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Facing the Fear of Writing

Writing is an essential skill in academics. Metrics of productivity are often quantified by number of publications and funded grants. Very few people are naturally talented scientific writers. One of the most daunting tasks for early career trainees is writing and then receiving the subsequent deluge of feedback and critiques from mentors, co-authors, and reviewers.

Like any other technique, refining one’s scientific writing skills takes time and practice. Scientific writing can be challenging, especially early in your training. Here are some tips that may help you develop this important scientific skill:

 

  • Try to write as much as possible. Writing scientific papers is different than preparing grant proposals. Try to gain experience in both by either submitting papers and grant applications and/or attending mock grant writing courses during your training.

 

  • Set aside time to write and minimize detractions. This can be challenging when we have smartphones, email inboxes, and social media accounts. Try to write in chunks. When preparing manuscripts, I like to start with putting together the figures and figure legends; then writing the results and methods, introduction, discussion and finally the abstract.

 

  • Do not worry about putting together a perfect draft. It is better to try to overcome the writing inertia by free writing and then later revising.

 

  • Keep multiple versions of your drafts. You may like how you previously described something or organized the document.

 

  • Do not be horrified about the amount of edits that you will receive. I remember how dejected I was when one of my drafts was littered with red tracking changes and comments. However, receiving drafts back with a plethora of feedback and revisions is a sign that your mentor/co-authors care about what you wrote and want to further your professional development. I am extremely fortunate that my mentors take the time to provide detailed and specific feedback on how to improve my writing. Also, do not take the critiques personally. If needed, look at the comments, put them aside, and come back to them another time when you are less emotional – this is especially relevant after you receive critical negative reviews on your manuscript and/or grant submissions.

 

  • Read the literature and other people’s grant applications. There is no correct way to write a good manuscript or successful grant application. However, you can learn many stylistic approaches by examining others’ writing.

 

I also recommend checking out some of the great blogs on scientific writing that my fellow AHA Early Career Bloggers wrote:

 

Good luck!

 

“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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Johnson & Johnson COVID-19 Vaccine

On February 27, 2021, the Johnson & Johnson COVID-19 Vaccine has been Authorized by the FDA for emergency use. Which makes it the third vaccine to be authorized in the United States. The emergency use authorization was granted after 43,783 participants (18 years of age and older) with no evidence of prior COVID-19 infection were randomized to the vaccine group versus the placebo (saline) group. The trial was conducted in eight countries across three continents with a diverse and broad population. Overall, the vaccine was 66% and 67% effective in preventing moderate to severe/critical COVID-19 occurring after 2 and 4 weeks respectively. Moreover, it provided a 77% and 85% in preventing severe/critical COVID-19 occurring after 2 and 4 weeks respectively. Similar to the other vaccines, the most commonly reported side effects were pain at the injection site, headache, fatigue, muscle aches, and nausea. It is still unclear whether the vaccine will decrease transmission of the virus. Additionally, the participants were only followed up for a median of 8 weeks, so long-term efficiency or safety is not available. One of the main advantages of this vaccine is that it is administered as a single shot.

In contrast to the Pfizer and Moderna vaccines which utilized messenger RNA. Johnson & Johnson’s vaccine used existing technology to add the gene for the COVID-19 spike protein to a modified Adenovirus. After receiving the vaccine, the body will be able to produce the COVID-19 spike protein to trigger the immune system to mount an immune response without causing the disease.

(Figure from Livingston EH, Malani PN, Creech CB. The Johnson & Johnson Vaccine for COVID-19. JAMA. Published online March 01, 2021. doi:10.1001/jama.2021.2927)

Although the Pfizer and Moderna Vaccines are very effective. Having an additional vaccine will accelerate the vaccination speed. Johnson and Johnson has begun shipping its COVID-19 vaccine and expects to deliver enough single-shot vaccines by the end of March to enable the full vaccination of more than 20 million people. Additionally, Merck will be manufacturing this vaccine which will ramp up the production speed. So far, more than 50 million people have received at least one dose of the vaccine. It is expected that by the end of May 2021, vaccines will be available for the entire adult population in the United States. For the time being, we have to practice social distancing, wear a mask, and hope for the best!

