hidden

AHA Women in Cardiology Blog Series: DEVELOPING YOUR NICHE

Written by :Sherry-Ann Brown MD PhD and Renee P. Bullock-Palmer MD

As the subspecialty of cardiology continues to expand, opportunities abound for developing new niches. A few, among others, of great interest to Women In Cardiology, are Cardiovascular Disease in Women, Cardio-Obstetrics, and Cardio-Oncology (especially breast cancer), as well as Structural Heart Disease and Sports Cardiology, among others. How does one develop a new niche? Various strategies are summarized in this blog as outlined below. Review all of these tips and take away the ones most relevant to your career, needs, goals, and interests.

EX.C.E.L.
Gain as much exposure as you can to the area within your subspecialty to which you would like to devote most of your career (1). The more you learn, and the more experience you gain, the more you will become an expert.

Networking is incredibly important. This applies locally, Regionally, nationally, and globally. The more exposure you gain to your colleagues and other leaders at your institution and in your national societies (1), the more you will become known as an international expert.

As you introduce yourself and market your brand, you must be aware of your own capabilities, as well as the capabilities of your institution (1). Gauge your talents, strengths, passions, and personality. Assess your background, training, and preparation. Determine how to best apply your abilities. Evaluate the availability off the tools, resources, and personnel you will need to achieve your professional goal of building a niche.

Expectations are key. Early on, establish expectations that your institution may have of you as you develop a new program (1). Expectations for patient care, education, research, community engagement, and institutional citizenship should be made clear. Your own expectations of support for your vision, as well as administrative time as applicable, ought to be delineated.

Know your limitations (1), weaknesses, and opportunities for growth. Stretch and develop yourself, but not beyond where your intellect and training are willing to go. Know too the limitations of what you have available to you at your institution.

P.Q.R.S.T.
Cultivate partnerships (2) with colleagues at various stages of building similar programs at other institutions. Being able to share mutual insights on patients in your niche will be invaluable.

As you attempt different approaches in your program building, be willing to be flexible and take “quicksteps” (a lively combination of steps in ballroom dancing). Adaptability in medicine and leadership are key, just like in ballroom dancing.

Make your rounds among various departments and divisions. Offer to give and coordinate multidisciplinary grand rounds and short presentations at the division or department meetings. Provide didactics for the fellows, residents, and students.

Consider knowledge gaps or needs in complementary subspecialties locally, and devise solutions that can help other subspecialists and enhance collaboration (2).

Remember, patient care occurs best in the setting of teamwork (2). Build your team. Know your team. Lead your team.

3Ls
Look at the landscape to assess changes on the horizon within your area of expertise. Adapt to these changes. Cardiology as a field is always evolving in several areas and this will affect your practice. There are ever emerging fields, such as Adult Congenital Heart Disease, Cardio-Oncology, Interventional Echocardiography, and Cardio-Obstetrics. Therefore, it is important to never stop learning and acquiring new skills. Do not become stagnant, otherwise, there is a risk of becoming irrelevant. Lean in, be present both at your institution by participating actively at department meetings, volunteering for committees at your institution in your area of interest, and offering your expertise to lead and/or guide initiatives in your department.

3As
Find and align yourself with other experts locally, nationally, and even globally. This will help develop new leadership skills and promote your skills. Networking is crucial in one’s career and is one of the key benefits of professional societal involvement. Professional societal involvement is also a great way to learn and develop new research ideas.

Being accessible to your colleagues is important and will be helpful in developing your niche. Accessibility can be a great way to promote your practice, as well as increase your patient referral base.

Being accountable for your work is critical as you establish your niche. Accountability is a vital part of good patient care and being an effective leader in your practice.

2Ps
Find a platform to share your expertise either through outreach by giving educational talks to providers at local grand rounds, or dinner talks and participation in regional conferences and webinars. Participate in writing groups when the opportunity arises, and publish articles in your field. Opportunities for research may be either locally at your institution or nationally with multi-institutional national studies or registries.

Patient care is paramount, to demonstrate the effectiveness of your practice on clinical outcomes. After all, we entered this profession to take care of patients – do not practice in a vacuum. Excellent patient care will establish you as a meaningful contributor to the Cardiology service line at your institution.

Conclusion
Finding your niche is an important part of establishing your career. Never forget your career goals and focus and do not lose sight of these. We have outlined several strategies that may be customized to your practice environment and professional goals.

REFERENCES:

  1. Kilic A. How to develop a niche: Focus on adult cardiac surgery. J Thorac Cardiovasc Surg. 2016;151(3):636-9.
  2. https://www.acc.org/membership/sections-and-councils/early-career-section/section-updates/2016/08/16/08/53/developing-a-niche-in-structural-heart-disease

 

“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.”

 

hidden

R.E.D. C.U.P.: FROM BURNOUT TO WELLNESS

American Heart Association Early Career Guest Blog

Sherry-Ann Brown MD PhD FAHA, Krishna Doshi BS

We cannot ignore what a recent president of the World Medical Association describes as the “physician burnout pandemic”. We must find ways to transform our professional lives from a state of burnout to a state of wellness. A study from the American College of Cardiology reported that 27% of cardiologists experience burnout (compared to 43% from Medscape), while 49.5% reported being under stress with limited energy (1). In another study, approximately 15% of cardiologists reported experiencing depression, and among these 33% easily became exasperated by patients and 32% felt less engaged with patients (2). Similarly, burned-out physicians noted an effect on their professional activities with both patients and colleagues (1).

