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Happy July 1: Cardiology Fellowship Begins

Anyone in the medical field knows the significance of July 1.  Don’t get sick in July, they say, because the hospital is full of brand-new residents and fellows.  For me, cardiology fellowship begins right where internal medicine residency left off—at Emory.  At least I know where to park and how to find the bathrooms.

This year we have a tight-knit group of six clinical fellows.  At orientation, we practiced performing echocardiograms on each other, taking turns squinting at gray speckles on a dark screen.  That night, we raised our drinks to say a toast—and to wash away our nerves.  And soon enough, I’m strolling into the hospital sporting my new white coat, which drapes over my shoulders like an oversized tent.  The coat fits awkwardly, in both a physical and figurative sense.

I’m told you don’t even feel like a real cardiologist until you’ve learned to perform heart catheterizations and read echocardiograms.  Ask me again in six months.  For now, I start with general consults, where I’m the cardiology consultant for other physicians in the hospital.  The hardest part about inexperience is the decision-making fatigue—even trivial decisions require excessive mental effort.  To overcome this, the goal is to see as many bread-and-butter cases as possible, to build a sort of muscle memory.

It’s been a wonderful year on this blog, reminiscing the end of residency, chronicling the start of fellowship, and pondering the milestones yet to come.  What gives me comfort at this moment is the supportive culture of my program, where I can always lean on co-fellows and attendings.  I’ll keep this mind as I tackle the next major hurdle—my first overnight call.  Just thinking about it gives me palpitations.

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The Joys of Teaching

This June I had the pleasure of working with high school students participating in the 4-H Teen Conference held at the University of Kentucky. Underneath their health major, another student and myself proposed a nutrition course titled #HealthGoals. Together, the objective of our course was to inform students of basic nutrition facts, guidelines, and consequences of overnutrition, as well as to introduce the students to fruits that are traditionally less eaten, and healthier snack options. While my colleague and I prepared intensively for the class, what we were not ready for was how much joy our group of students were going to bring us. We packed each day with interactive nutrition activities and games and on the last day played, what turned out to be, a very competitive game of jeopardy. However, what made each class spectacular was how engaged each student deemed to be. We received all types of questions ranging from why do we need water to what we thought about the ketogenic diet. With this being a group of high school students, one thing that was important to us was ensuring that each day be filled with engaging activities that would best promote learning and retention. Each student came equipped with varying educational backgrounds. However, whatever the case may be, we wanted, possibly their first, nutrition educational experience to be an impactful one.

For the course the bulk of the class consisted of a powerpoint prepared with basic nutrition facts such as how many servings of fruits and vegetables are required for their age group, for example. However, we made sure to break up the powerpoint with fun Kazoot.it quizzes. Other activities that the students did to break up the lecture included:

  • Create an individualized meal plan utilizing Choose MyPlate
  • Make a healthy “no bake” snack
  • 1-minute presentations on their favorite fruit/vegetable that included the season it is grown in, calories per serving, ways to prepare it, and key nutrients
  • “Non-traditional” fruit tasting that included students peeling and cutting the fruit
  • Jeopardy
  • Long and short term health goals and how to reach them

Maybe this is how it always feels to teach, or maybe we just got lucky with an amazing group of students. Whatever the case may be, this is a memory that I will cherish forever.

Can you think back to your first teaching experience? Is there anything that you would change or knowledge you would pass on to help future educators?

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What Is A Good Doctor?

Before beginning medical school, I believed that the best doctors were those who were geniuses, similar to the fictional Dr. House. They would walk in to a patient’s room, ask one or two questions, and immediately diagnose them without a sense of doubt. They would then walk out with a smug look as they told the team the correct treatment which ultimately saved the patient’s life. They remembered esoteric medical facts that solved mystery cases, leaving everyone else on the medical team in awe.

The more I go through medicine as a trainee, however, I am starting to realize the following: You will save more lives by being thorough than by trying to be a genius.

The best doctors chart checks their patients fully before seeing them. They read every note.  They review each lab and chase down every abnormality regardless of whether or not it is the patient’s primary problem. They read every sentence in an imaging report to make sure nothing is missed. When they interview a patient, their HPI and review of systems is exhaustive.

