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The Health Costs of Hunger Part 2: What we can do about it

If you read my February blog, you know that food insecurity is a complex and overwhelming issue in the United States. In 2018, 37.2 million Americans were food insecure and of that, 6 million were children. The health consequences of food insecurity are significant and contribute to growing rates of chronic disease American’s have experienced in the past few decades. With recent changes to programs such as the supplemental nutritional assistance program (or SNAP), more Americans are at risk for becoming food insecure.

The lack of stable access to adequate safe food affects a persons’ health and well-being in profound ways. And as health care providers used to acting, we want to do something about food insecurity in our communities.  But what can be done and where to start?  To answer these critical questions, I spoke with Alissa Glenn, consultant of food as medicine program at the Greater Cleveland Food Bank, who offered this advice.

  1. Acknowledge that food insecurity is pervasive and talk about it. Hunger affects people of every gender, age, race and ethnicity throughout the United States. Yet, an important reason people often do not pursue supportive programs such as SNAP, is the longstanding stigma around assistance. One of the best ways to break this stigma is by talking openly and compassionately about food insecurity in your community.
  2. Educate yourself and your colleagues. My February blog, had a lot of scientific resources on food insecurity hyperlinked. Last year, the AHA published a science advisory on innovative strategies to create a healthy and sustainable food system that can provide useful context. In addition, lay resources such as the Feeding America website and books like Stuffed and Starved can help explain this complex issue. Finally, consider inviting your local food bank to conduct a continuing education or a Grand Rounds session on addressing food insecurity in clinical settings. They can describe local resources in your own community and practice poverty simulations to help healthcare providers feel more comfortable discussing food insecurity with patients.
  3. Ask your patients about it. Screening for food insecurity is recommended by groups such as the American Association of Pediatrics which suggests incorporating such a screening at every patient visit. I know, we have to fit so much into each patient encounter that trying to fit in one more thing seems impossible. But a quick, simple strategy is to administer the Hunger Vital Sign™ (Left Insert).

It can be hard for patients to acknowledge they are food insecure so helping them feel comfortable can result in more honest answers. Best practices include asking screening questions after the patient has been with the provider for a while, having a team member with a longstanding relationship ask screening questions, and if possible, to ask them via tablet or computer to reduce awkwardness.

  1. Refer patients and family members who are food insecure and may need immediate help to local resources. This can include local food pantries, produce distribution sites, hot meals, and perhaps, onsite therapeutic food clinics. If your clinical setting is lucky enough to have to have a registered dietitian, involve them in developing a list of local resources to be distributed to patients. Case managers and outreach workers can also provide patients resources about short and long-term support for food insecurity. To find a food bank near you, please check out the Feeding America
  2. Advocate for anti-hunger programs. SNAP is the first line of defense against food insecurity. For every meal that a food bank provides, SNAP provides 9 meals. As the largest effort to address hunger in the U.S., changes to this program that reduce eligibility or benefits will increase the number of hungry Americans. Working with your community and engaging with your elected officials about how hunger influences the health care you provide are powerful ways to advocate for their continued support. To find out more about advocating for SNAP and the Child Nutrition Reauthorization Act, please review the Advocating for a Hunger-Free America
  3. Use your professional associations. As healthcare professionals, we have a powerful voice. Every day we talk with dozens of patients and family members about how to improve their health and well-being. As you get more comfortable talking with your patients talking about food insecurity, you will likely hear stories about how hunger affects their health. Work with your professional associations to collect those stories and with one voice advocate for changes in practice, education, and policy.

 Last month, the AHA released its 2030 Impact Goal. This ambitious statement recognized the importance of structural changes to achieve a world of more equitable, longer, healthier lives. It creates a framework from which professional organizations can harness the energy and experience of its members to initiate conversations about food insecurity, incorporate food insecurity education into the training of providers, increase food insecurity screening in clinical settings, and use the collective voice of 40 million volunteers and members to effectively advocate for anti-hunger programs.

There are many ways you can work with the AHA to reduce food insecurity in America. Consider working with your scientific council to propose a scientific statement on the effects of food insecurity on cardiovascular health, propose a workshop on clinical food insecurity protocols at a Scientific Sessions meeting, or write an editorial on your experiences helping a patient with food insecurity. The enormity of hunger in America, and its deleterious effects on the health of our patients, can be overwhelming. But even small steps such as reading a book on food insecurity, screening patients in your clinic, or advocating for structural change, can be powerful ways to help to reduce food insecurity.

“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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Science Communication Is The Bridge We Need

Nowadays it’s typical and obvious that conversations create and maintain their existence within “bubbles” or “echo chambers”. The examples are plenty and diverse, across all topics and around the whole world. This is partly a result of the expanding space that allows for more conversations to happen, namely the interconnected world of online web. Never before has it been easier to have a conversation between individuals that reside in different continents, and have the conversation be as fluent and dynamic, in real-time, as if the individuals are all sitting around the same table. And not only is it a matter of technology that facilitates these conversations, it is also the ability to have a large, common, and easily accessible wealth of information to fuel the talks. These factors combine to create a type of communication ecosystem so rich and diverse, that it has inevitably been utilized to support wide-ranging types of microenvironments and subject matters.

New ways facilitate the ability to communicate between individuals interested in ideas, regardless of the actual quality, reason or purpose of these ideas and conversations. It is however not my goal here to debate or argue against some of the prevailing conversations that exist now on the internet. That feels like an issue that requires a different format and a different type of communication than a blogpost in a health and science geared online platform! Instead, my goal today is to spotlight and encourage more of the type of rich communication possible, especially by directing my message towards… and you probably guessed this, scientists (and physicians and all other types of academics. Scientists get the headline in this blogpost because… well I’m a scientist myself!).

I believe that in this rich ecosystem of communication possibilities, there needs to be an increased effort by scientists to engage in open discussions with as many individuals as possible. This is counter to what has been the case for the past century, where scientists placed the highest priority into communicating their knowledge, investigative findings and even their questions (with no present answers) to other scientists, in platforms that are extremely inaccessible to the vast majority of the general public. Scientists (and academics in general) almost intentionally sidelined themselves from active participation in what the world was preoccupied with and talking about at any point in time.