References:

1) Livingston EH, Malani PN, Creech CB. The Johnson & Johnson Vaccine for COVID-19. JAMA. Published online March 01, 2021. doi:10.1001/jama.2021.2927

2)https://www.fda.gov/news-events/press-announcements/fda-issues-emergency-use-authorization-third-covid-19-vaccine

3)https://www.jnj.com/johnson-johnson-covid-19-vaccine-authorized-by-u-s-fda-for-emergency-usefirst-single-shot-vaccine-in-fight-against-global-pandemic

 

“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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Eating To Live Or Living To Eat? The Weight-Gain Struggle During a Pandemic

To my fellow physicians and patient providers, how many of your patients have gained weight and blamed it on the pandemic due to limited options for physical activity outside of the home?

Unsurprisingly, almost all of my patients I’ve seen over the past year have fallen victim to this, with good reason. They are protecting their health by avoiding exposure to COVID-19 but at the same time are unconsciously neglecting their health by not having the means or green light to engage in healthy behaviors such as going to the gym, walking in public spaces, and engaging in aerobic exercise and strength training. Our current restrictive environment combined with more time at home to eat and indulge is a fail-proof setup for adding on these harmful extra pounds.

So what can our patients control and how do we motivate them? This reminds me of my roommate in medical school who once told me that I “live to eat” because I would act immediately on a food craving and would also plan my next meal while actively eating a meal in front of me. I asked him if he also followed this same dogma of being an “emotional eater” and acted impulsively on energy-dense, nutritionally lacking foods. He responded with “I eat to live” because he only thinks about food when his body sends him the appropriate signals. I had to think about this. Yes, “stress-eating” is a habit that many of us are using as a coping mechanism during the COVID-19 pandemic.

Food culture is central in many cultures across the world. Food brings people together, establishes common ground amongst strangers, and provides satisfaction and emotional fulfillment while traveling, learning, and growing. We’re social creatures who naturally select to build connections that many times are centered around meals. But when the balance tips towards overindulgence and away from physical activity and healthy mindfulness is when chronic diseases such as coronary artery disease and its associated comorbidities arise.

For many of us, we understand what we should eat to become healthier, however, that does not mean we will actually follow this rationale to maintain a heart-healthy diet, especially during a pandemic when most of our day is spent sedentary in isolation at home. Despite having a master’s degree in Nutrition as part of my training, I can admit that I have invariably fell victim to the vices of food comfort at home. I was eating a lot of baked desserts after dinner but recently decided to replace this habit with a cup of hot chocolate made with soy milk and sugarless cocoa powder.

So how do we combat this? We know the right food prescriptions of diet to provide our patients and have all heard the saying of “you are what you eat.”

Let me quickly review the 4 strategies of motivational interviewing (OARS) and a few quick tips to help our patients (and ourselves) make gradual and achievable nutritional changes:

  • Open-ended questions- this allows your patient to explore and think more deeply about personal goals.
  • Affirmations- highlight your patient’s strengths and skills to support self-efficacy
  • Reflections– reflective listening and providing empathy deepens the trust with your patient; avoid making judgments as patients become may become defensive
  • Summaries- summarizing the above then allows you to move on to making a specific plan with your patient

Here are 5 tips to help your patients make healthier food choices during the pandemic:

  • Allow your patient to decide on 1-2 specific food goals per week (this can involve eliminating one food item they are able to identify that is unhealthy or decreasing the amount of this food item per day or week).
  • Empathize with the difficulty of being at home and that boredom by itself can cause overeating. Prior to eating, challenge them to take a few seconds to determine whether or not they are hungry or are deciding to eat because they are bored.
  • Make a goal of drinking at least 8 glasses of water a day- being underhydrated can in turn cause overeating of salt-laden foods.
  • “Eat your calories, don’t drink them.” Ensure that your patient is avoiding caloric beverages. If they enjoy fruit juices, ask that they try eating fruits as the fiber benefits are much more plentiful with less additive sugars.
  • Lastly, congratulate them on their decision to make a change and have a specific follow up plan to continue building on the changes they are making.

