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Concomitantly Being the Mentee and Mentor

We all need mentors to help guide us through our careers. I am very fortunate to have had and currently have many generous and knowledgeable mentors. I rely greatly on them to provide feedback and advice on how to navigate the many challenges of being a physician-scientist.

As early-career trainees, we are often concomitantly seeking mentorship and are being a mentor to younger trainees. Throughout my clinical and research training, I have had the opportunity to mentor many enthusiastic and talented undergraduate/graduate/medical students and residents. Since I have been a mentee for much longer than a mentor, I feel comfortable finding advisors who can assist with my career development. However, I feel relatively inexperienced as a mentor. I find mentoring challenging in that it requires adapting to the needs and personality of the trainee. I am constantly refining my coaching style and trying to emulate many of the outstanding mentors that I have.

For this blog, I have compiled a list of some tips that I have learned or received from others on how to be mentor-able and how to be an effective mentor.

Tips on How to Be a Good Mentee:

  1. Find the “right” mentors for you. Various factors play a role in making a match. Finding advisors is one of the most important steps needed to advance your career. It is not necessary to always find the most senior faculty members to be your mentor. There are many benefits of having a junior faculty member as a mentor, which I have discussed previously.
  2. Be accountable.
  3. Be receptive to feedback.
  4. Be respectful and appreciative. Respect your mentor’s time.
  5. Be diligent. You have to do the work. Mentorship is a two-way street so think about the value that you bring to the relationship (especially relevant to trainees who are completing research projects with their mentors).
  6. Let your mentor know what your short and long-term goals are and what you seek to gain from the mentorship.
  7. Keep in touch with your mentors. Update them on your achievements even after you have completed your training and/or moved to another institution.

Tips on How to Be a Good Mentor:

  1. Do not do all the work for the mentee.
  2. Give a new potential mentee a task/assignment to complete as a trial run to determine whether the mentee is committed and dependable. This may prevent loss of effort trying to mentor a trainee who may not be motivated or interested in your field.
  3. Be knowledgeable.
  4. Be a good listener and communicator.
  5. Keep your promises.
  6. Provide constructive, honest feedback.
  7. Encourage diversity of perspectives.
  8. Be available or willing to make time to meet with the trainee.
  9. Be open to learning from your mentees.
  10. Know your role and what your mentees’ expectations are for the relationship.
  11. Help provide opportunities for trainees (e.g. encourage attending conferences, submitting abstracts/papers, applying for awards, etc.) and help your mentees network with others.
  12. Emulate the excellent mentors that you know.

These lists are not comprehensive. I would love to hear about your thoughts, experiences, and advice on mentorship. I am especially interested to learn about the experiences of early-career investigators who have started new labs.

Thanks for reading and hope you have a safe, healthy, and happy new year!

“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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The Sweet Spot in Treatment of Heart Failure With Reduced Ejection Fraction: SGLT2 Inhibitors

I am pleased to have the opportunity to summarize an important recent paper on the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors by Drs. Muthiah Vaduganathan, Gregg Fonarow, and colleagues in JAMA Cardiology,1 that was published simultaneously with AHA20.

Background:

SGLT2 inhibitors are a class of medications that were initially developed for management of diabetes but were serendipitously found to be effective in treating individuals with heart failure. In May 2020, dapagliflozin became the first SGLT2 inhibitor approved by the US Food and Drug Administration (FDA) for use in patients with heart failure with reduced ejection fraction (HFrEF) after the pivotal Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial, which showed that dapagliflozin reduced heart failure events and mortality.2 In the EMPEROR-Reduced (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction) trial, use of another SGLT2 inhibitor, empagliflozin, was also found to reduce risk of cardiovascular death and heart failure hospitalizations.3

Major Question Addressed in the Paper: What proportion of contemporary patients with HFrEF in the US are potentially eligible for initiation of dapagliflozin based on the FDA label?

Approach: The investigators studied patients with HFrEF (EF≤40%) who were in the AHA Get With The Guidelines-Heart Failure (GWTG-HF) registry. They assessed patients admitted between January 2014 to September 2019 at 529 sites (started with 586,580 patients). Patients were excluded if they had any of the following based on the FDA label for dapagliflozin: estimated glomerular filtration rate [eGFR]<30 mL/min/1.73 m2 at discharge, dialysis (either history of chronic dialysis or required dialysis during hospitalization), and/or type 1 diabetes. After excluding patients who met the aforementioned criteria and those who had missing discharge eGFR or vital signs, the primary study cohort consisted of 154,714 patients at 406 sites.

Major Results:

  • Of the 154,714 patients studied in the GWTG-HF registry, 125,497 (81.1%) were candidates for initiation of dapagliflozin based on the FDA label.
  • When only looking at sites with ≥10 hospitalizations (355 sites that enrolled 154,522 patients), the median proportion of dapagliflozin candidates was still 81.1% (25th-75th percentiles 77.8-84.6%).
  • A higher proportion of patients without type 2 diabetes than with type 2 diabetes were candidates for dapagliflozin (85.5% vs. 75.6%).
  • The most frequent reason for not meeting the FDA label was eGFR<30 mL/min/1.73 m2, which was met more frequently in patients with a history of or new diagnosis of diabetes than those without diabetes (23.9% vs. 14.3%).
  • There was lower use of evidence-based heart failure therapies in the GWTG-HF patients compared to patients in the DAPA-HF trial.