Neither subspecialty nor practice setting appears to have an impact on burnout (1). Contributors to burnout among cardiologists have been listed as excessive workloads, large bureaucratic loads, balancing work and life, and after work emergencies impacting lifestyle (1)(2). The constantly evolving technology was also identified as a culprit, with 57% of cardiologists reportedly accessing the electronic medical record at home (1)(4). I think we may all be guilty of some of this. Further, in the era of COVID-19, most of our professional and social interactions have been transferred to virtual interfaces. The absence of physical togetherness can take its toll on our emotional or mental wellness, coupled with decreased social support for many in the pandemic (5).

One cardiologist wrote in a survey that our profession is the ‘most unhappy’ specialty, but also the least likely to seek professional help. Thus, to cope many physicians turn to food, alcohol, drugs, or smoking (2). The struggle is real across our professions, and we must as a society pursue recommendations for burnout mitigation strategies (4). These initiatives must be conducted in shared responsibility for physician wellness (4). Resilience-based interventions should consider job design, leadership, and management training (4), and must be endorsed by the C-suite, with commitment to broad-sweeping implantation across the institution. Reduction in administrative tasks for physicians, increasing non-physician support staff, and emphasizing teamwork can make a world of difference, as can fostering self-awareness, life-work balance or more aptly integration, and regular check-ins for mental health (4).

 R.E.D. C.U.P.

To avoid or overcome being in a state of burnout, there are key components of the journey to wellness that should also be embraced.

 Relationships

When we informally survey individuals in person or on social media, undoubtedly the number one catalyst for wellness is noted as relationships. Frequent personal interactions with others who know and understand us can help relieve some of the altruistic burdens we carry in our daily professional lives.

Exercise/Hobbies

Quite often exercise and hobbies are listed as mediators of wellness. Exercise can relieve stress and release endorphins that help improve mood. Hobbies can give an object of focus that takes our minds away from what troubles us, or perhaps what might otherwise consume or overwhelm us. Hobbies can also help us share our inner selves, interests, and creative skills with others.

Diversity/Delegate

Welcoming a diversity of perspectives and selectively delegating to individuals with the appropriate level of training and preparation can offload some of the pressure on our generally full plates. Surrounding yourselves with individuals who enjoy taking initiative and being resourceful can be mutually beneficial.

Compassion for self

Giving yourself permission to have compassion for yourself is tremendously underrated, especially by women. We are so used to caring for everyone else around us and sharing our compassion selflessly that we often forget to do so for ourselves. To bring our best selves to the table and to truly give our best to others, we need to first invest in our own selves in ways that matter most to each of us.

Unplug

The ability to intermittently unplug from sources of time-consuming or draining asks can free up incredible amounts of time and mental space that can be used on more enriching and life-affirming activities.

Purpose

A sense of purpose can give clear direction and allow us to prioritize opportunities more effectively.

Pursuing R.E.D. C.U.P. may help us collectively and collaboratively as we grow together on our journey from burnout to wellness.

 

 

References:

  1. Mehta LS, Lewis SJ, Duvernoy CS, Rzeszut AK, Walsh MN, Harrington RA, et al. Burnout and Career Satisfaction Among U.S. Cardiologists. J Am Coll Cardiol. 2019;73(25):3345-8.
  2. Nicholls M. Cardiologists and the Burnout scenario. Eur Heart J. 2019;40(1):5-6.
  3. Rotenstein LS, Torre M, Ramos MA, Rosales RC, Guille C, Sen S, et al. Prevalence of Burnout Among Physicians: A Systematic Review. JAMA. 2018;320(11):1131-50.
  4. Panagioti M, Geraghty K, Johnson J. How to prevent burnout in cardiologists? A review of the current evidence, gaps, and future directions. Trends Cardiovasc Med. 2018;28(1):1-7.
  5. Graham MM, Higginson L, Brindley PG, Jetly R. Feel Better, Work Better: The COVID-19 Perspective. Can J Cardiol. 2020;36(6):789-91.

“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.”

hidden

HOW TO SAY NO: R5

American Heart Association Early Career Guest Blog

Sherry-Ann Brown MD PhD FAHA, Mehnaz Rahman MD

For many of us, to nurture our continuous and whole sense of well-being, we are in a constant process of learning to say “no”. Here is one scenario that can help provide an effective framework for saying “no”.

Consider a new junior attending faculty member at the same academic institution where she trained as a Cardiology fellow. Her pursuit of wellness in this new role has fallen to the sidelines, as she first tries to establish a sense of authority within a society that has only ever known her as a trainee. While navigating this unfamiliar territory, a surprising source of anxiety has come from responding to requests to collaborate on projects. She consistently accepted almost every single one. The fellow in her aimed to please.

Although she approached each with the same work ethic, her interest in them was not as equitably distributed. At the end of her first year, her cup had “runneth over” – she was overworked and overcommitted admittedly she felt by her own doing.

She then realized that she had agreed to those undertakings because she did not quite have the words ready at the tip of her tongue to say “no”.  When respectfully declining a specific ask, she determined that it can help to have a practiced approach to the conversation, one that can produce a beneficial result for both parties.

As we discuss this scenario, we can recognize that in general, people appreciate ideas and potential solutions. Accordingly, we may not be able to fulfill every request, yet we can still be a resource and offer alternatives.

One framework for saying “no” is grounded in R5: Reframe, Refer, Reduce, Reorient, and Recommend. Saying “no” can be challenging. Sometimes we need to say “no” to the way the ask is presented or the specific focus of the ask.

