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Let’s Ban the Phrase “Social Issues”: Social Justice and Advanced Heart Failure Therapies

Everyone on our unit seems to know Tina. Tina is a 50-year-old Black woman. She is single, has two kids and does not have stable housing, currently living with an abusive man in one of the poorest neighborhoods in Baltimore. She has nonischemic cardiomyopathy and has been admitted numerous times to the inpatient Cardiology service.

Each time, she is admitted for acute decompensated heart failure, diuresis aggressively to euvolemia, and discharged. She has not “tolerated” previous attempts to start guideline-directed medical therapy (GDMT), so the only heart failure medication she takes at home is an oral diuretic. “Behavioral issues” are flagged all over her chart: she has left against medical advice, has demonstrated “poor insight” into her medical condition, and has refused medications and treatments.

This admission is no different. When I first meet her, she is teetering on cardiogenic shock, twenty pounds above her dry weight, dry heaving and confused, her extremities cool. She quickly turns around with inotropic support and diuretics and is now doing a lot better. I’ve managed to convince the team to re-trial GDMT and we have her on a low-dose ACE inhibitor and spironolactone. The nurses on our floor have also taken a liking to her and have banded together to help care for her on her own terms. Tina is doing all of the things we are asking of her.

But what will the future look like for Tina? She has entered that unfortunate spiral in which all patients with advanced heart failure find themselves: recurrent and increasingly frequent hospitalizations, progressive decline, and seemingly no way out. One day on rounds, we discuss her options. A member of our team mentions offhand that she is obviously not a candidate for advanced therapies due to her “social issues” and her lack of adherence to prescribed therapies.

Every time I hear the words “social issues” in the hospital, I shudder and think about how loaded the phrase is. It’s a catch-all euphemism that physicians use to describe patients who face obstacles extending beyond their medical environment and into their social or contextual environment. These patients, like Tina, share certain characteristics: they are female, Black or brown, poor and live in socioeconomically deprived neighborhoods. Moreover, these patients with “social issues” do not qualify for advanced heart failure therapies such as left ventricular assist devices (LVADs) and heart transplants.

Indeed, this trend is supported by the medical literature. A recent study published in Circulation: Cardiovascular Quality and Outcomes found that women, Black patients, Latinx patients, Medicare and Medicaid patients, and those living in lower-income areas were less likely to receive LVADs than their more privileged white, male, insured counterparts living in higher-income areas.1 Likewise, another recent study published in Circulation found that a patient’s race influenced decision-making around selection for a heart transplant.2 Disparities also extend to outcomes related to these advanced therapies, as highlighted by a Circulation: Heart Failure study that found socioeconomic and racial disparities in outcomes after a heart transplant.3

In the face of such evidence, we must challenge the status quo on behalf of our patients with “social issues.” We must question the presumption that they are simply ineligible for advanced heart failure therapies. We must investigate the role that personal, social, and contextual factors have played in bringing them to the precipice of death from end-stage heart failure. We must ask ourselves how their lifelong experiences with racism and discrimination in the hands of healthcare providers affect their trust in us. We must ask ourselves which societal forces of socioeconomic oppression and structural racism make it difficult for them to obtain the care they need to live a better life. And finally, we must look inward and acknowledge the ways in which we as health care providers perpetuate racism and discrimination against them through our own words, discussions, and actions.

Most importantly, we must figure out how to right this injustice, so that we do not just take it for granted that patients like Tina cannot access LVADs and heart transplants. We need to determine what we must do to help these patients receive the same advanced interventions that their privileged contemporaries are offered.  Everyone should have equal access to these therapies; our work as cardiologists, physicians and good citizens of our society is not done until the words “social issues” are banned from our lexicon and are no longer used to disqualify patients from receiving life-saving therapies.

References:

  1. Wang X, Luke AA, Vader JM, Maddox TM, Joynt Maddox KE. Disparities and Impact of Medicaid Expansion on Left Ventricular Assist Device Implantation and Outcomes. Circulation. Cardiovascular quality and outcomes. 2020;13(6):e006284.
  2. Kuehn BM. Race May Influence Transplant Decision Making in Heart Failure: Studies Also Detail Disparities in Hypertension Diagnosis, Statin Prescribing. Circulation. 2020;141(8):694-695.
  3. Wayda B, Clemons A, Givens RC, et al. Socioeconomic Disparities in Adherence and Outcomes After Heart Transplant: A UNOS (United Network for Organ Sharing) Registry Analysis. Circulation. Heart failure. 2018;11(3):e004173.

“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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Reflections of 2020: adaptations and lessons learned

2020 came, a pandemic hit, and 2020 left. It was an extraordinary year in which words such as unprecedented, exponential and social distancing forced their way into our ordinary vocabulary. Hopefully, we won’t have to live another year like that in our lifetimes, but let’s exercise some cautious optimism in that respect. It took a toll on everyone, both physically and mentally, but perhaps the brunt of it was borne by essential workers, notably those involved in healthcare. Many had to work extra hours, often at the expense of time spent with loved ones, often young children. Many of us have not been able to visit family in almost a year, due to travel restrictions or for fear of transmitting the virus to elderly parents and relatives. Many have suffered setbacks in training and professional development. We are all tired – COVID fatigue is real. We all had it bad, in some way or the other, but in the face of adversity lies the opportunity: the pandemic forced us to adapt, and it looks like the lessons we learned last year are certainly applicable for the immediately foreseeable future.