Histogram from Vaduganathan et al. evaluating the proportion of patients meeting the dapagliflozin FDA label criteria from hospitals with at least 10 eligible HFrEF hospitalizations.

Major Study Limitations: Since the GWTG-HF data are de-identified, only unique hospitalization episodes were presented so some patients may be represented more than once in this study. Glycated hemoglobin levels were not measured in a protocolized way, thus type 2 diabetes could be underdiagnosed in this study. Data regarding post-discharge labs and the use of therapies were not available.

Key Take Home Message: This study using a large AHA registry (GWTG-HF) strikingly found that 4 out of 5 adults with HFrEF (regardless of whether the patient has type 2 diabetes) may be eligible for initiation of dapagliflozin, supporting the broad applicability of this therapy in US clinical practice.

For further learning, there are several great OnDemand sessions from AHA20 on SGLT2 inhibitors.

AHA20 OnDemand Sessions on SGLT-2 inhibitors:

  • New Glucose-Lowering Agents with CV Benefits: Working… But How?
  • SGLT2i for Non-Diabetic Indications: Updates from Mega-Trials and Mechanistic Insights
  • Novel Anti-Diabetic Agents: A Tidal Wave of Change in the Cardiovascular Care of Patients with CKD
  • The Heart, the Kidney, and SGLT2 Inhibition: For Clinical Trials to Patient Care

Potential Future Research Directions:

  • Determine the mechanisms leading to the efficacy of SGLT2 inhibitors in HFrEF.
  • Investigate the renal effects of SGLT2 inhibitors and whether SGLT2 inhibitors can be safely used in patients with more severe chronic kidney disease.
    • DAPA-CKD4 (Dapagliflozin and Prevention of Adverse Outcomes in Chronic Kidney Disease), which included patients with eGFR as low as 25 mL/min/1.73 m2, showed that dapagliflozin reduced risk of sustained eGFR decline of at least 50%, end-stage kidney disease, or death from renal or cardiovascular causes regardless of the presence or absence of type 2 diabetes.
    • EMPEROR-Reduced included HFrEF patients with eGFR as low as 20 mL/min/1.73 m2.
  • Evaluate whether SGLT2 inhibitors are beneficial in patients with heart failure with preserved ejection fraction (HFpEF). Current ongoing/future clinical trials with HFpEF patients include DELIVER (NCT03619213), EMPEROR-Preserved (NCT03057951), EMPA-HEART 2 (NCT04461041), PRESERVED-HF (NCT03030235), and EMBRACE-HF (NCT03030222).
  • Assess the effects of simultaneous use of SGLT2 inhibitors and another class of diabetic medications that have shown beneficial cardiovascular disease (CVD) effects, glucagon-like peptide-1 receptor agonists (GLP-1RA) and determine which of these two classes of medications should be prioritized in drug-naïve patients with type 2 diabetes and atherosclerotic cardiovascular disease (ASCVD).

Potential mechanisms underlying the beneficial effects of SGLT2 inhibitors. Figure from Dr. Subodh Verma’s talk entitled “SGLT2 inhibitors: Why do they work” in the “New Glucose-Lowering Agents with CV Benefits: Working… But How?” session at AHA20.

 

References

  1. Vaduganathan M, Greene SJ, Zhang S, Grau-Sepulveda M, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC. Applicability of us food and drug administration labeling for dapagliflozin to patients with heart failure with reduced ejection fraction in us clinical practice: The get with the guidelines-heart failure (gwtg-hf) registry. JAMA Cardiol. 2020
  2. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Anand IS, Bělohlávek J, Böhm M, Chiang CE, Chopra VK, de Boer RA, Desai AS, Diez M, Drozdz J, Dukát A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Merkely B, Nicolau JC, O’Meara E, Petrie MC, Vinh PN, Schou M, Tereshchenko S, Verma S, Held C, DeMets DL, Docherty KF, Jhund PS, Bengtsson O, Sjöstrand M, Langkilde AM, Investigators D-HTCa. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med. 2019;381:1995-2008
  3. Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, Carson P, Januzzi J, Verma S, Tsutsui H, Brueckmann M, Jamal W, Kimura K, Schnee J, Zeller C, Cotton D, Bocchi E, Böhm M, Choi DJ, Chopra V, Chuquiure E, Giannetti N, Janssens S, Zhang J, Gonzalez Juanatey JR, Kaul S, Brunner-La Rocca HP, Merkely B, Nicholls SJ, Perrone S, Pina I, Ponikowski P, Sattar N, Senni M, Seronde MF, Spinar J, Squire I, Taddei S, Wanner C, Zannad F, Investigators E-RT. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383:1413-1424
  4. Heerspink HJL, Stefánsson BV, Correa-Rotter R, Chertow GM, Greene T, Hou FF, Mann JFE, McMurray JJV, Lindberg M, Rossing P, Sjöström CD, Toto RD, Langkilde AM, Wheeler DC, Investigators D-CTCa. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383:1436-1446

 

“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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AHA20 Scientific Sessions From the Perspective of a New Attendee

I was overwhelmed when I attended Scientific Sessions for the first time last year. There were thousands of participants and dozens of sessions occurring simultaneously in a very large convention center. It was challenging to try to attend all of the sessions that I was interested in. I was frequently disoriented in the large convention center. Coordinating central meeting spots with colleagues was difficult. Although AHA20 is virtual this year, seeing the vast number of sessions available covering many important topics can still be overwhelming, especially to a first-time attendee. As I mentioned in my last blog, trying to prioritize live events over OnDemand events may help keep you engaged during the conference.

