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Being an Immigrant Doctor in the USA in Midst of the Pandemic

Let’s go back to 2007. Very vividly I remember my first ever conversation at a coffee shop in Ahmedabad, India (my medical school town) which had sparked interest in this land of opportunity- The United States of America (USA) -thousands of miles away from home.  A few medical students were discussing their experience of clerkship in New York. “The air is so fresh and crisp,” they said. “By the way, if a patient with severe anemia gets admitted, they don’t discharge the patient just after giving blood transfusion- they actually find the etiology”! “Wow,” I said. “That’s how I want to practice. I want to find what’s wrong with my patients”. Having memorized all the possible causes of anemia, while witnessing lots of patients get discharged with outpatient follow up predominantly due to limited resources from the largest hospital in Asia- Civil Hospital, Ahmedabad, I was excited to learn physicians get to solve the jigsaw puzzle of diagnosis and then treat the patient in the USA. After quite a bit of back and forth with my family, I decided to come to the USA. I recall the day I left India. My entire extended family had gathered to say goodbye. After all, I was the first daughter amongst many, to leave the country alone, and pursue higher education in a distant land with no family whatsoever, at the tender age of 23. I remember, seeing tears and sadness amongst my family members but I was determined and happy. “I am going to the USA to be a cardiologist”, I had announced many times as the phone in our household kept ringing to wish me luck on my journey. I literally left on cloud seven, bursting with joy, on a one-way flight to Philadelphia, on February 18th, 2008.

Fast forward April 6th, 2021. India had recorded another surge in COVID numbers that day. Two in the morning, I kept tossing and turning in my bed. Three days later, I was supposed to fly on a bubble flight to India. India had done okay with COVID in early 2021 and my parents were vaccinated. I saw a chance to see them after 1.5 years but now this covid surge out of nowhere!? All these years, I always told my family, “I am only 17 hours away. I can fly if I need to. The world is smaller than ever”. COVID had changed a lot. The entire year I had literally imagined myself hanging over the Atlantic, with the body in the US and mind and heart in India, many times. To complicate the issue, I had to renew my visa to the USA this time, to return back to the USA. “what if India goes in lockdown”, “What if I catch the new highly infectious variant prevalent in India and give it to my mother, who has been diagnosed with pulmonary fibrosis” “What if they decide to quarantine me at the airport”, “what if I don’t get my visa renewed and cannot return to the USA”. 2:30 AM, I got up, canceled my flight tickets, my visa appointment, and other arrangements. Like a giant infant then, I cried for at least half an hour. It was not fair at so many levels. Yeah, I know, that I made that choice for myself. I know I had decided to leave my family and come to the USA. After all, Life is a matter of choices and every choice you make, makes you, as John Maxwell- an American author once said.  My stay in the USA had made me what I am today, but also made me feel how I felt during that night. I often think of the contrast in my experience when I came to this country compared to now.

This pandemic has been hard on immigrant physicians. During the early days of covid, I felt like stepping in a warzone as I entered the hospital. I would recite Hanuman Chalisa (Hindu hymn chanted for strength and courage) every single day multiple times as I saw COVID patients. I often discussed with fellow immigrant cardiologists- “we cannot get sick. God forbid if we get sick, who will take care of us? Who will update our families? what if we get so sick, we cannot do our jobs and get kicked out? What if we die? How will our family manage everything while thousands of miles away? For my married friends with children at home, it was challenging. Some were sleeping separately to keep the family safe. One of my friends who is an ICU physician told me he didn’t sleep well for months during the surge. The chances of getting COVID from super sick patients were high. If he became disabled or died, his family would lose their legal status, income and would be forced to leave the country. I have a close friend who lost his mother to COVID and couldn’t see her for the last time or do the death ritual as the eldest son. During hardship, it’s easy to think of extremes. Precovid, we were part of American society, flourishing professionally, doing well. COVID changed us. The sense of security and being home in the USA eluded. Where was home?

1/3 of the physicians in the USA are immigrants1. More than a third of those IMG (International Medical Graduates) have visa restrictions in spite of legally residing in the country and paying taxes as a US citizen. The top three countries that send IMGs to the USA are India, China, and the Philippines2. For those of you who think, immigrant physicians, take up opportunities from physicians that were born in the USA, the Association of American Medical Colleges projects a shortage of up to 139,000 physicians in the US by 20333. The jobs that offer visas often take advantage of the need for visas by foreign physicians by offering little compensation for a lot more work mostly in distant parts of the country. Professional and personal uncertainty posed by the pandemic has changed the future for many immigrants particularly the physicians having witnessed the surges of covid during the peak of the pandemic before vaccination started5.

I really hope in midst of an ongoing pandemic with no sight of the end, the immigration reform gives more flexibility to the physicians to travel to their home countries without the need for visa renewal. I also hope that this land of opportunity accelerates the permanent resident status for highly skilled physicians particularly those who are on the front lines during the pandemic and served their adopted country with vigor and in certain cases with their lives.

I don’t know how the COVID pandemic is going to change immigration patterns across the world. I often think about this, now being away from family for more than a year. This country has made me who I am today, and I am so incredibly grateful for my stay in the USA, for the education, incredible career opportunities, social status, and freedom I have acquired, particularly as a female cardiologist. However, I often wonder, if all the sacrifices that I have made are worth these successes. I guess the grass is always greener on the other side, but this pandemic has definitely made me pause and reflect on my choices and decisions.

