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In Sharing Your Pain, Your Help Others Heal – A tribute to, Dr. Basem Oraby, a resident physician we lost in 2020

I did not know Dr. Basem Oraby but when I wrote a blog in memory of my aunt, Dr, Somaya Saad Zaghloul, who died of COVID-19 in Egypt on December 1, 2020, his sister, a clinical pharmacist, Bassant Orabi, reached out to me on Twitter and said sharing my aunt’s story gave her the courage to share her little brother’s. A beautiful soul, taken from us far too soon. My conversation with Bassant was heart-wrenching but reminded me that in sharing my pain, others heal too. Her tribute is movingly painful. Our paths crossed because of tragic circumstances, but somewhere in there is a glimmer of light. Read on for Bassant’s tribute.

I never thought I would experience something as painful as holding my dad in my arms at 2:00 am with my eyes fixated on the monitor watching his EKG flatten, but I was wrong. Four years later, I saw my little brother Basem in a coffin. But in that coffin was not just my brother’s body, with his passing went his dreams of becoming an attending physician, the goals he planned on crushing, his jokes and unmatched sense of humor, and his outpouring of love and support to anyone in need. I could not believe my brother was gone.

It took me a long time to write a tribute worthy of the legacy Basem left behind.  Although Bassem died at the young age of 25, he lived his life to the fullest. I look back to January 15, 1995, and I see this tiny baby whose little cries captured my heart immediately. Basem was the kindest among our family, never hesitating to offer a helping hand or a shoulder to lean on. He was a true family young man who loved and protected his family. I remember the countless times he comforted me during my most difficult times and I now wonder if I will ever feel that much unconditional love again? Although I am 10 years older than him, he was and will always be my hero.

Basem was a loyal friend to many. It became even more evident by the outpouring of love from his friends all over the world after his death. His compassion and love for everyone were unsurpassed. He always went the extra mile for those he loved and cared about and always believed in saying only what was good. His beautiful heart and tender soul drew many to him. As I read countless messages from his professors, I got to know Basem as the brilliant physician he was. Losing our father was not easy on him, yet he found the will in himself to graduate from Weill Cornell Medical School in Qatar. Everything he did, he did with perseverance. He moved thousands of miles to pursue his dreams to train in internal medicine at Virginia Commonwealth University Health in Richmond, Virginia. He took pride in serving veterans and disadvantaged patients. I remember him being so proud to have diagnosed a case of cardiac amyloidosis, it was clear that medicine was his passion. Basem felt medicine was a career of helping people out of their dark roads. He was the compassionate doctor I wanted to see in an emergency department. 

Basem was a generous soul who never hesitated to help others in need. Basem was the 9-year-old kid who gave all his money to a taxi driver who could not afford the cost of his daughter’s chemotherapy, he was the teenager who supported refugees from his undergraduate scholarship stipend, and he was the young doctor who brought food to many who could not afford it.  I still cry that he died alone in America with no one around him, but soon I remember that such a beautiful soul is never alone. Every time I remember how much he wished he would come to visit us and how proud he was to be working and helping during a pandemic, I realize that he lived the life of giving he wanted.

I used to stand by his grave and weep, there was a hole in my heart that grew every day since we were informed of his death until the day then I realized that his true journey had just begun.  Though he is no longer with us, his love and support shower us. I think of all the charity work he contributed to including water wells, tents, education packages, medical glasses, and food among many other projects done in his name in Africa, Asia, and Europe. Even after his death, his legacy remains. I am inspired to be the best version of myself to make him proud.  

I wish his friends, colleagues, all those who knew him, and us, his family, continue his legacy of love, compassion, generosity, and kindness. I also ask you all to keep him in your prayers. Basem will always be a beautiful part of our journey. I will always carry you in my heart Basem.

In sharing my pain, I was able to help Bassant start her journey to healing. There is a power in vulnerability. You touch lives. As the late, great Dr. Maya Angelou told us, a legacy is every life you touch. Touch as many as you can.