COVID 19 served to magnify existing global healthcare disparities, triggering important conversations around it, and with that, hope for rectification. It saw the more widespread adoption of telemedicine as an integral component of healthcare delivery.  It made the scientific community realize the importance of good quality research and clinical trials and the benefits of sharing knowledge and collaboration.

In pathology class at medical school, we are taught cellular responses to stress and toxic insults. Adaptations are one of them:  Robbins pathology defines them as reversible functional and structural responses to more severe physiologic stresses and some pathologic stimuli, during which new but altered steady states are achieved, allowing the cell to survive and continue to function.1

COVID-19 forced adaptations at a far greater magnitude, and we are now at the altered steady state of what we call a “new normal”. Just as much as the pandemic forced healthcare systems to adapt to the crisis, it presented an opportunity for introspection and re-evaluation of our lives on a personal level, and there are important lessons I’ve learned in the process.

Communication: Just as with telemedicine, 2020 also saw us embrace social media in a way we hadn’t before. Indeed, in an increasingly digital global landscape, many of us had to depend on virtual interactions as being the primary and often the sole form of interaction. In addition to public social media handles, many physicians took to their private accounts to combat misinformation, providing an important channel for public health messaging among friends and social circles outside of medicine. With the advent of vaccines, this appears to be even more important in breaking down important information and allaying fears related to its side effects.

Adaptations in learning: Also virtually, we learnt to modify methods of learning, with conferences and meetings adapting to virtual platforms and regular educational content being far more widely available. Paradoxically, this has perhaps resulted in increased exposure and visibility of especially early career physicians, with opportunities for global networking and collaborations. Not too different from the times of in-person conferences, we now look forward to “meeting” friends on webinar platforms, with the camaraderie and friendly exchanges with colleagues in healthcare probably being more therapeutic than the educational content itself.

Building a support network: Perhaps my greatest learning from the last year is the importance of friendship, support, and mentorship. While we’ve been trained to adapt and be strong, this is a pandemic none of us have been equipped for. We’re used to being care-givers, not receivers, but in remembering that we’re also human and vulnerable, it is only healthy to actively seek out and lean on one’s support network: this can be family, friends, sometimes colleagues: to talk, chat, cry it out, or rant.

Mentorship: We have all faced challenges that were unprecedented and it was more than just training that was affected. Navigating through the uncertainties of early career practice can be challenging even in the most ordinary of times; hence the perspectives, solid life advice, and clarity provided by good mentorship during pandemic times cannot be understated. Additionally, the stress of working in a pandemic can give rise to inopportune moments, and I couldn’t be more grateful for mentors that have cut me slack, forgiven the shortcomings, and taught me resilience. It’s a lesson in maturity that I hope I can pay forward in my dealings with junior physicians as well.

Gratitude: Count your blessings and force yourself to do this.  Pause to celebrate the small victories.

As far as the science of adaptations goes, Robbins pathology will also tell you that when the stress is eliminated, the cell can recover to its original state without having suffered any harmful consequences.1 While it looks like we’re in for a few more challenging months before the “stressful” triggers might show any signs of waning, my optimistic takeaway is precisely the hope of this recovery to its original state, or at the very least, some semblance of a better new normal.

2020 is the year that taught me resilience, and it is a testament to our ability to adapt and pivot. I’m sure we’ve all found different mechanisms of adaptations that work for each of us, and I’d love to hear yours!

References

  1. Kumar v, Abbas AK, Aster JC. Cellular Responses to Stress and Toxic Insults: Adaptation, Injury, and Death. In Robbins & Cotran Pathologic Basis of Disease. 10th ed. New York, NY: Elsevier; 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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Self-Compassion: A Potential Antidote for Physician Burnout

Physicians have been facing a crisis for years: Burnout.  As defined by the 11th Revision of the International Classifications of Diseases (ICD-11), burnout is a syndrome of chronic occupational stress that is not managed successfully.  It is further characterized by physical and emotional dimensions which include: 1) feelings of energy depletion or exhaustion; 2) increased feelings of isolation, “separateness”, negativism, or cynicism related towards one’s job; or 3) reduced professional efficacy. (1) A recent survey found that more than 1 in 3 cardiologists in the U.S. report experiencing burnout.  Women and mid-career cardiologists experience even higher rates of burnout.  The data tells a similar story for the broader healthcare professional community: 35-54% of U.S physicians and nurses and 45-60% of medical students and residents have been reported to experience burnout (2).  Burnout creates a perpetual state of exhaustion truly impairing physician’s ability to care for others in a safe, effective, and efficient matter which heightens negativity that may already be pervasive in one’s life.  This cycle opens the door to harsh self-judgment or self-criticism and feelings of low self-esteem as well as depression. We not only have to break the cycle of burnout but also need to address the deep struggle of a harsh inner critic.  Self-compassion can serve as a potential antidote for physician burnout.

