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Developing Your Career as an Academic Physician

For all early-career physicians out there, I am sure you were not only looking for the latest in science at AHA 2020 but also some guidance on career development, and the session “Developing your Career as an Academic Physician” was just perfect.  Here I will review some of the fantastic talks from this session.

It started with “Pearls for Becoming an Academic Leader” by Dr. Jennifer S. Lawton, chief cardiac surgery at Johns Hopkins University, and offered the perfect blend of inspiration, encouragement, and advice on being an academic leader. I am sharing some pearls from this talk:

  • DECIDE: Decide if leadership is right for you and why you want to be a leader?
  • PREPARE: Prepare to be a leader (leadership books/courses), gain experience (program director, lab director, multidisciplinary teams, write protocols for your institution), learn time management for different roles (clinical, academic, leadership, mentorship), and build your credibility.
  • COMMUNICATE: Keep your CV updated and make it available at a moment’s notice and be ready to articulate your 5 and 10-year goals.
  • ATTACH: Attach yourself to mentors and learn from their success/failures and seek their advice regularly. Find sponsors who can open doors for you.
  • 70/20/10 Rule: Being an academic leader is 70% on the job training, 20% is learned from mentors/sponsors and 10% is formal leadership training.

The follow-up amazing talk was “What Really is Work-Life Balance” by Dr. Sasha Shillcutt, Tenured Professor of Anesthesiology at the University of Nebraska Medical Center. Loss of control over work is an important reason for burnout and this talk really re-framed my concept of Work-Life balance as it emphasized the concept that we are in the “driver’s seat” of our career. Two main concepts that were presented are:

  • Time Management Traps & Myths: Learn to say “No” to tasks that no longer interest you and success is directly linked to saying no.
  • Set Boundaries: Successful health care workers set boundaries that are intentional, efficient, and healthy. It takes practice and planning to set boundaries but they make your life easy.

“Maintaining Clinical Skills While Working in the Lab” is a challenge faced by physician-scientists and Dr. Emily MacKay from the University of Pennsylvania discussed some remarkable strategies for this.

  • Cognitive Reframing: The idea is to reframe your perspective about a challenge into an opportunity while the objective facts of the situation remain the same. For researchers that spend most of their time in the lab, make the most of your clinical time and develop “deliberate practice” where the focus is on quality, attention to detail, mindful and purposeful performance of procedures.
  • Context Switching: If you hit roadblocks with one problem where the solutions are not obvious you can physically distance yourself from the problem, and then come back to it later and this will help you find a solution.
  • Handling Commitment: Using the Eisenhower matrix to identify tasks that are urgent and important and need to be handled quickly vs tasks are urgent but not important and can be delegated or tasks that are important but not urgent and can be scheduled.

I will encourage all early careers to watch this session and take notes as it is full of pearls for career development.

 

“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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Late-Breaking Highlights: “To Screen Or Not To Screen And Then What? Studies of Detection and Treatment of AF”

This was an exciting session at AHA 2020 which focused on clinical trials of screening, monitoring, and early intervention in Atrial Fibrillation (AF). Screening of AF is a controversial topic and for individuals >65 years, current AHA guidelines give a Grade 2a recommendation for screening whereas USPSTF guidelines suggest that there is insufficient evidence for screening. In this article, I will be discussing studies that addressed AF screening and their implications on clinical practice with Dr. Stavros Stavrakis who is an electrophysiologist and Associate Professor at the University of Oklahoma Health Sciences Center, Oklahoma City.

Question: What are the important goals when we think about screening for AF?

Dr. Stavrakis: The important goals for screening in AF are to establish a diagnosis of new AF in patients at high risk of stroke so they can be anticoagulated, ultimately reducing the risk of stroke.

There were 3 important trials that addressed AF screening in different patient populations.

SEARCH AF

  • In patients who have undergone cardiac surgery and have a higher risk of stroke but no history of pre-operative or pre-discharge AF, what is the risk of developing AF/Aflutter in the sub-acute post discharge period?
  • 336 post-cardiac surgery patients (median CHADS2Vasc Score 4) but with little or no AF in the post-operative period (<24 hours of AF but no intent to anticoagulate at discharge) were randomized to continuous cardiac rhythm monitoring vs usual care during the sub-acute post discharge period.
  • In the enhanced cardiac rhythm monitoring group 19.6% participants developed AF/Aflutter as compared with 1.7% in the usual care group with an absolute rate difference 17.9% (p<0.001, NNS=6).

Question: What are the implications of this trial on clinical practice?

Dr. Stavrakis: Risk of POAF, although peaking at 48-72hours post-op, is not confined to the index hospitalization, continuous monitoring for POAF can identify AF in a significant proportion of patients (20%) that may need treatment with anticoagulation. Whether anticoagulation improves outcomes in these patients, remains to be determined.

VITAL-AF Trial

  • Among older adults (age>65) presenting to primary care visits, does point of care rhythm assessment with a single lead ECG result in increased diagnosis of AF?
  • 30,722 patients were randomized to screening vs control.
  • Screening did not significantly affect AF diagnosis in the overall study sample (1.74% vs 1.60%, p=0.33)
  • Increased likelihood of AF diagnosis at primary care encounter (p<0.02)
  • Effectiveness of screening varied by age with effective screening in age>85 (risk difference 1.88%, NNS=53)
  • Overall no difference in the initiation of anticoagulation

Question: What are the implications of this trial on clinical practice?

Dr. Stavrakis: There are 2 important implications from this trial.

  1. Screening everyone age>65 for AF at a single time point is not an efficient way to detect AF, especially if the usual care is very good in detecting AF by pulse palpation or BP device.Screening at age>85 may be more effective than usual care to identify silent AF, but it is uncertain if it changes management or outcomes

mSTOPS

  • Can screening for AF by wearing an ECG patch improve clinical outcomes at 3-years?
  • 1718 actively monitored participants vs 3371 matched observational controls with analysis of 3-year clinical outcomes.
  • Mean duration of follow-up was 29 months
  • 11.4% of actively monitored patients developed AF vs 7.3% of matched controls
  • No difference in anticoagulation prescription between both arms (45.2% vs 44%, p=0.84)
  • 3-year Primary combined end point (death, stroke, systemic embolism or MI) for entire cohort was 4.5 vs 5.5 per 100 person-year (HR 0.79, p<0.01) and for diagnosed AF patients it was 8.4 vs 13.8 per 100 person-year (HR 0.53, p<0.01).

Question: What are the implications of this trial on clinical practice?

Dr. Stavrakis: Clinical outcomes can be improved with AF screening provided these patients are followed up for extended periods of time. However, this was not a randomized trial and unknown confounders may have influenced the outcome.

Question: What are 3 important unanswered questions pertinent to screening of AF?

  1. What is the impact of AF screening on clinical outcomes? Large studies, adequately powered to detect clinical outcomes, are underway (SAFER, HEARTLINE, GUARD-AF).
  2. What is the optimal screening intensity that identifies AF which would benefit from anticoagulation?
  3. What is the minimum AF burden that, if identified with screening, would benefit from anticoagulation?

“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.”