[This is the last photo Dr. Basem Oraby took with his family at the airport before heading to the US for residency]

“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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Gratitude on Our Worst Days

My dad desperately tried to get a hold of me on the morning of December 1, 2020 but for some reason, I hadn’t seen that he called me and so I found out my aunt, Dr. Somaya Saad Zaghloul, succumbed to COVID-19 via my mom and aunt’s medical school classmate on Facebook Messenger. Exactly what my dad was trying to prevent. I called my parents immediately and the tragic news was confirmed. We were desperately praying since her admission to the hospital that she would be one of the lucky ones, but that morning, God had other plans. I in turn desperately called my brothers and sister so that they wouldn’t find out through social media as I had and in comforting them through my tears, I reminded them that Aunt Somaya was diagnosed with rheumatoid arthritis at age 17 and that during the last several years her pain was debilitating. She needed a wheelchair to get around when her legs couldn’t carry her very far, but despite that, she was teaching her medical school courses up until she was diagnosed with the cruel virus; now, she was no longer in pain. The epitome of grace, of resilience, of living life to the absolute fullest, of smiling through your struggle, of generosity, of welcoming everyone into your home, of always looking like a million bucks (bright red lipstick and all) even if you weren’t feeling like it, of loving deeply, and of being grateful for every blessing. She was legendary.

Another cruel reminder to be grateful for everything we’re blessed with, the big things, the small things, and everything in between; the things we take for granted every day like waking up with a roof over our head, food on our table, clothes on our back, a sound mind, legs that carry us, and the ability to go to work. Every morning I wake up with a routine that includes prayer and meditation, exercise, listening to the previous day’s The Breakfast Club episode, setting my intention for the day, and importantly, writing down at least 1 thing I am grateful for and I make it something specific. My morning power hour gets me through the toughest days and makes the best ones even more fabulous, it keeps me grounded. Gratitude, when practiced regularly improves mental wellness, increases empathy, reduces anger, increases happiness and satisfaction, improves self-esteem, and best of all, helps you sleep better. I highly recommend including it in your daily routine either every morning or before you sleep at night. The practice has changed the way I view the world and how I deal with its curveballs.

Every Christmas, I request to be on call on the inpatient Heart Failure and Transplant service to honor the death of my uncle, Dr. Ali Saad Zaghloul, from a massive heart attack on December 25, 2016, a tragic death I first found out about ironically via social media. Now, I will be honoring both my aunt and uncle every December for the entire month by feeding the less fortunate, by working the holidays so others who celebrate can spend time with their families, by remembering to always be kind and forgiving, by living each day like it were my very last, and most important, being there for patients who need the most support during their most vulnerable moments.

I hope we take the lessons 2020 taught us into 2021. My biggest lesson remains that human connections are the most important thing in this world. I wish you a safe, socially distanced, and serene holiday season. The light at the end of the tunnel is not so far away anymore, we’re almost there. I’m sending an overabundance of love and light to everyone who needs it right now. The souls who’ve departed us far too soon will live on forever through all those they touched.

Drs. Ali and Somaya Saad Zaghloul

“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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Advancing Cardiovascular Health for All

Finally, some excellent news in a year ravaged by innumerable tragedies, the first Black Indian American woman, Kamala Harris, is vice president-elect of the United States, and the American Heart Association has made a commitment to advance cardiovascular health for all-; what a great start to November 2020. I got to attend the American Heart Association’s news conference on the organization’s Call to Action: Structural Racism as a Fundamental Driver of Health Disparities, and unlike many of the committee, workgroup, and taskforce meetings I have attended or the emails and newsletters I have read since the newfound interest in structural racism, this felt real.

The American Heart Association’s Impact Goal read: As champions for health equity, by 2024, the American Heart Association will advance cardiovascular health for all, including identifying and removing barriers to health care access and quality. What struck me was the emphasis on structural racism being a major cause of poor health and premature death. Many of the other meetings I sat in on, you know, the committees, the task forces, and the workgroups, rarely acknowledged structural racism as the root cause. We cannot fix healthcare until we acknowledge that structural racism has contributed to the grave inequities in medicine.