They go a step beyond by remembering personal facts about each patient that they see. They comfort patients when there is doubt, and they inspire their trainees to be better and spend more time on their craft. They know when the risks and harm of invasive procedures outweigh the potential benefits. They do not see time as a boundary and focus their effort on addressing every patient’s medical and psychosocial care.

An attending once told me, “The only factor that will remain the same between who you are now and who you will be 5 years from now is your work ethic. Experience is always going to make you better and build on your knowledge. However, it’s how thorough you are that is going to make the difference.”

 

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Public Speaking: How (and why) to give a killer talk.

When my sister was in law school, I visited a class with her— not on torts or contracts, but on public speaking. They practiced things like improv games and role playing. They videotaped themselves speaking and did self-critiques. Now, persuasive public speaking is obviously a skill that lawyers need, but we science folks need it to. Do we not regularly need to convince people of the value of our work? We do. And many of us never get very good at it.

Why Should You Bother With Presenting, When It’s So Nerve Wracking?

Here’s a short list of reasons why you might give a talk: Disseminate science. Make a name for yourself. Defend your dissertation. Get hired in an academic position. Get things on your CV that look good when you’re chasing tenure. Educate the public (I want to put in a plug for this one— speak to a general audience sometimes! Science is for everyone). Teach students. Share clinical knowledge— think grand rounds. Persuade colleagues to adopt better practices. Make something complex and specialized more accessible to a wider audience. Get free or discounted conference fees (maybe!). Get paid (maybe!). Get your travel paid for (maybe!).

author at Disney world

The author presented at a conference held at Disneyland– who says work can’t be fun?

How Can you Hone Your Speaking Skills? 

If I’ve done my job so far, you’re convinced that giving a talk can help your career. But not all talks are created equal! We’ve all sat through terrible talks, shifting in our seats and surreptitiously checking twitter. Conversely, a truly excellent talk can be inspiring. How do you set yourself up to give one of those?

My suggestions:

  • Practice often. Give your talk to a colleague who will be honest with you. Give your talk to a friend who’s not in your field to judge clarity.
  • Time yourself until you know you have it down to the required length— and give yourself a buffer (plan to talk for 20 minutes if the slot is for 25).
  • Use visuals thoughtfully & be sure they help you make your key points. Never say “I know you can’t see this but,” or, “I’m sorry this is such a busy slide.” If you see those issues, fix them.
  • Don’t read your slides. They’re there to help the audience follow along, not to serve as cue cards. Remember that what you write in your paper isn’t exactly the same what you say in your talk— keep the ideas, but spoken language is often less formal and less complex. Also when someone is reading a script, it’s clear to the audience. So get used to speaking from key points rather than scripted sentences.
  • Tell stories. This is a universally engaging technique. Whether this means including a personal anecdote or a real-world application related to your subject, it helps make you interesting and memorable.
  • Know your audience.  How much background do you need to give? What terms do you need to define? Are they interested in the fine points of your data, or just the take-home message?
  • Pay attention to great (and awful) talks you attend. What made it good, or bad?
  • Consider inclusivity. Are you speaking at an event that represents varied races, genders, fields, and ages? NIH head Francis Collins recently committed to saying “yes” only to events with a diverse makeup. You can do this too. Second, consider the images and references in your materials. Are they culturally inclusive? If not, fix it.

 

What Can I Speak About, and Where Can I Do It?

Say yes a lot when you’re new— both the exposure and the practice are valuable. When you’re more established, you have to learn to say no to things, but when you’re finding your way, every time you say yes, you are honing your skills.

The author presenting at a national conference

Here are a few talks I’ve given recently:

  • Cardiovascular Physical assessment skills 101 (to NP students).
  • Women’s heart health: Know your risk and live your life (to retirement community residents)
  • Symptom trajectories after an emergency department visit for acute coronary syndrome (to a research regional conference audience)
  • Simulation in nurse practitioner education (to an education-based national conference audience)
  • Education strategies to expand access to care in rural and underserved communities (for a job talk)
  • Technology innovations to engage online NP students (to a national practice-based conference audience)

Note that they’re all to different audiences, and while the content overlaps in two of my main focus areas (women’s cardiovascular health and nurse practitioner education), I didn’t try to give the same talk to every group I spoke to.