 

References:

1  https://www.newamericaneconomy.org/issues/healthcare/

2  Harker YS. In rural towns, immigrant doctors fill a critical need. Health Affairs. 2018;37(1):161-164.  u

3  https://www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf

4  https://blogs.bmj.com/bmj/2021/02/04/my-blackness-enters-the-room-first-an-immigrant-physicians-perspective-on-systemic-racism-in-the-us/

5  Benji K Mathews, MD, SFHM, Manpreet Malik, MD, FHM, Immigrant Physicians Fill a Critical Need in COVID

 

“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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5 Daily Struggles of an Early Career Physician

For this month’s blog entry, I’ve decided to share a more reflective piece. In now just over six months into my young career, my early morning routine is pretty set in stone. Wake up. Shower. Scrubs. Coffee. Mask. Keys. Go! But what happens from approximately 8 am – 5 pm is still evolving.

This blog will briefly go over my daily struggles, but I could just as easily share five daily rewards/positives/joys of an early career physician … and maybe next month I will.

  • I’m the attending (physician). Part of being fresh out of training is that nobody knows. Whether you stay at your home institution or move to a new setting, you’re likely the new kid on the block in the Doctors’ Lounge or the EMR’s attestation text box. Despite proudly wearing my “attending physician” ID badge, I find myself constantly having to reiterate that I’m the supervising doctor. I recently entered the room to begin time out for a transesophageal echo and was stopped by the anesthesiologist because we couldn’t begin the case without the cardiologist present. Another time, I was asked if I was the fellow doing the case with Dr. X, a well-known echocardiographer. Despite how this may sound, I quite like the shocked look on my patient’s faces when I walk in and introduce myself as the person who will be managing their complex cardiovascular disease – or my ability to walk through the medical center unbothered and largely unnoticed while taking in some much needed Miami sun.
  • One of my daily struggles is not knowing how to say “no.” As a medical trainee, you’re often the person called upon to do the tasks that no one else wants to take on. Whether it be consent for a procedure or calling the pharmacy to correct a prescription, you’re often faced with the rhetorical question of “can you please…?” or “ would you mind…?” Well, this doesn’t really stop when you’re a newly appointed faculty. I often reply to emails first or make phone calls because I’ve been there and I know that I CAN help in that way. Eventually, though, I will need to learn when this is impinging on time that could be well allocated to more important tasks.
  • To do or not to do. From the moment my first patient shares with me the reason for their visit, there is a tug-o-war in my head between doing something and doing nothing. A wise professor once told me that 70% of medical conditions resolve without the doctor doing anything. We’re tasked with identifying the 30% of the time when we can make an impactful difference in the disease course. I once read a Wall Street Journal article titled “When Doing Nothing is the Best Medicine.” This is much easier said than done, but I’ve found that many patients just want reassurance that what ails them will not lead to their untimely demise. Explaining my thought process, and clearly stating that we can always order more tests or perform more studies at a later date if things don’t get better, has served me well so far.
  • Leaving work at work. It’s not uncommon to find a trainee spending extra time in the hospital or in the clinic finishing tasks that their attending doesn’t want to find undone in the morning. When you’re the attending, the decision as to what can wait until later lies with you. When I first started my new job, I often stayed up late replying to emails or finishing notes, or making calls from home. What I’ve found is that not everything needs to be done now. I have frequently reminded myself of the following diagram, as it has helped me leave work at work and not take it home with me.

Source: https://luxafor.com/the-eisenhower-matrix/

  • Work/Life Balance. As physicians, we’re tuned to work work work until you can’t work anymore. It’s commonplace for physicians to work well past the retirement age, and sometimes until they are no longer with us. My mentors have shared with me that the decision to prioritize family, vacation, rest starts NOW. It is a lot harder to put into practice. There is always something that needs to be attended to, whether your “out of work” auto-reply is posted or not. I’ve made it a goal of mine to fully utilize the ample paid time off afforded to me by my employer, and to truly disconnect during these times. It’s still very hard, and I haven’t perfected it, but making it a priority is the first step.

Thank you for reading, and please share with me some struggles that you’re having as an early career physician. I can be reached on Twitter @DrDapo. Until next time!

 

“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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The Rising Value of Plain Science Talk: Part 1

When it comes to placing value on something newly discovered or innovated in the scientific fields, a key yet somewhat lost-in-the-shuffle point is the ability to communicate to a wide audience why this discovery or innovation is rated as highly valuable. Most scientific discoveries, novel techniques, and significant leaps forward in knowledge and implementation are “communicated” via academic publications in journals that have significant value to academics and subspecialists but have limited general public exposure, and in specialty conferences and society meetings where only paying members and interested individuals are able to participate in.

Even when some of those journals are more widely distributed and recognized (Nature, Science, New England Journal of Medicine, The Lancet, etc.), the actual articles in those journals are written in extremely precise, yet somewhat too technical of a format, to capture the attention and translate the knowledge to the wide swath of the population that might encounter it. And Even when the conferences and meetings are more accessible and have reduced barriers to entry and participation, the actual presentations (the talks, the posters, the workshops) are all geared to communicate directly to peers in the field, not to an interested yet general-knowledge audience.

This is not to say the work itself and researchers doing it are not producing important knowledge. New discoveries and innovations are the keys to maintaining or improving the planet and all its inhabitants’ health.  Knowledge is the key to propelling societies forward. The issue is that for so long, the methods of communication of this type of information has been restricted, both by the avenues that contain this information (journals and conferences that are inaccessible to the public) and the written/spoken formats used to transmit this information (articles and talks delivered in overly technical ways).