Be well,

Kyla Lara-Breitinger, MD, MS

References:

https://psycnet.apa.org/record/1998-04654-001

 

“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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Evaluating ML/AI Models in Clinical Research

The number of machine learning (ML) and artificial intelligence (AI) models published in clinical research is increasing yearly. Whether clinicians choose to dive deep into the mathematical and computer science underpinnings of these algorithms or simply want to be conscientious consumers of new and relevant research to their line of work, it is important to become familiar with reading literature in this field.

To that end, Quer et al. recently wrote a State-of-the-Art Review in the Journal of The American College of Cardiology detailing the research landscape for ML and AI within cardiology including concrete tips on how a non-ML expert can interpret these studies. At its core, ML is about prediction, and models are created to make accurate predictions on new or unseen data. Inspired by their work and incorporating many of their recommendations, below is a list of considerations for when you are critically evaluating an ML/AI model in clinical research:

  1. What question is addressed and what problem tackled? How important is it? Regardless of a model’s performance or the accuracy, its usefulness is determined by its clinical application. Everything must go back to the patient.
  2. How does the ML/AI model compare to traditional models for the given task? Many studies have shown little additional benefit when comparing ML/AI models to standard statistical approaches including logistic regression for clinical questions that have been extensively researched in the past with key predictors of the outcome of interest identified. The promise of ML/AI really exists in incorporating novel data sources and data structures, including time-series information and continuous input from wearable sensors, raw images and signals such as that from common studies including echos and ECGs, and harmonizing unique data types together.
  3. To which broad category does the model fall into? Most machine learning models fall into buckets of supervised learning algorithms, unsupervised learning algorithms, or reinforcement learning. Each approach is slightly different with a unique end product. Supervised learning algorithms learn patterns in the data that allow them to predict whether a specific observation falls within a specific class or category, for example determining if a photo is a cat or a dog. This requires data that is labeled for the algorithm to learn from, i.e. someone or something has provided data that is correctly tagged as a dog or cat. Unsupervised learning does not require observations with labels but instead combs through the observations to look for those that are similar to each other. Reinforcement learning a separate task in which an agent is trained to optimize choices made to attain a stated goal. All of these have been used clinically in recent literature.
  4. How were the data and labels generated? Garbage in = garbage out. Your model is only as good as the data it was trained on and the accuracy of the labels. It’s important to know where this information came from.
  5. Model training, validation/performance, generalizability. A common approach to training models is to split the data into a training set with unique observations left for the test set to validate the model. It is critical to train and test on different data with no overlap. Model performance is tracked with metrics similar to those used to evaluate clinical models, including sensitivity, specificity, positive predictive value, negative predictive value, and AUC, although the names associated with those measures may be different. Additional measures such as an F-score may be used. Arguably more important, however, is generalizability. This is how well the model performs in an entirely unique cohort, often from another center, although many of the currently published studies do not include this step.
  6. How clinically useful are these findings, and is the model interpretable? Basically, is the juice worth the squeeze? And can a human understand why the model made its conclusion? A common knock against deep learning neural networks for example is that although they are incredibly skilled at learning from data and making accurate predictions on new data, how they do so is a “black box,” although new ML/AI methods have started to account for this.
  7. How reproducible are the results? Did the authors share their code or dataset? If they used an EHR phenotype to generate their cohort, can you do the same thing at your institution?

These points are meant to summarize and add to some important aspects of this recently published article, but it is an excellent read and I encourage everyone to review it in its entirety.

Reference:

Quer, G., et al. (2021). “Machine Learning and the Future of Cardiovascular Care.” Journal of the American College of Cardiology 77(3): 300-313.

 

“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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Black Lives Matter in Heart Transplant Too

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

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

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

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

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

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

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

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

References

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

“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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Misinformation and being a scientist during the 21st Century

In a recently published paper, Dr. Lykke Sylow shares three challenges for scientists during a time where not only misinformation, but the quantity of misinformation questions what science stands for (1).