If we can perceive benefit from modifying the ask so that it actually fits with our career goals and specialty interests, then we can say “no” to the original ask while reframing it to a more fitting ask for us.

If we choose not to reframe the ask, we can refer the asker to someone else who we feel could be interested in working on such a task.

Alternatively, we could reduce the original ask to limit the portion for which we would be responsible.

Further, often those asking do not know how full our plates are and may need to be kindly informed or reoriented, so that they can better understand your perspective as you say “no”; you can even solicit their input as you think about how to prioritize your time on pre-existing projects.

Finally, recommend a new deadline or seeking out more resources if you would find working on the opportunity valuable but time-consuming or limited in available resources.

Remember, those asking for your involvement are genuinely interested in working with you, recognize you as an asset, and will more often than not be receptive to your counteroffer. Saying “no” the right way will leave the door open to future opportunities that you may be waiting or looking for.

We can continue to recalibrate our expectations of ourselves, as we engage in projects that keep us passionate and hope that our journeys to wellness become smoother with time and practice.

“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.”

hidden

WELLNESS MATTERS

American Heart Association Early Career Guest Blog

Sherry-Ann Brown MD PhD FAHA

WELLNESS

The World Health Organization defines wellness as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity”. The terms in this definition inspire similar words such as continuous (state), whole (complete), tangible (physical) and intangible (mental), as well as togetherness or community (social).

 PANDEMIC WELLNESS

Indeed, during the pandemic, we often say or hear, “We are all in this together”. The global community has rallied around each other to get through the coronavirus disease of 2019 (COVID-19) well. In the midst of a nation in turmoil with pandemics juxtaposed (coronavirus and racial and ethnic inequities), we find ourselves in the middle of it all as physicians.

SAFETY & WELLNESS

Along with everyone else in medical authority, we encourage those around us and all we serve to distance physically more so than socially. We want people to remain social, to enhance wellness. Yet, we need that socialization to be safe and physically distant, to foster tangible wellness.

 WELLNESS NOT CANCELLED

We encourage everyone to recognize that conversations, relationships, love, songs, reading, hope, joy, getting outdoors, music, family, and self-care should not and will not be canceled. This is the good stuff. The intangible components of wellness.

WELLNESS HEROES

So many of us in health care are sacrificing this period of our lives or in fact our very lives so that our patients can be whole. This altruism that led us here is continuous and indestructible by the #rona. Many of us turn to visual wellness inspired by COVID-19 to help capture the essence and sentiments of these challenging times. Art and other forms of creative expression of what’s inside of us or in society can motivate us to see more, be more, and serve more.

These matters at hand are crucial to help maintain our state of complete physical, mental, and social well-being. If we are honest with ourselves, we recognize that most of us live at best in a state of incomplete well-being. Yet, we can stand together against cancellation of our will and empower each other on this journey to wellness. It’s never been a destination. It’s always been a process that we continue to learn daily.

 

“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.”

hidden

NEGOTIATING YOUR FIRST CONTRACT

American Heart Association Women in Cardiology Blog Series

NEGOTIATING YOUR FIRST CONTRACT

Victoria Thomas MD, Simone Bailey MD, Sherry-Ann Brown MD PhD

Women are less likely to negotiate their contracts than men 1-3. Approximately 20% of women do not engage in contract negotiation 1. Despite improvements over time in the number of women negotiating their contracts, disparities persist in compensation and rank 4-5. Further, few resources exist to specifically guide women on how to negotiate salary and other beneficial components of the contract.

Optimal negotiation of your contract positions you well for future opportunities, promotion, visibility, and professional satisfaction. Know the process of negotiating your contract (Box 1, Image), know the perks or components of your contract (Box 2, Image), and know the resources available to you as you navigate and negotiate your contract (Box 3, Image). When reviewing contracts, consider the entire package, including malpractice insurance (with tail), paid time off, noncompete stipulations, salary, and incentives 6. Remember, time is money! Negotiate the allocation of your time: in/outpatient, research, medical education, and administration. If you are in academics, consider your incoming rank, clinical title, future promotion opportunities, and research funding if applicable. A clinical title may not cost the department and could set you up for deserved recognition and administrative time. Contracts should specify the requirements and duties of the physician and the employer explicitly, provide clear compensation models, and define term and termination protocols.

Weigh all options, such as preferences for an academic or private practice setting. Be cognizant of important non-work factors: geographic location, significant others, children, and recreational activities, as these greatly affect working decisions. Be firm on your deal makers and breakers prior to contract negotiations 6. Ask for more than you really want. This will likely lead to compromise down to a mutually accepted agreement. Be sure to present special requests in a manner that creates shared interests, and have these written into the contract. It is acceptable to communicate your desires early on and your concerns as the process evolves and recommend modifications that you would like to implement. Remember, verbal promises or assurances are not contractually valid. It is also advised to seek legal counsel with expertise in physician contracts to help you identify loopholes, pitfalls, and modifiable terms.

When entering negotiations, remember to be respectful, humble, appreciative, and also know your worth. The 2020 Medscape Cardiology Compensation Report found that male cardiologists earn approximately 16% more than their female colleagues 7. The average salary for men was $449,000, while women averaged $386,000 7. A study has shown that women lose an average of $7,000  in their first-year salary and may lose up to $1,000,000 over the span of each of their careers 1. As a means to reduce the wage gap, women must increase their efficacy and advocacy through contract salary negotiations. Let the employer make the initial salary offer so that you do not ask for less than you may have been offered or lead them to think that salary is your top priority. Review national reports to determine average salaries for similar physicians in your state of interest and talk with trusted colleagues 8. Other factors such as call, relocation fees, sign-on bonus, student loan repayment, and continuing medical education time and expenses can be negotiated as part of your compensation packet.