The missing ingredient in a recipe that would serve a much greater audience with something more palatable and engaging is called Knowledge Transfer & Translation (KTT). There are many definitions and formats that shape what the KTT factor is, depending on the organization that places importance on it. In a generalized way, I’ll define KTT as: a plan to disseminate newly acquired information to the broadest set of interested parties, accompanied with a framework of how to advance this new knowledge into actions that benefit (sometimes “profit”, in business sectors) the knowledge seekers and broad general public.

Knowledge Transfer and Translation has not always been a focus in academic research circles. Most scientists think of KTT as someone else’s job. I did! In the years it took for me to gain enough education and real research experience (a journey that spans more than a decade, from BSc to MSc to PhD to research fellowship), the vast majority of my time learning has been with the singular aim of discovery & innovation. Once the discovery is made, the only requirement my academic world asks of me is to report this discovery, in the form of a research article that only my peers in knowledge can truly appreciate in full, and maybe talk about this discovery in a 10-min presentation at a conference where many of my peers and interested members of the field I occupy congregate on an annual basis.

However, this traditional and old-fashioned view of the role of an academic has begun to change in the past few years. Discovery and innovation are still the driving forces of academic research, but increasingly, the values placed on those discoveries and innovations are complemented by how much Knowledge Transfer and Translation is placed behind these discoveries and innovations to propel them beyond the circles of subspeciality academic fields. Novel avenues of sharing knowledge have entered the hallways and labs of academia: Online platforms. The digital world with its massive reach and accelerated speed of information sharing is an essential and increasingly irreplaceable tool to implement the KTT directives needed to advance our societies. Science communication (#SciComm) has taken on a new meaning and many new forms that were simply unavailable a few years ago. Social Media has complemented and amplified the use of Traditional Media in broadcasting research and academic data that normally had few ways to reach the proverbial “center stage”.

I’ll tackle this ever-growing list of new and exciting ways of science communication on Part 2 of this series of blogposts, coming May 2021. Until then, you can always reach me for feedback or just to say hi (Twitter: @MoAlKhalafPhD), I am an “Extremely Online Scientist”!

 

“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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Bias

A middle-aged black woman presents to her local emergency department via emergency medical services (EMS) with chest and back pains, nausea, and vomiting. She has a history of IV drug abuse and is disheveled in appearance. Prior to her arrival, EMS notes that her chest pain appears non-cardiac and provides supportive care while en route to the hospital. She is triaged to the appropriate care and an emergency provider assesses the patient. 

The patient continues to have chest discomfort and nausea. The emergency team agrees with the EMS assessment and deems her symptoms as atypical for a cardiac etiology. An EKG is performed which demonstrates subtle ST-segment elevations in her inferior leads as well as faint reciprocal changes. However, the catheterization lab was not activated at this point. 

High sensitivity troponin ultimately revealed a modest enzyme leak and the cardiology team was consulted. The patient was urgently taken to the cath lab to reveal an acute lesion of her proximal right coronary artery. There were no complications during the procedure and she ultimately had an uneventful hospital course. 

Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. These biases are activated involuntarily, without an individual’s awareness or intentional control. Unfortunately, we are all susceptible to bias and there is extensive evidence showing how bias can lead to differential treatment of patients by race, gender, age, weight, language, socioeconomic status, and insurance status. As such, it begs the question, if our patient had no history of drug abuse or was white, would their acute myocardial infarction been treated faster? 

A seminal 2007 study of internal medicine and emergency medicine residents found that, while the participants reported no explicit racial bias, Implicit Association Tests (IATs) indicated an implicit preference towards White Americans. Further, the higher the preference, the more likely that physician was to treat Whites and not treat Blacks with early thrombolysis in the setting of acute myocardial infarction. 

While it is clear the effects of implicit bias in medicine, it is also clear that implicit bias is malleable. There are a number of leading strategies for combating implicit bias including stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for contact with individuals from different groups. Further, new research must be conducted to find more innovative techniques for managing implicit bias. As clinicians, it is our responsibility to be constantly aware of our bias and to actively work to address that bias in every patient encounter. 

References 

  1. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238. doi:10.1007/s11606-007-0258-5

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

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On the Basis of Sex: Are males more vulnerable in severity and mortality from COVID-19?

Fig1: Data source: The sex, Gender and Covid-19 Project. (https://globalhealth5050.org/the-sex-gender-and-covid-19-project/about-us/)

As we just passed our first anniversary of fighting COVID-19, we are in a better position than we used to be a year ago. Nationwide vaccine efforts encourage us to see the light at the end of the tunnel. However, the virus is still lurking around and always finds its way back in many unpredictable forms as it evolves rapidly. We need to stay vigilant and use what we learned from the previous years’ knowledge to guide us defend any future attacks. One pertinent piece of information we discovered is that COVID-19 attacks us unequally. People are over 65 years old and people with any underlying complications are more at risk. Another important discovery is that there is a sex difference in infection, severity, and death among women and men.

In most countries, the incidence of infection (percent of cases) is similar in both sexes. However, men consistently develop more serious symptoms and have more mortalities across age groups on a global level (Fig1). More specifically, men account for about 59% to 75% of total mortality1. It’s indisputable that sex is an important factor when it comes to understand and combat COVID-19. Here are a couple of candidate mechanisms potentially contributing to sex-biased COVID-19 mortality.