For this blog, I wanted to feature the perspective of Javier E. Sierra-Pagan, a first-time attendee of Scientific Sessions. Javier is an F30-funded medical scientist (MD/PhD) trainee (who is in his 5th year in the program, 3rd year as a PhD student) at the University of Minnesota Medical School. He is currently studying mechanisms of cardiovascular development and regeneration. He is interested in Cardiology. I am fortunate to work at the same research institute as Javier and have his lab bench next to mine!

Question: What are you looking forward to at AHA Scientific Sessions this year? Any specific events that you are interested in?

Javier: I’m really looking forward to listening to good talks regarding cardiovascular development and disease. Given the current pandemic, I am particularly interested in any talks regarding SARS-CoV-2 and its implications on cardiovascular disease. As a young trainee, I’m interested in attending some of the networking events to get to know more individuals in my field of research. 

Question: How has your experience with AHA Scientific Sessions been so far?

Javier: It has been great so far. I felt a little overwhelmed at the beginning with how big this conference is, but after setting my agenda and identifying good talks to attend to, I felt more comfortable and very excited about Scientific Sessions.

Question: How are you preparing for AHA Scientific Sessions?

Javier: I’m approaching Scientific Sessions with an open mind. It is my first time attending it and I’m just trying to learn as much as I can from both basic science, as well as clinical medicine. The benefit of having such a big conference is that I can learn a little bit from so many different areas in the field of cardiology. 

Question: How has COVID-19 affected your research?

Javier: The pandemic has put a lot of stress on everybody for sure. At the beginning of the pandemic, I was fortunate to be primarily focused on writing and submitting a manuscript, which allowed me to work from home. Now we are in a different situation entering November. I am working more hours in the laboratory and trying to stay safe while also maintaining my productivity. I haven’t had any significant setbacks with regards to my thesis, but I did want to attend some conferences in the Spring that were ultimately canceled because of COVID-19.

Question: Anything else you want to add?

Javier: I look forward to attending more AHA meetings in the future (hopefully in person) and interacting with colleagues from the field. I definitely miss the scientific conversations that happen in the hallways or in the elevators when you are trying to get to a lecture room. 

Thank you, Javier, for discussing your experience with other trainees!

Remember that you can watch all of the OnDemand AHA20 content until January 4, 2021, which can help relieve the stress of cramming in as many sessions as possible into 5 days. If you are an early career investigator or trainee and would like to be featured in one of my upcoming monthly blogs, please let me know (you can message me on Twitter or email me at szprisco@umn.edu)!

 

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

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How to Stay Engaged During Virtual AHA Scientific Sessions

Attending AHA Scientific Sessions is one of the highlights of my year. I was looking forward to visiting Dallas and seeing old and new friends, along with presenting the research projects that I am excited about. Of course, it is difficult to replicate the in-person networking and interactions with friends, colleagues, and collaborators with virtual conferences, but there are many ways to try to improve your experience during AHA20. Dr. Elizabeth Knight (@TheKnightNurse) wrote a great blog about tips for attending virtual meetings.

 

With a conference the size of AHA20, it is important to find a way to stay engaged in order to maximize the benefits that you can receive from attending the meeting. Below are some suggestions to help you try to stay engaged throughout AHA20:

  • Follow the #AHA20 hashtag, @AHAMeetings, @AHAScience, @AHAResearch, the AHA20 Virtual CoPilots, and the AHA Social Media Ambassadors (you can find this list at @AHAMeetings and with the hashtag #AHAEarlyCareerBlogger) on Twitter.
  • Engage and discuss your experience at AHA20 with others. Tweet about the sessions that you are attending and the highlights of the findings. Tag your colleagues, mentors, #AHA20, @AHAMeetings, and some of the Social Media Ambassadors. Also, find some other people (e.g., colleagues in your lab or department) to have more in-depth talks about some of the exciting research you saw.
  • There is a plethora of great research and science presented during many on-demand sessions. Make a list of all of the programs you want to watch. You can use the AHA Scientific Sessions Online Program Planner (https://professional.heart.org/en/meetings/scientific-sessions/programming) or AHA Conferences mobile app (that can be downloaded through the Apple App Store or Google Play) to mark the sessions that you are interested in. Try to watch some of these sessions over Scientific Sessions and set aside some time the rest of the year to watch the other sessions that you are interested in. You can access the on-demand content until January 4, 2021.
  • Try to attend all of the live sessions that you are interested in, especially sessions in the FIT/Early Career Lounge and the Interactive Zoom Events. Here are some (but not a comprehensive list of) potential events that may be valuable for early career trainees:

On Friday 11/13:

  • Women and Leadership: Going from Good to Great (WPD.03) – Fri 11/13 from 10:30-11:30am CST
  • Racism in Medicine: What Medical Centers & Training Programs Can Do To Be Antiracist (FIT.01) – Fri 11/13 from 12-1pm CST
  • Prioritizing Self and Wellness During Cardiovascular Training (FIT.05) – Fri 11/13 from 5-5:50pm CST
  • CVSN (Council on Cardiovascular and Stroke Nursing) Research Mentoring Committee Mingle with the Mentors (WPD.05) – Fri 11/13 from 5-6pm CST
  • Imposter Syndrome – Our Stories (WPD.06) – Fri 11/13 from 5-6pm CST
  • Young Hearts Early Career Mentoring Roundtable Discussions (ECE.02) – Fri 11/13 from 6-7pm CST
  • Matching into Cardiology Fellowship: The Inside Scoop From Program Directors & AHA FITs (FIT.06) – Fri 11/13 from 6-7pm CST
  • Women in Cardiology Meet Up (WPD.07) – Fri 11/13 from 6-7pm CST

On Saturday 11/14:

  • Cardiovascular Imaging Early Career Roundtable (IM.EC.678) – Sat 11/14 from 5-6pm CST
  • My First Grant Funding Breakthrough – Tips and Tricks for Early Career Researchers (ECE.03) – Sat 11/14 from 5-5:50pm CST
  • Fireside Chat: What You Need to Know for a Career in Sports Cardiology (FIT.07) – Sat 11/14 from 5-5:50pm CST
  • Happy Hour with Distinguished Scientists (HQ.07) – Sat 11/14 from 5-6pm CST
  • ReSS Young Investigator Networking Event (ReSS.07)– Sat 11/14 from 5-7pm CST
  • Who’s the perfect mentee? (ECE.04) – Sat 11/14, 6-7pm CST
  • Fireside Chat: What You Need to Know for a Career in Heart Failure (FIT.08) – Sat 11/14 from 6-7pm CST

On Sunday 11/15:

  • Speed Mentoring: Meet the Experts in Pulmonary Vascular Disease (PH.EC.694) – Sun 11/15 from 10:30-11:30am CST
  • How I Did This: Lessons Learned in Developing a Career in Cardiometabolic Health (CM.EC.668) – Sun 11/15 from 12-1pm CST
  • Tips to Residency Interview Webinar (ECE.05) – Sun 11/15 from 5-5:50pm CST
  • PVD Council Virtual Networking Session (ECE.06) – Sun 11/15 from 6-7pm CST
  • Fireside Chat: What You Need to Know for a Career in Interventional (FIT.10) – Sun 11/15 from 6-7pm CST

On Monday 11/16:

  • Surviving and Thriving in the Early Career Lessons Learned? – Live Zoom Discussion (ECE.07) – Mon 11/16 from 5-5:50pm CST
  • Fireside Chat: What You Need to Know for a Career in Imaging (FIT.11) – Mon 11/16 from 5-5:50pm CST
  • Happy Hour with Distinguished Scientists (HQ.09) – Mon 11/16 from 5-6pm CST
  • Navigating Academic Paths for Women and Minorities Roundtable – ATVB Women’s Leadership Committee (WPD.09) – Mon 11/16 from 5-6pm CST
  • BCVS Early Career Social Networking (ECE.08) – Mon 11/16 from 6-7pm CST
  • Fireside Chat: What You Need to Know for a Career in Critical Care (FIT.12) – Mon 11/16 from 6-7pm CST

On Tuesday 11/17:

  • Developing a Career in Cardiovascular Omics (ECE.09) – Tue 11/17 from 5-5:50pm CST
  • Fireside Chat: What You Need to Know for a Career in Pediatric Cardiology (FIT.13) – Tue 11/17 from 5-5:50pm CST
  • Professional & Personal Self-Care (WPD.11) – Tue 11/17 from 5:30-6:30pm CST
  • ATVB Council Networking Session (ECE.10) – Tue 11/17 from 6-7pm CST
  • Fireside Chat: What You Need to Know for a Career in Preventive Cardiology(FIT.14) – Tue 11/17 from 6-7pm CST

Looking forward to connecting with you during AHA20!

 

“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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My Experience at BCVS20

Thank you to the organizers for putting together a vibrant and informative fully virtual AHA Basic Cardiovascular Sciences Scientific Sessions 2020 (BCVS20) conference this year!

While I have attended many meetings and classes virtually this year, BCVS20 was the first major scientific conference that I attended virtually and I did not know what to expect. I was pleasantly surprised by the many benefits of participating in the meeting virtually but there were many things that I missed about attending meetings in person.

I enjoyed the convenience of being able to work in specific sessions into my usual work week of attending clinic, doing lab experiments, and attending classes and into my personal life. Additionally, I liked being able to watch some sessions in the comfort of my home, sitting next to my dog. Similar to fellow AHA blogger, Dr. Mo Al-Khalaf, I also appreciated being able to easily jump between many live sessions without having to run across a large convention center. Moreover, I felt that it was sometimes easier to pay attention to certain talks without the distraction of being in a crowded area with many simultaneous presentations. I was impressed by the quality of the presenters’ talks and efforts by the participants to stimulate lively discussions.