In your negotiations, make your best pitch 9. Demonstrate your uniqueness as a candidate and show your creativity. Develop new strategies using your specific skillsets to benefit your employer in areas with knowledge or personnel gaps. Adequate preparation is the most emphasized skill in negotiating any contract. Look ahead of time at what your employer needs and listen well in conversations (in and out of the formal scheduled interview) and emails 9-10. Recognize that every conversation whether in-person, by phone, or through email is part of the negotiation process, and small talk is necessary (often sprinkled in fairy dust). Lead with confidence, and be open to concessions, to show your collaborative nature.

Align with the American Heart Association or American College of Cardiology Women in Cardiology Section, with an emphasis of early matriculation while in training. These organizations not only offer career development and networking opportunities, but they also offer sessions for contract negotiation. Contract negotiation preparation and practice will allow for greater success when navigating your first contract. This will help to overcome challenges related to compensation and promotion inequities, and better communicate career expectations prior to solidifying post-training employment.

BOX 1. NEGOTIATING YOUR FIRST CONTRACT: TIPS ON PROCESS

  • Consider life outside of work: social climate, recreation, partner, children
  • Discuss shared priorities and interests to support solutions with your employer
  • Ensure the contract clearly states non-clinical roles and other promises which may have been made to you during the interview process
  • Get in writing any specific unique requests that you may desire
  • Review national reports on average salaries in your specialty and state
  • Speak with trusted colleagues for an idea of fair wages for your specialty
  • Ask for a higher salary if what is offered does not meet your expectations

 

BOX 2. NEGOTIATING YOUR FIRST CONTRACT: TIPS ON PERKS

  • Sign-on bonus
  • Relocation stipend
  • Non-compete stipulations
  • Malpractice insurance coverage with tail
  • Inpatient vs. outpatient service
  • Salary
  • Student Loan Repayment Plans
  • Dedicated Administrative or Research Time
  • Bonus/incentives
  • PTO (CME, Vacation, Sick days, etc)
  • Academic rank, promotion, and protected time for academic pursuits

 

BOX 3. NEGOTIATING YOUR FIRST CONTRACT: TIPS ON RESOURCES

  • PracticeLink (website); understanding the job search process
  • Getting to Yes (book); understanding negotiation
  • Good to Great (book); understanding the goals of your employer
  • ACC and AHA WIC Discussions; understanding strategies for women
  • Negotiation Skills: Negotiation Strategies and Negotiation Techniques
    to Help You Become a Better Negotiator; understanding power of negotiation
  • American Medical Group Association (AMGA) Compensation Survey;
    comparing compensation by specialty, region, and group size
  • Association of American Medical Colleges (AAMC) Faculty Salary Survey Results; comparing compensation within academia

 

REFERENCES:

  1. https://hbr.org/2018/06/research-women-ask-for-raises-as-often-as-men-but-are-less-likely-to-get-them
  2. Kugler, K. G., Reif, J. A. M., Kaschner, T., & Brodbeck, F. C. (2018). Gender differences in the initiation of negotiations: A meta-analysis. Psychological Bulletin, 144(2), 198–222
  3. Bowles  HR. Why women don’t negotiate their job offers.Harvard Business Review.https://hbr-org.proxy.library.vanderbilt.edu/2014/06/why-women-dont-negotiate-their-job-offers/. Published June 19, 2014. Accessed April 16, 2016.
  4. Jagsi  R, Biga  C, Poppas  A,  et al.  Work activities and compensation of male and female cardiologists. J Am Coll Cardiol. 2016;67(5):529-541.
  5. Mehta, L. S., Fisher, K., Rzeszut, A. K., Lipner, R., Mitchell, S., Dill, M., … & Douglas, P. S. (2019). Current demographic status of cardiologists in the United States. Jama Cardiology4(10), 1029-1033
  6. Fisher, Roger, William L. Ury, and Bruce Patton. Getting to yes: Negotiating agreement without giving in. Penguin, 2011.
  7. Lo Sasso  AT, Richards  MR, Chou  CF, Gerber  SE.  The $16,819 pay gap for newly trained physicians: the unexplained trend of men earning more than women. Health Aff (Millwood). 2011;30(2):193-201.
  8. https://www.medscape.com/slideshow/2020-compensation-cardiologist-6012721
  9. Bowles, Hannah Riley, Bobbi Thomason, and Julia B. Bear. “Reconceptualizing what and how women negotiate for career advancement.” Academy of Management Journal62.6 (2019): 1645-1671.
  10. Fischer, Lauren H., and Anureet K. Bajaj. “Learning how to ask: women and negotiation.” Plastic and Reconstructive Surgery139.3 (2017): 753-758.

“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.”

hidden

My Professional Journey

I was fascinated by the body’s circulatory system in high school. I was also concerned about heart disease being the number one killer of adults in the world. I figured I would become a cardiologist and help save hundreds, thousands, or even millions of people over time in personalized and public health care from fatal heart conditions. I suspected then that I would one day be a physician in cardiovascular diseases.

In college, everyone knew. I majored in Physics, spent lots of time in Spanish, and met my humanities and social sciences requirements, yet everyone knew I was destined for medical school. I completed all my premedical studies, volunteered at a local hospital, and shadowed doctors, and pursued research. My high honors senior thesis for the Bachelor’s and my excellent Master’s thesis were ultimately based on analyzing blood samples to determine health and disease and make predictions, using quantitative analytical methods in genomics and transcriptomics (gene expression profiles). Those studies in the blood were the closest I could get to the circulatory system as a physics major doing biomedical research at that time. It was fantastic!