Hormones

Many sex differences in the manifestation of disease development have long been attributed to sex hormones, particularly in the realm of immune responses. Both innate and adaptive immune responses are affected by sex-dependent factors2. Males are more susceptible to infections caused by parasites, fungi, bacteria, and viruses, one of the possible determining factors is sex hormone3. More specifically, the immune-suppressive androgens reside in males and immune protective estrogens reside in females. Females might produce more antibodies and launch a stronger immune defense to infection because of estrogens, while males lack the advantage to react the same way. Female hormones, estrogens, can ameliorate the severity of influenza infections by suppressing pro-inflammatory responses in mice4. The anti-inflammatory activity of estrogen is potentially through the regulation of the SOCS3 and STAT3 signaling pathways, specifically to promote the progression of the anti-inflammatory process towards the IL-10-dependent pathway in macrophages5. Sex hormones can regulate the immune response via regulating circadian rhythm, microbial composition, and transcriptional regulation such as estrogen receptors (ERs) and peroxisome proliferator-activated receptors (PPARs)6.

Fig2: Potential mechanisms of male bias of COVID-19 mortality7.

Sex chromosomes

One of the fundamental differences between men and women is the X and Y sex chromosomes. Females have two X chromosomes with a functional one and an inactive one to maintain the balance of chromosomal X gene dosage, while males only have one functional X chromosome and one Y chromosome to maintain the identity of sex-specific effects and testis development. This evolutional advantage in females provides a “back-up” plan in case of a “disease gene” on X chromosome inherited from either the maternal or paternal side. Some genes can escape from X chromosomal inactivation and consequently express higher levels. The gene encoding a receptor that is responsible for SAS-CoV-2 virus cellular entry is called ACE2. ACE2 locates at X chromosome and is potentially a target for ineffective chromosome inactivation, and which could cause a female-biased increased level of ACE2 expression7. A higher level of ACE2 in females promotes viral clearance. On the contrary, a lower level of ACE2 causes dysregulated inflammation, increased cardiovascular comorbidities, increased risk of respiratory failure in males7 (Fig2). Other inflammatory response-related genes on the X chromosome include pattern recognition receptors such as toll-like receptor 7 (TLR7), TLR8, interleukin-1 receptor-associated genes, and NFKB essential modulator genes8. Additionally, it has been shown that TLR3, TLR7, and TLR9 are female-biased while TLR2 and TLR4 are male-biased. These differences potentially reveal why males and females respond to infection differently7,8. The research on understanding sex dimorphisms in immunity is critical to help us fight COVID-19 more effectively.

In conclusion, strong evidence shows that COVID-19 affects men and women unequally. Aside from socio-economic, lifestyle and environmental differences, biology plays an important role in male-biased COVID-19 severity and mortality. To understand and combat infection more precisely, we need to consider sex as a biological variable and develop therapeutic strategies for men and women respectively.

References

  1. Griffith DM, Sharma G, Holliday CS, Enyia OK, Valliere M, Semlow AR, Stewart EC, Blumenthal RS. Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Differences in Mortality and Recommendations for Practice and Policy Interventions. Preventing chronic disease. 2020;17:E63.
  2. Markle JG, Fish EN. SeXX matters in immunity. Trends in Immunology. 2014;35(3):97–104.
  3. Klein SL. The effects of hormones on sex differences in infection: from genes to behavior. Neuroscience & Biobehavioral Reviews. 2000;24(6):627–638.
  4. Robinson DP, Lorenzo ME, Jian W, Klein SL. Elevated 17β-Estradiol Protects Females from Influenza A Virus Pathogenesis by Suppressing Inflammatory Responses. PLOS Pathogens. 2011;7(7):e1002149.
  5. Villa A, Rizzi N, Vegeto E, Ciana P, Maggi A. Estrogen accelerates the resolution of inflammation in macrophagic cells. Scientific Reports. 2015;5(1):15224.
  6. Taneja V. Sex Hormones Determine Immune Response. Frontiers in immunology. 2018;9:1931.
  7. Bienvenu LA, Noonan J, Wang X, Peter K. Higher mortality of COVID-19 in males: sex differences in immune response and cardiovascular comorbidities. Cardiovascular Research. 2020;116(14):2197–2206.
  8. Pradhan A, Olsson P-E. Sex differences in severity and mortality from COVID-19: are males more vulnerable? Biology of Sex Differences. 2020;11(1):53.

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

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My Journey as a Physician-Scientist Trainee

In this blog, I discuss my journey as a physician-scientist trainee to provide some insights to aspiring physician-scientists and in the hopes of encouraging others to consider pursuing this very rewarding career.

During the early part of my undergraduate training, I was not sure whether I wanted to go to graduate or medical school. I worked in a basic science lab throughout my undergraduate education. I enjoyed my time in the lab and the scientific process. As I was researching graduate and medical schools, I discovered MD/PhD and Medical Scientist Training Programs (MSTP) and thought that this would be a great option to merge my passions for medicine and basic science research.

I was fortunate to have the opportunity to be a part of the MSTP at the Medical College of Wisconsin (MCW). Prior to starting medical school, I did not know what medical specialty I wanted to go into or what specific project I wanted to work on. My MSTP training lasted 8 years. I rotated through labs the summer before the first year of medical school and the summer between the first and second years of medical school. After the second year of medical school, I joined the lab of Howard Jacob, Ph.D. and studied the genetic basis of hypertension and renal disease for four years. I loved my time in graduate school and the research environment in the Department of Physiology. I was so fortunate to be in the Department of Physiology at MCW where many of the faculty were generous mentors to trainees. I am especially grateful for all the mentorship that I received from Dr. Jacob, Dr. Joseph Lazar, Dr. Allen Cowley, Dr. Andrew Greene, Dr. Joseph Barbieri and the entire MSTP. Serendipitously, Dr. Ivor Benjamin (AHA president from 2018-2019) moved to MCW when I was training there and was willing to be a member of my dissertation committee. He is a phenomenal role model for aspiring physician-scientists. I am very appreciative that he took the time to mentor me clinically and scientifically. With his encouragement and guidance, I subsequently decided to pursue additional training in Cardiology with the goal of becoming a cardiovascular translational researcher.