One of the saddest things to me is that marginalized individuals may not even be aware that they are recipients of disparate care. One of my best friend’s uncles, a Black man, was turned away from an emergency department with a new diagnosis of diabetes and unrelenting nausea with some paperwork to apply for insurance coverage and died of a massive myocardial infarction at home. The patients we turn down for heart transplant or left ventricular assist devices because of lack of financial security- souls that will haunt me forever. The Black non-English speaking man who presented to an emergency department with acute myocardial infarction and then delayed in his care led to his death. I read these statistics in medical journals and saw stories on television, but when I started witnessing the injustices firsthand and became the go-to person for my Black friends who wanted assurance that their parents, grandparents, aunts, uncles, and they themselves were receiving “good” care (oftentimes they were not), I became even more determined to do my part in dismantling these oppressive systems.

And just so we are clear, dismantling structural racism does not mean adding Black and Latinx members to a committee, for example, that continues to be led by individuals perpetuating oppressive systems; it means removing the oppressors and replacing them with individuals committed to driving change. Being part of the change means looking around the spaces you are in and recognizing what the problems are, and fixing them. Everyone is responsible. Until we address societal racism, we will never address inequities in medicine. Expecting a patient who is a single, working mother, who lives in a food desert, and who did not have the privilege of going to a top-rated public school to be successful with the same tools provided an executive at a Fortune 500 company is ludicrous. We must provide each patient with the tools that will contribute to their success, but ideally, no provisions would be necessary if we lived in a just society. Justice is the overarching goal.

The highlights of the American Heart Association’s advisory are direct- 1. The ascertainment that structural racism is a current and pervasive problem, 2. The acknowledgment that structural racism is real and produces adverse effects, and 3. The burdens of mitigating the impact of structural racism is a shared responsibility. Profound. All hands on deck; the individuals that deny the pervasiveness of structural racism, and it is the root cause of healthcare inequities must be phased out. Additionally, the American Heart Association listed key areas to address to eliminate structural racism and its negative effects, including restructuring systems, implementing policies, eliminating inequities, fostering allyship, and supporting research. And allyship does not mean supporting the mission when you are around people passionate about dismantling systemic racism, allyship means looking within your own families, circles, and workplace and driving change. Allyship is not wearing a Black Lives Matter pin on your white coat, kneeling with a White Coats for Black Lives sign, sitting on a diversity and inclusion committee, or Tweeting an article on the late, great Congressman John Lewis; allyship is using your privilege and platform to drive change.

I do not claim to be an expert in racism, far from it, but I do know we each have to play a role in dismantling the oppressive systems that have left Black and Latinx patients without access to quality healthcare. For me, my contribution to driving change is mentoring and sponsoring Black women and men interested in careers in medicine so we can change the face of medicine and secondly, working to eliminate inequity in organ allocation in heart transplant by improving outreach to neglected communities and creating pre-transplant “Bootcamp” programs where, instead of turning a patient down for smoking, for example, providing them with the tools necessary to become an ideal transplant candidate. Just like transplant centers are penalized for excessive mortality, transplant centers should be penalized for not expanding outreach to BIPOC communities.

I want to end with the powerful words of Reverend Dr. Martin Luther King, Jr, may he continue to Rest in Power because I cannot end this better myself- “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Physicians, advanced practice providers, scientists, nurses, technicians, administrators, policymakers, and anyone with a stake in healthcare- we have so much work to do, but I remain full of hope.

 

“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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Bring Your Whole Self to Work

“Pretend you are going to be interviewed by a conservative, old white man in a bowtie”.

This was the advice I was given when I asked what I should wear, how I should do my hair, and how I should present myself when I interviewed for medical school. I remembered those words when I interviewed for every step of my journey in medicine since, including 1 residency, 3 fellowships, and my first “real” job as an attending. I wore conservative-colored suits (I remember my younger brother telling me I looked like a flight attendant before one interview- not the look I was going for, but okay), always straightened my hair (I never wore my natural curls), and I always thought of that advice before every interview- conservative, old, white, man, bowtie.