By the time I started medical school, I figured that if I didn’t become a cardiologist, then I would be an oncologist or practice medical genetics (thinking that would be the closest thing to genomics). In medical school didactics, I quickly learned that medical genetics back then wasn’t what I thought it would be, and it didn’t focus on adults as much as I would have liked. Oncology lectures focused less on the conversation with the patient and more on signaling pathways that I had not yet begun to understand. I decided maybe that was not for me either. The physiology of the heart indeed captured my heart; the lungs and kidney were great too. So there I was, back to the heart and its circulatory system.

In my third year of medical school, I faced a dilemma. I enjoyed Psychiatry, Radiology, General Surgery, Orthopedic Surgery, Family Medicine, and Pediatrics, among other rotations, as well as my electives in Cardiology. What was I to do with my life as a doctor? I could almost see myself doing any of those! Almost.

During the PhD of my MD/PhD program, I shadowed a general cardiologist. I noticed that most of his patients were older and already in atrial fibrillation or heart failure. I asked myself, “Where are the 40-60 year olds before this happens?” I decided to create Preventive Cardiology. That was in 2006. I googled and saw that it already existed! In fact, we had just recruited a brand new faculty cardiologist, whose focus was prevention. I quickly became her mentee and spent some time in clinic with her. I realized that when it really came down to it, I saw myself managing and even more so preventing heart disease.

Then one day, I saw an email about a pilot research study in cardio-oncology. Thankfully, I was able to be a part of the study and learn more about this emerging field. This was in 2010. Almost a decade ago, I realized that my calling in medicine was to practice preventive cardiology and cardio-oncology and pioneer the merging of the two.

So, in my fourth year of medical school, I spent lots of time in various Cardiology clinics, to gain knowledge and exposure in other fields within Cardiology. I also had the opportunity to spend time in Medical Oncology and Radiation Oncology clinics, as well as with the radiation therapy technicians, treatment planners, and medical physicists. I performed literature reviews on my own and brought in articles to discuss with the Cardiologists, Medical Oncologists, and Radiation Oncologists. My favorite paper then is still quoted today in many experts’ presentations on ischemic heart disease risk resulting from radiation therapy.

With such incredible exposure to Cardiology, Oncology, and Cardio-Oncology patient care, research, and education, I thought about what I wanted to do most in the world as a professional. It became clear to me in my fourth year of medical school that I wanted to manage and, even more profoundly, prevent heart disease in the general population and in individuals with a current or prior history of cancer, and especially too in women. During that year, I got to present on my learning experiences in patient care, research, and education to the entire Cardiology department.

In 2012, in my last year of medical school and the MD/PhD program, I matched into the highly selective clinician investigator program at Mayo Clinic in Rochester, MN. I signed on the dotted line in advance for Internal Medicine Residency, Cardiology Fellowship, and Postdoctoral Research Fellowship. Everyone, therefore, knew I was for sure destined to #ChooseCardiology.

During my second year of residency, during my Oncology rotation, I cared for a woman with congestive heart failure thought to be due to anthracycline therapy administered many years before. That blew the whole thing open. I informed my faculty and advisors in Oncology, Preventive Cardiology, and Cardio-Oncology that I desired and planned to pursue both Preventive Cardiology and Cardio-Oncology and find ways to merge the two.

Over seven years at Mayo Clinic, I was, therefore, able to focus much of my research and subspecialty training and learning efforts in Preventive Cardiology and Cardio-Oncology (see CardioOncTrain.com). I also had the privilege of several clinic sessions in Heart Disease in Women. To me, all three are related, in so many ways.

My mission, therefore, is to protect the heart from ischemia, arrhythmia, cardiomyopathy, and other ailments in the general population, and particularly those individuals with a current or prior history of cancer (and especially in women).

Thus, I am now a cardiologist, with special emphases in preventive cardiology and cardio-oncology, especially in women. I am also a poet, and writing poetry about science, medicine, and now the heart has truly become one of my greatest joys (see LyricalMezzanine.com).

I share this story with you as an example of an individualized pathway in #ChooseCardiology. Perhaps you too are leaning towards areas in Cardiology to which you have not had much exposure, yet you know somebody has to do it, and that it must be created. Don’t let the unknown obscure the certainty of your calling. Find mentors and advisors who will believe in your potential and vision and spur you on, and who will one day be proud and excited to see your passion become reality.

 

“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.”

hidden

Pandemics Juxtaposed

Many of you are wondering about what I as a leader in various ways am thinking about the racial pandemic, juxtaposed with the coronavirus pandemic.

In the coronavirus pandemic, I had been starting my emails with something like, “I hope you have been able to stay well during these unprecedented times”.

This morning, I started to write an email to a group of people.

At first, I typed, “I hope you are well”.

Then I deleted that and started over.

And then wrote, “I hope you are sorting through these multiply tumultuous times.”

I deleted that too and skipped that intro altogether, and instead decided to share it with you all.

Let me tell you why. You should already be able to figure this out, but let me walk you through it.

Here it is.

Plainly and simply.

I hope you are NOT well.

I hope you are not OK with seeing what is going on in the world around you. I hope you are not OK with the global ignorance we have as people. I hope you’re not OK with the complacency with which we live our lives.

I hope you are NOT well.

I hope that your heart has been breaking inside due to centuries and decades of injustice.