Dr. Lykke Sylow is an assistant professor for the department of Nutrition, Exercise and Sports at the University of Copenhagen. Her line of research involves muscle insulin sensitivity, GTPase, exercise cancer cachexia and metabolism. Dr. Sylow shares the following three challenges in a recent publication: 1) Balancing correct interpretation of results with the need for promotion, 2) Schism between the need for fast scientific communication and scientific trustworthiness, 3) Tackling the social media platforms as they take a leading role in how we seek information.

The figure below highlights the incentivization for scientists to promote their research findings, thus the idea of bias comes to mind. This supports challenging circumstances to rely on the public to determine if scientific results are correctly interpreted and translated into a meaningful and comprehensive message (2).

https://doi.org/10.1073/pnas.1317516111

It is important to notice the complexity of the third model and the larger circle of the socio-political context that may often be overlooked.

The next figure below similarly highlights the reliance on the public to balance political and societal concerns with what is shared to them (3). Think about the citizens never-ending exposure to streams of very often contradictory information and/or arguments. Science cannot tackle this age of misinformation alone.

10.1073/pnas.1704882114

I reached out and asked two other scientists for their thoughts about the current state of science and misinformation. Dr. Derek Kingsley is an associate professor at Kent State University in the School of Health Sciences in Kent, OH, US. Dr. Kingsley’s research involved cardiovascular dynamics and outcomes with resistance exercise interventions. His responses are below:

  1. “During times like these it is important to remind scientists to slow down. Good science takes time. It seems that nothing can come quick enough these days, but we all have to remember that is never how science works.”
  2. “When it comes to sifting through information it is important to look for repetitions and commonalities in the data. Science is about repetition. Any experiment should be repeatable, and produce similar findings. Three or four studies do something a little bit different, but the story should generally be the same.  If you find a study that stands out as different, then you have to ask the question, why is this one study different?” Dr. Kingsley reminds us that the difference could be strength or a weakness. He stated, “You should probably read more than just one piece of information from one source.”
  3. Finally he finished by stating “Look to understand both sides of the coin.” While commonalities are important, so are differences.  Scientists should embrace and understand them.  A great argument or point of discussion requires an open-mind, so at the minimum people should be exposed to both sides. This allows them to make a decision supported by the embraced evidence. Remember, this doesn’t make the other side wrong, sometimes it’s just a different perspective.”

Dr. Babajide Ojo is currently a research Fellow at Cincinnati Children’s, in Cincinnati, Ohio, US. His interests are involved with gastroenterology, hepatology, and nutrition. Dr. Ojo is earlier than Dr. Kingsley in his career and shared his thoughts shared below.

  1. He states the first challenge is related to fear. “Misinformation sells and already has a huge following. Breaking through huge following can be a bit scary especially for young scientists trying to establish themselves. Social media is now the number one channel for communicating scientific information to lay audiences. As a scientist with nutrition training, I see the supplement industry as a mess. People spewing a lot of advice on social media that are not backed by repeatable and valid research. My fear is not always about challenging the fake experts, but if I get into it with people on social media for this “good cause”, I worry about my image with my boss, my employer, future employers, and so on. What if some of the big supplement companies have some influence in government regulatory bodies, or with my employer?  Unfortunately, this is a real worry for some of my colleagues.”
  2. Dr. Ojo statement reminds us there is little to no reward in academia for science communication to lay audiences. “Why bother? So we decide to focus our time on what pays the bills– the science. This creates a vacuum that the fake experts have capitalized on.”
  3. Finally the third challenge Dr. Ojo states is related to the dearth of mentors. “When you look at senior scientists and achievers in your field, most individuals are where they are at because of science. Therefore, we naturally thread the path of our seniors to achieve that level of excellence in the field.”