After completing my Ph.D., I returned to clinical training to complete the third and fourth years of medical school. I subsequently joined a dedicated Physician-Scientist Training Program (PSTP) at the University of Minnesota that allowed me to simultaneously match into Internal Medicine residency and Cardiology fellowship and secure protected research time for postdoctoral research training. After completing medical school, I finished two years of Internal Medicine training and the first year of clinical Cardiology fellowship. I then joined a basic science laboratory and am now conducting research investigating the mechanisms of right ventricular dysfunction in pulmonary hypertension. I am fortunate to have three years of protected research time (I am currently in year 2 of research). During my postdoctoral research fellowship, I also see pulmonary hypertension patients in the clinic one-half day a week. After I complete my research time, I will then return to a clinical Cardiology fellowship to complete the last year of clinical training.

My journey to becoming a physician-scientist is still ongoing but there is never a day that I regret choosing this career. While the training can be long and arduous, it is rewarding. The transitions between research and clinical training can be challenging and you may constantly feel that you are trying to catch up with your peers. However, the job is never boring and there is always so much to learn! In clinical training, you gain a wide breadth of knowledge and when doing research, you study a narrow topic in depth. As a physician-scientist, you provide unique insights into what are the clinically relevant questions that need to be addressed. Whenever I am frustrated with troubleshooting experiments in the lab, feel that I am losing focus, or am dejected after paper/grant/award rejections, I become re-inspired and motivated to advance my research after seeing patients and being reminded of the many gaps in our medical knowledge.

The delineated path above was my path towards becoming a physician-scientist. There are multiple paths to becoming a translational researcher. Many medical trainees join labs or research groups during or after clinical training.

Here are some pearls that I picked up as an aspiring translational researcher:

  • When you are at the beginning of your medical training as a medical or MSTP student, you do not need to know exactly what you will do in the future. Be open-minded.
  • Selecting a mentor and lab environment that are a good fit for you is more important than the specific project you work on as a Ph.D. student. It is not expected and highly unlikely that you will study the exact same topic that you did your PhD work on for the rest of your career.
  • Throughout your training, find supportive environments and mentors. I am very thankful for the support of Dr. Kurt Prins, Dr. Thenappan Thenappan, Dr. Joseph Metzger, Dr. Samuel Dudley, Dr. Peter Crawford, Dr. Jane Chen, Dr. Cliff Steer and the entire PSTP, the CTSI program, and the entire Cardiology fellowship program at the University of Minnesota.
  • Be persistent and resilient.
  • Mentor and encourage others to become physician-scientists, especially those who are underrepresented in the biomedical community.
  • Enjoy the journey.

For any early-career trainees who are interested in becoming physician-scientists, feel free to contact me if you have any questions! I really hope that some of you strongly consider joining this very gratifying and important

 

“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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CDC Guidelines for the Vaccinated Population

It has been more than a year since the World Health Organization declared COVID-19 as a pandemic. In the past year, more than 130 million people were diagnosed with COVID-19, and we have lost 3 million lives globally. Within a record time, several effective vaccines were developed. Given that the vaccinated population is rapidly increasing, the Centers for disease control and prevention (CDC) released new guidelines for the fully vaccinated population. (figure 1)

CDC recommendations for the fully vaccinated population:

  • You can gather indoors with fully vaccinated people without social distancing or wearing a mask.
  • You can gather indoors with unvaccinated people from 1 household without social distancing or wearing a mask. Unless they are considered to be at high risk for severe COVID infection.
  • For domestic travel, you do not need to get tested before or after travel or self-quarantine after travel.
  • You do NOT need to get tested before leaving the United States unless your destination requires it.
  • You still need to show a negative test result or documentation of recovery from COVID-19 before boarding a flight to the United States.
  • You should still get tested 3-5 days after international travel.
  • You do NOT need to self-quarantine after arriving in the United States.
  • If you’ve been around someone who has COVID-19, you do not need to stay away from others or get tested unless you have symptoms.

Based on solid data, we know that all three approved vaccines in the United States are very effective in preventing the disease, especially deaths and severe forms. However, there are a few questions that remain to be determined in the next few months.

  • What is the effectiveness of different vaccines on the various new COVID-19 variants?
  • Can fully vaccinate people spread the disease?
  • For how long is the vaccine effective?

Currently, in the United States, the average number of shots per day is 3 million. Earlier this week, the public health agency reported more than 4 million shots were administered in 1 day. According to the CDC, more than 60 million people are fully vaccinated and 104.2 million U.S. residents, or 31% of the population, have received at least one vaccine dose. With the current pace, vaccines will be available for every adult in the United States by the end of May. Since the beginning of this pandemic, we have faced a lot of challenges in different aspects but finally now as the number of cases is significantly decreasing and the vaccinated population is expanding, we are definitely heading in the right direction!