I hope your well-being has been ruffled knowing that all are NOT well.

That all is NOT well.

We all agreed that as a society the goal is to be well.

However, the goal we should desire is for all to be well.

We cannot be true to ourselves until we honestly recognize that all are not well until the futures of our black men, women, boys, girls, and babies in this country and around the world are well.

Until then, how can you be well?

Together, in community, how can we be well?

We can be well when we start to admit that we are not.

We can be well when we commit to open dialogue and truthful conversation about race.

We can be well when we recognize our ineptitude as a society at understanding and addressing what ails us.

We can be well when it finally legitimately rings true that all men, women, boys, girls, and babies in the United States are indeed understood, recognized, perceived, and treated as equal.

“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.”

hidden

Telemedicine May Play A Role In Rural And Urban Community Engagement

Telemedicine may be the original term for remote patient care management using telecommunications beyond a phone call, but telehealth is also used. While the two terms are often used interchangeably, one could propose that telehealth could encompass more of a wellness approach that is proactive than the typical reactive nature of medicine. Traditionally, we have focused predominantly on management of disease. Yet, it may be more prudent and cost-effective to focus even more so on health, wellness, and prevention of disease. Nevertheless, for the purpose of this article, the term telemedicine will be used.

Many institutions are now pursuing telemedicine, or are planning to do so in the near future. Of course, several hospitals and medical systems are appropriately concerned about reimbursement. Reimbursement currently associates with more rural communities. However, there is also a role for telemedicine in less rural neighborhoods. If we are to ubiquitously implement telemedicine equitably, we may need to remove those boundaries of rural versus not, in telemedicine allocation decision-making. We need to be great stewards of our healthcare resources, and we need to determine where to best direct our efforts. Rural communities may benefit most from telemedicine, but other communities can as well. Perhaps in the most urban communities, telemedicine might be needed much more than anticipated. It is often in urban communities that we find limited community engagement with nearby health centers. Would the level of community engagement with health care centers in urban communities improve if telemedicine were more available in these areas? Availability and feasibility would depend on the source of provision and financing of the tools needed for telemedicine. These tools would include at a minimum internet access, computers or smart phones, physiology monitoring and diagnostic equipment, and free or costly apps. It should be recognized that telemedicine itself alone cannot effect community engagement. In fact, community engagement itself would be needed for adoption of telemedicine throughout the community. It might seem like a circular argument, because it is.

We often attempt to practice medicine or innovate in silos. Yet, it is when we remove the boundaries between the silos or blur the lines between neighborhoods and cross-pollinate that we can find nonlinear progress. Synergy can be found in the overlap of various kinds of disruptive innovation. Synergy can also be found in the overlap between the perspectives of community dwellers and healthcare professionals and innovators. Healthcare research and practice is now moving towards greater incorporation of the patient voice, choice, desires, values, and goals, not as bystanders, but as drivers. Not only should we take this approach at the level of the individual patient, but at the level of the population or community. Thus, community engagement is needed for adoption of telemedicine, and telemedicine itself perhaps may help to further catalyze community engagement. It therefore appears that telemedicine is not only about providing care for the individual patient in their home, whether due to patient location or mobility or simply patient preference. It would seem that telemedicine is also about providing care for the population and a community and enhancing relationships among community dwellers and their healthcare providers. This would potentially apply to rural, urban, and also global communities and populations.

It may also be more cost-effective to pursue telemedicine for patients in both rural and urban areas locally, regionally, nationally, and globally, before our patients in urban and rural communities become unwell and need to be hospitalized. Overall, medicine is very slowly moving towards prevention. Telemedicine could facilitate disease prevention in urban, rural, and global populations, as well as joint management of the most remote locally hospitalized patients before their inpatient status worsens. This could limit morbidity and mortality and decrease health care costs in the long run.

hidden

Artificial Intelligence in Cardiology: Opportunities for Cardio-Oncology

History was made recently with the inaugural and first ever continuing medical education conference on artificial intelligence (#AI) in Cardiology. While most of the presentations were on artificial intelligence or cardiology or both, several sessions also made reference to other fields in which AI has been or is being used, such as Oncology. There was even one study presented on Cardio-Oncology. As study after study was presented, it became clear to me that perhaps several of these techniques and methodologies could potentially be useful to our patients in Cardio-Oncology.

Every single piece of technology started with one single prototype. Every single new piece of software started with one single algorithm. Every single patent started with one single idea. Every single idea started with the impact that disruptive technology could have for at least one single patient – one single case.

As I view various case reports in Cardio-Oncology, I think about how #AI could influence care delivery to potentially improve outcomes and the experience for each patient and their health professionals.

One example that was reiterated in multiple presentations was that of the ECG. Applying #AI to the ECG has been shown in the studies presented to determine the age, sex, and heart condition of the individual. Details were shown for a case of hypertrophic cardiomyopathy (yes, HCM, not just left ventricular hypertrophy) diagnosed via #AI analysis of an ECG that appeared relatively unremarkable to physicians’ eyes. After the septal surgery/procedure, although the ECG then looked remarkably abnormal to physicians’ eyes, the #AI algorithm could identify resolution of the hypertrophic cardiomyopathy.

Another example reiterated throughout the conference was identifying undiagnosed left ventricular systolic dysfunction, in a general community population and also in patients referred to a cardio-oncology practice at a large referral center.