The Need for Self-Compassion as a Physician

Compassion is defined as a sympathetic concern for the suffering of others. (3) As physicians, we know compassion. Compassion, empathy, and altruism play a key role in the patient-physician relationship.  It is the cornerstone of our communication.  Burnout, with its characteristic loss of empathy, can challenge even the strongest presence of humanism in our patient-physician relationships.  Despite the exhaustion, many physicians are able to push through burnout for the sake of patient well-being. However, we are often most challenged to treat ourselves with the same level of compassion as we treat our patients or others.  Burnout can accelerate feelings of professional inadequacy that can lead to a state of deep suffering: negative thoughts about one’s self, one’s professions, and one’s workplace.  Additionally, it can become isolating with a tendency to feel alone in our suffering.  While physicians may not always be aware of their level of self-criticism, it is, in many cases, ubiquitous among physicians.

For many physicians, self-criticism can be a strong source of motivation.  The trade-off, however, can be quite harmful.  Self-criticism deepens the stress-induced threat-based system in our brain that actually directs the harmful stress response back to ourselves (the source of our criticism).  Perpetual self-criticism is closely linked to chronic stress, burnout, and depression.  Self-compassion can break the cycle of self-criticism. Recent studies on self-compassion have revealed a direct relationship between self-compression and feelings of greater well-being.  Self-compassion is the act of directing compassion towards oneself when dealing with a failure, a personal struggle or negative thoughts about oneself. Self-compassion leads with kindness and understanding instead of self-criticism and self-judgment in response to personal shortcomings (4).

Defining Self-Compassion

Dr. Kristen Neff, a pioneer in the field of self-compassion research, defines self-compassion in three components:

  • Self-kindness – characterized by approaching oneself with warmth and understanding versus self-judgment, anger, or negative emotions when confronted with feelings of failure or inadequacies. Self-kindness sits at the core of self-compassion.
  • Common humanity – the understanding that when a mistake happens or something does not go our way, it is part of a shared human experience rather than a state of “isolation”. Often times we can feel as though we are the only ones experiencing negative outcomes overcome by an overwhelming sensation of “why me”.  Self-compassion recognizes that these outcomes are a part of a shared human experience.
  • Mindfulness – the state of being aware of the present moment is an essential part of self-compassion. It steadies the mind to be present and helps curtail negative reactivity from one’s emotions.  It is a non-judgmental state of mind where one can observe his or her emotions passively such that we avoid becoming “over-identified” by our emotions (4).

Self-compassion has been identified as an effective way to enhance well-being and reduce burnout for healthcare professionals (5). Ultimately, the practice of self-compassion is a skill.  For physicians, it should be considered one of the essential skills for our personal and professional health. The more we practice self-compassion the more compassion we will have to give our patients. For more information about how you can incorporate self-compassion in your life check out the resources listed below.

 

References:

  1. Burnout an “occupational phenomenon”: International Classification of Disease. World Health Organization.  https://www.who.int/news/item/28-05-2019-burn-out-an-occupational-phenomenon-international-classification-of-diseases Accessed: 1/10/2020
  2. Mehta, LS et al. Practice factors affecting cardiology wellbeing: The American College of Cardiology 2019 Burnout Study.  Presented March 28, 2020. ACC 2020.
  3. Oxford Learner’s Dictionaries. https://www.oxfordlearnersdictionaries.com/us/definition/american_english/compassion Accessed: 1/10/2020
  4. Neff, K. (2011) Self-Compassion: The Proven Power of Being Kind to Yourself.  HarperCollins Publishers.
  5. Neff, KD et al. Caring for others without losing yourself: An adaptation of the Mindful Self-Compassion program for healthcare communities. Journal of Clin Psychol. 2020;1-20.

Resources for physicians to learn more about self-compassion:

  1. “Self-Compassion for Caregivers” by Kristen Neff https://www.youtube.com/watch?v=jJ9wGfwE-YE&feature=youtu.be
  2. An Exercise to Change Your Critical Self-Talk by Kristen Neff https://self-compassion.org/exercise-5-changing-critical-self-talk/
  1. Self-Compassion by Kristen Neff https://self-compassion.org/
  2. Center for Mindful Self-Compassion. https://centerformsc.org/

 

“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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In Pursuit of Converting Resolutions into Regular Routines

I love the idea of New Year’s Resolutions. At the stroke of midnight, you take a moment to reflect on the past year and think about all the things you would like to do better in the next… call my parents more often, express more gratitude to those around me, eat out less, save more, read and write more, go to bed earlier, drink more water… my list of planned improvements goes on and on. With a new year dawning, everything seems possible on January 1st. However, like so many others, I tend to make lots of New Year’s resolutions in January, stick with them for a few weeks, and then gradually abandon them by February as deadlines build and the reality of life sets in. Determined to defy the odds and convert my resolutions into routines this year, I sought strategies online. No surprise, there are many articles out there, but here are three pieces of advice that I found helpful and will use to better design my resolutions this year.  

  • Be honest with yourself and choose a well-defined resolution that is achievable. “False hope syndrome” is a term used by psychologists to describe the cycle of making overambitious goals, experiencing discouragement when these goals are not achieved, and then returning to the same overambitious goals in the future with the false hope that the results will be different (J. Polivy 2001; Janet Polivy and Herman 2002). This cycle of continued failure can overtime lower an individual’s self-esteem. Thus, to avoid this outcome, be reasonable about your goals. In addition, as the year progresses and the goal feels increasingly out of reach, feel free to refine your goals to ensure that slow (but steady) progress is still made.  
  • Set yourself up for success with a plan. Design a plan that includes tasks that will make it easier to adhere to your goals. In addition, in your plan provide opportunities for immediate rewards that will help you keep going. Studies have shown that immediate rewards help individuals stay motivated and ultimately promote the success of long-term goals (Woolley and Fishbach 2017)
  • Establish accountability by working with like minded people. In a recent study of over 1000 resolution makers (Oscarsson et al. 2020), it was found that individuals in social support groups were more likely to stick with their resolutions than individuals tackling their resolutions alone. Thus, when you make a resolution, share it with others and find support groups where you can encourage one another to keep going.      