Figure 1:
CDC recommendations for fully vaccinated people

References:

  • https://www.cdc.gov/coronavirus/2019-ncov/vaccines/fully-vaccinated-guidance.html

“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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Reducing Disparities through Diversity and Inclusion in Stroke Science, Clinical Trial Enrollment, and Community Engagement

As part of its mission to be a relentless force for a world of longer, healthier lives, the American Heart Association (AHA) has been working diligently to eliminate barriers to health equity in the U.S. diverse population through education and research, raising awareness through their many programs and initiatives.  In the stroke arena, we continue to face significant inequities related to stroke incidence, prevalence, care, and outcomes in ethnic minorities.1  Consequently, there has been a number of initiatives launched to address these disparities.  The Health Equity and Actionable Disparities in Stroke Symposium, a collaborative initiative of the American Heart Association and National Institute of Neurological Disorders and Stroke, took place in 2020 with the goals of reducing inequities in stroke care and research. It also aimed to accelerate the translation of research findings to improve outcomes for racial and ethnic minorities.1

This year the American Heart Association continues the efforts to promote awareness of the importance of diversity and inclusion in stroke science.  A roundtable session took place on Friday, March 17, during the last day of the prestigious 2021 International Stroke Conference.  A panel of experts shared their views and presented alternatives to improve diversity and Inclusion in the healthcare workforce, clinical trial enrollment, and community engagement.  The expert roundtable included experts in the field such as Dr. Emelia Benjamin, MD ScM FAHA, Michele Evans, MD, Michelle Jones-London, Ph.D., Bernadette Boden-Albala, MD MPH, Fern Webb, Ph.D., Candace Whitfield, BS, Trudy Gaillard, RN Ph.D., Mellanie Springer, MD MSc. Mr. Olajide Williams, MS served as the moderator of the roundtable. The panelists presented a fresh and clear view of the diversity and inclusion barriers encountered in the research arena.  They also offered alternatives to support inclusion and diversity in the development of research protocols, proposal procedures through institutional review boards, and through community engagement, with the use of community-based participatory research.

The experts highlighted the issue of representativeness in the conduct of research and presented diversity as a solution. Diversity in research means that people of different ages, different racial and ethnic groups and both men and women participate in research studies. The lack of diversity in participants of research impedes the ability to generalize study results and make medical advancements of effective therapies. It may further prevent some populations from experiencing the benefits of research innovations and receipt of high-quality care.2

In the context of clinical trial enrollment, the speakers emphasized the importance of having a diverse sample.  They also discussed the need for inclusivity of minority groups during the enrollment period. They also highlighted the importance of informed consent forms available in other languages to facilitate the diversity of the sample during enrollment. They also suggested the approval of translated informed consent forms in an expedited fashion to avoid delays in the consenting process for ethnic minority groups.  Another very important factor was the importance of having the infrastructure to support diversity and inclusion in the stroke science workforce. Factors such as the hiring of clinicians and research personnel that may resemble the target population of interest are vital to facilitate the recruitment of ethnic minority groups much needed in these studies.3

As academicians and researchers, we should advocate for diversity as it drives excellence and enhances innovation in the biomedical sciences, leading to novel findings and treatment of diverse populations.3 Diverse and inclusive scientific teams can generate new research questions, develop methodical and analytical approaches to better understand study populations, and offer approaches to problem-solving from multiple and different perspectives.  Moreover, the promotion of diverse groups presents opportunities for the inclusion of individuals with different perspectives who can complement each other and inform of new approaches.3  This may further strengthen the approach of the research team through the various phases of the research process, especially when their diversity and inclusion match the racial and ethnic minority group under study.

One of the experts, Dr. Michelle Evans highlighted the importance of community-based participatory engagement in research, especially in ethnic minorities.  Another speaker, Dr. Trudy Gaillard discussed the opportunity to engage members in the community, stakeholders, and utilize this as a venue to engage study participants through community-based participatory research (CBPR).  Engaging in active reflection and adopting promising partnering practices are important for CBPR partnerships working to improve health equity.4

The roundtable presentation aligns with current National Institutes of Health (NIH) strategies to support diversity and inclusion in the science community. A program called UNITE was launched in 2020 to tackle the problem of racism and discrimination in science while developing methods to promote diversity and inclusion across the biomedical enterprise. Some of its functions include understanding stakeholder experiences through listening and learning, pursuing research on health disparities, minority health, and health equity, improving the NIH culture and structure for equity, inclusion and excellence, transparency, communication, and accountability with internal and external stakeholders, changing policy, culture, and structure to promote workforce diversity (NIH, 2021).5

In addition to NIH, the National Institute of Neurological Disorders and Stroke (NINDS) (2021) is committing to diversity, equity, and inclusion in the neuroscience community as both an employer and funding agency, addressing the stark differences in neurological health outcomes related to where one lives, has access to care, their race/ethnicity, and socioeconomic status.6  In the process of implementation of these initiatives, it will be important to note that implementation science can exacerbate health disparities if its use is biased toward entities that already have the highest capacities for delivering evidence-based interventions.

There is a call for making efficient use of existing data by applying epidemiologic and simulation modeling to understand what drives disparities and how these can be overcome.  There is also a need for designing new research studies that include populations experiencing disparities in cardiovascular disease, neurological disease, and stroke.7  It will be interesting to observe in the next coming months, the implementation of some of these strategies to promote diversity and inclusion in stroke science. Much remains to be done to bridge the gap and reduce healthcare-related disparities in racial-ethnic minority groups, especially in the context of stroke science. In the meantime, it is up to us to continue the work of raising awareness, promoting diversity and inclusion in our academic circles, in the science field, and in our communities.

For additional information on the efforts American Heart Association to support diversity and inclusion in heart science, please be sure to check out https://www.heart.org/en/about-us/diversity-inclusion.