Fast forward to “attending’hood”, I would never heed that advice. I started wearing my hair curly as a protest to what “professional” hair should look like, presented on stage in pink blazers and dresses, and brought my whole self to work. When I interview prospective internal medicine residents or cardiology fellows, the most important 3 pieces of their application in my opinion are their letters of recommendation, their personal statement, and their extracurricular activities outside of medicine. While the abstracts, presentations, and publications are fantastic, they do not tell me who you are as a human being. From the letters, you get a glimpse of how others see the applicant, from the personal statement you hear a story, and from the extracurricular activities you learn about passions. My favorite part of the interviews is talking to candidates about who they are, what lights that fire within them, and what kind of vibe they bring to medicine. When I read your application, I want to know your story.

I love what I do in medicine- advanced heart failure and transplant cardiology- I love the research I do but I also love my life outside of medicine. And I am always confused when people are surprised that I love college football, I love LeBron James, my favorite radio show is The Breakfast Club, and I listen to trap music. I love going to concerts, throwing outrageous birthday parties, and going on girls’ trips. I care deeply about equity in medicine and politics that affect the most vulnerable among us and will continue to work my butt off to crush inequities in organ allocation. To me, these are not 2 different worlds. This is just my whole world. So yes, I will keep bringing my whole self to work.

To be completely honest, I am not sure how I should advise my mentees, most of whom are women and men of color, on how to dress or style their hair or carry themselves during their interviews. People of color are judged more harshly, and I would not want my advice of bringing your whole self to the interview be the reason they did not get the position. But then again, who wants to be at a place that does not accept all of them.

I still say, bring your whole self. Every part of it. The authentic you.

And to my mentees I say, continue sharing your magic with a world that desperately needs it.

 

“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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Black Lives Matter- Doctors, We Need to Talk

I immigrated to America with my siblings and mom in the summer of 1998. Three years later on April 7, 2001, when I was a freshman in college at the University of Cincinnati, the Cincinnati Police killed an unarmed Black teenager named Timothy Thomas, igniting several days of protests. That was the first time I came face-to-face with the cruel reality of racism, police brutality, and violence against the Black community in America. After Timothy Thomas came many others. Sean Bell. Oscar Grant. Trayvon Martin. Rekia Boyd. Eric Garner. Michael Brown. Tanisha Anderson. Tamir Rice. Walter Scott. Freddie Gray. Sandra Bland. Samuel DuBose. Alton Sterling. Philando Castile. Stephon Clark. Atatiana Jefferson. Breonna Taylor.  Ahmaud Arbery. [and many, many more…]. And most recently, George Floyd- who like his 6-year-old daughter Gianna said while sitting on the shoulders of one of her father’s best friends, retired NBA player Stephen Jackson, her “daddy changed the world”. The world watched in horror as a police officer kneeled on Mr. Floyd’s neck for 8 minutes and 46 seconds as he pleaded for his breath, killing him on May 25, 2020. Protests erupted all over the world.

I wish I knew the answers. I wish I knew how to change the world. I wish I knew how to change the reality of being Black in America. What I do know is that this time it feels different. This time I am hopeful. This time I have witnessed people speaking up who never speak up. I have seen hearts shattered all over the world and emotions exploding across every continent. Systemic racism is a disease in America and the system needs dismantling. Change can no longer wait.

Why did I say we needed to talk, doctors? Because we desperately need to. Violence, police brutality, and injustices against the Black community are a public health crisis. How do we expect to talk to Black patients about blood pressure and glucose control without addressing the trauma Black women and men experience on a regular basis living while Black in America? We took an oath, to serve mankind, now is our time to step up like we have never stepped up before. This is not a bipartisan issue; this is a human issue.

Academic and non-academic medical institutions all over America kneeled on June 5, 2020 in remembrance of Mr. George Floyd after they issued statements (ranging in directness of messaging) denouncing his soul-crushing murder. While this display was profound, we cannot stop there. We must move past the vigils, remembrances, thoughts, and prayers, emails, diversity and inclusion workgroups, and committees, and meeting after meeting after meeting, to the implementation of initiatives that dismantle the systemic racism ripe in medicine. Black women and men are grossly underrepresented beginning in medical school all the way to professorships, tenured positions, chiefs of divisions, and medical school deans.

