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From Race-Based Medicine to Fighting Structural Racism

“Race is the child of racism, not the father.”

-Ta-Nehisi Coates, Between the World and Me.

BiDil, a combination of isosorbide dinitrate and hydralazine, was approved by the FDA in 2005 to treat heart failure in African Americans— the first race-based indication in the U.S. Though some groups lauded this move as a win for the underserved Black community, controversy soon emerged— and rightly so. Why did the researchers come to the conclusion that this combination of drugs worked better for one racial group than another? Why did the FDA take the action to approve it this way? The answers were not reassuring.

Did you know that there is no genetic basis for discrete racial categories? If not, this is likely because of what you were taught in training. It’s time to unlearn some falsehoods! The concept of race is not, in fact, biological, but social. It is not race, but racism that creates and perpetuates inequities.

Race-based medicine is bad medicine. Period. Dorothy Roberts gave a seminal TED talk in 2015 explaining this concept. The persistent myths that characteristics like pain tolerance vary by race are damaging and false. It is up to us, as clinicians and scientists, to dismantle the racist structures and processes within health care and within our larger communities that harm people of color. We cannot allow the fiction of biological racial difference to obscure the reality of racism.

Race can be an important variable to include, analyze, and understand in science and medicine, but not because of biology— because of structural racism. Diagnosis and treatment should not differ by race. Rather, social determinants of health must be part of all the care we provide, and all the research we conduct. We need to fundamentally reexamine the characteristics we use to ensure diversity and external validity. Yes, we need data on race, that that’s not enough.

As we see stark and alarming differences in COVID-19 among racial groups, the realities of racism’s health impacts are writ large. Living and working conditions, rather than biological differences, drive the differential infection and death rates. We, as the next generation of scientists and clinicians, can seize this moment to create lasting change and move toward health equity.

How?

  • Question assumptions. Race-based decisions in medicine are often due to force of habit, tradition, and education. Ask why and if there’s not a good reason, stop. Why do we give race as a defining characteristic in our case presentations? Why do we calculate creatinine clearance differently? Why do we prescribe differently?
  • Assess your biases. Try the Harvard bias test, for example. No one is without bias! Seek out training. Eradicate blind spots. Form accountability groups with colleagues. This work can be uncomfortable, but it’s necessary.
  • Solicit input. Whether you are a researcher or a clinician, the community you serve needs to be involved. Do not assume you always know what’s best. If you ask, and listen, you will discover the values and priorities of the community. Trust-building takes work and time. Demonstrate trustworthiness and remember that iatrophobia is justified by history.
  • In research, define race and specify the reason for its inclusion. Use a sociopolitical rather than biological framework, and name contributing factors. Name racism and related forms of oppression that may be operating[1].
  • In clinical care, assess and address social determinants of health. Advocate for equity-focused community practices: food banks, suspension of evictions, support for access to broadband internet to increase access to healthcare and education, and provision of paid time off for sick leave & quarantine, among other actions. Identify needed resources and provide them.[1]

 

Sustainable change is never straightforward, never easy, and rarely rapid. As early-career professionals, we have many years to fight this fight. Let’s not waste any of them.

 

References:

[1]Boyd, R., Lindo, E., Weeks, L., & McLemore, M. (2020). On Racism: A New Standard For Publishing On Racial Health Inequities. Health Affairs Blog.

https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/?utm_medium=social&utm_source=twitter&utm_campaign=blog&utm_content=Boyd&

[1] Haynes, N., Cooper, L., & Albert, N. (2020). At the Heart of the Matter: Unmasking and Addressing the Toll of COVID-19 on Diverse Populations. Circulation, 142 (2).

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048126

 

“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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A New Way To Participate

One of the characteristics of attending medium to large scientific sessions is the time-honored act of… running from room to room trying to catch glimpses of talks that interested you, but have of course ended up in different rooms, minutes apart. Many of us have done this, and to an extent, I don’t mind it! I can always count on being able to reach my daily step count targets whenever I’m attending a conference, without needing to set aside 30mins dedicated to a walk or morning run.

The current global health crisis has ushered in new and accelerated inevitable changes in the way science research is conducted, disseminated, and discussed within the community. Each one of these aspects has shown the malleable and highly valued ability for science, and society, to adapt to new paradigms of work. There have been many challenges and losses in the way research has been affected (a partial or total work-from-home status doesn’t translate to equal productivity for lab based work). But at the same time, this ongoing pandemic response has also provided a launching pad for some very innovative and future friendly adjustments.