Whether it’s remembering your fundamentals like repeatability, or strengths and limitations of a study design, or bringing a concern to help mentorship types of relationships change focus. Dr. Sylow puts misinformation concern best by stating in the article,

“The concern is less about perceptions of consensus, but about what it stands for. If the public are convinced that science is not settled, why would the public weigh scientific facts more heavily than conspiracy beliefs or “alternative facts.”

Misinformation is here to stay, scientists should continue to engage with transparency in the best ways available. You can find Dr. Sylow’s publication in the references below.

  1. Sylow L. Three challenges of being a scientist in an age of misinformation.
  2. Scheufele DA. Science communication as political communication. Proceedings of the National Academy of Sciences. 2014 Sep 16;111(Supplement 4):13585-92.
  3. Drummond C, Fischhoff B. Individuals with greater science literacy and education have more polarized beliefs on controversial science topics. Proceedings of the National Academy of Sciences. 2017 Sep 5;114(36):9587-92.

 

“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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Art in Science

In 2020, my resolution/quarantine hobby was learning how to draw and paint. The year before, I had to make a figure for a review paper, but I was paralyzed for weeks because I didn’t know what to make, and I thought I was bad at drawing. Determined not to let that happen again, I started figure drawing and soon delved into the intricacies of portraying plants and animals in watercolor. It reminded me of the botany class I took in college where every week we trekked through the Illinois forest and made anatomically accurate sketches of the plants we saw.

Art and science have always gone hand in hand. Leonardo da Vinci was skilled in dissection and was one of the first to create detailed drawings of the human heart and describe coronary artery disease. Current science and medical illustrators use a mix of photorealism, illustrative diagrams, and data visualizations as teaching tools. Other times, art is used to tell a story or promote the public interest, as Ashley Cecil did during her time as artist-in-residence at the Carnegie Museum of Natural History and the Richards-Zawacki lab at the University of Pittsburgh.

Illustrations have been essential during the COVID-19 pandemic, starting with the spiky blob that has been the face of the virus. Everywhere we go, there are images of proper mask-wearing, hand-washing, social distancing, COVID-19 symptoms to watch for, nasal swab testing procedures, and now, vaccination information. Data visualizations (less artsy) such as the Johns Hopkins COVID-19 dashboard have also helped us to keep track of infection trends.

CDC/ Alissa Eckert, MSMI; Dan Higgins, MAMS

Although text and graphs get the point across, there are many opportunities for scientists and physicians to incorporate illustrations:

  • When you want to grab or keep people’s attention. Even simple graphics can add humor and visual interest.
  • When talking to people outside of your field. People may not know the same jargon that you do, it can be easier to convey information with images.
  • For complex ideas, pathways, and processes that are difficult to digest with long, dense paragraphs. Graphical abstracts are also becoming a more popular way to summarize papers.
  • When photographs are too detailed or not possible to take. Anything from a simple sketch to a full color drawing can fill the void.
  • For emphasis. Some points may need to be repeated in different formats.

For future papers and presentations, I’ll be less hesitant to incorporate illustrations of my own. Even if you don’t consider yourself an artist, images and illustrations are freely available from sites such as Smart Servier Medical Art or the CDC’s Public Health Image Library. Or make drawing your newest hobby, too, to gain a greater understanding of your work and the world around you.

“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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February: Black History and American Heart Month

The month of February celebrates Black history and cardiovascular disease – both of which offer unique opportunities. Black History Month celebrates the contributions of African Americans while American Heart Month provides opportunities to highlight the burden of cardiovascular disease. This is no way an exhaustive list, but who have contributed to the history of medicine.

James Derham (or perhaps it was Durham) is believed to be the first Black person to officially practice medicine in the U.S and without a medical degree. It is believed he learned by way of apprenticeships which was a major form of passing skills to those who didn’t (or couldn’t) attend university. He was born a slave and worked for many doctors. He was able to buy his freedom and continue to practice, but by the early 1800s, James disappears from history. Some say he was murdered and others believe he left Philadelphia to practice medicine elsewhere.