My resolution for 2021:  Establish a writing routine
As an academic, a recurring personal resolution has been to establish a writing routine to stay on top of my many writing tasks. In adhering to the three pieces of advice above, my achievable resolution will be to write for 1 hour a day (5 days a week) in the morning before I get started with my lab work. To ensure I write daily, I will plan to write as I drink my coffee, which I have every morning. With regards to immediate rewards, my immediate reward will be a functional first draft of a paper. Lastly, to ensure I keep with this routine, I will form a writing group with my fellow postdocs.

“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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Professional Resolutions with a New Perspective

Let me add myself to the collective millions (billions?) of folks who are glad to have passed the year-end milestone and are hoping, beyond a shadow of a doubt, that this coming calendar year is very different! We can finally say now “2020 is behind us!”. Many have faced personal and professional challenges that could not be foreseen. Some have had success as well, despite the difficulties on the road to personal and professional progress. Some have had success because 2020 provided them ingredients for it, and I hope that these individuals utilized this success to benefit others, and provide support to those in need.

Like many others, I use the page-flip into a new calendar year as a marker and opportunity to reflect and reset my mind. By no means is this necessary, I have had years where I was firmly anti “year-end mindset”, because a calendar switch is an arbitrary marker of time passing, and I think a lot of folks have had, or still have, this outlook, which is fine! Still, I think this year I wanted to write this blogpost about professional resolutions just as a fun exercise, and maybe (hopefully) put something out there that would benefit (inspire?!?) someone towards a path for professional advancement. This resolutions list will not contain personal goals like achieving the desired weight or reading more books. Let’s get started.

(Submitted by author, modified from CC-0 images at pixabay.com)

1) Explore and find the potential to grow your professional community.

Trainees and early career folks tend to be very focused on their individual or small team “projects”. While this is important, it could obscure the wider “community” aspect of advancement that’s needed to build and expand one’s career. In 2021, I want to continue exploring new ways to participate in professional community building (like joining committees, participating in campaigns, being active in welcoming new members at work, to give a few examples). However possible, find the potential to grow and connect with other professionals within the field.

2) Make ambitious and novel plans for professional advancement projects (with a catch).

One of the things that are very commonly mentioned about 2020 is the reduction/delay/loss of some desired professional accomplishments, which were planned or anticipated before the global health crisis materialized and became unavoidable. A lot of trainees and early career professionals spent much of 2020 trying to salvage whatever they could to complete tasks. This is understandable. Having said that, the “salvaging work” mentality is at best a temporary approach to professional advancement, and at worst, an active hindrance to progress. Making a concerted effort to plan and perform novel and ambitious projects in the new year is a way to get one’s career trajectory back on a climbing slope. The catch I alluded to earlier is vital to note here: in addition to being ambitious in planning, be forgiving of yourself as you track the progress of these new projects. The global health crisis is still ongoing, and everyone is navigating new territory with this whole career advancement reality.

3) Highlight and celebrate all successes on your career path (small or big).

There is a prevalent stream of thinking within academic, scientific, and medical spaces that orient members of these communities to only focus on the biggest accomplishments achieved. Celebrating a publication years in the making, a graduation (also years in the making), a promotion to more senior status (years in the making… do you see the trend?!), and so on. The past year has certainly reduced the number of success stories for many, especially for the early career folks. In 2021, I think it would greatly benefit us to celebrate more professional milestones, even the small ones, and to highlight and be proud of any professional success achieved. The longer we delay enjoying the journey we are on, the longer and drearier the journey will feel like, and maybe even become. The old saying “success begets more success” can be made more accurate by saying “celebrating success paves the way for more success”.

So, as we all metaphorically and collectively turn the page and start a new chapter, leaving 2020 behind us, I aim and resolve myself to advancing my professional life by connecting more, thinking of novel, fun, and ambitious new projects, and to celebrate each small or big step forward on my early career path towards a fulfilling professional journey. Have a happy and healthy new year!

“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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Exercise: New Year Resolutions in the Midst of the COVID Pandemic

New Year. New Resolutions. With the start of the New Year, many of us make commitments to improve our health. Some of us take on a new routine or hobby, give up or change old habits.  As the holidays go, many of us take on the resolution to engage in more exercise and lose the extra pounds gained through the indulgence during the holidays.  As we embark on the new journey to better health at the start of a new year, it is important to know that we are not alone. There are many around us that are also trying to engage in a healthy resolution to be fit. And there are many resources available to increase our physical activity and remain fit throughout the year.

It has been well established that physical activity contributes to many health benefits. Those who engage in regular exercise benefit from better sleep, growth, development, mood, and overall health.1 On the contrary, the lack of exercise and an increase in sedentary behaviors may contribute to overweight and obesity. Overweight and obesity have deleterious effects in adults, including increased risk of cardiovascular disease, cancer, metabolic syndrome, depression, poor quality of life, and decreased life span.