Recently, #AI in Cardiology has been used most frequently for monitoring and detection of arrhythmias, such as atrial fibrillation. Everyone can purchase their own wearable to determine this. Physicians are also now prescribing these wearables for ease-of-use, given their pervasive presence and coupling with smartphones owned by much of the population or provided temporarily by the physician group. Such wearables are transitioning from standalone electrodes, to watches, skin patches, and clothing (e.g., shirts, shorts).

Many direct-to-consumer #AI applications in daily life actually are not wearable, such as Alexa and Siri. One study described the ability of #AI to help diagnose mood disorders and cardiac conditions and risk factors by simply “listening to” and analyzing voice patterns. The timing of a young man’s “voice breaking” can potentially predict his risk for heart disease!

A popular use for #AI in medicine overall is to assist with interpretation of various imaging, such as chest X-rays, MRIs, or CT scans. This applies in Cardiology as well. Further, in Cardiology, #AI is being used to help guide the procurement of echocardiograms. The algorithms provide visual instructions (such as curved arrows) to indicate directions in which the ultrasound probe should be moved to obtain the standard view, to which the algorithm is comparing the image being procured moment-by-moment. The idea is for #AI to help less experienced sonographers or echocardiographers learn and perform echocardiography even more expediently.

The theme of the conference was current advances and future applications of #AI in Cardiology. Accordingly, a historical perspective was given, describing some of the earliest attempts at #AI in various fields. A video of a possible precursor to current automated vacuum cleaners was shown, from archives dating back to the 1960s. In addition to ways in which #AI is now being studied or applied, future opportunities for using #AI were also postulated, for example for coronary artery disease, since stress tests are not 100% sensitive and the gold standard coronary angiography is invasive. #AI could help stratify patients who needed versus did not need the invasive procedure for recurrent convincing symptoms in the absence of a positive stress test. Of course, coronary CT angiography could help fill this gap, but #AI might assist with decision-making sooner.

There have been studies on #AI in Cardiology, and studies on #AI in Oncology, and at least one study in #AI in Cardio-Oncology – a study I predicted; one that is quite intuitive and mentioned above. I propose that we continue to apply #AI in Cardio-Oncology, so that the field can catch up with the rest of Cardiology and Oncology, and help us continue to develop this emergent and burgeoning multidisciplinary subspecialty.

This is an exciting time for me to be alive. I am an early adopter of artificial intelligence. I look forward to seeing more and more the availability of #AI to enhance our use of electrocardiography, echocardiography, wearables, biosensors, voice analysis, and more in Cardiology, and particularly in Cardio-Oncology, with an emphasis on primary and primordial prevention even before secondary and tertiary prevention in the area of Preventive Cardio-Oncology, and especially in women.

 

 

 

hidden

Preventive Cardio-Oncology: The Role Of High Intensity Interval Training

Heart disease is the number one killer of survivors of cancer1, 2, 3. It is our responsibility to help our patients with cancer understand and mitigate this risk. Prevention of heart disease in these patients should occur at three stages: in Cardio-Oncology prehabilitation2, 4, habilitation2, 4, and rehabilitation2, 4, 5. At all three stages, exercise is a key component and can be optimized with consideration of high intensity interval training (HIIT).

HIIT has emerged as an exercise structure that adds more efficiency and power to typical continuous exercise regimens. Studies in the general population suggest that HIIT is safe and non-inferior or superior to continuous exercise regimens in its effect on fitness6, 7, lipids7, 8, blood pressure9, blood glucose levels9, waist circumference8, body fat percentage7, 8, insulin resistance7, and more. Beneficial findings and safety have also been reported for individuals with cardiovascular disease (including coronary artery disease and heart failure)10, as well as cancer11.

The format of HIIT is just as it sounds – incorporating high intensity intervals into exercise training. This is not necessarily training for marathons, sprints, or triathlons. This is training for life. Life that individuals with cancer fight so hard for. We owe it to these individuals to help them live their best life when their cancer is in remission. Part of that is their best heart health, and incorporating heart-healthy behaviors most seamlessly into their daily lives. One safe, effective, and efficient way to do that is with HIIT. In HIIT, following warmup individuals work out at high intensity for 30-120 seconds, then either rest or work out at low/moderate intensity for 30-120, alternating between the two for the duration of their set-aside exercise time or program. For example, an individual on a bicycle would cycle at 10 mph for 30-120 seconds, then at 0 or 5-9 mph for 30-120 seconds, alternating between the two for the duration of their set-aside exercise time or program. The new physical activity and prevention of cardiovascular disease guidelines provide great additional examples of moderate versus high intensity aerobic exercises12, 13.

A recent article suggested that HIIT may be the answer to meeting the needs of women in cardiac rehabilitation14. Indeed, HIIT may also be part of the solution to meeting the needs of women in Cardio-Oncology prehabilitation, habilitation, and rehabilitation. Yet for several years, clinicians and researchers have noted a myriad of barriers faced by women in cardiac rehabilitation14, 15, and that a plethora of women are not referred to cardiac rehab at all15. Besides time and accessibility limitations, other reported barriers include lower education level, multiple comorbid conditions, non-English native language, lack of social support, and high burden of family responsibilities. It should therefore be noted that while HIIT may serve as part of the answer to meeting the needs of women in cardiac rehabilitation or in Cardio-Oncology prehabilitation, habilitation, and rehabilitation, other solutions will be needed to address the variety of barriers unrelated to time and accessibility. The use of automatic referral and assisted enrollment can improve the participation of women in cardiac rehabilitation15, while incentive-based strategies and home-based programs may enhance program completion15. Additional solutions will be needed to address remaining barriers, such as health literacy related to lower education level, multiple comorbidities, non-English native language, high burden of family responsibilities, and of course adverse effects of cancer therapies.