 

Vivien Theodore Thomas was born in New Iberia, Louisiana and attending high school in Nashville in the 1920s. Vivien always wanted to be a doctor but due to the Great Depression he was forced to work instead. He eventually, became an assistant to surgeon Alfred Blalcok – most noted for his work in shock and Tetralogy of Fallot. Their hard work (along with Dr. Helen Taussig) created the Blalock-Thomas-Taussig Shunt, an operation that ushered in the modern era of cardiac surgery. In 1976, Vivien was awarded an honorary doctorate and named an instructor for surgery at Johns Hopkins School of Medicine. A great movie I saw about Vivien was Something the Lord Made and highly recommend it.

 

Rebecca Lee Crumpler was an American nurse, physician, and later turned author. She is believed to be the first African American woman to become a doctor of medicine in the U.S, studying at New England Female Medical College. In 1883, she wrote Book of Medical Discourses dedicated to maternal and pediatric medical care. It was the first publications written by an African American about medicine. After the Civil War, she continued to treat women and children in Virgina. She also worked for the Freedmen’s Bureau to provide medical care for freed slaves.

 

Edith Mae Irby was inspired to become a physician after unfortunately seeing her sister pass from typhoid fever. At a young age, she saw health care disparities first hand and believed her sister passed prematurely due to lack of care because her family was poor. This sparked a fire for Edith to become a physician that found her reward in service not wealth. Edith was the first African-American student admitted to the University of Arkansas Medical School in 1948 and believed to be the first black student enrolled in any all-white medical school in the South. This comes 6 years before the Supreme Court’s decision on Brown v Board of Education.

In the words of poet laureate Amanda Gorman in the poem titled “The Hill We Climb” she states “we will not march back to what was, but move to what shall be.” This exemplifies both Black History and American Heart Month. Knowing where we came from helps us better see where we are going and I look forward to see where we go.

 

“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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So You Want To Apply To Cardiology Fellowship: Tips From the 2020 Application Cycle

The fellowship match process for Cardiology, an increasingly saturated subspecialty with an ever-expanding applicant pool, is extremely competitive. However, the 2020 application cycle proved to be an entirely different beast, with the COVID-19 pandemic and the inability to interview in-person adding layers of complexity to an already confusing process.

Applicants and fellowship program directors alike wrung their hands over the impersonal nature of Zoom interviews (how could you really feel the “vibe” of a place from a Zoom?). Sure, costs decreased because programs were not “wining and dining” applicants and applicants did not have to travel while working full-time. But this democratization of the application process had the adverse effect of leading many applicants to apply to many more programs. Cardiology program directors were overwhelmed by record numbers of applications. Concurrently, applicants were distressed about not receiving interview invitations. It was tough.

As someone that just matched into Cardiology, I would like to offer some unsolicited advice for future fellowship applicants:

DO be judicious in how you build your Cardiology resume

Fellowship applicants are told that they need to join projects or produce manuscripts to “show interest” in Cardiology. While it is important that you explore Cardiology outside of your clinical rotations, it is also important to choose quality over quantity and not over-commit to projects for the sole purpose of buffing your resume. For each possible project or extracurricular activity, be a little bit selfish and ask yourself, what will I get out of this experience? Will you acquire new skills? Will you gain valuable new insight or knowledge? Will you build relationships with great mentors? How will that project fit into your personal narrative or your career interests within Cardiology? Your time is precious. Spend it developing meaningful, in-depth experiences that help you grow as a future cardiologist, not just checking off boxes.

DO give yourself time to make your personal statement about YOU

Writing is hard. I love writing, but I find it uniquely painful and time-consuming. My first drafts are awful; I go through countless edits before landing on a final product that I can tolerate. Writing personal statements is EXTRA hard because we are bad at writing about ourselves and framing our lives and career goals into a short, neat narrative. Instead, we resort to narratives about patients (nice, but says nothing about who YOU are) or generic maxims (ditto). Your personal statement needs to be PERSONAL. It should be about YOU, the journey you took to get to where you are today, and the journey you hope to embark on next. What MUST the reader absolutely know about you by the time they get to the end of the essay? Does a sentence or paragraph reveal anything about you or does it serve a purpose in telling your story? If the answer to either of these questions is “No,” cut that sentence/paragraph out. Be brutal. Lastly, find out who in your life is a good editor and ask them for lots of feedback.