To that extent, it is highly encouraging and exciting, to see that in the past few years, attention and valuable effort has been put into the wide-ranging field of Science Communication (#SciComm), by a growing number of young and established scientists, that answered the call of science beyond the walls of the lab, or the research group, university or hospital that houses them.  #SciComm can have many forms, and all of them are totally appropriate, depending on how it is performed, and by whom, and for what purpose. #SciComm can be an addition to the portfolio of an active scientist (student, early-career or even a fully tenured senior investigator). #SciComm can also be an entry-level job by a recent science graduate that has an interest in media and public outreach. #SciComm can also be a lengthy career all on its own, spanning decades (you know who’s basically a #SciCommer: Bill Nye! Also, David Suzuki, and Sir David Attenborough!).

Science communication to the public takes a completely different form, of course, compared to science communication between peers. Academic and medical publications read by their intended communities are perfect examples of “conversation bubbles” and echo chambers. There is no doubt a benefit in having conversations between subject-matter experts. The increased potential of collaboration and the advancement of ideas and innovations has greatly benefited from the ability to communicate within these well-structured communication bubbles. So I would not want this type of discussion to end or be discouraged at all. However, it is increasingly evident that scientists also need to utilize, and take advantage of, the widening communication avenues. Otherwise, the role scientists play in the expanding world will inevitably shrink and become marginalized.

(Collage assembled from pixabay.com images)

New avenues for scientists (and everyone else) exist in all relevant communication styles: If writing is preferred, many blogs/online magazines and newsletters are accessible (or easily created), which can be utilized to “translate” knowledge that exists in academic and medical publications, and allow far easier accessibility for the public. A word of caution here is warranted though: it is important to learn about the content provider (publisher), and vet the content on that platform, to know for sure the value and accuracy that is present there. As scientists, we must value our own output, and make sure it gets sorted into a worthwhile content provider/publisher, and never in a “predatory” or compromised communication form. We should not lend credibility to something that fosters false or biased or unproductive content.

Moving on, when audio style communication is desirable, then podcasts are the modern-day addition to the “radio” format of science communication. And finally, if video is the go-to communication medium, then YouTube is there for everyone. And just like with my words of caution regarding writing and content disseminating new avenues, one must be careful about Podcast and YouTube channels that one is thinking of contributing to; great options exist and are highly recommended, but there also exists a large number of channels and content distributors that would do more harm than benefit to the overall science and general public. Today I’m not going to tackle the world of Social Media here (Twitter, Instagram, TikTok, etc), but know that these also count towards #SciComm (and probably could be the most dominant force of communication moving forward). That’s a future topic to write about!

So, as a scientist, an early career professional, and an enthusiastic communicator of knowledge, to as a wide an audience as I can reach, I’ll continue to encourage, support and amplify the desire for more science communication, and utilization of the expanding avenues available for everyone. Because when science is available for all, the world can tackle more challenges, and everyone can benefit.

 

“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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March Madness – Dealing with the Stressing of Training

March is synonymous with college basketball, winning brackets (or losing in my case), and general merriment. For those of us in medicine, it may have a different meaning – stresses of matching, winter blues, and a general feeling of being burnt out. For me, March was one of the hardest months to get through in training, despite it being my birthday month.

Living in Massachusetts means long winters and I notice the general spirit of trainees tends to drop during this time. The novelty of winter has grown old, as the holidays have passed and we all seem to anxiously await the spring. The grueling winter days make it challenging to be outdoors, inhibiting us from enjoying our hobbies, and in short, tired of being cold. My friends who have trained or are working in cold climates (i.e Minnesota, Michigan, Wisconsin, Vermont to mention a few) have echoed the same sentiment. My personal interactions with interns and residents are often highlighted by fatigue, decreased empathy towards patients, and a desperate need for “the year to be over.” So, what are the tools we can use to help get through our own March Madness?

Here are a few tips and tricks that have helped me improve my wellbeing.

  • Stress to Strength: Growing up, I played soccer, basketball, tennis, tried picking up running (but limited by jumpers’ knee), and occasionally surfing. Clearly, none of these are great activities if it’s cold outside which caused me to feel claustrophobic in the winters. I instead work out in the hospital gym much more to try to stay active and have a positive outlet for when I am stressed. I often get asked, “what’s a good strategy for me to make it to the gym with our crazy schedule?” I’ve realized not everyone wants to go to the gym before work (which is my routine) but having small, achievable goals is the way to go. For example, try going one day before work, one day after work, and once during the weekend. You don’t need to go every single day to be healthy or stress-free. Having a few days per week in dedicated time slots will help create structure and not make going to work out feel like a chore.
  • Mindfulness: Mindfulness is becoming more popular in the west and for valid reasons. It is the ability to pay attention to the present moment with curiosity, openness, and acceptance. We can exacerbate stress if we ruminate about the past, worry about the future, or even engage in self-criticism; and I have been guilty of all 3. I discovered a great app called “Headspace” that helped me with guided mediation and mindfulness. The app has evolved to help fit nearly everyone’s needs and I have recommended it to several friends/colleagues.
  • Making my list, checking it twice: Trainees have so many tasks they need to complete: pre-rounding, rounding, Epic tasks, notes, discharge summaries, more Epic tasks, case reports, quality improvement projects, and if they have time – grocery shopping. I always keep a list of tasks I need to complete – partly because it helps me stay organized, but also my obsessive-compulsive personality LOVES to cross tasks off the list. If you get overwhelmed with the countless tasks you have to do, start keeping a list. This will help create structure, organization, and improve productivity.