Today I’ll focus on one of those changes, related specifically to conference attendance. This is by no means a novel idea, but I find myself thinking a lot about it, and I’d like to share some of those thoughts. Online based conferences have existed before Covid-19 became a house-hold idea and reality. Even more novel are Social Media “conferences”, an example being the Royal Society of Chemistry putting on the #RSCPoster Twitter Conference earlier this year (planned in early 2019, before covid).

The fact of the matter is, the movement to have scientific meetings and conferences be better adjusted within the online space has been gathering momentum for years. I for one, have served as “Twitter Ambassador” for a handful of conferences over the past couple of years, because conference organizers, participants, and various communities, have found tangible and positive effects of having conferences be more open, interactive, and far-reaching, beyond the walls of the hotel or center that brings together the in-real-life attendees.

(photo taken by Mo Al-Khalaf, 2020)

This year the Basic Cardiovascular Sciences headline annual meeting, better known this week as #BCVS20 is a fully virtual conference. As an early career molecular biologist researching mechanisms of heart disease, this is one of the “can’t miss” events on my calendar. My previous experiences for these type of conferences has been very rewarding, and advantageous in propelling my research and career. Before Covid-19, I was very much looking forward to this meeting scheduled to be in Chicago. When it was announced that the meeting will become fully virtual, I knew that there will be some experience that’ll get lost in the format change. But I also appreciated the diligent and effective leadership that made this call, because this was definitively the right call, for the safety of the attendees, and all the workers that would be involved in administering and pulling off a successful meeting (a meeting that brings 1000+ folks, in one building for a few days).

So far, I must say I find the #BCVS20 experience to be quite rewarding. It is different, and the limited and reformatted ways of networking and engagement takes a little bit of time to get used to. But overall, I believe there is great potential to make this format, or better yet, a hybrid format where both online and in-real-life parallel options available, a very appealing and appropriate next step in the evolution of how these types of meetings can be conducted. The ability to cater to a worldwide audience, and the convenience provided to allow attendees to participate and learn from field experts without the difficulty of planning a trip, is without a doubt an advantage to students and early career professionals, who do frequently face difficulties in attending such meetings.

One thing I note: Unlike past conference going experiences, I definitely need to put in the 30-minute daily jog before or after the day’s sessions… because there is no need to run from room to room to catch talks that you’re interested in… it’s all just a mouse click or head turn to a second screen away!

“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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On Blood and Bridges: Remembering Congressman John Lewis

I was recently reading a Time magazine article, which included previously unreported coverage of Congressman John Lewis, the Civil Rights icon, who succumbed to cancer last week. When asked why he continued to tell his story, he responded:

          …it affects me — and sometimes it brings me to tears. But I think it’s important to tell it. Maybe it will help educate or inspire other people so they too can do something, they too can make a contribution.

As history tells us, Congressman Lewis, then a 25-year-old leader of the Student Nonviolent Coordinating Committee (SNCC) and coordinator of “Freedom Rides,” helped lead a march for voting rights from Selma, Alabama towards the state capital of Montgomery over the Edmund Pettus Bridge. The protestors were met with force by the state and local police. Mr. Lewis’ skull was fractured by the strike of a club. His was just one of numerous injuries endured by protestors. This fateful day—“Bloody Sunday”—March 7, 1965, is commemorated annually. People at home watched in shock and dismay as the protestors were brutalized. The ferocity of the images pricked the consciousness of the nation and resulted in many joining the cause. Their humanity wouldn’t allow them to sit passively and watch other humans decimated.

          I gave a little blood on that bridge

Fast forward 55 years…

On March, 13, 2020, the US declared a state of emergency in response the COVID-19 pandemic. US citizens across the country were advised to shelter-in-place to slow the spread of the novel coronavirus that had invaded our shores. Away from typical distractions of work, traffic, and the hustle of everyday life that usually occupies our minds, many sat fixated on the television as we watched cases and mortality increase. Amidst this vacuum, we were confronted by shocking visuals: a video of a police officer kneeling on the neck of an unarmed black man for 8 minutes and 46 seconds. In the context of social distancing, Americans were challenged to face themselves. The reality of racial inequities in the US, previously shielded by a cognitive dissonance (e.g., “we don’t know what happened before the video”), was now proximal and palpable. We had nowhere to go. We had to sit with it. As in the 1960s, we were outraged by the inhumanity – as we should be.