DO be realistic / DON’T take away opportunities from other people

Some applicants are overly confident and do not apply to enough programs. Some apply to way too many, ultimately interviewing at programs in which they are not truly interested, thus shutting out other applicants who would have loved to interview at those programs. How do I know if I am a competitive applicant? How many applications is too many?, you might ask. The only way to know is to make a list of programs to which you’d like to apply and show it to trusted advisors (e.g. your program director). Solicit their honest feedback so that you can make an informed decision about what you need to do to be able to match.

DO research the institutions to which you apply and interview

There are many great Cardiology fellowship programs. There are no “best” programs. The best program for you is one that aligns with your career goals. Different programs have different flavors, strengths, and weaknesses. While interviewing, I realized that some programs were a great fit for me and my specific interests, while other, equally amazing programs were not. The only way to figure out whether a program might be well-tailored to your interests is to research programs before you apply (search online, talk to people that know the program), research them again before your interview, and ask lots of questions during your interview day. If you know before you even apply that a program would not be a good fit for you, why apply there?

DO pre-plan your Zoom interview space

Are you the kind of person that goes with the flow? Or do you get anxious and feel the need to exert control over your surroundings? If you are the former, then great! If you are more high-strung, however, plan your Zoom space out in advance so that there are no unpleasant surprises on Game Day. Where are you going to place the camera? Does your laptop need to be propped up so that the camera is in line with your eyesight? Do you need additional lighting so that others can see you well? Is there too much noise from your surrounding milieu? Does your location have a reliable internet connection? Do you wish to display anything behind you while you are on Zoom? Note that anything you display on screen [e.g. books, artwork] is an open invitation for the interviewer to ask you questions about said item.

DO talk to acquaintances at fellowship programs

Now that interviews are on Zoom, it is as important as ever to talk to current Cardiology fellows and solicit their honest opinions about programs. I found talking one-on-one with people I knew at various fellowship programs to be more helpful in giving me a sense of that program’s “vibe” than just about anything else I heard on interview day. Ask to talk one-on-one with a fellow at every program with which you interview (i.e. someone who attended your medical school or residency, who is from a similar area or who has something in common with you). After these conversations, I felt more confident that I knew what I needed to know in order to make informed decisions about where to place programs on my rank list.

DO think about your “5-10 year plan” and career goals

We all dread the interview question about our “5-10 year plan.” However, rest assured that you will be asked about it at virtually every interview. The fellowship is the final training ground before you launch into your career. Because many people often stay at their institution after fellowship, your fellowship interview in some ways doubles as a faculty interview. The program will view you as a long-term investment and they want to know what you would bring to the department. With that in mind, think about your narrative. How will you “package” yourself? Sure, everyone knows that things might change in the future, but as things stand right now, what niche will you carve out for yourself if you become faculty in the department after fellowship? You should be ready to answer these questions.

DON’T be afraid to preserve your spirit

Interviewing can be fun, but it can also be stressful when paired with an 80-hour-per-week job. Find ways to decompress before, after, or during your interview day. Exercise as needed, spend time with family, debrief with friends, take breaks. For self-care, on Zoom interview days, I would select a 30-60 minute window when I was not on camera and leave my apartment to grab a coffee (yes, I went to the coffee shop in a suit!). It broke up my day, reenergized me, and made me feel like I was at a real in-person interview.

DO be yourself
You should always be professional and courteous to others. However, that does not mean that you need to be a robot! Do not be afraid to let your personality shine. You will have more interesting interactions with others and you will come across as more relatable. More importantly, depending on how the people on the other side of the screen respond, it may help you decide if a program is the right fit for you. Never be anyone other than yourself. You deserve to be at a program that will welcome you for who you are.