Consider asking a senior scientist or mentor to throw things your way— they are likely turning down invitations that they’re too busy to accept. Submit abstracts to local, regional, and national conferences. Volunteer to give guest lectures to students. With this kind of exposure, you can really build your reputation as an expert on your area. Break a leg!

 

Public speaking resources:

 

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It’s conference season! Did you pack your inclusive resources?

Summer is in full swing, which means it’s conference season! At every stage of our careers, conferences are essential for our growth as professionals, but these meetings need to be inclusive of everyone attending for them to have the most meaningful impact. Maybe you’ve never had any issues attending a conference and don’t really see why something like this would need to be discussed, in which case, great for you, but I implore you to keep reading!

conference attendees

Photo by Product School on Unsplash

Diversity within our scientific communities is extremely powerful and strengthens the outcomes of our work, however, the structure of our community has traditionally only taken one kind of person into account, which prevents the rest of the members from flourishing. We need to ensure that these critical meetings are inclusive from the planning stages all the way to the actual presentations given on the day. Whether you are planning the meeting, presenting or attending, there are ways we can all work together to make these experiences successful for everyone.

Luckily, other organizations have put together helpful resources focused on this specific topic that we can all benefit from. These are obviously just a few select resources – I urge you to start with these but seek out more.

  • If you are planning a meeting or symposium, the 500 Women Scientists have created a comprehensive guide to organizing an inclusive meeting that is definitely worth using. It also explains what implicit bias is and why guides like this are necessary. There are also resources for mindful gender pronoun usage as well as ensuring gender neutral restrooms are available.
  • To make sure that your conference is accessible to disabled people as well, Gabi Serrato Marks published this guide via the Union of Concerned Scientists. What’s great about this How-To is that it’s helpful for organizers, presenters and attendees.
    • Google slides and PowerPoint now allows you to automatically add closed captions to your presentation, which automatically increases the accessibility!
  • Does the conference have reasonable accommodations for lactating scientists? Access to these spaces is critical for those caring for infants while attending the conference – this wonderful guide is a great place for organizers to start as well as for attendees to use to suggest improvements.
  • Academic conferences also need to be prepared to handle reports of harassment (sexual or otherwise) during the meeting. Does your professional society have a code of conduct for expected behavior and enforcement procedures to handle these issues? If not, the American Geophysical Union, has a great example to suggest for the future.

Conference season should be an exciting time for all scientists/physicians, let’s work together to make sure this becomes the reality.

 

 

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Managing High Blood Pressure by Managing Stress

manage stressWe are faced with a number of changes in our lives. The old saying, “life happens” generally means take the changes as they come and keep it moving. The human body is not equipped to distinguish between distress and eustress. Amazing life changes happens such as getting acknowledged for an accomplishment, passing the preliminary exams for a PhD program, getting the job of your dreams, or even getting the funding you have worked so hard to apply for consideration. Contrarily, changes that can be viewed as less than optimal such as being passed over for a promotion, losing the sole source of your family’s income, death of dreams, and rejection are all sources of stress. Good or bad, these events affect hypertensive rates potentially leading to a more serious chronic illness such as heart attacks, strokes, or even metabolic disease.

Often people, especially scientist and clinicians think their stress is just a way of life and there is nothing that can be done about that constant state. Scientist are always on the hunt for research funding and publishing; while clinicians holds the consequences of a person’s life in each of their decisions. These are significant burdens for a person to hold. It is imperative to manage stress as a means of preventing and treating high blood pressure. It is definitely easier said than done, but attempting these steps to control stress could lead to a better life:

  • Sleep quality and quantity can make a huge difference in managing mental alertness and energy but sleep allows the body time to relax and heal. Quality sleep can aid in the reduction of blood pressure leading to vascular repair.
  • Reiki principles that include meditation enhances muscle and mental relaxation. This include activities such as guided imagery, deep breathing, and massage therapy to act as stress-relievers.
  • Strengthen your social network. Connect with others by taking a class, joining an organization, or participating in a support group.
  • Try to resolve negative situations quickly so they do not fester. It is best to let go of adverse events and interactions; whether it is something that is in or out of your control
  • Don’t be afraid to ask for help from a counselor. Although there is a negative stigma surrounding seeing a therapist they are the best resource for dealing with stressful situations because your spouse, friends, and neighbors generally have as much going on as you and their opinions can be clouded by their own experiences.