As a Black woman, it’s difficult to think of a time when I wasn’t completely aware of race relations in this country. Seeing others enlightened and even corroborating the stories of injustice in the US that I have known to be true as early as middle school was encouraging. However, I’d like to challenge our comfort a bit further. The same racism that cracked the skull of a peaceful protestor and kneeled on the neck of an unarmed man is the racism that ignores a black mother’s request for medical attention, dismisses the reports of pain of a black patient with a clearly broken bone, or assumes that black bodies die sooner as a matter of biology. Racism is both the lifeblood and the heartbeat of racial disparities in health and healthcare.

Racism built the communities in which we live, the public schools we are able to attend, and the types of businesses in our neighborhoods that provide basic necessities, such as food. It built our Capitol building and the home of our nation’s chief executive. It even built our most premier educational institutions and their medical and research empires. Racism lives in our silence as much as (if not more than) it lives in violence. It quietly sits within the foundations of our institutions and leaches its contaminants into our social spaces in a way that is both proliferative and reinforcing.

So, where do we go from here? Congressman Lewis once recounted a story of hearing Dr. Martin Luther King, Jr. speak. He spoke of:

          …the “spirit of history” inviting him to take his place.

Though it may mean protesting, it may also be interpreted as taking an active role in addressing health disparities in our respective places. If you’re reading this, your place is probably in healthcare, research, policy, or in the community; if not, it could also be finance, criminal justice, human resources, or administration. Regardless of your position, everyone can and MUST make a contribution if we desire to see the best of what our society could be. As during shelter in place, if we can steady ourselves long enough, we will hear the echoes of humans in despair beckoning our individual and collective humanity to act. Together, we have to “slow the spread” of racism—a pandemic1 that stretches as far back as our nation’s earliest years.

Let’s honor Congressman Lewis. This is our bridge. Let’s be human.

 

References

  1. Williams DR and Cooper LA. COVID-19 and Health Equity—A New Kind of “Herd Immunity” JAMA. 2020;323(24): 2478-2480.

“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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Housing and Health Equity in Cardiovascular Disease

So far, 2020 has been a year of public health crises. By early spring, it was apparent that people living in socio-economically disadvantaged areas were being hit hardest by Covid-19 [1]. In these same areas, people across the United States took to the streets protesting the murder of George Floyd, an unarmed Black man – in police custody [2]. In the words of James Baldwin, “It demands great spiritual resilience not to hate the hater whose foot is on your neck, and an even greater miracle of perception and charity not to teach your child to hate.”, and we as a country are still looking for this resilience [3]. Among the many consequences of this year’s events, these tragedies have really prompted a long, hard look at our healthcare system. One recently published article that was particularly heartening to read was the American Heart Association’s Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research Scientific Statement on “Importance of Housing and Cardiovascular Health and Well-Being”. It outlines how housing stability, quality, affordability, and neighborhood environment are linked to cardiovascular disease. The statement doesn’t shy away from evidence of how increased psychosocial stress in the Black community and other social determinants of health are associated with cardiovascular health disparities.

The world has changed profoundly over the past year and while we continue to strive to show charity to others in our everyday encounters, I look forward to reading more research that will help inform how we as a community can better address health inequity.

References:

“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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COVID-19: Looking for a silver lining

It’s July 2020, and the COVID-19 pandemic shows no signs of ending. A friend recently asked me if I ‘d ever imagined such a scenario when I decided to do medicine. The answer is no. None of us, not even our mentors had trained for a pandemic of this magnitude. Still, while this is still far from a “when life gives you lemons make lemonade” scenario, looking for those elusive positives in this global catastrophe is just one way to remain optimistic in the face of such unprecedented adversity.

So unprecedented, in fact, that as our hospital committees initially met to formulate new standards of operation, I found that as fellows in training (FIT) and (very) early-career physicians, my colleagues and I had much to contribute in terms of protocols and guidelines, even in guidance documents of national societies. With the need for rapid update of data and protocols in an extremely volatile situation, a FIT and early career COVID response team was formulated, to submit recommendations on a variety of aspects ranging from infection control, requirements for personal protective equipment (PPE), zonal divisions of hospital, allocations of responsibility and treatment protocols of infected staff, based on international guidance. It was something I had never done before, and taught me the important aspects of healthcare administration, outside of clinical work, and a renewed appreciation for what those in management do (It’s not easy to keep everyone happy!)