 

  • Reach Out: We all need to have friends, family, and colleagues to turn to when we are feeling burnt out. Fortunately, many training programs have resources available from their GME office, which are often underutilized. My clinic preceptor (and friend) Dr. Brigid Carlson has invited me out for coffee, dinner with her family, and always welcomes me to speak to her if I am feeling overwhelmed. Knowing I have someone to turn to has helped me not “bottle things up.”

Although March Madness is traditionally stressful with college basketball, it should not be the same for the workplace. With spring on the horizon, many of us feel the stresses of training but there are resources to help us to continue to be successful.

“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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How Coronavirus (COVID-19) can affect your heart health?

The rapid spread of the coronavirus (now known as COVID-19) has sparked a global alarm. The World Health Organization (WHO) has declared a state of public health emergency of international concern (PHEIC), as many countries are grappling with a rise in the number of confirmed cases. As of March 5th 2020, data from WHO have shown that more than 95,499 confirmed cases have been identified in 84 countries/territories with more than > 99% of the cases emerging from China1. In the United States, the Centers for Disease Control and Prevention (CDC) have increased the risk from Coronavirus spread to level 3 and advised against non-essential travels to China, Iran, Italy, and South Korea. “It is not so much a questions of if this will happen anymore, but rather more a question of exactly when this will happen and how many people in this country will have severe illness” said Dr. Nancy Messonier, director of the National Center for Immunization and Respiratory Disease at the Center for Disease Control and Prevention in the United States.

What is coronavirus?

Coronavirus (CoV) are a large family of viruses that causes illness ranging from the common cold to more severe diseases such as the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-Cov). A novel coronavirus (nCov) is a new strain that has not been previously identified in humans. Coronavirus are zoonotic, meaning they can transmit between animals (such as bats, cats, camel, and cattle) and human.

What is the clinical profile of COVID-19 infection?

 Coronavirus infection is spread from human-to-human via droplets or direct contact. The infection is estimated to have a mean incubation period of 6.4 days (0-27 days), and a basic reproduction number of 2.24-3.58. Fever was the most common clinical feature followed by cough, shortness of breath, body ache, headache, and sore throat. There have been reports of gastrointestinal symptoms (nausea, vomiting, or diarrhea) before respiratory symptoms occur, but this is largely a respiratory virus. Those who have the virus may not have obvious symptoms (asymptomatic), or may have symptoms ranging from mild to severe. In some cases, the virus could be life-threatening. Older adults are less likely to present with fever, thus close assessment of these group of patients with other symptoms such as cough and shortness of breath is critical.

What are the cardiac Implications of COVID-19?

Early reports show that 50% of hospitalized COVID-19 patients had an underlying chronic medical illness, 80% of which are cardiovascular and cerebrovascular disease. The American College of Cardiology (ACC) issued a bulletin recently to warn patients with heart disease about their potential risk for complications if they contracted the disease. This does not mean that patients with cardiovascular disease or with cerebrovascular disease are at increased risk of getting coronavirus. However, they should practice additional precautions, since they are at great risk for complications. Nearly 20% of people developed Acute Respiratory Distress Syndrome (ARDS) according to a case report of Wuhan hospitalized patients. In addition, 7.2% of patients developed acute cardiac injury, 8.7% shock, 3.6% developed acute kidney injury, and 16.7% developed arrhythmia. Several unpublished first-hand reports suggest at least some patients develop myocarditis. Therefore, it would be reasonable to triage patients with COVID-19 infection according to the presence of underlying cardiovascular disease, renal disease, respiratory and other chronic diseases for prioritized treatment.

Several experts suggested rigorous use of guideline-directed plaque stabilizers (such as ACE-inhibitors, Statin, Beta-blockers, Aspirin) as it could protect cardiovascular patients during wide-spread outbreak of the virus. Furthermore, it is important for patients with cardiovascular disease to remain up to date with vaccination, including pneumococcal vaccine given the risk of secondary bacterial infection. It would be also crucial to receive the influenza vaccine to prevent any other sources of fever which could be initially confused with coronavirus infection.

The outbreak of COVID-19 has become a global clinical and public health threat. Knowledge about this novel virus remains limited. What we can do now is aggressively implement infection control measures to prevent the spread of COVID-19 via human- to- human transmission.

References:

  1. World Health Organization declares Global Emergency: A review of the 2019 Novel Coronavirus (COVID-19), International Journal of Surgery, (March 2020)
  2. Travel Health Notices: https://wwwnc.cdc.gov/travel/notices#travel-notice-definitions
  3. Chen H, Zhou M, Dong X, et al. Epidemiological and Clinical Characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: a descriptive study. Lancet 2020; published online January 29. https://www.thelancet.com/action/showPdf?pii=S0140-6736%2820%2930211-7
  4. Wang D, Hu B, Hu C, et al.Clinical Characteristics of 138 Hospitalized Patients with2019 Novel Coronavirus- Infected Pneumonia in Wuhan, China. JAMA. Published online February 07, 2020. doi:10.1001/jama.2020.1585
  5. Cardiac Implications of Novel Coronavirus (COVID-19): https://www.acc.org/~/media/665AFA1E710B4B3293138D14BE8D1213.pdf

 

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

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A Paycheck Away: Financial Fitness in Medicine Part II

In the first installment of this three-part series, I summarized the current state of financial fitness among early-career medical professionals in the United States. I also reviewed a few general changes in philosophy that can help you begin to improve your financial health starting today. The response to that blog has been largely positive; and in the days after its posting, I received text messages from friends/colleagues expressing their desire for specific measures to take in the last year of fellowship — or first few years of independent practice. This blog post will, therefore, focus on specifics.