I do not know all the answers, but I do have some suggestions:

  • When you get invited to speak at a school about being a doctor, rather than feel good for the day and add it to your curriculum vitae, connect with a Black student or 2 that may be interested in medicine and mentor them. Find out if your institution has a summer program for minority students interested in medicine and get them connected. Maintain a relationship with them and guide them through their journey in medicine. You may be the only person that has made them feel like they belong in medicine and that their dream is within reach.
  • Recruit Black women and men into your residency and fellowship programs and mentor and sponsor them throughout their training. If they are interested in research, provide them with opportunities to work with your team. Amplify their voices and work on the national and international stages you have the privilege of presenting on. Recommend them for local, national, and international committees. Recommend them for speaking opportunities. Connect them with your colleagues and friends at other institutions during their job searches.
  • Recruit Black women and men into your institutions and work hard to retain and promote them. Recommend them for leadership positions. Guide junior faculty in their research efforts and put them on your grants. Cite their work. Get them to the podium on national and international stages. Invite them to meetings where big decisions are being made. Recommend them for local, national, and international committee positions (other than the cliché “Diversity and Inclusion Committee” positions). Recommend them for promotions and tenure.
  • Let go of the idea that Black patients are the responsibility of safety net hospitals alone. In any given city, there are more Black residents than what a single hospital can handle. Go into Black communities and build relationships and welcome Black patients into your hospitals. If Black patients say they are not comfortable being cared for at your hospital, then you desperately need to change the face of your hospital.
  • Which brings me to my next point, diversifying your hospitals means diversifying the faces from environmental services, valet, and food services all the way to division chairs and hospital presidents.
  • Speak up right then and there, every single time, in defense of your Black students, trainees, and colleagues when discrimination occurs in your presence. And defend them when they are discriminated against when they are not present.

Nothing seems to have changed since I immigrated here in 1998 but I do feel that this time is different. My fellow doctors, this is not the time to watch from the sidelines. It is not the burden of Black doctors to dismantle the systemic racism that plagues medicine. Use your privilege to act, I promise you will not lose it. When this wave of protests, kneeling, and anti-racism training settles, I want us to remember those horrific 8 minutes and 46 seconds and remember the role we each must play in dismantling systemic racism.

Rest in paradise Black Queens and Kings. We will not let up.

Black Lives Matter- today, tomorrow, and forever.

“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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Wellness Amid a Pandemic

I think about wellness often and the unique aspects of being a physician that make preserving our wellbeing even more important. Of course, this COVID-19 pandemic has tested all of us and the things we turn to for wellness and our escape from medicine, may not be available to us right now. After work dinner and drinks, early morning group fitness classes, and young professional networking events have been replaced by Netlfix© and dine-in, home workouts, and Zoom “wine” downs. We all had to dig down deep inside to find new venues for wellness and if we were lucky, our institutions provided resources to help us during this crazy time. What this pandemic taught me was that there are things I still needed to work on to build my resilience even further- and I am totally okay with that. Working on ourselves to better ourselves should be a continuous goal- everyone has room for improvement.

As a single woman living in the city, my nights and weekends were always filled with social events. I felt very isolated and realized how much of my free time was being occupied by my friends and the events I attended as part of my wellness routines. I miss my morning classes at bootcamp and will never complain again when my alarm wakes me up at 4:25am to get to class- whenever that may be. Some of the things that have helped me are FaceTime and Houseparty dates with friends and family, walking outside on the few sunny days Boston has graced us with, trying to eat healthy when I can, in-home workouts which I am not a fan of to be completely honest, but most important, was being vulnerable with friends, family, colleagues, and even patients who asked how I was doing during our virtual visits. I met with a Wellness Coach provided through my institution and the lightbulb moment for me was when he reminded me to be kind to myself. I remember seeing posts all over social media about how we should be building businesses, getting in shape, writing grants, or checking off any other number of “goals” because we have “so much time” and feeling bad, but I got over that. In the middle of this crisis, all our lives have been disrupted, some much more so than others, and we are all doing the absolute best we can. I remind myself to be grateful and I started writing specific things down that I am grateful for each day.