These testing times were also an opportunity to lead with empathy, help cultivate an essence of team spirit, and collective resilience as a team. When we had an initial outbreak of cases among our healthcare workers in April, I learnt what real leadership is – the importance of being transparent, even in the face of chaos. I learnt what it means to be present and to lead with empathy, to “be there” for junior colleagues and nurses. In the sea of misinformation, I also learnt to speak up for what was right, with authorities, rectify misconceptions especially relating to evidence-based treatment and push for the changes that were needed. Even now, everybody is still apprehensive. In more ways than one, the pandemic offered an opportunity for a much-needed change of culture within work environments, and more open discourse between peers and colleagues, a positive change that we hope will last beyond these difficult times.

While we educate ourselves on everything that isn’t cardiology, most formal training especially in terms of procedures, is still on hold as we respond to the pandemic. Locally, we have somewhat adapted to a virtual learning platform for residents. However, practising in South Asia, exposure to cutting edge technology and insights from international leaders in the field has generally been limited to the ability to be able to travel for in-person meetings overseas. Despite the chaos, the learning must not stop — while restrictions to international travel may have blocked the networking opportunities of in-person meetings, in a strange paradox, the online interactions might just have brought the world closer.

Just this week, I attended webinars from 2 different continents, without having to apply for any educational leave. Moreover, most of these virtual meetings and webinars are free of cost, and especially for fellows, the opportunity to participate and interact with world-class faculty. (Disclaimer: They are by no means a substitute for the real deal, but I’m trying hard to count the positives here!).

Like so many others I know, 2020 was supposed to be “my year” too. But tough luck. It’s not easy having to endure the stress of colleagues and family falling sick, and having to battle on, knowing fully well that it might very well be you, next. It’s important to embrace the situation and cultivate positive vibes, engage in self-care and your own wellness, however limited the options may be. By not being able to travel to see family, or even out of town for a break, it has been overwhelming to say the very least, but I can safely say that I’ve probably helped more people in the last few months, than I have on all my years as a doctor. That would probably be the biggest silver lining of them all—the opportunity to serve so many people. But in uncertain times like these, we’re all apprehensive. We don’t know when this will end. It’s a marathon, not a sprint, and we need to find the silver lining in this new normal, for the sake of our own sanity. At the same time, it’s also imperative that we consolidate the positive effects of the pandemic, the growth it has led to, and incorporate them into our practice as physicians and people.

“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 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.”

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A Graduating Fellows Guide to Pediatric Cardiology Resources

July is an important month for medical education— whether it’s graduating from med school and starting intern year, finally becoming a senior or starting fellowship.  With fellowship ending for me, and starting for many, I started to compile a list of resources for pediatric cardiology to share.

Many of these resources were passed down to me by seniors or mentors, but also many were found on twitter (read more about how you can use this to your advantage in my previous blog). Some emerged recently during COVID-19 in an effort to bring pediatric cardiology together virtually and bridge education gaps for webinars, lectures and more.

For online resources, I recommend creating a folder on your browser and saving sources for easy access later. Another helpful thing for me was saving the links to Moss & Adams, Mayo Clinic Board Review, & Lai echo e-books in this folder so that you can access them anytime and not have to carry the books around(you can find the codes in the front cover of the book).

Below are websites for great lectures, webinars and reading, clinical resources, apps, podcasts, important organizations and ways to find job postings. Enjoy and please share!

Websites for Lectures, Reading and Resources:
Heart UniversityEducational video on pediatric and adult congenital heart disease (ACHD) includes pathology lectures by Dr. Robert Anderson. They also host great webinars on various topics with leaders in the field.
SPCTPD PC-NES (Pediatric Cardiology National Education Series), a lecture series that was started to provide education to fellows during the pandemic— you can access all the previous lectures that were given on various topics with lecturers from around the country, this is planned to continue in the fall.
SCMR– Cardiac MRI case based webinars.
ACHA– ACHD association with webinars on various topics.
Dr. Robert Pass EP lectures; Excellent weekly EP conferences(Mondays 7am EST) with the Mount Sinai pediatric cardiology fellows, past conferences are on this YouTube page and the link to join live is sent via pediheartnet(see below), you can also find Dr. Pass on his podcast(below) and on twitter!
Multimedia Manual of Cardio-thoracic Surgery Surgical videos and descriptions geared towards surgeons but helpful to explain and see common CHD procedures).
Cardiology Notes– Summaries of various chapters from Moss & Adams, Lai Echo, as well as other pediatric cardiology tests and resources.
Parameterz website for Z scores to use for echo, easy to use on desktop or phone
Virtual TEE (Toronto) – TEE simulator.