As the global COVID‐19 pandemic unfolded in year 2020, over 90% of U.S. adult residents found themselves confined to their homes, with restaurants, shops, schools, and workplaces shut down to prevent the disease from spread.2 For some, it meant additional changes, including working remotely, homeschooling children, and personal changes in lifestyle behaviors. Some of these, unfortunately, have led to increased sedentary activity and decreased physical activity, known risk factors associated with overweight and obesity.

For some groups, the transition to lockdown and social distancing has resulted in increased physical activity, especially for bodyweight training, and higher adherence to a healthier diet. Some individuals have engaged in higher consumption of farmers’ produce or purchasing of organic fruits and vegetables, resulting in lower body mass index.3   However, this has not been the norm. More studies report adults experiencing five-to-ten pound increases in weight as a result of increased eating in the home environment. The increased levels of stress, combined with the lack of dietary restraint, snacking after meals, reduced physical activity, and inadequate sleep has further aggravated the risk of overweight and obesity in our population.4   Some groups report less frequent consumption of vegetables, fruit, and legumes during the quarantine, and higher adherence to meat, dairy, and fast-foods.5   Anxiety, depression, self-reported boredom, and solitude have worsened the consumption of snacks, unhealthy foods, cereals, and sweets. These have correlated with higher weight gain for many.6

Being overweight not only increases the risk of infection and complications for those categorized as obese. Recent studies also suggest that the large prevalence of obese individuals within the population might increase the chance of appearance of the more virulent viral strain, and prolong the virus shedding throughout the total population. This may further increase the overall mortality rate as a result of COVID-19. A study on previous influenza pandemics suggests losing weight with a mild caloric restriction, including AMPK activators and PPAR gamma activators in the drug treatment for obesity-associated diabetes. Practicing mild-to-moderate physical exercise may further improve our immune response. Regular physical exercise enhances levels of cytokine production mediated via TLR (toll-like receptor) signaling pathways during microbial infection, improving host resistance to pathogen invasion.7 Regular physical activity may then serve as a cornerstone measure to improve our defenses against influenza viral infection, cardiometabolic diseases, and COVID-19.

Physical activity remains one of the seven modifiable health behaviors and an important metric of The American Heart Association (AHA) Life’s Simple 7 (LS7), associated with improved cardiovascular disease survival and reduced healthcare costs.8   As we battle the restrictions imposed by the pandemic, we have to also think that these circumstances present opportunities to engage our communities in healthy lifestyle practices. Practice aimed to increase our physical activity, may contribute to improving overall health status in the midst of the COVID pandemic.

Here are some ideas on how to meet the New Year resolution to exercise and increase our levels of physical activity:

  • Move More
    • Set up a timer or alarm to move at least once every hour.
    • A good starting goal is to engage in physical activity at least 150 minutes a week. This represents three 50-minute sessions or five 30-minute sessions a week.
    • Start slowly. Gradually build up to at least 30 minutes of activity on most or all days of the week.
    • Check with your healthcare provider before beginning a physical activity program and follow their recommendations.
  • Establish a routine
    • Start with small changes.
    • Make the time.
    • Try to engage in exercising consistently at the same time every day and every week.
    • Stick to the new routine for at least a month.
    • Find a convenient time and place to do activities.
    • Be flexible. If you miss an exercise opportunity, get back on track.
    • Work physical activity or exercise session into your day in another way.
    • Keep reasonable expectations of yourself and your physical activity or exercise routines.
    • Reward or praise yourself for sticking to the changes.
    • Use non-food items to reward yourself.
  • Get support
    • Find buddies or friends who are also making the same commitment to be fit and engage in physical activity.
    • Invite others to join you on your journey.
    • It becomes more fun when you exercise or move in a company.

Start the New Year with a commitment to better health by increasing activity and engaging in regular exercise. Engage others in exercise while keeping social distancing guidelines. Celebrate the small changes. Make a commitment to a Better You!

References:

  1. Centers for Disease Control (CDC). Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. Physical Activity Basics. Reviewed 2020 Nov 18. Accessed 2021 Jan 13. https://www.cdc.gov/physicalactivity/basics/index.htm
  2. Bhutani S, Cooper JA. COVID-19-Related Home Confinement in Adults: Weight Gain Risks and Opportunities. Obesity (Silver Spring). 2020;28(9):1576-1577. doi:10.1002/oby.22904
  3. Di Renzo L, Gualtieri P, Pivari F, et al. Eating habits and lifestyle changes during COVID-19 lockdown: an Italian survey. J Transl Med. 2020;18(1):229. Published 2020 Jun 8. doi:10.1186/s12967-020-02399-5
  4. Zachary Z, Brianna F, Brianna L, et al. Self-quarantine and weight gain related risk factors during the COVID-19 pandemic. Obes Res Clin Pract. 2020;14(3):210-216. doi:10.1016/j.orcp.2020.05.004
  5. Sidor A, Rzymski P. Dietary Choices and Habits during COVID-19 Lockdown: Experience from Poland. Nutrients. 2020;12(6):1657. Published 2020 Jun 3. doi:10.3390/nu12061657
  6. Pellegrini M, Ponzo V, Rosato R, et al. Changes in Weight and Nutritional Habits in Adults with Obesity during the “Lockdown” Period Caused by the COVID-19 Virus Emergency. Nutrients. 2020;12(7):2016. Published 2020 Jul 7. doi:10.3390/nu12072016
  7. Luzi L, Radaelli MG. Influenza and obesity: its odd relationship and the lessons for COVID-19 pandemic. Acta Diabetol. 2020;57(6):759-764. doi:10.1007/s00592-020-01522-8
  8. Garg PK, O’Neal WT, Mok Y, Heiss G, Coresh J, Matsushita K. Life’s Simple 7 and Peripheral Artery Disease Risk: The Atherosclerosis Risk in Communities Study. Am J Prev Med. 2018;55(5):642-649. doi:10.1016/j.amepre.2018.06.021