I recently started working with a mentor to help with stress and how to interact with individuals to manage stress. As the young adults say, “I like to keep it 100” but often being brutally honest is not received well by the masses. I also made the determination that whether working or interacting on a personal level, I will not extend myself beyond my comfort zone nor will I compromise my values or ethics to fit into anyone’s idea of what I should be doing. Staying true to oneself is among the first steps to happiness and managing blood pressure. I have found that when I over extend myself, my stress level increases and my performance decrease in some areas (namely self care). My life, your life, is not worth negativity. Being that stress is inevitable, I choose the eustress. It is my opinion that this type of stress leads to self happiness and the contribution of the happiness of others.

Thank you for reading this blog. If you would like to share some of your methods for dealing with stress or how you keep your life stress limited, let me know comment or tweet @AnberithaT so we can share ideas.

 

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Learning to Lead in New Ways

Last November, I attended Career Advancement and Leadership Skills for Women in Healthcare, an illuminating conference that changed my approaches to my personal and professional development.

Led by Drs. Julie Silver and Saurabha Bhatnagar, this Harvard Medical School women’s leadership course delivers evidence-based strategies, skills development, and education to help women across health professions assume and succeed in leadership positions. Executive leaders from my institution have written about the critical need for health systems to support emerging physician leaders and to nurture them at each stage of professional advancement. Considering these organizational priorities, I thought that this course would effectively combine education with skills development in a unique environment and would provide strategic and cultural alignment with my own interests in leadership.

The course itself spanned two and a half days with a mix of daily morning plenary sessions, afternoon small group breakout sessions, and evening networking opportunities. From the outset, the tone of the conference was unlike that of any I had previously attended. There was a sense of genuine camaraderie in the rooms, despite the huge number of attendees largely from different clinical, research, and administrative backgrounds. Interpersonal interactions were built on a mutual understanding of the obstacles of underrepresentation and inequity. I noticed how openly women discussed successes and failures, asked questions, and negotiated when surrounded by a supportive group with shared experiences. As one of the few trainees in attendance, I felt especially empowered through hearing about the career trajectories of these successful women leaders.

The first day of the conference focused on identifying your mission and vision, recognizing your leadership potential and style, and learning strategic planning. Here are five of my top takeaways from day 1:

5 takeaways from day 1

The second day focused on refining your oral and written communication skills. Here are five of my top takeaways from day 2:

key takeaways from day 2

In the last session of the conference, Dr. Silver delivered an impassioned call to action for us to take our newly developed skills back to our institutions to share with others and to advance our own careers. After I returned home, I created my own customized plan for career development using the course principles. I also led an abbreviated career advancement and leadership skills workshop for my institution’s Women in Cardiology group, sharing the highlights of what I had learned with my resident, fellow, and faculty colleagues.

For more content from the conference, check out the #SheLeadsHealthcare hashtag on Twitter and this year’s conference project, the #BeEthical campaign.

This year’s course is scheduled for November 14-16, 2019 in Boston, Massachusetts. If you work in health care and are interested in developing your leadership skills, I strongly recommend investing in your personal and professional development through a course like this or another similar experience.

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Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

Balancing versus Integration of Motherhood and Your Career as a Female Cardiologist

As we recently closed the academic year last month, I attended our graduating fellows’ dinner and I was reminded of the continued challenges of motherhood for many female cardiologists.  This reminder came in the form of a conversation I had with one of our Interventional Cardiology fellows who was completing her Interventional fellowship and we were discussing the challenges of being a mother and navigating a career in Cardiology. I gave her some pearls of wisdom from my own experiences that I have had so far in my career and am still learning myself.