Podcasts:
Pediheart– Peds Cardiology Podcast hosted by Dr. Robert Pass (above) – review of recent literature and topics usually with a great guest, tune in each week (released Friday) and learn to appreciate Opera too.
CardionerdsMostly geared toward adult cardiology with some overlap to Peds.
PCICS– Cardiac ICU topics and discussion with various leaders in the field.

Apps: (links are to the apple store, but they should be available through google play too!)
EP tools lite– Various EP calculators including WPW pathway localization tool.
Heartpedia Great resource for education for patients, medical students and residents with easy to use interactive diagrams of common CHD and repairs.
Pacemaker Using the patient’s chest XR, snap a picture of the pacemaker and this will tell you who the maker is (Medtronic, St. Jude, etc.)
Practice Update– Follow topics (i.e. Cardiology) and receive virtual “stacks” of the latest literature on that topic with quick reviews and links to full text.
Dimity– Use this app to make patient phone calls from your phone so your number shows up as the hospital line and not your number or unknown. Very helpful for home call!

Conferences/Organizations: all conferences through 2020 are now virtual allowing you to access more content. Remember as a fellow your membership and registration is usually discounted or free, take advantage while you can!
ACC Annually in March.
ASE Annually in the summer (virtual August 8-10) and only $75 for fellows).
PICS-AICS Cath focused conference annually in September.
AHAAnnually in November.
PCICS Annually in December for those interested in cardiac ICU. Bonus fact- they are also hosting virtual meetings on experience and research related to COVID-19 and pediatric cardiac care.
PAC3, PC4 & NPC-QICCollaborative organizations to improve outcomes in congenital heart disease, along with these are great organizations for quality improvement and outcomes research and hold an annual conference along with webinars.
CHOP pediatric cardiology update  Annual dedicated pediatric cardiology conference in February.

Job Postings: below are links to sites that may be helpful as you are looking for jobs, don’t hesitate to reach out to people, have your mentors reach out or cast a wide net, you may find opportunities that aren’t posted.
Pediheartnet- A list server with job postings; this also facilitates discussion between cardiologists around the world, this is the server that the weekly EP conferences (above) will be sent out on and other great opportunities- a must join!
Other sites for job postings-
Congenital Cardiology Today
CareerMD Pediatric Cardiology Job Bulletin
NEJM Career Center ACC Career & AHA Career Centerrefine your search by specialty and receive emails with new postings.

Happy July, and don’t forget to be kind and welcoming to someone new in the hospital, you were there once too!

“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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Knowledge Advances Incrementally

Learning and advancing one’s personal and professional goals is a dynamic and active process. We never truly “finish” learning anything. We get better and better at tasks the more we practice them. We increase the accuracy of our data the more analysis on bigger and more relevant sets of samples we collect and measure. The scientific method is built on accepting the facts as they get unveiled, fully realizing that optimization and accuracy comes gradually with more work done and more information gathering.

One of the present global issues that I want to address here is the erroneous practice of some individuals that point out shifts in recommendations and gradual changes in the understanding of a scientific/medical phenomenon, and using these shifts and changes in the information shared as basis for doubt and denial for the whole process. Certainly when it comes to complex and novel discoveries/puzzles to solve, there will be a period of optimization and incremental advancement in understanding. These could lead to changes in conclusions from where things were first reported, to where they are now, and to where they will be in the future as more and more science is uncovered and facts are checked and replicated.

The act of refuting what we presently know and understand of a novel discovery or challenge to tackle, simply because the present understanding doesn’t match exactly what was previously reported and shared, is simply an act of refusing to accept that human beings are, by nature, dynamic learners. We gain more as we try, experience, and process information. Humans are not the kind of species that begin and end their lives with the same genetically programmed set of actions and behaviors inherited from the previous generation and are carried down to their progeny. Each one of us knows more now than we knew when we were younger. Experience matters. Time to perform more measurements and analysis brings us closer to accuracy and understanding. In other words, we get wiser as a whole, the more we experience and accumulate data.

Individuals that insist on focusing on the divergence of information coming from science and medicine, that’s separated by a non-trivial amount of time, are trying to sow doubt and nullify the value gained by executing the scientific method to its fullest potential. Accuracy, and a full understanding of anything complex, requires optimization, replication and diverse set of experts working separately and together, to incrementally achieve the most precise understanding of a challenge or novel discovery.

Our society benefits from scientifically assessed and understood information. Evidence-based decision making is far superior to other forms of societal choices, made by and for the public. And as mentioned here, the precision and accuracy of scientific information gathering advances the more time is allowed for investigation and understanding. We should celebrate and embrace changes accumulated with more data analysis and scientific rigor applied to test the facts uncovered along the way.