May is Mental Health Awareness Month and as physicians, we shy away from talking about such things. It may be that we are supposed to be superheroes who are invincible, or it may be that if we did seek help and received a diagnosis we would have to declare it on some medical state licensing applications, or we may just be afraid. Mental health is one of the many aspects of overall wellbeing and there are many ways to reach out for help for those who need it. COVID-19 has had many casualties and we must guard our mental health during this pandemic. Find what works for you and do it. Reach out when you need to and remember that it is totally okay to not be okay. Protect your mind, body, and soul as these are key aspects of our overall wellbeing. I feel optimistic about our future. When we come out on the other side of this let us take all the lessons we learned and remember to never take things such as human contact for granted again.

Stay safe and stay healthy.

“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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Another (Louder) Call to Improve the Care We Provide Heart Failure Patients

I am always taken aback when I recommend a switch to sacubitril/valsartan in a patient with heart failure with reduced ejection fraction (HFrEF) and the response is “my patient feels fine”. This is a common response and certainly not a good enough reason to not optimize guideline directed medical therapy (GDMT) in patients with HFrEF. Optimization of GDMT in HFrEF, known to improve morbidity and mortality (1,2), is dismal. The Change the Management of Patients with Heart Failure (CHAMP-HF) registry included patients in the United States with chronic HFrEF receiving at least one oral medication for management of HF and showed >25% of eligible patients are not prescribed angiotensin converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor, >33% are not prescribed a beta blocker, >50% are not prescribed a mineralocorticoid receptor antagonist. Remarkably, even among those receiving GDMT fewer than 25% are prescribed target doses and only 1% of eligible patients are simultaneously on target doses of all 3 classes of GDMT (3,4).

The mechanisms for suboptimal prescription of GDMT in HFrEF are complex and undertreatment is even more evident among women, minority patient populations, and patients from economically disadvantaged backgrounds, among others. Cost is certainly an issue, especially with more novel HF therapies and co-pay assistance programs are not always available to our most vulnerable patients. There are not enough HF cardiologists to take care of the continuously increasing population of HF patients and therefore, optimization of GDMT needs to be done by general cardiologists and primary care clinicians as well. We should also become creative and use telemedicine to optimize GDMT more efficiently. We do our patients a disservice by not optimizing GDMT that improves HF morbidity and mortality.

And just as optimization of GDMT is not ideal, neither is our evaluation of etiology of HF. Optimization of GDMT and determination of etiology of HF whose management may change disease trajectory should be undertaken in all patients with new-onset HF. This begins with a fundamental understanding of the various etiologies of HF, the laboratory and imaging testing needed, and the best treatment strategy for the underlying etiology discovered- if any (cue, “idiopathic” cardiomyopathy). O’Connor and colleagues’ observational cohort study from the Get With The Guidelines- Heart Failure (GWTG-HF) registry demonstrates the need to improve the testing we perform to exclude coronary artery disease (CAD) as the underlying etiology of new-onset HF.4

Why is this important? Well, of course for treatment, which involves deciding whether medical therapy (aspirin, statins) or revascularization (surgical or percutaneous) is a more optimal strategy. And most important to improve disease trajectory as continued ischemia will lead to worsening HF. O’Connor and colleagues found that the majority of  17,185 patients hospitalized for new-onset HF did not receive testing for CAD either during the hospitalization or in the 90 days before and after, despite data demonstrating that 60% (!!!) of HF patients have concomitant significant CAD.4 And consistent with disparities I mentioned earlier regarding the undertreatment of women with GDMT, men were more likely to be tested for CAD.

Diagnosing and treating CAD provides an opportunity to discuss risk factor modification with patients such as smoking cessation, diabetes control, exercise, healthy diets etc.… to further mitigate future risk. The importance of optimization of GDMT in patients with HFrEF cannot be understated and analogous to this, is the importance of examining the underlying etiology of HF in patients with new-onset HF with preserved, borderline, or reduced EF to improve disease trajectory. Furthermore, inequities in both aspects of the care of HF patients in terms of identification of etiology and optimization of GDMT, must be addressed on a national level. We have plenty of data illustrating suboptimal optimization of GDMT in those with established HFrEF and suboptimal testing for CAD in those with new-onset HF. The next steps are understanding the mechanisms and implementing strategies to improve care. The need for this is critical to reduce morbidity and mortality in all HF patients.