These conversations took me back thirteen years ago when I started my fellowship as a general cardiology fellow and was entering into my ninth month of pregnancy. I still remember walking into the cardiology conference room on the first day of fellowship orientation and feeling all the doubts and fears of wondering if I would make it through those three years. Although I had completed my Internal Medicine residency and had garnered the recognition from my attendings and colleagues as a Chief Resident, my confidence was shaken as a young soon to be mother entering this challenging field. There are many pearls of wisdom I have learnt or have been taught along the way. In this month’s blog I will be discussing a few of these pearls of wisdom.

Before discussing these pearls I will delve into the statistics with regards to females and our experience in the Cardiology field.

 

Statistics on Gender gaps in Cardiology  and its Challenges for Mothers

Unfortunately there is still a scarcity of females in the Cardiology field.  Females represent only 13 % of Cardiologists in the United States (US)1. Female representation is even lower in the procedural fields of Cardiology such as Interventional Cardiology where only approximately 8% of interventional cardiologists are females and only 6% of electrophysiologists are females1. Among Cardiologists in the US, 72 percent of female cardiologists are mothers and 86 percent of male cardiologists are fathers. It is important to note that most of these fathers (57%) have a spouse who provides child care at home while only 13% of these mothers have similar support1. This poses a significant challenge for mothers in the field of Cardiology as most often there are long work hours in addition to overnight call particularly during fellowship training. There is also a significant lack of scheduling flexibility during these training years and also in practice. These challenges often result in reliance on extended family members, colleagues,  or hired help to assist with child care.

Another challenge in our field is the concern with regards to radiation exposure particularly during procedural rotations and for proderural specialties such as Interventional Cardiology, Electrophysiology as well as the emerging field of Structural Cardiac Imaging. This poses challenges for mothers who are considering pregnancy or who are pregnant.

Generally, the Cardiology field is perceived as a very difficult field with long and grueling work hours. This perception along with the very unfortunate fact that it is still a male predominant field with potential gender bias and discrimination has resulted in many very talented females avoiding this field altogether.

As mothers in Cardiology we are pulled in 2 different directions, one direction with regards to our patient care and professional duties and responsibilities and the other direction with regards to our duties and responsibilities as a mother. While this seems daunting, there are several actions that can be taken to mitigate these challenges so that we can feel fulfilled both as a mother and as a Cardiologist.

 

Pearls of Wisdom

Build Your Support System- Your “Village”

Regardless of whether you are in training or in practice as a Mother in Cardiology, one thing will remain true throughout your career, you will need to create and build your “village” of support. This village of support will be a necessity particularly with regards to child care during long days and long nights at work. This village of support involves your spouse, extended family members, your colleagues and/or hired help.  This is a must, you will not be able to do this all on your own as much as we may have that “superwoman” mentality. Once you have created and built this village of support you should show your appreciation for each member of this village. This appreciation will go a long way especially when they may have to be called upon in the middle of the night or on weekends to provide child care when you have patient care duties to attend to.

 

Focus on Quality rather than Quantity of time with our Children:

Time with our children is precious, therefore focusing on making that time quality time is what is most important and will be the most memorable. Therefore, on weekends or days when you are away from work spending time with your children doing activities that are engaging, meaningful and fun is important.

 

Time Management

Planning your time both at work and at home with your children is a key factor. A family calendar is very useful in planning and managing time with your kids to ensure that there are no work scheduling conflicts. The weekend is a good time to reset, recover and plan for the week ahead. This may mean that meal plans are created for the week and food may need to be prepped ahead on the weekends so that preparing dinner in the week can be less daunting. This also applies to lunches for the children in the week.Grocery shopping should also be planned to alleviate that additional stress of getting this done in the week. Grocery delivery services may also be useful in this regard. Time for household chores should also be planned and if you are able to outsource some of these tasks to your spouse, older aged children, extended family members or hired help this is recommended.

Time management is also important at work to minimize any unnecessary distractions or interruptions so that we can perform our patient care duties in a safe and time efficient manner. Taking work home should be minimized as this often robs us of precious time that should be spent with our children and has the potential to result in professional burnout.