As we step out into and carry on in our Early Careers, it is important for us to be aware of high intensity interval training and its incredible potential to elevate our care of women and men in cardiac rehabilitation in Preventive Cardiology, as well as in Cardio-Oncology prehabilitation, habilitation, and rehabilitation.

References
1. Mehta LS, Watson KE, Barac A, Beckie TM, Bittner V, Cruz-Flores S, Dent S, Kondapalli L, Ky B, Okwuosa T, Piña IL, Volgman AS; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Quality of Care and Outcomes Research. Cardiovascular Disease and Breast Cancer: Where These Entities Intersect: A Scientific Statement From the American Heart Association. 2018 Feb 20;137(8):e30-e66. doi: 10.1161/CIR.0000000000000556. Epub 2018 Feb 1.

2. Squires RW, Shultz AM, Herrmann J. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.

3. Patnaik JL, Byers T, DiGuiseppi C, Dabelea D, Denberg TD. Cardiovascular disease competes with breast cancer as the leading cause of death for older females diagnosed with breast cancer: a retrospective cohort study. Breast Cancer Res. 2011 Jun 20;13(3):R64. doi: 10.1186/bcr2901.

4. https://earlycareervoice.professional.heart.org/preventive-cardio-oncology-the-rise-of-prehabilitation/. Accessed April 20, 2019.

5. Gilchrist SC, Barac A, Ades PA, Alfano CM, Franklin BA, Jones LW, La Gerche A, Ligibel JA, Lopez G, Madan K, Oeffinger KC, Salamone J, Scott JM, Squires RW, Thomas RJ, Treat-Jacobson DJ, Wright JS; American Heart Association Exercise, Cardiac Rehabilitation, and Secondary Prevention Committee of the Council on Clinical Cardiology; Council on Cardiovascular and Stroke Nursing; and Council on Peripheral Vascular Disease. Cardio-Oncology Rehabilitation to Manage Cardiovascular Outcomes in Cancer Patients and Survivors: A Scientific Statement from the American Heart Association. Circulation. 2019 Apr 8:CIR0000000000000679. doi: 10.1161/CIR.0000000000000679. [Epub ahead of print].

6. Su L, Fu J, Sun S, Zhao G, Cheng W, Dou C, Quan M. Effects of HIIT and MICT on cardiovascular risk factors in adults with overweight and/or obesity: A meta-analysis. PLoS One 2019 Jan 28;14(1):e0210644. doi: 10.1371/journal.pone.0210644. eCollection 2019.

7. Fisher G, Brown AW, Bohan Brown MM, Alcorn A, Noles C, Winwood L, Resuehr H, George B, Jeansonne MM, Allison DB. High Intensity Interval- vs Moderate Intensity- Training for Improving Cardiometabolic Health in Overweight or Obese Males: A Randomized Controlled Trial. PLoS One 2015 Oct 21;10(10):e0138853. doi: 10.1371/journal.pone.0138853. eCollection 2015.

8. Stavrinou PS, Bogdanis GC, Giannaki CD, Terzis G, Hadjicharalambous M. High-intensity Interval Training Frequency: Cardiometabolic Effects and Quality of Life. Int J Sports Med. 2018 Feb;39(3):210-217. doi: 10.1055/s-0043-125074. Epub 2018 Feb 2.

9. Batacan RB Jr, Duncan MJ, Dalbo VJ, Tucker PS, Fenning AS. Effects of high-intensity interval training on cardiometabolic health: a systematic review and meta-analysis of intervention studies. Br J Sports Med. 2017 Mar;51(6):494-503. doi: 10.1136/bjsports-2015-095841. Epub 2016 Oct 20. Review.

10. Wewege MA, Ahn D, Yu J, Liou K, Keech A. High Intensity Interval Training for Patients With Cardiovascular Disease—Is It Safe? A Systematic Review. J Am Heart Assoc. 2018 Nov 6;7(21):e009305. doi: 10.1161/JAHA.118.009305.

11. Mugele H, Freitag N, Wilhelmi J, Yang Y, Cheng S, Bloch W, Schumann M. High-intensity interval training in the therapy and aftercare of cancer patients: a systematic review with meta-analysis.
Mugele H, Freitag N, Wilhelmi J, Yang Y, Cheng S, Bloch W, Schumann M.
J Cancer Surviv. 2019 Apr;13(2):205-223. doi: 10.1007/s11764-019-00743-3. Epub 2019 Feb 26. Review.

12. Piercy KL, Troiano RP, Ballard RM, Carlson SA, Fulton JE, Galuska DA, George SM, Olson RD. The Physical Activity Guidelines for Americans. JAMA. 2018 Nov 20;320(19):2020-2028. doi: 10.1001/jama.2018.14854.

13. Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol. 2019 Mar 17. pii: S0735-1097(19)33876-8. doi: 10.1016/j.jacc.2019.03.009.

14. Way KL, Reed JL. Meeting the Needs of Women in Cardiac Rehabilitation. Circulation. 2019; 139(10):1247–1248.

15. Supervía M, Medina-Inojosa JR, Yeung C, Lopez-Jimenez F, Squires RW, Pérez-Terzic CM, Brewer LC, Leth SE, Thomas RJ. Cardiac Rehabilitation for Women: A Systematic Review of Barriers and Solutions. Mayo Clin Proc. 2017 Mar 13. pii: S0025-6196(17)30026-5. doi: 10.1016/j.mayocp.2017.01.002. [Epub ahead of print] Review.