I did not take time off to attend the meeting and I felt that the week of BCVS20 was extremely busy for me. Although I appreciate the convenience of having a fully virtual meeting, I miss being able to take a short reprieve from some of my usual responsibilities to give my undivided attention to specific sessions. Furthermore, due to my other obligations, I was unable to attend some of the very valuable, live early career sessions. However, the ability to rewatch the BCVS20 sessions (which are available for 90 days after the meeting) will allow me to catch up on many of the sessions that I missed!

While there are many benefits to attending in-person meetings, not least of which is being able to see your friends and colleagues in person, having a virtual meeting allows people throughout the world to conveniently participate in and attend a meeting. I hope that conferences in the future will continue to be a hybrid in-person and virtual format to accommodate everyone’s busy schedules.

For those of you who attended the BCVS20 meeting, don’t forget to provide your feedback on the meeting via the link emailed to you. If you missed registering for the meeting, it is not too late to get access to the recorded sessions. I hope to continue seeing many of you either virtually or in-person during future AHA meetings!

 

“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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Residency and Fellowship Interviews During COVID-19

As early-career physicians started residency and many physicians began fellowship training this month, it’s hard to think that recruitment for next year’s residency and fellowship classes is beginning soon. The COVID-19 pandemic has disrupted many of our usual routines and processes. Similarly, this year’s residency and fellowship interviews are going to be different than previous year’s interviews. The Association of American Medical Colleges (AAMC) has now recommended that all interviews for medical school, residency, and fellowship be conducted virtually this year.

There are many potential benefits of virtual interviews, including but not limited to:

  • Lowering the financial burden of traveling and housing during interviews.
  • Not having to spend time traveling and potentially being able to interview at more programs without physical distance complicating scheduling. For example, one can interview at a West Coast program one day and interview at an East Coast program the same or following day.
  • Missing fewer days of work/school/rotations for interviews.
  • Not having to frequently pack and unpack and worry that you forgot to pack something important.
  • Not having to tour a campus during the winter months (especially in heels) or drive in the snow.
  • Sleeping in your own bed before an interview.

For those of you who will be interviewing virtually for residency and fellowship programs this year, I have gathered some advice from my Cardiology fellowship program director (@rhythmkeys) and program coordinators (@UmnCardsfellow). Of course, also ask your mentors and other colleagues for advice. Remember that this is a new experience for both you and the programs so there may be some road bumps and steep learning curves.

  • Be open-minded. Fight the urge to stay at the same training institution because of unfamiliarity with a new city and/or program.
  • Spend time researching the programs and cities that you are interested in. Many programs (including ours) will have virtual tours/videos of our facilities and city. Take advantage of the publicly available information about a program/city (i.e. Google Maps is a great way to explore a campus/city in the comfort of your own home).
  • Ask more questions about a program and environment than you usually would if you were interviewing in person in order to get a feel for the culture/environment of a program since this may be more difficult to determine when interviewing virtually.
  • Try to consider the interview as “normal” as possible. Be professional. Be prepared. Login into your computer and the virtual meeting early in case you encounter technical difficulties.
  • Do not worry too much about technical difficulties. Virtual interviews are also new for the programs. Most programs will have contingency plans in place if there are technical difficulties.
  • Here is some great advice on how to master the art of virtual interviews from fellow AHA early career blogger, Dr. Barinder “Ricky” Hansra (@RickyHansra).
  • Reach out to current or past trainees at a specific program. Most of us are happy to talk about our experience in the program. If any of you are interested in the Internal Medicine or Cardiology fellowship program at the University of Minnesota, please feel free to contact me! Interviewees at our program will be able to still meet with current fellows during their interview days and I assume that this will be a part of interviews at most programs.

Depending on the experience of the programs and applicants this year, perhaps virtual interviewing for medical school, residency, and fellowships will continue in the future. Interviewing virtually may be more convenient and cost-effective. Best of luck to all of you interviewing for medical school, residency, fellowships, or jobs this year and stay safe!

“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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Taking a public stand for social justice

My heart is broken after the recent events and the loss of George Floyd’s life in Minneapolis, my beloved home over the last couple of years, along with many other recent tragedies that highlight the racial injustices in the United States. Like many, I hope that these events will lead to fundamental changes and improvements in our society.

I admire the institutions, organizations, companies, leaders, and my colleagues who are making public statements in support of efforts to lead to social justice. I think that it is important to acknowledge that as a society, we are now expecting many organizations, institutions, companies, and leaders (political, academic, organizational, etc.) to take a public stand against racism, a topic that many organizations and businesses previously shied away from making public comments on. This is a positive shift in our culture. One of the initial ways to lead to long-lasting change is to acknowledge that there is a problem. My home institution, the University of Minnesota was quick to make a public statement condemning racism and social injustices after George Floyd’s death. As researchers and healthcare providers, we know that there are health inequities, magnified by the COVID-19 pandemic which my fellow AHA blogger, Dr. Anika Hines (@DrAnikaLHines) recently discussed.