Time management is also vital with regards to professional activities such as board exam preparation and research activities. My advice is to start planning for these early in your training to give yourself enough lead time to be well prepared for the exam and with regards to research, enough lead time to complete your research activity during your training. As a fellow and even as a practicing cardiologist, a study guide should be created early so that you spend some time each day studying for board exams if applicable and reading the medical literature to keep yourself up to date in the field. Audio files are very useful especially during your commute to and from work as this will readily facilitate board exam preparation and even keeping up with the medical literature.

 

Prioritization

Making a “to do” list and prioritizing this list is important. You cannot do it all at the same time. There are times that less valuable activities with regards to motherhood or with regards to your profession may have to be placed on the “back burner” and revisited at another time when you may be available. There are times when these less valuable activities may even have to be deferred.

 

Finding Your “Me Time” is Important.

It is important to find the time to recharge and take care of yourself. Self care involves small things from finding the time at work to eat healthfully and rehydrate throughout the day. Self care also involves making the time to participate in an activity that takes you away from the throws of the day. This activity may be a hobby such as arts and crafts, gardening, playing an instrument, playing a sport or exercising.  Making the time to exercise is also vital to maintain not only your health but to maintain your physical and mental endurance. Getting adequate sleep is another important part of self care as sleep deprivation results in increased risk of professional burnout and not being able to function at your best throughout  the day. The emphasis is on making this time as often times it is far easier to have an excuse of not having the time to do these activities and it may create guilt as a mother. However, it is important to remember that if you are not happy and energized then this may be reflected at work and at home and in the long run will likely lead to a lack of fulfillment as a mother and as a cardiologist.

If you are feeling overwhelmed, it is important to seek assistance with your responsibilities if possible. Sometimes this assistance may have to be hired help. There are many services in the market that assist not only in child care but also provides assistance with other responsibilities such as professional cleaning services and laundry service. There are also tutoring services available to assist  school  aged children to not only ensure that they are completing assignments but to also ensure that they are keeping up with the school syllabus throughout the school year.

 

Finding a Mentor

Finding a mentor is important as this person not only provides guidance with regards to your career but could also be an advocate for you during your fellowship training. Developing and maintaining this mentorship relationship is invaluable and may evolve as you progress in your career. Having more than one mentor is often recommended as no one mentor will be able to provide guidance on every aspect of your career. For more ideas on the value of mentorship in Cardiology see my earlier blog on this topic.2

 

Negotiate for A Flexible Work Schedule

If it is possible it can be useful if a flexible schedule could be negotiated with your fellowship program director. An example of this would be allowing for time off for maternity leave after delivery of your child with the understanding that your fellowship completion date would be delayed to ensure that the 36 months of fellowship training is completed. Another example is re-arranging the fellowship rotation schedule to avoid exposure to radiation during cardiac cath rotations in your pregnancy. Therefore, during the pregnancy period rotations could be limited to those outside of the cardiac catheterization lab.

As a practicing cardiologist there may be more flexibility for negotiating with your practice group if in private practice or the Cardiology Chair if you are working in a hospital based academic setting to allow for an extended maternity leave  or to have the ability to go part time during the pregnancy. There are unique challenges to these arrangements in a relative value unit (RVU) based productivity model. However, it is useful to try to negotiate for these arrangements to ensure that you have the time that you need to take care of your child after the delivery as those moments are precious and also to ensure that you are able to have the greatest chance for a healthy pregnancy with regards to a reasonable work schedule.

 

Change the things you can and accept the things you cannot change

As a working mother in a demanding job as a Cardiologist it is important to remember that you cannot do it all and you are not perfect. This is a struggle for most of us to remember as many of us are high achieving women. However, as mothers and as physicians we should strive to do our best for our children and the best for our patients with the understanding that there are times the outcome may not be what we hoped for. During these moments we have to realize that we are also human and we can only be expected to change the things we can and accept the things that we cannot change.