LAST YEAR OF TRAINING: “FINISH STRONG”

(Image: ESPN)

  • Buy individual disability insurance before June 30th. Health is wealth, and you should protect your most valuable financial asset (as a resident/fellow, this is plainly your future earning potential) in the event that you’re incapacitated in any way. Disability insurance essentially pays you a set amount of income per month while you are unable to work. This set amount depends on the plan you choose – typically expect to spend 2-4% of the income insured. Premiums depend on your current age, health, income, etc. This is why it’s important for you to lock yourself into a plan now, while you’re making significantly less income and still exercising 4 times a week. Most university-based hospitals offer group policies that are essentially generic plans from one insurer for all employees who opt-in as part of their compensation plan. I advise you, however, to find an insurance agent on your own. This individual will find provide you with all the options on the marketplace, with specialty-specific plans that can travel with you if you leave your current/future employer. You can also increase your policy (i.e. the monthly payout) as your income increases throughout your career without having to repeat a medical exam or questionnaire. (further reading)
  • Have a lawyer review your contract/offer. One way to really start off on the wrong foot is to have a contract that limits your earning potential and adversely affects your work-life balance. Have a legal professional who deals specifically with physician contracts in your state, and better yet in your county/region of the state. Some employers, for instance, will offer an attractive base pay with an unattainable RVU requirement in order to receive that shiny new base pay. Things to ask about: fairness of non-compete clause, stipulations regarding with/without cause termination, work RVU requirement, bonus structure, and feasibility, 401k match, tuition/education benefits. Things to look up: MGMA DataDive survey results for your specialty and city, AMA Physician Practice Benchmark survey results for your specialty and city.
  • Open a low fee, high-interest checking/savings account. If you’re like me and you’ve had the same checking account since you were a freshman in college, it may be time to reevaluate if that’s the best option for you. There are so many great low/no-fee options out there for you to direct deposit your new paychecks into. There are also options that allow you to invest in the market easily, or offer credits for doing so. Ultimately, what you want is for your bank accounts to protect and grow your money rather than slowly bleed you of it. I personally recommend taking a look at Charles Schwab but here are some other outstanding options for you to consider.

FIRST YEAR AS ATTENDING: “GET YOUR LEGS UNDER YOU”

(Image: Attack of the Cute)

  • Enjoy it. You’ve put in years and years of tireless effort to finally get to this point. While your college roommates were buying homes, cars and building investment portfolios, you were spending endless nights in the library or on the wards. Make a bucket list today, and make an effort to check one of those things off each year. Maybe it’s a safari in Tanzania, or it’s the Rolex that your grandpa/grandma always wore. Go for it. You deserve it.
  • Physician mortgage loan. Most people want to own a home eventually. It’s part of the American dream. It also makes sense financially (let’s play a game: calculate the total amount of rent you’ve paid from age 18 until now…then keep track of that number each month until it stops growing). So what exactly is a physician mortgage loan? It’s a special benefit provided by banks across the country that allows early-career physicians (usually < 5 years out of training) to secure mortgages of up to ~$900k with 0-5% down payment. In any other situation, with such a low down payment, the borrower would pay a fee to the bank to ensure that they won’t default on the loan; this is called a PMI (Private Mortgage Insurance). In order to secure one of these mortgages, you need to typically have a credit score of 700 and a signed contract showing your anticipated salary. That’s right, NO PAY STUBS. Many physicians actually close on their home before they even begin working. With the 15-20% that you’re saving on a down payment, go ahead and pay down those student loans.
  • If married with loans, file taxes as separate. It always comes up during tax season whether married couples should file jointly or separately. For most couples reading this, one or both partners is a physician. The average physician income in somewhere around $200,000 per year. The average physician’s student loan debt is also somewhere around $200,000. Assuming that your situation is somewhere around the average, it usually makes sense to file separately. The main downside to filing separately is that the current tax code includes credits that are only available to couples filing jointly. However, most or all of these credits only pertain to household incomes well below that of even a single income physician household. The benefits of filing separately pertain to income-driven loan repayment programs and other income-based plans you may have. If you file your taxes separately, your lender will consider only your income (not your spouse’s) in calculating your monthly payments. This can significantly reduce your monthly payments!

It’s important for physicians to tend to our financial fitness as we tend to our physical fitness. Just like everything in life, practice makes perfect. Try saving 20% of your resident/fellow salary this month. Practice trading stocks using a simulator like Investopedia’s.

If you’re going to be an attending in July 2020, plan out how the rest of the year looks for you financially, so it won’t be such a surprise when you get there. Lastly, read about the mistakes that these financially savvy physicians made here. Learning from others’ mistakes is just as good as learning from your own.

That’s all for now! Please feel free to tweet me or email me any particular questions you have, and I’ll try to answer right away as well as incorporate them into future posts.

 

“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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Writing is Hard— And Here’s Why You Should Do it

If you are in academia, you are likely familiar with the “publish or perish” mantra. Publishing in peer-reviewed journals is absolutely valuable, both for researchers and for clinicians. It’s a robust way to develop and share knowledge. It can help you get promoted. It can raise your profile in your field. But for people with competing demands (teaching, clinical practice, the rest of your life), it’s not always accessible.

Don’t worry— there are other reasons to write and other ways to publish. In navigating what kind of writing and publishing is valuable, it’s crucial to understand your goals. One size does not fit all. The best approach for you depends on your professional trajectory. If you have an academic appointment and you are pursuing tenure and promotion, then yes, data-based and peer-reviewed publications are your priority. But perhaps your role is different, or broader— maybe you see yourself as a public educator or advocate, a clinical expert, or a mentor. Writing is hugely valuable in these roles as well, but it doesn’t necessarily look the same. Or, to put it in other terms, writing is like medication admiration. You need to check the “5 rights”: What’s the right drug (topic), dose (length), route (venue), time (frequency), and patient (author)?

If you are not (or not solely) pursuing an academic career in the sciences, think outside the box, and consider:

  • Writing about science and medicine for a popular audience— think of influential physician and nurse authors like Theresa Brown, Atul Gawande, Lisa Sanders, or Jerome Groopman.
  • Write for a clinical audience— in my field, Journal for Nurse Practitioners or American Family Physician, for example, publish articles on clinical topics.
  • Writing creatively, in health humanities publications (or some medical journals publish poetry on occasion). Or write to nourish your life outside of science and medicine (the poet William Carlos Williams was a physician).
  • Writing for a blog. Blogging is a great way to share ideas and influence rapidly and less formally.
  • Writing as a personal practice. Many highly successful people practice some form of journaling as a way of working out ideas and thoughts that later serve as the basis of important work. A writing routine– even if it’s ten minutes a day– can be a catalyst for creative and productive work.