“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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Equity & Inclusion in Medicine – Part 1: my experience as a BIPOC in medical training

As someone who integrated her elementary school in Ohio (a Yeshiva), enrolled in an exclusive prep school in New England and became the first AA female in her cardiology program, I’ve spent my life analyzing how to adapt to environments in which I was different. When I enter an environment, I learn the lay of the land, identify key players, and observe interactions. I am a fourth-generation African American physician and was raised learning about my relatives’ experiences as minorities in medicine. If I, as early as age 9, could learn how to thrive in diverse environments others can too. I would like to share these experiences and make a case for diversity in cardiology. With this blog, I will help kick off the New Year with part 1 of a multiple part series that aims to define bias in medical training; openly make a case for and provide solutions towards inclusion in cardiology.

In this blog, I will review specific features that demonstrate bias, which can lead to less diversity in training programs. These are topics related to experiences in medicine that are shared by myself as well as my BIPOC and women colleagues.

Affirmative Action, The myth

There’s this assumption that BIPOC has a leg up unfairly given by Affirmative Action, and therefore are enrolled in academic programs without earning it and being unqualified. Truthfully,  nepotism and ease of identifying mentors provide more opportunities than any small % quota which does not seem to translate to faculty positions. In research, at times I have had to become my own mentor to continue to propel myself forward. Without visible faculty mentors, it is difficult to envision a role in academic medicine which makes this career aspiration less likely for many BIPOC. The educational system’s balance as a whole has been skewed related to the American Caste system (consider reading Caste by Isabel Wilkerson). This affects testing metrics and exposure to certain educational experiences. However, with the right inclusion, training, and belief in someone; talented students will become great physicians and cardiologists. In fact, this idea that BIPOC is all unqualified is ironic; many of us feel we have to work twice as hard with a cool and steady temperament all the way through (think of President Obama) to get half as far. Despite strong backgrounds; I often hear colleagues make comments like: “ They are not as clinical.” I already know the race before hearing the full story. We can’t all be inept; not possible.

Double Standards/ Lack of Benefit of the Doubt

Double standards, a topic at this nation’s center as we watched different responses to the siege on Capitol Hill. In cardiology and medicine, it is not uncommon that the same errors in one person may receive a different response from leadership compared to another. One cardiologist stated that he, like many of his colleagues, inadvertently caused a coronary dissection. The response, however, was harsher than what his colleagues experienced for the same incident.  One simple misunderstanding with a BIPOC resident or medical student led to unnecessary poor feedback to this resident that could have been remedied with a conversation. She was not given the benefit of the doubt like her peers would have; in fact, I don’t think the incident would have been reported at all considering how trivial it was. At times, we feel closely observed and overly scrutinized. At times by other women and BIPOC as well. Perhaps there is a “crabs in a barrel” mentality when there are so few represented in one place, this can actually create tension. What’s most difficult is, there’s less ability to be human; which is amplified when it seems as if there is not always a trustworthy authority to turn to. It may not be that one BIPOC placed in a leadership position; they may not want to rock the boat.

So we feel that we must work twice as hard; smile (wear the mask long before COVID19), with only marginal to no room for error (there is a great scene in the movie about the Tuskegee Airmen on HBO that highlights this point).

Abstract Feedback

Often we receive feedback that is very vague and abstract and seemingly more personal than constructive. It’s generally a vague comment that has one racking their brain over and over with no real tangible solution provided by the person giving the feedback; this was described in “Research: Vague Feedback Is Holding Women Back.” For example, I was once told, “You’re too confident.” How do I change my confidence? How can I be less confident, but at least somewhat self-assured? Do you see how this happens? Not too uncommonly we receive nonactionable feedback that has one racking their brain and can have an emotional impact. It’s distracting. Actionable feedback is more helpful especially if it is not something very personal and aimed more at patient care. One mentee of mine received an overall vague evaluation and marked her with critical deficiencies without good evidence. I did not want this practice to continue, and I wrote to the associate program director to describe the scenario and shared my concerns. It was determined that this evaluation was a mistake after a larger review. Imagine a situation had it stayed on her record; it could have had negative implications to her career, especially, when she is planning to pursue a selective fellowship.