References:

  1. Towfighi A, Benson RT, Tagge R, Moy CS, Wright CB, Ovbiagele B. Inaugural Health Equity and Actionable Disparities in Stroke: Understanding and Problem-Solving Symposium. Stroke. 2020;51(11):3382-3391. doi:10.1161/STROKEAHA.120.030423
  2. University of Maryland. Health Equity Project. (2021). Top five reasons why diversity is important in research. Retrieved from https://buildingtrustumd.org/unit/importance-of-research/importance-of-diversity#:~:text=Diversity%20in%20research%20means%20that%20people%20of%20different,specific%20reasons%20why%20diversity%20in%20research%20is%20important.
  3. Swartz TH, Palermo AS, Masur SK, Aberg JA. The Science and Value of Diversity: Closing the Gaps in Our Understanding of Inclusion and Diversity. J Infect Dis. 2019;220(220 Suppl 2):S33-S41. doi:10.1093/infdis/jiz174
  4. Dickson E, Magarati M, Boursaw B, et al. Characteristics and Practices Within Research Partnerships for Health and Social Equity. Nurs Res. 2020;69(1):51-61. doi:10.1097/NNR.0000000000000399
  5. National Institutes of Health. (NIH). (2021). Ending Structural Racism. Retrieved from https://www.nih.gov/ending-structural-racism/unite on 4/2/21.
  6. National NINDS (2021). NINDS is committed to ending structural racism. Retrieved from https://www.ninds.nih.gov/News-Events/Directors-Messages/All-Directors-Messages/NINDS-committed-ending-structural-racism
  7. McNulty M, Smith JD, Villamar J, et al. Implementation Research Methodologies for Achieving Scientific Equity and Health Equity. Ethn Dis. 2019;29(Suppl 1):83-92. Published 2019 Feb 21. doi:10.18865/ed.29.S1.83

 

“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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State of the Union: Cryoablation vs Radiofrequency Ablation for Atrial Fibrillation in the United States

Background

The concept of catheter ablation for atrial fibrillation (AF) was pioneered by Michel Haissaguerre from Bordeaux, France. In their landmark paper, Haissaguerre et al. described that the majority of triggers for atrial fibrillation (AF) can be mapped in the sleeves of muscles that extend into the pulmonary veins, and ablating these triggers leads to freedom from AF 1. This approach ultimately evolved into pulmonary vein isolation which remains one of the most commonly performed electrophysiological procedures today.

Essentially, the two common approaches involve radiofrequency ablation (RFA) or cryoablation (CRA). In general, most of the catheter guidance in RFA is with the help of electroanatomical mapping, and point by point lesions are made by heating the tissue, but it has a longer operator learning curve. CRA requires more extensive fluoroscopic guidance and can create circular lesions in a single step using a balloon that causes cellular necrosis by freezing the tissue 3. Since these two techniques differ in the source of energy, fluoroscopy time, need for electroanatomic guidance, learning curve, and procedure time, an important question arises: what is the best energy source to perform catheter ablation?

Multiple randomized controlled trials and observational studies have attempted to answer this question. A recent meta-analysis of 14 randomized trials and 34 observational studies that included 7951 patients undergoing CRA vs 9641 patients undergoing RFA showed that over a mean follow up of 14 ± 7 months, CRA reduced the incidence of AF recurrence as compared with RFA (RR 0.86; 95% CI 0.78-0.94; p=0.001) . While the rate of phrenic nerve palsy was higher in CRA, rates of other complications like pericardial effusion, tamponade, and vascular complications were lower as compared with RFA. Interestingly, CRA procedure time was shorter than RFA by almost 20 mins4.

While this meta-analysis is based on results of multiple randomized and observational studies done under controlled settings, there is a paucity of real-world data comparing CRA vs RFA. This important question was addressed by Friedman et al in their analysis of Get With The Guidelines® – Atrial Fibrillation (GWTG-AFIB) registry 5 which gives a comprehensive understanding of the state of union regarding CRA vs RFA for AF (Figure 1)**.

GWTG-AFIB Registry

It is a large hospital-based quality improvement registry that is based on a partnership between the American Heart Association and Heart Rhythm Society and contains data on patients with AF or atrial flutter who have an overnight stay at a hospital in the United States 6.

Research Question

What are the differences in real-world patient and peri-procedural characteristics and in-hospital outcomes between CRA vs RFA?

Patient Characteristics

In total 5247 patients were included with 1465 undergoing CRA and 3782 undergoing RFA at 33 different sites. More patients undergoing CRA had paroxysmal AF (60% vs 48%) and no prior history of AF ablation (87.5% vs 73.8%) with similar CHA2DS2-VASc scores5.

Procedural Characteristics

The procedure times were shorter with CRA (129 min vs 179 min, p<0.001) but the ablation times were similar (27 min vs 35 min, p=0.15). There was an increase in fluoroscopy time with CRA vs RFA (19 min vs 11 min, p<0.001). The use of intracardiac echocardiography and electro anatomic mapping were less common with CRA; 87.3% vs 93.9%, p<0.001 and 87.7% vs 94.6%, p<0.001 respectively 5.

In-Hospital Complications

Phrenic nerve injury was more common with CRA (0.9% vs 0.1%, p=0.0001). Total complications were more with RFA (5.4% vs 2.3%, p<0.0001) however these were attributed to more volume overload and other events. The risk of any complication was less common with CRA (OR 0.45, 95% CI 0.25-0.79, p =0.0056).