If you want to write more, no matter what the content and context, consider:

  • Never “just” give a talk— can it also be a paper? A poster? Explore it fully, and expand the potential audience for your work by considering different venues and angles. Get more mileage from each project you take on.
  • Say yes. . . and say no. Take on projects and accept invitations that allow you to develop an idea— but only ones that align with your goals and interests. Don’t say yes if you truly don’t have the bandwidth, or if the offer doesn’t advance your progress in some way. But DO say yes to things that are outside of your comfort zone. You might expand your expertise and influence in valuable ways.
  • Join (or start) writing groups: accountability & feedback are invaluable. Colleagues who will read your work and give you mock reviews are precious. Develop these relationships early in your career and they will serve you well.
  • Look at author guidelines for publications you read (whether these are high-impact journals or tiny blogs). Could you make a contribution?
  • Think about your unique skills and experiences. What is it that you have that no one else does? What do you have to say that you haven’t heard said before? You have a unique voice and you should use it. I have heard many writers say they created work they wanted to read but couldn’t find. The novelist Barbara Kingsolver says, “don’t try to figure out what other people want to hear from you; figure out what you have to say.”This is great advice to produce writing with a strong point of view.

 How will you include more writing in your professional life?

“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 teaching Professionalism

Professionalism is a multi-faceted concept that carries different meanings to different people; it ranges from a physician’s bedside manner and acknowledging mistakes, to how one interacts with their peers and if they show up on time. Not only that, but this all-encompassing term is cited as a core competency by the American Association of Medical Colleges. It is also a part of the American Medical Association’s code of ethics and explicitly mentioned in the syllabi of most medical schools and training programs across the U.S. Despite the broad acceptance of professionalism as a key character component of a well-rounded clinician, there is a significant difficulty experienced in trying to teach this to trainees. This may seem a little long-winded, but this is a subject that really resonated with me, and with JAMA instituting a professionalism section a few years ago, there have been more and more pieces published on the topic; I’m happy to see that this is gaining more traction. Everybody will tell you that administrative burdens and needing to deal with insurance providers for prior auths and the like definitely contribute to burnout, but having unprofessional colleagues can be just as burdensome and unsafe for patients!

I recently came across an excellent piece in the New England Journal of Medicine titled “Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework” wherein Dr. Wasserman, Redinger, and Gibb attempted to tackle the difficult yet important concept of professionalism in medical training. The article made a strong case for treating lapses in professionalism as if they were medical errors of varying severity, and they included an infographic, as well as gave several examples to go with this framework. In my opinion, professionalism is one of those behaviors that is nearly impossible to teach in a classroom and is often developed through a mix of modeling behaviors from more senior physicians, as well as a little bit of one’s own personality/temperament mixed in.

There was an example cited by the authors that centers around a medical student who has begun a collaboration with a mentor on some database analysis. The mentor states this is an IRB-exempt study and urges the student to begin analysis immediately, but the student’s research office instructs her not to download the data until getting an official exemption was issued by the IRB. The mentor pressures the student into downloading it anyways, and the student gets reprimanded for this. Wasserman et al suggest this is a lapse in professionalism at the lowest level – “no-fault suboptimality” resulting from the student’s faulty understanding that the supervisor (mentor) is right. They focus on teaching the student “strategies for diplomatically addressing her mentor” and acknowledge it is a difficult situation. What they don’t do, however, is acknowledge the context of this lapse of professionalism; they make no mention of addressing the mentor’s behavior or holding them accountable.

By all means, I agree that the student’s incorrect logic needs to be addressed. But, by not addressing the lapse in the professionalism of the mentor, I think the authors missed an opportunity to strengthen the analogy of professionalism and medical errors. In the “Just Culture” movement, physicians were just as accountable as nurses, who were as accountable as medical students for speaking up against unsafe practices. In this scenario, I would argue that the mentor is more liable, and should be held even more accountable than the medical student. As the authors have already made clear, trainees are still developing their understanding of professionalism, but this mentor is arguably an individual who has completed their training and should have a stronger grasp of professionalism than a mere medical student.

I concede that their article was aimed moreso at addressing lapses in professionalism of trainees, but this circles back to my personal view of how professionalism is developed. As others have stated, ensuring an individual trainee’s “competence in the area of professionalism requires the concerted efforts of many.” However, what about non-trainees? You could assume that a hospital board or professional society will self-govern to ensure professional behaviors, but with a term that is so loosely defined, and with financial incentives on the line, how much would someone be able to move the needle? I think most of us can remember at least one time (or many), when a senior physician tore into a helpless colleague, or became frustrated and lost their temper. How often do you think these individuals get a time-out or get part of their wages withheld as a punishment?

This brings me to my point: if the system is flawed, how does putting additional pressure on trainees fix that? The “do as I say, not as I do” approach has never been tested in a randomized trial, but conventional teaching theory (and common sense) will tell you that this is not effective. I myself am a trainee still (you’re reading the Fellows In Training blog, duh), so I certainly do not have all the answers.

From my time spent in developing medical school curricula, and sitting on academic disciplinary committees, I’ve come away with a few insights that I think might help. When the issue is a systems issue – such as “well everyone in my class skips grand rounds, I thought it was ok” the individual who got caught usually got caught due to chance, and reprimanding them would be unfair. Wasserman et al mentioned that the system needs to be changed, but didn’t talk about how. I’m gonna piggyback on that, because systems changes are difficult, and can be nuanced depending on the problem.

I think that lapses in professionalism should be addressed, but a better approach would be one that relies on positive feedback rather than only mentioning professionalism when it is missing. For example, in my medical school, and most training programs, at the middle and end points of a rotation, mentors would take the medical students for some formative “feedback”. Sometimes they were going off a form issued by the medical school, other times they would go off what they felt should be emphasized. If throughout a trainee’s career, different levels of professional behavior are emphasized by instructors, this could go a long way.

