Nasrien E. Ibrahim, MD – The Early Career Voice

Protecting Your Peace- 5 Things to Consider Before Saying Yes

March 25, 2021March 23, 2021 Nasrien E. Ibrahim, MD

Early in my career, I jumped at nearly every opportunity that came along. I wanted to impress everyone, and I wanted to prove to them that I deserved to be there. At that point in my career, I felt it was important to seize every chance because, even though I had endured years of school and training, I hadn’t yet figured out exactly what I wanted to do with my life. Taking on every challenge that came along was extremely enlightening. It allowed me to realize what I loved, what I just liked, and what I could barely stand doing. This approach also connected me with many people from so many different specialties. Eventually, it simply became exhausting.

When I took on a task, and I took on a lot of them, I wanted to do everything to the very best of my ability. I would eventually learn that you have to put even more energy into doing things you do not actually like. While the networking and building human connections aspect of my work was incredible, it became very clear that I could not go on doing work I had no interest in.

Now I approach new opportunities a little differently. Instead of eagerly jumping in, I take some time to consider what this might mean for my schedule, my well-being, and my overall goals. Burnout is very real, and I’m already a very busy person. For new chances like this, I evaluate them in terms of my Five Ps: Pay, Promote, Passion, Push, and Purpose.

Pay

What is the financial compensation? Is there a budget attached, and is it reasonable? For many opportunities I research the pay history to find out what my white, male counterparts would make for the same position. When it comes to pay, remember: If you don’t ask for it, you’ll never get it.

Promote

Will this opportunity promote me? Some people are okay being right where they are in their career, but others are still eagerly climbing that ladder. Sometimes opportunities are exactly what you need to take you to the next level, regardless ofpay or how satisfying they might appear.

Push

Will this opportunity push me? Will it challenge me? Will I learn something new, or will it force me out of my comfort zone? Opportunities that push you are often the ones that help you grow.

Passion

Am I passionate about this opportunity? Is it something I love doing so much that I’d do it for free just because it enriches my life? In the past, opportunities like mentoring or health advocacy have been obvious choices simply because of my passion for them.

Purpose

Does this opportunity align with my Purpose? We all have a purpose on this earth and opportunities that present themselves to us are the best when they align with our purpose.

After asking these five questions, if a given opportunity meets one or more of my Five Ps, I say yes! Otherwise, I have to pass. Just setting boundaries isn’t enough, you have to work to enforce those boundaries as well.

Protect your peace, Queens, and Kings.

“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.”

Black Lives Matter in Heart Transplant Too

February 26, 2021February 25, 2021 Nasrien E. Ibrahim, MD

Written by Isaiah A. Peoples MD, MS, Christy N. Taylor MD, MPH, and Nasrien E. Ibrahim MD

The current climate in America has taken the rose-colored lens off society and allowed the world to see the gross disparities faced by Black Americans and other marginalized groups. Initiated by the multiple murders of unarmed Black Americans by police officers to the unprecedented dissimilarities in the death rate of Black and brown people due to COVID-19. This has given pause to the medical community; forcing us to reflect on the ever-increasing health disparities facilitated by institutional racism, which has sadly been perpetuated in medicine including in heart transplants. This is partially reflected by the low number of hearts being transplanted to people of color even when medically indicated. Often the factors of financial and social “requirements” are what lead to many being turned down for transplantation. These are young patients, Black patients, brown patients, patients with young children, patients without financial means, patients without caregivers, patients neglected in the healthcare system; souls that will haunt us forever. Our healthcare system is broken.

Heart transplantation is one of the greatest innovations in medicine to date. Helping patients with end-stage heart failure (HF) and New York Heart Association IV symptoms have a second chance at life, hiking the Grand Canyon, or keeping up with their young children- nothing comes close. However, along the continuum of HF from the prescription of guideline-directed medical therapies (GDMT) including internal cardioverters defibrillators to advanced therapies including heart transplant, Black patients are undertreated.

Transplant selection is a complicated process where ethics, emotions, and implicit biases occasionally muddle the process further. A study by Dr. Khadijah A. Breathett and colleagues examining racial bias in the allocation of advanced HF therapies found Black women were judged more harshly by appearance and adequacy of social support.¹ In transplant selection there are non-modifiable factors as well as modifiable factors to consider, with modifiable factors carrying the greatest risk for bias and inequitable listing and organ allocation decisions. Patients too sick to survive, for example, a patient with multi-organ failure intubated and on extracorporeal membrane oxygenation or patients with active cancer have absolute contraindications- these are non-modifiable. Age cut-offs vary across transplant centers, but in all cases, the same standards must be held for all patients to ensure equity.