Furthermore, as healthcare providers and researchers, we are often leaders in our communities and are able to provide a voice to those who are disadvantaged. Another fellow blogger, Dr. Elizabeth Knight (@TheKnightNurse) recently wrote about the importance of advocacy by healthcare providers. Racism and social inequalities are public health issues. Many organizations that we are a part of have made public statements for social justice. The American Heart Association and American College of Cardiology have made a joint statement with the Association of Black Cardiologists against racism and social inequities. Similarly, the American Medical Association and Association of American Medical Colleges have also made public statements condemning racism and advocating for change. Additionally, many healthcare providers across the country have kneeled and protested for #WhiteCoatsforBlackLives over the last couple of days. When the organizations and institutions that we are a part of take a public stand against racism and social injustices, we then feel supported in our efforts.

I encourage trainees to pay attention to which organizations and institutions are making statements against racism and social injustices and are committed to making changes.

Be an active ally. Listen and learn. Be kind. Be safe.

“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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The Importance of Maintaining the Public’s Trust in Science and Medicine

Often, and especially during the COVID-19 pandemic, there is a plethora of misinformation that is spread. We have all probably seen at least one scientific publication, news article, social media post, or YouTube video that is spreading information that is not accurate. Every day, I am bombarded by conspiracy theories or unfounded scientific claims while skimming through social media. During a time when information is rapidly disseminated through the internet, it is often difficult to extinguish a lie.

Sometimes, misinformation is inadvertently spread by well-meaning individuals who have not had the time or energy to confirm or critically appraise the information shared. “Liking”, “retweeting”, and/or sharing a post from a colleague/friend/relative is facile. We have all probably “retweeted” or shared certain articles and posts that we did not completely critically assess before sharing. Sometimes dissecting truth from fallacy is difficult, especially when information is disseminated widely. Our current technological advances with the internet and social media magnify opinions, good and bad. Occasionally, one may think, if multiple people I know and/or respect are sharing certain information and the number of posts about the false information outnumber those on the truth, then the misinformation must be true.

Occasionally, misinformation about science or medicine is shared by members of our own scientific and/or medical communities, which can sometimes be more damaging to our profession. For example, more assumed credibility may be given to a scientist or healthcare provider, even if his/her expertise is not in the area that is commented on. Conspiracy theorists may continually reference these “experts” to support their arguments. Sometimes, refuting incorrect information requires massive efforts but may never eliminate the long-lasting negative effects of the misinformation. For example, Andrew Wakefield’s infamous, now retracted scientific article that was published in The Lancet and falsely claimed an association between the measles, mumps, and rubella vaccine with autism is unfortunately still being referenced to support arguments against vaccinations even though multiple studies have overwhelmingly refuted the claims made in the retracted article.

With less malicious intent, some misinformation may be spread by the media or others in reference to research articles. Certain conclusions of research papers are sometimes not justified by the data presented due to inadequate sample size, biases, issues with the experimental design, etc. During a pandemic, since rapid dissemination of scientific and medical information is needed, there is frequently a tradeoff with the scientific rigor and reproducibility of the results. Since access to papers in preprint servers are available to the public, the media and public figures may tout certain research findings as truth when they have not been vetted by the peer-review process. A fellow AHA early career blogger, Dr. Allison Webel (@allisonwebelPhD), recently wrote an outstanding blog discussing the importance of the peer-review process (https://earlycareervoice.professional.heart.org/in-defense-of-peer-review/). Of note, even peer-reviewed articles are not free from research misconduct and incorrect conclusions. There are many articles retracted from high impact journals. Before the development of the internet and social media, critiques and feedback of research findings were typically only discussed at scientific meetings or at other selective venues (e.g., local conferences/presentations, journals typically not viewed by lay people, etc.). Now, these debates occur in the public arena with beneficial and negative aspects and frequently with nonexperts. These public debates may dilute the truth when unfounded comments are perpetuated.

What should we do about the spread of misinformation? Propaganda and false information are always going to be spread but we should try to mitigate their breadth and potential damage. On an individual level, researchers should thoroughly assess their results and determine whether their data are valid and whether the claims they make in publications are justified by the data before presenting the findings to the public. Limit overreaching conclusions. Scrutiny of results by authors and the research community is essential to the scientific process. Developments and advances in science often occur when findings are reproduced either within a specific lab/group or by other labs/groups and this is especially important to realize during a time when a deluge of single-center, small sample size papers are published about the COVID-19 pandemic. Dr. Elizabeth Knight (@TheKnightNurse), another fellow AHA early career blogger, recently calls to attention the scientific lessons learned from the current pandemic (https://earlycareervoice.professional.heart.org/evidence-whats-good-whats-good-enough-whats-dangerous-lessons-for-now-and-later/).