One example of this would be that mentors are instructed to focus on the aspect of timeliness and respectfulness with first-year students, making sure to comment on these in each student’s feedback; but when they give feedback to third years, they emphasize other aspects of professionalism, such as truthfulness, admitting to mistakes, knowledge gaps, etc.

Many theories have been put forth as to why professionalism can be such a difficult concept to teach and practice, but I think a critical shortcoming we have to acknowledge is the disconnect between the two worlds that trainees must straddle: the world in which we teach professionalism, and the world in which they practice.

 

References:

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

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Vaper Vapor

January 2020 has come and gone. Resolutions were set (and some broken). I suspect—given what we know about the effects of smoking—that somewhere among the estimated 34.2 million smokers in the US 1,2  lie a few who resolved to shake the habit. Cigarette smoking is the leading cause of preventable disease and death in the United States accounting for more than 480,000 deaths every year (about 1 in 5 deaths).1

But, What About Vaping?

In November 2019, the AHA launched its #quitlying campaign to address the youth vaping crisis. As an AHA Early Career blogger, I began to tweet (@DrAnikaLHines) what I was learning about vaping (a topic that I’ve otherwise not broached) from the 2019 Scientific Sessions:

  • From 2017 to 2019, e-cigarette use among high school students increased by 135%3 (about 25% of high school students have “vaped” in the past 30 days).3 E-cigarette use tripled among middle school students—from 3.3% to 10.5%.3
  • E-cigarette use drove a 59% increase in use of any tobacco product among high school students (from 19.6% in 2017 to 31.2% in 2018).3
  • While more research is needed, the Surgeon General has concluded that several studies show E-cigarette use is “strongly associated” with the use of other tobacco products among youth and young adults, including conventional cigarettes.3
  • Many questions remain about the long-term health effects of these products and their effectiveness in helping smokers quit.4
  • The evidence is already clear that it is unsafe for young people to use e-cigarettes or any other product containing nicotine.4
  • Some of the flavorings found in e-cigarettes have been shown to cause serious lung disease when inhaled.5

Well, fellow bloggers and I were met with backlash and cries of “vaping saved my life” and “vaping is harm reduction” and “vaping is promoted as a cessation technique in Europe” and my favorite—‘big heart, quit crying” by individual (adult) users and small retailers. As I mentioned before, I don’t research vaping, so I had no retort. I do, however, live in a department that happens to be seated in the hotbed of the tobacco discourse (Virginia) and jam-packed with researchers who have devoted their careers to cancer prevention and tobacco products. Literally! VCU has a Center for the Study of Tobacco Products. Here’s what I’ve learned about alternative tobacco products being used in Virginia (and nationally):

  1. Not every vape is created the same. The two products at the core of discussion are e-cigarette and tobacco-heated products.10 E-cigarettes are battery-powered and heat liquid usually containing nicotine in order to produce an aerosol. There’s a wide variety of designs, electrical power, levels of nicotine delivery, and flavors.10 Devices include cig-a-like, refillable tank systems, and pod mod innovations. On the other hand, heated tobacco products (also electronic), heat tobacco to produce an aerosol containing nicotine.11 (This is where tobacco giants like Phillip Morris have become involved, including their “I quit ordinary smoking” (IQOS) product approved for sale by the FDA in April 2019).10
  2. Adult and youth reasons for use differ; so, there are separate sets of issues. Adults cite quitting/reducing smoking and health reasons for using e-cigarettes. Youth attribute their vaping to their social networks (friends and family who use them) and/or the availability of flavors.6 Data from 2013 indicated that 13.1% of high school e-cigarette users had never used another tobacco product.3 E-cigarette use is strongly associated with the use of other tobacco products among youth and young adults, including conventional cigarettes.3,7,8
  3. The long-term effects of alternative tobacco products in adult smokers, including e-cigarettes and heated tobacco products, remain unclear; however, preventing nicotine addiction among youth is a priority. Studies of the effectiveness of products as smoking cessation approaches are inconclusive. The Centers for Disease Control and Prevention says that e-cigarettes are not safe for youth, young adults, pregnant women, or adults who do not currently use tobacco products.4 Heated tobacco products, such as the IQOS device, have been linked to pulmonary disease and cancer, but not to the same extent as combustible products.9

Summary

We don’t know everything, but we know enough to say that vaping is not a “harmless” habit. It is not recommended for youth, young adults, pregnant women or adult non-smokers.4 Smokers who opt into e-cigarettes should know that there’s no guarantee that it will help them quit and that e-cigarettes bear their own risks of injury and mortality. E-cigarettes are not recommended as a smoking cessation aid. Further, a recent CDC study found that most adult e-cigarette users don’t stop using combustible products, but become “dual users”.11

My Take

As I see it, the biggest issue is framing vaping as harmless. More alarming, is the interplay between peer influence and attractive flavoring that draws youth into a nicotine addiction long before their brains have the capacity to make an informed decision.

Vaper vapor, indeed.

 

References

1. Centers for Disease Control and Prevention. Current Cigarette Smoking Among Adults in the United States, 2019.

2. Creamer MR, Wang TW, Babb S, et al. Tobacco Product Use and Cessation Indicators Among Adults – United States, 2018. Morbidity and Mortality Weekly Report 2019, 68(45);1013-1019.

3. Campaign for Tobacco-Free Kids, “Electronic Cigarettes and Youth”, November 8, 2019 / Laura Bach. Accessed at: https://www.tobaccofreekids.org/assets/factsheets/0382.pdf

4. CDC, “Electronic Cigarettes.” https://www.cdc.gov/tobacco/basic_information/e-cigarettes/.

5. HHS, E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2016, p 184.

6. Tsai J, Walton K, Coleman BN, et al. Reasons for electronic cigarette use among middle and high school students – National youth tobacco survey, United States, 2016. Morb Mortal Wkly Rep. 2018;67(6):196-200. doi:10.15585/mmwr.mm6706a5

7. Barrington-Trimis, JL, et al., “E-Cigarettes and Future Cigarette Use,” Pediatrics, 138(1), published online July 2016. Wills, TA, et al., “Ecigarette use is differentially related to smoking onset among lower risk adolescents,” Tobacco Control, published online August 19, 2016.