References

  1. Yancy CW, Jessup M, Bozkurt B et al. 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Failure Society of America. Circulation 2017;137.
  2. Yancy CW, Januzzi JL, Allen LA et al. 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction. Journal of the American College of Cardiology 2017.
  3. Greene SJ, Butler J, Albert NM et al. Contemporary Utilization and Dosing of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: From the CHAMP-HF Registry. Journal of the American College of Cardiology 2018.
  4. O’Connor, Kyle D., et al. “Testing for Coronary Artery Disease in Older Patients With New-Onset Heart Failure.” Circulation: Heart Failure, vol. 13, no. 4, 2020, doi:10.1161/circheartfailure.120.006963.

“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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Dear Kobe

 

Dear Kobe,

Thank you for inspiring all of us in medicine too.

Sincerely,

The future of medicine.

From Los Angeles to Manila, sports fans and people that know nothing about sports were shattered by the deaths of Alyssa, John, and Keri Altobelli, Gianna and Kobe Bryant, Payton and Sarah Chester, Christina Mauser, and Ara Zobayan aboard that helicopter on Sunday January 26, 2020 in Calabasas, California. We all knew exactly what we were doing when OJ was found not guilty, when we realized Prince would never perform Purple Rain again, when Whitney was found in her bathtub, and when we found out Robin Williams would never star in a Broadway play of Patch Adams. Kobe’s death will be no different. I was sitting on my couch watching reruns of a show on BET with one of my best friends. We sat there stunned for several hours hoping this was some sort of sick joke, but as every news outlet and social media platform picked up the tragedy, I felt sick.

Death is inevitable. It’s the only thing we know for sure is going to happen to every single one of us. But like I said in my previous blog about being on heart donor call, when the deaths are unexpected and take young people, they are shocking, they are life altering, they are gut wrenching. They remind you that life is fragile and our time here is limited.

Kobe’s legacy will live on forever through the magic he shared with people he knew directly and with people he never met, like myself, who grew up watching him, sometimes hating him because he was destroying your team. His work ethic was unmatched, and his love of the game surpassed every athlete’s of our generation.

What did and can we, as clinicians, scientists, and educators, learn from the Black Mamba?

  • To show up in every single thing we do, every single time
  • To love our family and friends and make them a priority despite how busy we may be
  • To leave the world a better place for future generations coming behind us
  • To inspire those around us to be the very best human beings they can possibly be
  • To inspire people to live their life’s purpose
  • To inspire people to live each day like it’s their very last
  • To bring grit and passion to everything we do
  • To find that fire inside and keep it ignited
  • To set monstrous goals, crush them, and then set even bigger goals
  • To find the things we love doing outside of medicine and do them with our whole heart. I mean, you won an Oscar, Kobe
  • To love deeply
  • To never take no for an answer
  • To bring heart to everything we do
  • To know when it’s time to leave the stage
  • That without obstacles there is no growth
  • That we can be fierce AND kind
  • That there are no ceilings
  • That records are made to be broken
  • That one human being can indeed have a profound impact on the entire world
  • That when we feel like quitting, we should ask, what would Kobe do?

May you, your daughter, and all the passengers aboard that helicopter RIP. Your legacy will live on through all of those you touched. There are no words to express how grateful we are to have been touched by your magic.

So, what legacy are you going to leave behind?

 

“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 My Heart Failure/Transplant Fellowship Changed Me

When I started my Advanced Heart Failure/Transplant fellowship, my program director told me this year would change my life. I thought, “Yeah okay, whatever.” Boy, did that year change my life. The way I looked at the world changed entirely. Transplant is one of the most incredible medical therapies available to patients with end-stage heart, kidney, and liver disease, amongst others. Because of the generosity of the donor and the donor’s family, someone else is given a second chance at life. I always tell my heart transplant patients that they should now be celebrating 2 birthdays every year- to commemorate the gift of life given to them a second time over.