Assumptions

During a medical school interview, I was asked if they should accept fewer women due to pregnancy. I was never comfortable sharing my pregnancy considering this was my first introduction. He assumed women couldn’t make these decisions, and that, affirmative action should be taken away (this was 2008; not long ago). I have also found that, before really knowing one’s interest, it is assumed a female cardiologist will pursue a career in imaging. I am often asked “ You’re doing imaging, right?” Or I’ve heard, “ she is an imager, typical.” This can impact cath scheduling if there are no fixed schedules for all fellows. In fact, scheduling is where bias can creep in ( I have heard of giving longer hours to BIPOC forcing one group of residents to threaten federal intervention.) This can be avoided with as much equal scheduling as possible (not always perfectly feasible) without assuming anything. Assumptions are not meant to be hurtful; it’s human nature. However, at times it may pigeonhole folks to roles that must end with women’s health, equity, or inclusion (exceptionally relevant roles). These folks can also have leadership roles related to other clinical interests as well.

Certainly, these may not all be unique to BIPOC and women; however, I hear similar stories over and over again, as if they are told by the same person. As we enter into a new era, I hope cardiology joins the future of progress. In parts II and III, I will answer why inclusion is important and some solutions on how to cultivate an inclusive specialty.


For this series, we will be discussing –

Part 1. My experience
Being hypnotized that I am lower in the caste system and limited. The emotion clouded my abilities and held me back from further progress. I have to prove my resume more than my colleagues every time and it’s exhausting. In research, I’ve felt like an outsider constantly having to build my own way and have been directly judged for lack of prolific publications.

Part 2. Why?
Embracing difference can help a program evolve (% diversity at Harvard ) it’s a win-win; a synergistic relationship in which we grow together. Representation matters, and to diversify the workforce will help the patients’ comfort and compliance.

Part 3. How?
Aim for a standard similar to Goldman Sachs’s 25%1.  Provide resources and assistance to BIPOC. Show up for each other. Engage ABC and uplift ; normalize discussing differences and being different. Check in with your BIPOC trainees’ wellbeings, if there are issues driven by bias speak up with your peers in a collegial way.

 

Reference

  1. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774738?utm_source=twitter&utm_medium=social_jamajno&utm_term=4395647160&utm_campaign=article_alert&linkId=108893385

“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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Hopes for 2021

As 2020 concluded with all of the unprecedented events, with the tragedies people had to suffer and are still suffering from, with all the good and bad, we enter the New Year of 2021 with some hope; hoping for better health, better strategies to combat what we are dealing with in this pandemic, and being more responsible for each other.

COVID-19 Pandemic

COVID-19 pandemic has changed how we live our lives, and the impact of this pandemic will likely last at least a few years, if not more after the pandemic is over. There are a lot of “unknowns” about COVID-19 infection, including the long-term effects of this infection and the effectiveness of some medications, that we will get to encounter and manage in the next several years.

COVID-19 Vaccine

With multiple effective vaccines discovered recently, healthcare workers were given priority to get the vaccine, followed by more vulnerable patients, including the elderly and those with significant comorbidities. The Centers of Disease Control and Prevention (CDC) website provides helpful information on the currently available vaccines in the United States (US), Pfizer, and Moderna, including their storage, preparation, and expected side effects (Link is provided below) [1].  The hope is that by the Spring of 2021, 75% of the population in the United States will be vaccinated.  Moreover, efforts by international organizations, including the World Health Organization (WHO), to distribute the vaccine to all countries are ongoing [2].

COVID-19 New Strains

We have seen the discovery of new strains of COVID-19 infection in the United Kingdom and, most recently, the US. These new mutant strains of COVID-19 may not be covered by the available vaccines, as such, the vaccine is an additional layer of protection, with the other protection measures, including social distancing, masks, and hygiene, which may be the most important way to prevent the spread of these new strains at this point of time.

With all that being said, our hopes for a “normal 2021” depend on how we handle the COVID-19 pandemic, we may not see everything going back to normal in 2021, but we can work on making the initial right steps now so that we have less grief, less “loss,” fewer travel restrictions, with healthier and happier upcoming years!!

Special thank you to my sister, Rawan Ya’acoub, an assistant professor of Doctor of Pharmacy/Clinical Pharmacology at the University of Jordan in Amman, Jordan, who helped me write this blog, and for all of her support.

 

References

  • S. COVID-19 Vaccine Product Information: https://www.cdc.gov/vaccines/covid-19/info-by-product/index.html
  • COVID-19 vaccines: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines

 

“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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In Sharing Your Pain, Your Help Others Heal – A tribute to, Dr. Basem Oraby, a resident physician we lost in 2020

I did not know Dr. Basem Oraby but when I wrote a blog in memory of my aunt, Dr, Somaya Saad Zaghloul, who died of COVID-19 in Egypt on December 1, 2020, his sister, a clinical pharmacist, Bassant Orabi, reached out to me on Twitter and said sharing my aunt’s story gave her the courage to share her little brother’s. A beautiful soul, taken from us far too soon. My conversation with Bassant was heart-wrenching but reminded me that in sharing my pain, others heal too. Her tribute is movingly painful. Our paths crossed because of tragic circumstances, but somewhere in there is a glimmer of light. Read on for Bassant’s tribute.

I never thought I would experience something as painful as holding my dad in my arms at 2:00 am with my eyes fixated on the monitor watching his EKG flatten, but I was wrong. Four years later, I saw my little brother Basem in a coffin. But in that coffin was not just my brother’s body, with his passing went his dreams of becoming an attending physician, the goals he planned on crushing, his jokes and unmatched sense of humor, and his outpouring of love and support to anyone in need. I could not believe my brother was gone.