How do we influence other people’s opinions? Internal changes are often easier to make than changing other people’s opinions. However, we are all likely an influential source of information within our own social circles and networks. We may feel more comfortable directly communicating with people we know to correct misinformation. Altering the opinions of people who we do not personally know is more challenging. At minimum, as researchers and healthcare providers, we should not intentionally try to deceive the public. Flagrant dishonesty from researchers and/or healthcare providers may erode the public’s trust in our profession, possibly to a greater extent than a nonexpert’s comments. We all make mistakes and honest misunderstandings and misinterpretations can affect all of us. However, deliberately lying and abusing the influence of one’s position as a scientist or healthcare professional is more offensive. I do not know how best to address colleagues who blatantly mislead the public. If an individual we personally know is deceiving others, we can directly communicate with him/her about the impact of the misinformation. Depending on the extent of the damage created by an individual in our professional community who is propagating false information, should we review his/her ability to maintain as a member of our profession?

What are your thoughts on how we can preserve the public’s trust in science and medicine?

“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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Thoughts from a Physician Scientist Trainee During the COVID-19/SARS-CoV-2 Pandemic

I had a very difficult time figuring out a blog topic for this month. It has been difficult to think about topics other than COVID-19. Like a lot of you, my usual routine has dramatically changed over the last couple of weeks. Additionally, I find myself having a difficult time concentrating with emotions sometimes fluctuating from fear, anger, grief, and frustration, to hope and pride. Some of my recent days have been occupied by reading a plethora of articles, blogs, or social media posts about COVID-19, being anxious about the next time my husband or I see patients, urging people to practice social distancing and to donate PPE, and contacting family and friends to check on their physical and emotional well-being along with trying to complete some work.

I am currently a Cardiology postdoctoral fellow who has protected time to complete basic science research. I started my postdoctoral research fellowship this academic year and my hope was to immerse myself in basic science research over the next couple of years. I was hoping to have a productive lab experience and find an area that I could ultimately build my future research career. These few years of protected research time are critical to my development as a physician-scientist. From a research perspective, I have recently experienced a multitude of failures and disappointments this year (with some intermittent successes): failed experiments that have required an extensive amount of troubleshooting, rejected papers, triaged grant applications, etc. I know that I am not alone in experiencing the frequent failures that one encounters in research. My usual strategy is to be persistent, keep busy, and continue to move all research projects forward in the hopes that at least one of the projects will be fruitful which is currently difficult to do. A few weeks ago, we were informed that all non-essential experiments should stop and that no new experiments should be started. Fortunately, my lab mentor respected this request and prioritized our health and safety. However, as we reduced our wet lab work to only essential animal experiments that were already started, I could not help but feel grief for the loss of potential research milestones.

The COVID-19 pandemic has further emphasized the societal importance of investing in research endeavors and researchers longtime. There are many articles and commentaries on early career investigators being disheartened by the challenges of an academic research career along with the diminishing pool of physician scientists. The presence of the COVID-19 pandemic has further highlighted the below changes that should be made:

  1. Increased funding for research: The study of mechanisms of disease along with development of therapies requires extensive time and effort. Multiple valiant researchers are currently studying COVID-19/SARS-CoV-2 with the fundamental goal of saving lives. Continuous societal investment in research will hopefully lead to the prevention of pandemics and earlier development of therapies for various diseases in the future.
  2. Increased financial and other support for trainees and early career investigators: Supporting early career investigators through training/career development grants, travel awards, local/national/international workshops, and opportunities to present work at national/international meetings will decrease attrition from academic research careers.
  3. Consideration of changes to the peer review process: The COVID-19 pandemic has emphasized the importance of rapid dissemination of information. While the peer review process is important in trying to only publish scientifically valid results, the process is imperfect. Frequently, the peer review process is inefficient (which is difficult since reviewers and editors are busy). Often there are many additional experiments that are requested for. During a time where completing additional experiments is difficult, I think reviewers should consider whether the request to complete additional experiments is necessary and would change the conclusion or validity of the study. In order to more quickly disseminate findings, many investigators are now putting their publications in preprint servers. However, some investigators have reservations about putting unpublished material on preprint servers while their papers are simultaneously undergoing the peer review process.
  4. Improve the efficiency of translating basic science research to the bedside: There are several bureaucratic and administrative barriers that impede translating basic science findings to the bedside. Processes that balance patient safety and improve efficiency are needed.

We will continue to learn a lot about how about to improve science and medicine during this time. Stay safe and be kind!

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

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Why Should We Care About Sex Differences in Do Not Attempt Resuscitation Orders After In-Hospital Cardiac Arrest?

As an AHA Early Career Blogger and member of the Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation (3CPR), I am pleased to have the opportunity to summarize the recently published paper in the Journal of the American Heart Association (JAHA), “Do Sex Differences Exist in the Establishment of ‘Do Not Attempt Resuscitation’ Orders and Survival in Patients Successfully Resuscitated From In-Hospital Cardiac Arrest?”1 This paper was published in February during American Heart Month in the JAHA Spotlight: Go Red for Women 2020 series in conjunction with AHA’s Go Red for Women initiative.