 

Work-Life Integration vs. Work Life Balance

Over the last 5 to 10 years the term “work life integration” has been seen as a more realistic goal for working mothers rather than “work life balance” as the latter is seen as more of a myth and a rather unrealistic goal for many. The boundaries between your professional life and your personal life is often blurred especially in a demanding field such as Cardiology. This is even more true in today’s practice environment with electronic medical records and constant connectivity between emails and texts. It is most desirable to unplug when we are away from work, however this is not always possible. We also have to embrace the fact we are working mothers in a demanding field that we can find fulfilling but is sometimes daunting. This means that achieving a balance between your professional life and your personal life is often impossible and many times we may have to incorporate the two roles in a more adaptive work-life integration model. This may mean that there are times you may have to take the kids along with you to a scientific medical meeting and this could be made possible particularly if your spouse or family member is able to attend with you to take care of the children while you are attending the sessions at the meeting. This integration of both of your roles allow for a happier situation both for yourself as a mother not having to spend a prolonged time away from your children  and a happy situation for the children who often see this as vacation time with you. In fact several cardiology professional meetings have made accommodations for nursing mothers with areas designated at the meeting for nursing. This has a far reaching and positive impact for female cardiologists as this encourages attendance to these meetings even if nursing.

 

Conclusion

Being a female cardiologist and a mother, I consider to be a blessing. Our children often look up to us as positive role models as we navigate through a challenging and demanding Cardiology field to take care of our patients while also being able to take care of our children and provide the best life possible for them. I also believe that being a mother teaches us many skills that we often even subconsciously apply to our  jobs as physicians to make us better listeners to our patients and better communicators with our patients. Being a mother also makes us more efficient with our time and more productive at work3. Our children also learn the values of hard work, dedication, compassion and empathy from our role as a Cardiologist. Embracing our roles of motherhood and a practicing female cardiologist can be fulfilling as we have the privilege of having a meaningful positive impact on the health of our patients while taking the best care of our children and “yes” we can have the best of both worlds.

 

References:

  1. Lewis SJ, Mehta LS, Douglas PS, Gulati M, Limacher MC, Poppas A, Walsh MN, Rzeszut AK, Duvernoy CS; American College of Cardiology Women in Cardiology Leadership Council. Changes in the Professional Lives of Cardiologists Over 2 Decades.J Am Coll Cardiol. 2017 Jan 31;69(4):452-462. doi: 10.1016/j.jacc.2016.11.027. Epub 2016 Dec 21. Review.
  2. Bullock-Palmer RP. The Invaluable Importance of Mentorship Throughout Your Career as a Female Cardiologist. American Heart Association Early Career blog site. February 25, 2019. https://earlycareervoice.professional.heart.org/the-invaluable-importance-of-mentorship-throughout-your-career-as-a-female-cardiologist/
  3. Krapf M, Ursprung HW, and Zimmermann C. Parenthood and Productivity of Highly Skilled Labor: Evidence from the Groves of Academe January 11, 2014
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Infrared Thermography-A Novel Technique for Assessment of Regional Blood Flow/Perfusion?

There has been increasing emphasis on non-invasive assessment of regional perfusion abnormality/ endothelial dysfunction-which have often been linked to poor cardiovascular outcomes. Infrared thermography (IT) is a ‘non-contact’ imaging modality which detects infrared heat from the surface of the body and quantifies skin temperature as a surrogate for blood flow for specific vascular territories.2 It may be used to study physiologic blood flow abnormalities related to temperature distribution in various conditions specifically in the extremities. It produces a visual heat-map display and allows objective temperature measurement with regional temperature assessment to evaluate vascular perfusion.2 IT has the advantages of being noninvasive, fast, reliable, with non-contact, capable of producing multiple recordings at short time intervals, and safe for patients and doctors.1 The temperatures of a large number of points on the area of skin under consideration is measured, and a ‘heat map’ is subsequently produced with color coding for areas of relative ‘colder’ temperatures, or elevated temperatures as a consequence of local inflammation, after acclimatization of the individual to ambient temperature.