Implications

This study gives an important insight into the contemporary practice of CRA vs RFA in the United States. Overall, despite the increasing popularity of CRA, RFA still remains the most common type of catheter ablation for AF. It appears that patients undergoing RFA are in general more complex with a history of prior ablation or persistent AF, and more likely to have co-morbidities like heart failure and obstructive sleep apnea. These differences in the patient characteristics like history of persistent AF may explain the observed differences in complications with RFA. Another interesting observation from this study is that more RFA were performed at academic/teaching hospitals (91.7% vs 83.8%) and the likely explanation is that the procedure requires more time and expertise than is generally available at larger academic centers.

An encouraging observation from this real-world cohort of patients is that the rate of nerve injury was lower in both CRA (0.9%) and RFA (0.1%) arms as compared to the large randomized FIRE and ICE trial 3 (CRA 2.7%, RFA 0%) and comparable to the meta-analysis by Fortuni 4 (transient phrenic nerve palsy with CRA 3.2% and with RFA 0.05; permanent phrenic nerve palsy with CRA 0.6% and with RFA 0.04% ).

Future Directions

In future a comparison of longitudinal outcomes like recurrence of AF, quality of life, AF symptoms, incidence of heart failure, incidence of stroke, incidence of thromboembolic complications, AF related hospitalizations, cost of care and mortality, between CRA and RFA will be important.

Figure 1: Comparison of patient and periprocedural characteristics and in-hospital complications between cryoablation and radiofrequency ablation from Get With The Guidelines® atrial fibrillation registry.

**This study was funded by a GWTG-AFib Early Career Investigator Award.  

References

  1. Haïssaguerre M, Jaïs P, Shah DC, Takahashi A, Hocini M, Quiniou G, et al. Spontaneous Initiation of Atrial Fibrillation by Ectopic Beats Originating in the Pulmonary Veins. New England Journal of Medicine 1998;339:659–666. doi:10.1056/NEJM199809033391003.
  2. Wellens Hein J. J. Pulmonary Vein Ablation in Atrial Fibrillation. Circulation 2000;102:2562–2564. doi:10.1161/01.CIR.102.21.2562.
  3. Kuck K-H, Brugada J, Fürnkranz A, Metzner A, Ouyang F, Chun KRJ, et al. Cryoballoon or Radiofrequency Ablation for Paroxysmal Atrial Fibrillation. New England Journal of Medicine 2016;374:2235–2245. doi:10.1056/NEJMoa1602014.
  4. Fortuni F, Casula M, Sanzo A, Angelini F, Cornara S, Somaschini A, et al. Meta-Analysis Comparing Cryoballoon Versus Radiofrequency as First Ablation Procedure for Atrial Fibrillation. Am J Cardiol 2020;125:1170–1179. doi:10.1016/j.amjcard.2020.01.016.
  5. Friedman DJ, Holmes D, Curtis AB, Ellenbogen KA, Frankel DS, Knight BP, et al. Procedure characteristics and outcomes of atrial fibrillation ablation procedures using cryoballoon versus radiofrequency ablation: A report from the GWTG-AFIB registry. Journal of Cardiovascular Electrophysiology 2021;32:248–259. doi:https://doi.org/10.1111/jce.14858.
  6. Get With The Guidelines- AFIB Registry. WwwHeartOrg n.d. https://www.heart.org/en/professional/quality-improvement/get-with-the-guidelines/get-with-the-guidelines-afib (accessed March 15, 2021).

“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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“Paid Leave Regardless of Pregnancy Outcome? While New Zealand pioneers the future for women, the US continues to be left behind.”

As I approach the final weeks before delivering my second child in cardiology fellowship, my friends outside of medicine ask if I’ve started maternity leave. I answer, “No, I’m saving the 7 weeks of paid leave to start at the time of delivery.” Like most women physician mothers, I have a suspicion you can relate. We want to maximize our time with our newborns before returning to work. While every pregnancy varies, the last few weeks can be quite challenging, depending on the clinical and procedural duties required, all while balancing the responsibilities of “nesting” and mentally preparing for this new addition. While our preferences may differ on how much time we’d ideally spend on maternity leave, I feel it’s worth the few moments to reflect that maybe we would like the opportunity to have more time if we were granted it. That being said, there continues to be a lack of standardization of maternity leave across the country.

As we approach the end of #InternationalWomensMonth and celebrate women across the world and discuss #equalpay, the news of New Zealand’s approval of paid leave after miscarriage announced a few days ago in the NY Times is so fitting for a finale1. Ginny Anderson, the Labour member of Parliament who drafted this bill, stated.

“I felt that it would give women the confidence to be able to request that leave if it was required, as opposed to just being stoic and getting on with life, when they knew that they needed time, physically or psychologically, to get over the grief.”

I have been fortunate to not experience the immeasurable pain of losing a baby through miscarriage or stillbirth. As healthcare providers, we are all aware of the 10-20% of known pregnancies resulting in miscarriages, and with more women, in general, pursuing careers and getting married later in life, us “older mothers” are at increased risk of miscarriage and gestational complications. The jury continues to be out on whether the culture of medicine that embraces night shifts and working long hours contributes to physician miscarriages2. Regardless, the culture of appearing calloused immediately after such a devastating loss and carrying on as expected while mentally grappling with the physical and emotional trauma that lingers seems primitive.

As I hold growing belly during this final stretch, my hope is for all women who desire to be mothers to have the same opportunity to have the time and space to deal with whatever comes down the road. While the rise in pregnancy hormones may explain my emotional post today, the humility I feel and sensitivity to women who may be coping in isolation is not lost on me.

With a warm heart,

Kyla Lara-Breitinger, MD, MS

“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.”