Modifiable risk factors are where decisions are more likely to be influenced by implicit biases and where the greyest zones exist. When patients are asked to identify social support systems do we consider a group of church members who agree to care for the patient in a rotating fashion adequate support or does a family member or partner need to be identified? What about patients with insurance but limited finances to the extent co-payments are unaffordable? Do we expect patients to fundraise or does the transplant institution assist in some costs for a prespecified number of patients each year? Do we expand insurance coverage? What about undocumented patients, patients without insurance, and patients in prison? What about patients with substance use disorders? Are we morally obligated to assist them to ensure future transplant candidacy? Modifiable is where things get murky.

We wanted to examine the percentage of Black patients who received heart transplants in the highest volume transplant centers in the United States relative to the demographics of the cities where these transplant centers reside; we looked at 2019 data for sake of completeness (Table 1). We recognize this is merely a snapshot in the history of transplant programs from a bird’s eye view, that cities may have multiple transplant centers, Black patients may prefer certain centers, and finally, the city demographics are from 7/1/2019 and may differ if we had year’s end demographics. HF is more prevalent and is associated with higher mortality and morbidity in Black individuals than in white individuals² and once it has developed, Black patients have more events and worse health status compared to white patients. As such, the proportion of Black patients transplanted at each center should in theory at the very least match demographics of the city where the transplant center is located, but without granular data, we cannot be certain.

What we are certain of is the need for improving the care Black patients with HF receive. The first and most important is earning trust amongst Black communities and reestablishing the doctor-patient relationship through community engagement. This will allow us to inform Black communities about the transplant process and when a transplant should be considered and what to expect. We must develop GDMT optimization programs in Black communities to reduce morbidity and mortality, identify patients who need device therapies, and identify those who do not improve and require evaluation for transplant earlier since Black patients are sicker when listed and more likely to die waiting with longer wait times.³ Additionally, transplant centers should be tasked to develop outreach programs to Black, Hispanic, minoritized, and marginalized communities and perform a prespecified number of transplants in patients who lack financial means based on transplant center volume. Implicit bias and antiracist training for all team members involved in transplant selection must be required and transplant selection teams must be diversified by concerted efforts in hiring diverse faculty but also improving the diversity of the pipeline. And for modifiable factors, rigorous efforts such as substance treatment programs and involvement of weight loss clinics must be attempted consistently with our moral obligation to assist patients in becoming eligible for transplant.

Heart transplant is one of the most incredible things in medicine, we must ensure it is accessible to all by dismantling the oppressive systems in place that have made access to organs inequitable. Black Lives Matter in Heart Transplant Too.

References

Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Yee RH, Knapp SM, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E and Sweitzer NK. Association of Gender and Race With Allocation of Advanced Heart Failure Therapies. JAMA Network Open. 2020;3:e2011044-e2011044.
Sharma A, Colvin-Adams M and Yancy CW. Heart failure in African Americans: Disparities can be overcome. Cleveland Clinic Journal of Medicine. 2014;81:301-311.
Lala A, Ferket BS, Rowland J, Pagani FD, Gelijns AC, Moskowitz AJ, Horowitz CR, Pinney SP, Bagiella E and Mancini DM. Abstract 17340: Disparities in Wait Times for Heart Transplant by Racial and Ethnic Minorities. Circulation. 2018;138:A17340-A17340.
United States Census Bureau https://www.census.gov/quickfacts/fact/table/US/PST045219 accessed 12/20/2020.
United Network for Organ Sharing https://optn.transplant.hrsa.gov/data/view-data-reports/center-data/ accessed 12/20/2020.

10 Questions with 2 Legends

February 10, 2021February 9, 2021 Nasrien E. Ibrahim, MD

Stories That Ignite Movements

I had the honor of interviewing two legends who I admire very much. Dr. Cleve Francis, the first Black cardiologist at the Inova Health System, a Country Music Singer signed by Capitol Records and featured in the African American Museum of history (!!), and an entire movement in and of himself and Dr. , the Coach K of cardiology, a man with an unmatched vision, a true ally, and a queen and kingmaker as many of his mentees call him. I wanted to know how hearing Dr. Fancis’s story of challenges and triumph impacted the way Dr. O’Connor leads Inova Heart and Vascular and the Journal of the American College of Cardiology: Heart Failure with a focus on diversity, equity, and inclusion.