Of particular interest for practitioners of cardiovascular medicine is the utility of IT in the assessment of peripheral vascular diseases and more specifically in the assessment of hand perfusion after trans radial cardiac catheterization. IT has been shown to be capable of diagnosing  lower extremity peripheral arterial diseases, especially post exercise1. Of possible greater interest to the interventional community specifically, IT has recently shown2 a possible way to assess for microvascular dysfunction in the circulation of the hand post trans radial cardiac catheterization. There appears to be some concern for patients with poor circulation of the ulnar artery. As a practicing interventional cardiologist, after recently becoming aware of this modality, it appears to be a novel way to monitor for hand microvascular dysfunction in real-time, especially for prolonged radial cases or those with compromised baseline ulnar artery flow. There also appears to be scope for future research in identifying best practices and interventions to improve such microvascular dysfunction, should they occur. It would be interesting to hear of experience(s) in using this novel technology!

 

References:

  1. Huang CL, Wu YW, Hwang CL, Jong YS, Chao CL, Chen WJ, et al. The application of infrared thermography in evaluation of patients at high risk for lower extremity peripheral arterial disease. J Vasc Surg 2011;54:1074–80.
  2. Maki KA, Griza DS, Phillips SA, Wolska BM, Vidovich MI. Altered Hand Temperatures Following Transradial Cardiac Catheterization: A Thermography Study. Cardiovasc Revasc Med. 2019 Jun;20(6):496-502. doi: 10.1016/j.carrev.2018.07.024.
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To RESTART or Not to RESTART- That is The Question

During the European Stroke Organization conference, clinical trial results were presented, including investigation of treatments and outcomes of both ischemic and hemorrhagic stroke.

One of the most remarkable and surprising results were from the RESTART trial1 presented by Professor Rustam Al-Shahi Salman (Twitter @BleedingStroke) from the University of Edinburgh. This randomized open label trial was designed to answer the question whether antiplatelet medications can be safely restarted in patients who survive a recent intracerebral hemorrhage. The study participants were enrolled from 122 hospitals in the UK and included adults who had developed an intracerebral hemorrhage while on an antithrombotic medication for prevention of ischemic vascular disease.1 A total of 537 patients were randomly assigned to either restart or continue to avoid antiplatelet medication and followed for a median of 2 years for a primary outcome of recurrent symptomatic intracerebral hemorrhage.  In the group assigned to restarting antiplatelet medications, 12 of 268 subjects experienced recurrent intracerebral hemorrhage as compared to 23 of 268 in the group assigned to avoid antiplatelets (p=0.06).1 The rates of all major hemorrhage events in the two groups were similar: 7% in the treatment group and 9% in the avoiding group (p=0.27). There was no difference in the rates of occlusive vascular events which were seen at 15% in the treatment group and 14% in the avoiding group (p=0.92).1

Prior evidence suggests that aspirin is beneficial for secondary prevention of ischemic vascular events, notwithstanding a small increase in the risk of intracerebral hemorrhage2. RESTART is the first RCT studying the effects of restarting aspirin in patients with a prior history of ischemic vascular disease and a recent intracerebral hemorrhage. While not statistically significant, the results demonstrate a lower rate of recurrent hemorrhage if antiplatelet medications are resumed for prevention of occlusive vascular disease despite a recent intracerebral hemorrhage. The composite secondary outcome of non-fatal MI, non-fatal stroke or death from a vascular cause was seen at a significantly lower rate in the treatment group (p=0.025) as compared to the antiplatelet avoiding group.2

The reduced risk of recurrent hemorrhage risk is a surprising finding and needs further confirmation. The authors postulate that this can be potentially explained by shared mechanistic pathways between ischemic stroke and intracerebral hemorrhage.

The results from this trial provide reassurance that antiplatelet medications can be safely restarted for secondary ischemic event prophylaxis in patients with a recent intracerebral hemorrhage. There are ongoing clinical trials including RESTART-Fr3 and STAT ICH4 and the results from these would provide more insight into the effects of antiplatelet therapy resumption after an intracerebral hemorrhage.

 

References:

  1. Effects of antiplatelet therapy after stroke due to intracerebral haemorrhage (RESTART): a randomised, open-label trial. Lancet. 2019 May 21. RESTART Collaboration.
  2. Antithrombotic Trialists’ (ATT) Collaboration Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet. 2009; 373: 1849-1860. Baigent C, Blackwell L et al.
  3. https://clinicaltrials.gov/ct2/show/NCT02966119
  4. https://clinicaltrials.gov/ct2/show/NCT03186729