8. Berry, KM, et al., “Association of Electronic Cigarette Use with Subsequent Initiation of Tobacco Cigarettes in US Youths,” JAMA Network Open, 2(2), published online February 1, 2019.

 9. Salman R, Talih S, El-Hage R, et al. Free-Base and Total Nicotine, Reactive Oxygen Species, and Carbonyl Emissions From IQOS, a Heated Tobacco Product. Nicotine Tob Res. 2019;21(9):1285-1288. doi:10.1093/ntr/nty23

10. Barnes AJ and Snell LM. Alternative Tobacco Products Use in Virginia. https://hbp.vcu.edu/media/hbp/policybriefs/pdfs/VCU_eCig_10-19_F2.pdf

11. CDC, Electronic Cigarettes, What’s the Bottom Line? https://www.cdc.gov/tobacco/basic_information/e-cigarettes/pdfs/Electronic-Cigarettes-Infographic-p.pdf

 

“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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Building an academic portfolio during medical training: Part 2 – finding your research team

In my previous blog, we discussed why it is important for medical students and trainees to consider research collaborations outside their own institutions, and what types of research studies can be performed using this type of collaboration between young researchers. In this blog, I will focus on how to find potential collaborators and/or join a multi-institutional team of young researchers.

Once you decide to explore this non-traditional way of doing research, the first challenge you will be facing is how to find potential research team members. At this point, you need to take a step back and ask yourself 2 essential questions:

  • “What area(s) of research am I interested in?” – This will largely be dependent on the particular specialty you are interested in pursuing as a career, and whether you have a general interest in this specialty or a more focused area that you would like to explore.
  • “What skillsets can I bring to the table in such collaboration?” – No matter how novice you are in medical research, you can always be a valuable team member provided that you are willing to learn, work hard and acquire new skills. But it is essential for you to know exactly what you can or cannot do, to be able to find your right position within a team. A successful research team requires a myriad of skills, some are basic, such as searching the literature or collecting data, some are more advanced, such as conception of research ideas or scientific writing, and others are specialized, such as relevant statistical knowledge and competency in using a statistical software or experience with using one of the databases that we previously discussed e.g. National Inpatient Sample (NIS).

Answering these 2 questions will help you present yourself in an honest and practical way to your potential collaborators, and will ensure that you achieve the 2 fundamental goals of any collaboration: to benefit and to be beneficial. It also gives you an idea about what potential skills you can work on acquiring to increase your value as a team member.

Now that you know what you want and what you can offer, it is time to find your collaborators. The easiest and most straight-forward way is to collaborate with people that you had previous experience with, like your medical school colleagues, or co-residents from your previous training program who have similar research interests. However, this may not be an available option to you, so what to do in this case? – If you are still taking your very first steps in the research field, you would be better off joining a team that is already established rather than building a new team. There are several ways to identify multi-institutional research teams that are already up and running:

  • Word of mouthyou may have heard about one or more resident or fellow who does this type of research, and in that case, you could reach out directly to them.
  • Medical literatureyou could search within your field of interest for recently published meta-analyses, systematic reviews, or articles that use one of the publicly available databases that we mentioned, and examine the authors’ list. What you would want to look for are articles that are authored by people affiliated with different institutions. Next step, would be to look up some of these authors on PubMed and see if that same group of authors (or some of them) publish these types of articles frequently together. Once you identify a particular group of collaborating authors, then you could look them up to check if they are mostly residents and fellows.
  • Social mediathis is another great tool for research collaboration. Twitter, in particular, is becoming an invaluable platform for sharing medical knowledge and recent research articles. Many of the currently active research groups promote their work on Twitter, and using the same process we just discussed, one can easily identify active members of these groups and reach out to them directly. Further, many researchers nowadays reach out on Twitter when they need young motivated medical trainees to help out with ongoing projects. So I would strongly encourage you to get on Twitter if you haven’t already done so and to start following people with similar research interests.

At this point, you know your research field of interest, you are aware of what you have to offer as a research team member, and you have identified potential research team(s) that you would like to be part of. You should be ready to reach out. What is the best way of presenting yourself? How can you maximize your chances of success in joining a team? This will be the topic of my next blog. So stay tuned…

 

“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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Cardiovascular diseases in women: the heart of the matter

It was 4 am one winter night on call when I got paged:

“Youngish diabetic female, mid-thirties, chest pain for a few hours. Unremarkable ECG. Let me send troponins and see. Doesn’t seem cardiac.”

“Doesn’t seem cardiac”

Dismissed, just like that, because she was young, and because she was a woman.

A proper listen to her symptoms revealed that this could indeed, be cardiac. She was admitted, her troponins were raised, a coronary angiography done a few hours later showed an occluded principal obtuse marginal branch which was stented. She was symptom-free the same day.

Fortunately for her, a definitive culprit lesion in her coronaries could be identified, that was amenable to stenting and thus treated. For the majority of women with non-obstructive coronaries, presenting with myocardial infarction with non-obstructive coronary arteries (MINOCA)1 or ischemia with no obstructive coronary arteries (INOCA), investigations would very likely have stopped right there, with that normal coronary angiography. Dismissed.

CVD in women

Cardiovascular disease (CVD) is the number one cause of mortality among women across the globe.2 Despite improved treatment algorithms and the enormous strides made in cardiovascular care, women continue to have worse clinical outcomes than men, partly owing to them being underdiagnosed, understudied and undertreated.