When I say that year changed my life, it truly did, and that change is lasting. When we’re on heart donor call and we’re evaluating hearts for suitability for our recipients, they’re usually younger hearts and cause of death is almost always unexpected. The stories are tragic- suicides, car accidents, freak accidents, and unintended drug overdoses, amongst other causes of death. As I sit in my pajamas (donor heart evaluations happen in the middle of the night a lot) on my laptop making sure I look through all personal and medical details available to me, I can’t help but create an image in my mind of who this donor is, what they may have looked like, where they worked, how much pain they must have been in if their death was intentional, and most gut-wrenching is all the people they left behind. Death is never easy, but when the donors are young, when the deaths are intentional, when the deaths are completely unexpected, it makes me realize how grateful we should be for this life we are living.

That year completely changed how I look at the world. No longer was I going to “sweat the small stuff” whether they were work related or personal. Every donor call reminds me that we sometimes spend so much time, energy, and emotions on things that, in the grand scheme of life, are truly insignificant. I became a happier and more content person. This year taught me that human connections are the most important thing in this world. My family, the friends I consider family, my friends at work, my patients, and all the people I cross paths with that have an impact on my life.

And on the other side of death, after I have pictured this life lost and the family and friends they’ve left behind, I get to tell one of our patients with end-stage heart failure that a heart “has become available” to them and now their life is going to change. I can’t imagine how they feel but I’ve heard all kinds of the emotions on the other end of that phone- tears, shock, anxious smiles that can be heard through the phone, and more tears. My patients tell me it’s a very emotional experience from the time they’re listing. Some have said it feels weird to be “waiting for someone to die” so that they can live. Some have noted guilt. Some of my patients have developed relationships with their donor’s families and I can only imagine how surreal that must feel.

What I do know is that I couldn’t imagine myself doing anything else and that being a Transplant Cardiologist has truly changed my life. I am grateful to the patients who have allowed me to play a small role in their journey and forever grateful to the donors and their families for this incredible gift of life.

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AHA19 Was the Juice I Didn’t Realize I Needed

I left Scientific Sessions 2019 (AHA19) feeling so refreshed, empowered, motivated, and ready to rock it when I got home to Boston. I’ve been told this a lot, but I really felt it this time – that conferences serve more than just to educate and provide a venue for networking; they rejuvenate you. We all exist in our silos within our various institutions, but when we’re at AHA’s scientific conferences, we’re surrounded by people from all over the world, sharing science, friendship, and most important, hope for the future of medicine. AHA19 was particularly diverse in my eyes, I saw more people of color than I have seen at any scientific session, both attending and sharing their science.

When I’m at my institution, I sometimes forget about the world outside of it. You get caught up in the things going on at your institution and the work your research team is doing. You forget that there’s an entire world out there doing brilliant work too and that we’re all in this together – to better medicine and to open doors for the generations we will be passing the baton to. Attending conferences is one of the best ways to exit that bubble.

During the AHA President’s address, when several students from all over Philadelphia were on the stage sharing their stories as part of their ant-vaping campaign – #QuitLying Big Vape – I was assured that the future of medicine is so, so, so bright. The diversity of the students on that stage made me so proud and made me even more determined to work so hard in order to have the ability to create opportunities for the underrepresented women and men who will be our next generation’s healthcare leaders. It’s moments like these that you remember your life’s purpose.

My life’s purpose in medicine is 2-fold. 1) To make sure underserved, underrepresented, and disadvantaged patients receive world-class healthcare. Meaning, if you’re a Google executive or a school environmental services employee- you have the exact same access to healthcare, including organ transplantation. And 2) To make it to the top so that I can create opportunities for historically underrepresented women and men in medicine too. Get to the table and bring all of my friends, and by friends, I mean the women and men missed for opportunities because of the color of their skin, their religious preference or lack thereof, their sexual orientation, the way they wear their hair, their socioeconomic status, their disabilities, or any number of superficial factors that contribute to inequities in medicine.

When you identify your life’s purpose and keep it at the center of every decision you make, I can’t imagine not succeeding. We’ve been given a gift – we are scientists, academics, teachers, advocates, activists, and most important, we are healers. It’s our responsibility to pay that gift forward. Especially to those who don’t have a voice and haven’t made it through those doors yet.

I came home from AHA19 ready to crush more goals and added new ones to my list. AHA19 was literally the juice I didn’t realize I needed. I’m looking forward to AHA20 already.

 

 

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.