It is a self-correcting and enhancing mechanism, built into the scientific method and research process that we implement as scientists and healthcare researchers and providers. Sure this means that some data and knowledge will shift with time, but this should be seen as progress, and we should not let mis-informers and pseudoscience spreading behavior and individuals hijack the system of self-correction and improvement built into our method.

And as a last point to make: Scientists, medical researchers, and everyone involved in healthcare, research and academia should find ways to communicate and/or amplify voices of communicators that are on the front-lines of providing evidence-based information to the public. The best use of the scientific process is when the product of this process is shared with everyone.

“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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CardioPulmonary Resuscitation (CPR) in the Time of COVID-19

As we continue to see the increasing number of coronavirus disease 2019 (COVID-19) cases and amid the second peak of this pandemic in the United States (US), everyone from physicians to the general public should know how to approach and perform basic life support (BLS) with certain precautions and modifications of routine BLS protocols for patients with suspected or confirmed COVID-19 status. Importantly, rescuers should always balance the immediate needs of patients with their own safety. Several recently published articles have demonstrated that many patients with COVID-19 can present with cardiac arrest or experience cardiac arrest while hospitalized. In this post, I am going to share a few points on recommended modifications in order to ensure a safe yet effective CPR protocol for our patients.

  • Reduce Provider Exposure to COVID-19

Resuscitations carry added risks to rescuers and healthcare workers for many reasons. CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway [1]. It is important to keep in mind that these viral particles can remain suspended in the air with a half-life of around 1 hour per some reports and can be inhaled by those nearby [1]. In addition, resuscitation efforts require numerous providers to work in close proximity to each other and to the patient; thus, the advised social distancing protocols may not be applicable.

Strategies

  • Before entering the scene, all rescuers should don personal protective equipment (PPE) to guard against both airborne and droplet particles.
  • Limit personnel on the scene to only those essential for patient care.
  • In settings with protocols in place and expertise in their use, consider replacing manual chest compressions with mechanical CPR devices to reduce the number of rescuers whenever it is available and in patients who meet the manufacturer’s height and weight criteria.
  • It is important to clearly communicate the COVID-19 status to anyone arriving to the scene and when transferring patients to another setting.

 

  • Prioritize Oxygenation and Ventilation Strategies with Lower Aerosolization Risk
Strategies
  • Attach a high-efficiency particulate air (HEPA) filter securely [Figure 1], if available, to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths.
  • After healthcare providers assess the rhythm and defibrillate any ventricular arrhythmias, patients in cardiac arrest should be intubated with a cuffed tube at the earliest feasible opportunity. Connect the endotracheal tube to a ventilator with a HEPA filter when available.
  • Minimize the likelihood of failed intubation attempts by doing the following:
    • Assign the provider/approach with the best chance of first-pass success, and
    • Pause chest compressions while intubating with minimal disruption.
  • Video laryngoscopy may reduce exposure to aerosolized particles and should be considered.
  • Once on a closed circuit, minimize disconnections in order to reduce aerosolization.
  • Barriers can be used to minimize spread of the particles during aerosol-generating procedures (Figure 2).

Figure 1: A high-efficiency particulate air (HEPA) filter (arrow) is securely attached to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths [2].

Figure 2: Example of barriers potentially used to minimize the spread of the particles during aerosol-generating procedures [2].

  •  Consider the Appropriateness of Starting and Continuing Resuscitation

Like any cardiac arrest, it is important to know when resuscitation efforts are likely to be futile. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high, especially with increasing age and comorbidities, particularly cardiovascular disease. As such, it is critical to consider all these factors in determining the appropriateness of initial and continued resuscitation efforts, to weigh the likelihood of success against the risk to rescuers.

Strategies
  • Address goals of care with patients, or their proxies, in anticipation of the potential need for increased levels of care.
  • Healthcare systems and Emergency Medical Services (EMS) agencies should institute policies to guide frontline providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19 on the scene, early in the process. The risk stratification and potential policies should be communicated to patients (or proxy) during discussions of goals of care.

In conclusion, there have been modifications to the routine CPR protocols in patients with suspected or confirmed COVID-19. With the increasing number of COVID-19 cases, it is very important, for us as physicians and for the general public as well, to review recommended modifications to BLS protocols and apply them where possible, in a step to win the battle against this virus during these unprecedented times!!

References

“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.”