It took me a long time to write a tribute worthy of the legacy Basem left behind.  Although Bassem died at the young age of 25, he lived his life to the fullest. I look back to January 15, 1995, and I see this tiny baby whose little cries captured my heart immediately. Basem was the kindest among our family, never hesitating to offer a helping hand or a shoulder to lean on. He was a true family young man who loved and protected his family. I remember the countless times he comforted me during my most difficult times and I now wonder if I will ever feel that much unconditional love again? Although I am 10 years older than him, he was and will always be my hero.

Basem was a loyal friend to many. It became even more evident by the outpouring of love from his friends all over the world after his death. His compassion and love for everyone were unsurpassed. He always went the extra mile for those he loved and cared about and always believed in saying only what was good. His beautiful heart and tender soul drew many to him. As I read countless messages from his professors, I got to know Basem as the brilliant physician he was. Losing our father was not easy on him, yet he found the will in himself to graduate from Weill Cornell Medical School in Qatar. Everything he did, he did with perseverance. He moved thousands of miles to pursue his dreams to train in internal medicine at Virginia Commonwealth University Health in Richmond, Virginia. He took pride in serving veterans and disadvantaged patients. I remember him being so proud to have diagnosed a case of cardiac amyloidosis, it was clear that medicine was his passion. Basem felt medicine was a career of helping people out of their dark roads. He was the compassionate doctor I wanted to see in an emergency department. 

Basem was a generous soul who never hesitated to help others in need. Basem was the 9-year-old kid who gave all his money to a taxi driver who could not afford the cost of his daughter’s chemotherapy, he was the teenager who supported refugees from his undergraduate scholarship stipend, and he was the young doctor who brought food to many who could not afford it.  I still cry that he died alone in America with no one around him, but soon I remember that such a beautiful soul is never alone. Every time I remember how much he wished he would come to visit us and how proud he was to be working and helping during a pandemic, I realize that he lived the life of giving he wanted.

I used to stand by his grave and weep, there was a hole in my heart that grew every day since we were informed of his death until the day then I realized that his true journey had just begun.  Though he is no longer with us, his love and support shower us. I think of all the charity work he contributed to including water wells, tents, education packages, medical glasses, and food among many other projects done in his name in Africa, Asia, and Europe. Even after his death, his legacy remains. I am inspired to be the best version of myself to make him proud.  

I wish his friends, colleagues, all those who knew him, and us, his family, continue his legacy of love, compassion, generosity, and kindness. I also ask you all to keep him in your prayers. Basem will always be a beautiful part of our journey. I will always carry you in my heart Basem.

In sharing my pain, I was able to help Bassant start her journey to healing. There is a power in vulnerability. You touch lives. As the late, great Dr. Maya Angelou told us, a legacy is every life you touch. Touch as many as you can.

[This is the last photo Dr. Basem Oraby took with his family at the airport before heading to the US for residency]

“The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.”

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COVID Fatigue

Anesthesia alert! This overhead call alerting pending intubation can be heard bellowing throughout the hallways of my medical center several times throughout the day and is seemingly the soundtrack of COVID-19. My typical routine is to pause, make sure it’s not sounding the alarm to my patient’s room, and then continue with my workday.

It has been 304 days since the WHO has declared COVID-19 a pandemic. COVID numbers at my medical center continue to rise, and although the vaccine is widely available to hospital staff, we are continuing to see some of our highest numbers since the beginning of the pandemic.

As a general cardiology fellow on the advanced heart failure service at a high volume mechanical circulatory support and transplant center, we really get to know our patients while taking care of them during their index hospitalizations. For the past two weeks, I’ve gotten to know one patient in particular. She presented in cardiogenic shock, was stabilized on inotropes and a balloon pump, with plans for upcoming destination therapy LVAD implantation.

Every day when we come to her bedside, she is on FaceTime with her partner. Today, the day before her LVAD implantation, we walked to her bedside, and once again she was on FaceTime with her devoted partner. She is obviously loved. Considering that she was going for LVAD the following day, we spent a bit more time explaining the procedure in-depth to the patient and her partner. After discussing all of the technical details, she timidly asked “Do you think my partner could come to spend the night with me tonight? I just need to see my love and it’s been so long.” You could see the tears begin to drop from her face and her partners.

Donning and doffing, wearing the N95, not knowing what anyone looks like without their mask; things have become routine. Health-care workers have adapted so well to the ever-demanding challenges of practicing medicine in the era of COVID-19. We’ve made guidelines, adjusted our practice, established routines, and found ways to provide quality medical care in the darkest of times. We’ve become oddly accustomed to these necessary rituals in order to protect ourselves, our loved ones, and the patients that we care for.

But none of this is normal.

At that moment, when we told our patient that the person who loved her the most in this world could not sit with her the night before a life-altering surgery, it became dramatically apparent to me that all of this is abnormal. The weight of 304 days of pandemic sat heavy in my heart and the sounds of endless anesthesia alerts echoed in my head.

Depression and burnout were prevalent in the healthcare field even before the pandemic. COVID-19 has undoubtedly placed an added burden on all healthcare providers. I implore people to take time off if you can, spend time with family if able, and be thoughtful of your mental well being because this past year has been anything but normal.

“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.”