratio of 1.15 (CI: 1.09-1.21) for early discontinuation of antihypertensive medication (fig 2).3

Fig 1. Early statin discontinuation vs. continued use and cumulative incidence of myocardial infarction (top panel) and death from cardiovascular disease (bottom panel).

Fig 2. Statin-related news stories and early discontinuation of statin, antihypertensive medication, and use of insulin among statin users.

It is worrisome that patients’ very own life might be at stake due to misleading propaganda that feeds from the fear of exaggerating adverse events for specific treatments (drugs, vaccines, etc.). To have these very own propaganda makers, in an ungracious second act, pretending to be messiahs, to promise patients the “healthiest” option available for their disease, thus creating widely successful businesses by selling non-effective products at the expense of putting the populations’ health at risk.

But this misinformation phenomenon has been more impactful and dreadful during the pandemic since we are dealing with a highly transmissible disease, where the cost of disinformation results in more people getting infected with Covid19 ,or dying because of Covid19.

But what can we do as healthcare professionals? As scientists? The first thing to do is to speak up. We must not be silent as false and misleading information spreads. The truth tends not to be soothing, hopeful, nor easy to process, and during this cumbersome year, this might become a more challenging task when coming to terms with “the new normal.” The evidence does not change because of our feelings, thus making it imperative to face the facts. Our role as physicians, healthcare workers, and scientists is to be modern versions of Prometheus, and reside on the frontline to fight back misinformation by being leaders that defend the torch truth, and share it with the world.

Dr. Anthony Fauci is the perfect example of the leadership we all must show as bearers of the torch of truth, as his statements are based on hard facts and science. Nonetheless, his remarks often failed to reassure people during these unprecedented times since he has been very cautious by avoiding making any premature conclusions regarding the effectiveness of a treatment or on the efficacy of a vaccine without proper evidence, as it should be.

However, this lack of reassurance opens a door for opportunistic scientists and medical doctors such as America’s Frontline Doctors, that earlier during the year claimed that Covid19 could be treated with hydroxychloroquine, widely tested as being not useful.4,5 This bold claimed amid the uncertainty lived in the beginning of the pandemic, unleashed an incontrollable confirmation bias, as people would feel reassure when “doctors” tell them there is a cure for this virus; despite the fact that the “doctors” making such claims were not infectious disease experts, nor did they have any real evidence to support those claims. This mere example highlights the importance of raising our voices to spread real facts to prevent landslides of false information spread.

We must be empathetic to those that are sharing or commenting on false information. When seen friends or family doing this, please give them the benefit of the doubt, as people share information thinking of their well-being and that of others and, most of the time, is not out of a primary motive to harm or do wrong. When I have encountered my family or friends doing this, I try to reach out to them and ask them what they learned from the information they are sharing and explain to them the inaccuracies of all the misleading content on the news they are spreading. At last, I tell them to send me privately all the videos, chats, news they get so we can discuss them before sharing them. By doing this, the fake news chain will break, and more people will start acquiring critical thinking before sharing news from a field that is unknown or unfamiliar to their area of expertise, in this case, medical and healthcare related news.

Finally, I would like to share a pamphlet on how to fight misinformation from Dr. Tim Caufield from the University of Alberta that outlies four main steps, help stop the spread, and craft a message to counter misinformation, promote a regulatory response, and debunking (fig 3). Let us all unite our voices so they can be loud enough to bury misinformation.

Fig 3. Fighting misinformation pamphlet (https://www.ualberta.ca/law/faculty-and-research/health-law-institute/fighting-misinformation.html)

Acknowledgments
I would like to thank Dr. Anne Marie Navar for her conference “How Misinformation Steers Patients off Course” As it encouraged me to write todays blog on this pressing issue. I encourage you all to see her conference on the Scintific Sessions website.

References

Medellin. Personal médico del Hospital General fue agredido por caso de covid-19. El Tiempo. https://www.eltiempo.com/colombia/medellin/coronavirus-en-medellin-denuncian-agresion-a-personal-medico-del-hospital-general-de-medellin-527090. Published 2020. Accessed.
Griffin J. Medical professionals push back after Trump says COVID-19 cases are inflated to ‘get more money’. Daily Herald 2020.
Nielsen SF, Nordestgaard BG. Negative statin-related news stories decrease statin persistence and increase myocardial infarction and cardiovascular mortality: a nationwide prospective cohort study. Eur Heart J. 2016;37(11):908-916.
Boulware DR, Pullen MF, Bangdiwala AS, et al. A Randomized Trial of Hydroxychloroquine as Postexposure Prophylaxis for Covid-19. New England Journal of Medicine. 2020;383(6):517-525.
Effect of Hydroxychloroquine in Hospitalized Patients with Covid-19. New England Journal of Medicine. 2020.