There is so much power in sharing stories and listening to understand.

Francis, I read the editorial Dr. O’Oconnor wrote about you (will link JACC HF editorial) and I knew you were a legend, but when I met you over Zoom, your magic was palpable. How has your journey from Jennings, Louisiana to Country Music to being the first Black cardiologist in the Inova Health System changed how you live life?

Dr. Francis: My journey is an act of defiance in a system of racial suppression and stereotypical fulfillment. This was and still is an amazing journey through time. I feel like someone from the past living in the present and able to influence the future. I was a witness to some of the horrors and hopelessness of racism and segregation. Learned from the love and strength of my mother’s challenge to me to not to be overcome by sadness or anger but to envision a better future. The journey from Jennings to Northern Virginia and Inova was a mixture of hard work, faith, luck, hope, and help from complete strangers and mentors who helped guide me along the way. It was a journey of focus and taking advantage of every possibility using the talents I was born with.

I read about the gut-wrenching stories of your college roommate not realizing you were Black before your arrival to the college dorms and packing up his stuff when he realized you were Black and you being profiled and security called on you at your own hospital. How have moments like that fueled your advocacy efforts?

Dr. Francis: Those episodes taught me that this was someone else’s problem. I felt sorry for my medical school roommate that was embarrassed by his family. I did later speak to him and he said that they had threatened to take him out of the school if he remained my roommate. I had seen enough of this kind of thing to not be bothered for one second. I was the only medical student with a private room- a good thing. The incident at the hospital reminded me what it is like to be in a white culture. You will always be Black and would not be given the benefit of a doubt. It was never assumed that I just might be a physician. The lesson here is to not let one negative incident alter one’s focus.

How has the landscape of cardiology changed since you first became a cardiologist? Or has it really?

Dr. Francis: Today cardiology has changed and there are many more Black professionals. In my earlier journey, racism was very explicit. There were signs saying, “whites only”. Today there are no explicit warning signs, but structural racism, institutional racism, and implicit bias continue to devastate the Black community. Other minoritized people have simply used laws passed as the result of Black protest and struggle to advance themselves while Black communities have been stranded.

O’Connor, what was your initial impression when you first heard Dr. Francis’s story?

Dr O’Connor: I grew up in an area of the DC suburbs that was and is very culturally diverse. I was aware of racism on some level, but I hadn’t given much thought to how the experiences of others in high school, college, and medical training might be different than mine.

I was not at all prepared for what I learned from Dr. Francis. I was tremendously moved by hearing the challenges and barriers he had to overcome and inspired by his resilience and determination. I was certain that others were similarly unaware of the pervasiveness of racism and the bias in the medical and healthcare profession, and I was even more certain that I wanted to do all I could to turn this situation around.

O’Connor, how has hearing Dr. Francis’s remarkable journey, with its challenges, wins, lessons, and record-shattering changed how you lead your institution and journal with regards to diversity, equity, and inclusion?

Dr. O’Connor: My conversations with Dr. Francis helped me to view processes, systems, and individual encounters in the workforce, in running the journal, and in the care of patients through a different lens. I became increasingly aware of racism and bias, however unintentional, that exists in our healthcare system and the medical profession at large. It was clear that so much more could be done to promote inclusion and I was determined to develop and implement a plan of action.

An important first step was to schedule a virtual Town Hall so that healthcare workers could hear Dr. Francis’s story firsthand. His sincerity and optimism in the face of challenges and indignities was so inspiring to me and I felt certain it would have the same effect on others.

I quickly put an Anti-Racism/Diversity/Inclusion Task Force in place, with Dr. Francis and Dr. Wayne Batchelor as Co-Chairs, and charged them to address: (1) education, awareness, and training; (2) diversity in talent recruitment; (3) community relations, and (4) disparities in cardiovascular care.

Similarly, I have resolved to take concrete steps to encourage diversity and inclusiveness in the review process for manuscripts and in heart failure research in general. As researchers and an editorial team, we must be more attentive to differences in the implications of research findings for the various subsets of the broad range of patients we serve and demand inclusiveness in research. I’m counting on your continued guidance in this regard.