 

“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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Update on ACC/AHA Valvular Heart Disease Guidelines 2020: Deep Dive into Aortic Stenosis Treatment Options

“2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease” was co-published in the Circulation and in the Journal of the American College of Cardiology on December 17th, 2020. In this article, I will provide the recommendations and updates from these guidelines particularly the new changes compared to the older valvular disease guideline statement from 2014 and a focused update from 2017 as it pertains to aortic stenosis. In developing these recommendations, the writing committee used the available research through March 1st, 2020. Given the explosion of trials and studies in aortic stenosis (AS) management, the guidelines serve as a one-stop-shop for clinicians to dive deep for some guidance while taking care of patients with AS.

Aortic valve Recommendations:

The major change from the previous guidelines is that for symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years, TAVI (transcatheter aortic valve implantation) is recommended (Class 1) while for symptomatic patients with severe AS between age 65-80 with no anatomic contraindication to transfemoral TAVI, shared decision-making is emphasized, and the recommendation is either SAVR (surgical aortic valve replacement) or TAVI (Class 1).  Timing of aortic stenosis treatment is still largely decided by symptoms; however, asymptomatic patients with severe AS and low EF <50% are considered Class 1 for treatment. Similarly asymptomatic patients with severe AS and decreased exercise tolerance, or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise, or very severe AS (V2 ≥5 m/s), a BNP level  >3 times normal, or serial testing shows an increase in V2 ≥0.3 m/s per year are a Class 2 indication for valve replacement. The guidelines note the evidence from low-risk PARTNER 3 and Evolut trials.

Class 1 indication for SAVR
Class 1/A: Symptomatic severe AS
Class 1/B-NR: Symptomatic low flow low gradient severe AS with reduced LV EF (left ventricular ejection fraction)
Class 1/B-NR: Symptomatic low flow low gradient severe AS with normal EF when AS is the cause of the symptoms.
Class 1/B-NR: Asymptomatic severe AS and an LVEF <50%
Class1/B-NR: Asymptomatic going for other cardiac surgery
Class 1 for  SAVR or TAVI
Class 1/A: Symptomatic severe AS patients 65 to 80 with no contraindication to TAVI either SAVR or TAVI
Class 1 for TAVI (transcatheter aortic valve implantation)
Class 1/A: Symptomatic severe AS patients >80 or for younger patients with a life expectancy <10 years, TAVI recommended
Class 1/B-NR Asymptomatic patients with age >80 years with severe AS and an LVEF<50

 

The guidelines put much emphasis on “shared decision making with the patient” taking into account the patient’s values and preferences and include the discussion of the risk of anticoagulation therapy and the potential need for and risk associated with aortic valve interventions. Another point to note from the guidelines is that the differences in the treatment approaches are driven by the overall risk of the patient. Risk assessment involves but is not limited to the STS(Society of Thoracic Surgeons) score. Per the new guidelines, low risk is defined by an STS score of <3%. A risk assessment also includes the determination of frailty, cardiac and other system compromises, and procedure-specific impediments. These are nicely outlined in the guidelines, and in my opinion, every general cardiologist should dive deep into these risk assessment tools to determine the risk associated with aortic valve procedural treatment accurately for an individual patient. Table 9 in the guidelines includes examples of procedure-specific risk factors for interventions not incorporated into existing risk scores. As the options for the treatment of aortic valve heart disease has broadened, the value of the multidisciplinary heart valve team and heart valve centers has become apparent and this is clearly recognized in the guidelines. Primary and comprehensive heart valve centers are defined by the expertise and treatment options offered in the management of patients with valvular heart disease.

Another point to note is that asymptomatic severe AS category, SAVR versus TAVI options are only available for patients with severe AS and low EF <50%. For other factors that indirectly identify LV decompensation or faster progression of AS like decreased exercise tolerance or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise or a BNP level i>3 times normal or serial testing shows an increase in V2 ≥0.3 m/s per year, SAVR is recommended in preference to TAVI.  As the level of evidence builds up for role of TAVI in an asymptomatic category, it has the potential to be truly be a game changer treatment option for AS patients.

References:

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published online ahead of print December 17, 2020]. Circulation. doi: 10.1161/CIR.0000000000000923

“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.”