In summary, Perman et al.1 used the Get With The Guidelines®-Resuscitation registry to determine whether there are sex differences in the establishment of “do not attempt resuscitation” (DNAR) orders after resuscitation from in-hospital cardiac arrest and whether the differences in DNAR use lead to differences in survival. They examined 71820 patients across 571 hospitals who had return of spontaneous circulation (ROSC) after in-hospital cardiac arrest and examined the association between de novo DNAR orders (any time after ROSC, within 12 hours of ROSC, or within 72 hours of ROSC) and sex and the association between sex, DNAR orders, and survival. The 72-hour time point was selected since after this time is when patients who are comatose after cardiac arrest begin to have neurologic findings that indicate poor prognosis and AHA guidelines recommend that the determination of neurologic prognosis should be delayed until at least 72 hours after ROSC (or 72 hours after reaching normothermia if targeted temperature management is used).

Of the 71820 patients, 42.4% of the cohort were women and women were on average older (mean±SD: 65.5±15.8 vs. 64.6±15.1 years; P<0.0001), less frequently of non-Hispanic white race (61.7% vs. 67.5%, P<0.0001), more likely to have a non-shockable cardiac arrest rhythm such as pulseless electrical activity (PEA) or asystole (81.6% vs. 78.0%, P<0.0001), and more likely to have a noncardiac illness at the time of admission (47.2% vs. 41.1%, P<0.0001) while men had a higher incidence of cardiac premorbid conditions.

Of the total cohort, 44.1% had a de novo DNAR order placed after ROSC. Of the entire cohort, 45.0% of women and 43.5% of men had a DNAR order after ROSC (unadjusted RR: 1.16; 95% CI, 1.12-1.21; adjusted RR [ARR]: 1.15; 95% CI, 1.10-1.20). Women had a higher rate of DNAR status early after resuscitation. Of those who had any DNAR order during the hospitalization, 51.8% of women compared to 46.5% of men had a DNAR order placed <12 hours after ROSC and 75.9% of women compared to 70.9% of men had a DNAR order placed <72 hours after ROSC. When adjusting for the patients’ demographics and cardiac arrest characteristics, female sex was associated with a higher likelihood of early DNAR <12 hours after ROSC (ARR: 1.40; 95% CI, 1.30-1.52) and DNAR <72 hours after ROSC (ARR: 1.35; 95% CI, 1.26-1.45) among those who had a DNAR order any time after ROSC.

Interestingly, after adjusting for patient and arrest characteristics, female sex was mildly associated with lower rates of survival to hospital discharge (ARR: 0.98; 95% CI, 0.96-1.00; P=0.04) and there were no differences in survival rate between men and women after adjusting for DNAR status within 72 hours. However, early DNAR status made within 72 hours of ROSC (combining data from men and women) was associated with decreased survival rate compared to those without a DNAR order or a DNAR order placed ≥72 hours after arrest (RR: 0.15; 95% CI, 0.14-0.17; P<0.0001).

This study by Perman et al.1 is not the first study to note differences in rates of do not resuscitate (DNR)/DNAR orders between men and women. Nakagawa et al.2 showed that women with acute intracranial hemorrhage were more likely to receive early (<24 hours from presentation) DNR orders than men. In a study of patients who received emergency surgery, women were more likely to receive a DNR order but morbidity and mortality rates were similar between men and women3.

Unfortunately, the reasons for women to more likely receive earlier DNR/DNAR orders are unknown at this time. Perhaps these differences could be due to patient preferences (e.g. women having earlier end of life discussions with family/surrogate decision-makers), implicit provider biases (e.g. female cancer patients were found to be more likely to receive early DNR orders from female physicians4), surrogate decision-maker biases, sociocultural factors, religious factors, situational influences, etc. Although DNR/DNAR orders are not requests for withdrawal of life-sustaining therapy, the presence of DNR/DNAR orders has previously been associated with decreased aggressive interventions and decreased survival to discharge for patients with out-of-hospital cardiac arrest5. This suggests that health care providers should be vigilant of the tendency to be less aggressive with care for patients with DNR/DNAR orders and ensure that their management plans align with the expectations of surrogate decision-makers. More robust qualitative data are needed in order to understand these differences.

References:

  1. Perman SM, Beaty BL, Daugherty SL, Havranek EP, Haukoos JS, Juarez-Colunga E, Bradley SM, Fendler TJ, Chan PS, † AHAGWTGRI. Do sex differences exist in the establishment of “Do not attempt resuscitation” Orders and survival in patients successfully resuscitated from in-hospital cardiac arrest? J Am Heart Assoc. 2020;9:e014200
  2. Nakagawa K, Vento MA, Seto TB, Koenig MA, Asai SM, Chang CW, Hemphill JC. Sex differences in the use of early do-not-resuscitate orders after intracerebral hemorrhage. Stroke. 2013;44:3229-3231
  3. Eachempati SR, Hydo L, Shou J, Barie PS. Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery. J Trauma. 2006;60:193-197; discussion 197-198
  4. Crosby MA, Cheng L, DeJesus AY, Travis EL, Rodriguez MA. Provider and patient gender influence on timing of do-not-resuscitate orders in hospitalized patients with cancer. J Palliat Med. 2016;19:728-733
  5. Richardson DK, Zive D, Daya M, Newgard CD. The impact of early do not resuscitate (dnr) orders on patient care and outcomes following resuscitation from out of hospital cardiac arrest. Resuscitation. 2013;84:483-487

“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.”