The murder of George Floyd on Memorial Day 5/25/2020, in the middle of a pandemic that disproportionally disseminated Black and brown communities ignited the medical community to look internally and develop initiatives to dismantle oppressive systems. Drs. Francis and O’Connor, what changes would you like to see in medicine and in cardiology specifically from a patient and clinician perspective?

Dr. Francis: In the face of the complexity of our discipline as cardiologists, we can build a tremendous level of trust between us and our patients. Our relationships extend over the years in many cases. We convince ordinary people with varying levels of “education” to undertake some of the most complex and dangerous procedures and treatments. In this pandemic, we should become one of the “Trusted Messengers “in advocating vaccination. We need to become more aware and involved in the social determinants of health for each of our patients and know that many factors outside of our medical offices and hospitals will ultimately determine the fate of our patients.

Dr. O’Connor: I would hope to see a greater outreach regarding risk factors and the importance of prevention. We need to take a more active role in screening for cardiovascular disease and assuring that appropriate and timely treatment is made available. More aggressive efforts to deliver care to underserved areas is critical, as is doing all we can to strengthen the bond between patient and physician. But even more importantly, we have to increase efforts to enroll representative cohorts in clinical trials to further the development of customized and individualized treatment strategies.

Francis, what advice do you have for my generation and the generation coming after mine? How do we get people in power to listen? How do we make lasting change?

Dr. Francis: From medical schools to advanced heart failure, we need to start treating people with diseases rather than treating diseases associated with people. When we continue to treat diseases, we assume no personal connection with the patient, and we have absolutely nothing in common with them. Things such as implicit bias would have little impact if we individualized each patient in our care. If we put it upon each of us to be personally aware of personal as well as structural and institutional matters. I disagree with forced bias training, but it should be available to all of those who seek it. It is good to advance the ideas of diversity and inclusion, but these are no substitute for equity. Institutions must ask themselves how many Black people do we have on-staff or in our administration? Unless this number reflects the general population, there is no equity and only inclusion and diversity. The correction of these disparities must be “intentional”.

O’Connor, what advice do you have for leaders in cardiology? Why should they be bold? Should they be concerned about backlash for speaking up against injustice? How can we change the face of who leads cardiology?

Dr. O’Connor: Most of us entered the medical profession to alleviate suffering and save lives. However unintentional, racism and bias in the system at large and its impact on patient care are not consistent with these goals. Bold action is needed to create a more equitable system and bring about change in research and day to day practice.

Francis, what is your biggest hope for 2021?

Dr. Francis: My greatest hope for 2021 is that we continue the efforts as Dr. Christopher O’Connor has done by appointing a task force of peers to work some of these issues out. At Inova for example, the Inova Heart and Vascular Institute Antiracism/Equality Taskforce that I co-chair with Dr. Wayne Batchelor has taken on issues of recruitment, healthcare disparities, community outreach, mentoring, training of cardiology fellows, and onboarding of new physicians. These efforts are already having an impact on our institution. These efforts are supported by the top administration in Inova.

O’Connor, what is your biggest hope for 2021?

Dr. O’Connor: COVID-19 has made the inequalities in our healthcare system even more apparent. While my biggest hope for 2021 is an end to the pandemic, I am equally hopeful that we will use the lessons from this pandemic to continue to work toward a healthcare system where disparities in care are a thing of the past.

This is how we change the things that are not right in our world, by listening to understand, by having empathy, by showing courage, by being resilient in our resolve but also working to dismantle systems that have oppressed Black people in America, by identifying true allies willing to use their privilege, power, and platforms to drive change, and by having hope. Thank you, a million times, over, Drs. Francis and O’Connor for sharing your stories and your advice, leaders like you give me hope for our future.

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

January 15, 2021January 14, 2021 Nasrien E. Ibrahim, MD

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]

Gratitude on Our Worst Days

December 9, 2020December 9, 2020 Nasrien E. Ibrahim, MD

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

Advancing Cardiovascular Health for All

November 13, 2020November 13, 2020 Nasrien E. Ibrahim, MD

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.

Bring Your Whole Self to Work

August 14, 2020August 14, 2020 Nasrien E. Ibrahim, MD

“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.

Black Lives Matter- Doctors, We Need to Talk

June 11, 2020June 11, 2020 Nasrien E. Ibrahim, MD

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.

Wellness Amid a Pandemic

May 14, 2020May 14, 2020 Nasrien E. Ibrahim, MD

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.

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

April 14, 2020April 17, 2020 Nasrien E. Ibrahim, MD

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

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.
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.
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.
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.