One size does not fit all: A spectrum of differences

The inherent biological differences between men and women, in addition to the socio-cultural attributes of gender, mean that women have very different characteristics of ischemia in terms of symptoms, triggers, and aetiologies.3

Symptoms: While chest pain is the predominant presenting symptom in both men and women in acute coronary syndrome (ACS), historically, women have been known to present with more “atypical” symptoms such as neck pain, fatigue, dyspnea or nausea, often triggered by emotional stress but even this time-honored notion has been challenged by a recent study that found that typical symptoms were more common among women and have greater predictive value in women than in men with myocardial infarction.4

Co-morbidities: Women with ACS are known to be older, with a clustering of risk factors and greater prevalence of co-morbidities.3  Particularly, diabetes, smoking and a family history of ischaemic heart disease have been shown to have a stronger impact on event rates among women.3 Younger women with ACS have been found to have a worse pre-event health status (both physical and mental) in comparison to men.5

The age paradox: Premenopausal women are thought to be relatively protected against CVD compared to similar-aged men, owing to favorable effects of estrogen on cardiovascular function and metabolism. Intriguingly though, recent studies report an increase in hospitalization rates of ACS among young women, despite a decline among younger men. The mechanisms behind these differences remain a fairly understudied area.

Delayed presentation: Women are also known to present later, frequently attributing their symptoms to a non-cardiac-related condition such as acid reflux, stress, or anxiety.2,3 This inaccurate symptom attribution, in addition to a lack of awareness of risk, and barriers to self-care in general, lead to a delay in seeking treatment, contributing to poorer outcomes.

Different etiologies: By virtue of an obstructed coronary artery, my patient got lucky in terms of prompt diagnosis and treatment. In about 10% of all patients, and in about a third of women, such a culprit coronary lesion cannot be identified on angiography.2,3 Furthermore, microvascular angina affects close to a half of patients with non-obstructive coronary arteries.7 This coronary microvascular dysfunction (CMD) is defined as the presence of symptoms and objective evidence of ischemia in absence of obstructive coronary artery disease, with blood flow reserve and/or inducible microvascular spasmAngina with no obstructive coronary arteries is twice as prevalent in women as in men, 7 and might also contribute to the pathogenesis of heart failure with preserved ejection fraction (HFpEF), which is also more commonly observed in women.9

Women are still under-studied in clinical trials

In the face of such a formidable gender disparity in CVD, women continue to be under-represented in some areas of cardiovascular clinical trials, particularly in ischaemic heart disease and heart failure drug trials, the most common cardiovascular conditions affecting women. In fact, a number of pivotal cardiovascular drug trials of 2019 had less than a quarter of women enroll.12-15 Interestingly, the PARAGON-HF trial, where 51.7% of patients were women, found a heterogeneity in treatment response: women with HFpEF responded better to valsartan-sacubitril, with a 28% reduction (rate ratio 0.73) in the primary endpoint.

In a compelling 2018 editorial, doctors Pilote and Raparelli explore the practical reasons for under-enrollment of women in cardiovascular drug trials, notably male-patterned inclusion criteria and gender-related barriers to screening and participation in trials, such as caretaking roles and low socioeconomic status. While proposing interventions to mitigate this issue (childcare and such support for women during time spent as a research participant, inclusion criteria that consider sex differences in pathophysiology, prespecified subgroup analyses, etc.), they warn that such under-representation of women could lead to sex-biased outcome measurements and missed opportunities to transfer results in clinical practice.

The issue, in essence, is not just about researching CVD in women: even within this large cohort, differences in symptoms, presentation and outcomes, heterogeneity related to age, ethnicity and geographic locations exist. Why younger women with ACS tend to have unfavorable prognoses is an as-yet unanswered question, with huge scope for research, as is microvascular dysfunction, known to be more prevalent among women.

What can be done?

With February being national heart month, and the American Heart Association’s #GoRedForWomen campaign soaring at its highest, it seems like a good time to reflect on what can (and should) be done for women with CVD. Because there is plenty left to do.

Raise awareness: It’s vital that both women and men are aware that heart disease is as big a killer in women as in men. The AHA’s signature women’s initiative Go Red for Women (https://www.goredforwomen.org/) and the sub-initiatives of Wear Red Day are great platforms dedicated to increase women’s heart health awareness. The Women’s Heart Alliance (https://www.womensheartalliance.org/) is another organization working to promote gender equity in research, prevention, awareness and treatment.

Enroll more women in clinical trials: it’s important to identify barriers accounting for the low inclusion of women in clinical trials, and actively intervene to overcome them.

Women’s Heart Health Clinic: a number of programs have successfully initiated women’s heart health clinics, exclusively catering to the diagnosis and treatment of this often-underestimated patient group.

Get more women involved: at every level, be it as clinical trialists, advocates, physicians, nurses or other health-care providers.

As physicians, perhaps the best thing we can do for our female patients is to pay more attention. Don’t dismiss a symptom, because nothing should “not seem cardiac” until proven otherwise.

So, yes:

Listen to her.

Diagnose her.

Investigate her.

Study her.

Treat her.

And don’t just #GoRedForWomen in February. #GoRedForWomen throughout the year.

 

References

  1. Pasupathy S, Tavella R, Beltrame JF. Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): The Past, Present, and Future Management. Circulation. 2017;135(16):1490-1493.
  2. Mehta LS, Beckie TM, DeVon HA, Grines CL, Krumholz HM, Johnson Mnet al; American Heart Association Cardiovascular Disease in Women and Special Populations Committee of the Council on Clinical Cardiology, Council on Epidemiology and Prevention, Council on Cardiovascular and Stroke Nursing, and Council on Quality of Care and Outcomes Research. Acute Myocardial Infarction in Women: A Scientific Statement From the American Heart Association. Circulation. 2016;133(9):916-47.
  3. Haider A, Bengs S, Luu J, Osto E, Siller-Matula JM, Muka T, et al. Sex and gender in cardiovascular medicine: presentation and outcomes of acute coronary syndrome. European Heart Journal (2019) 0, 1–14.
  4. Ferry AV, Anand A, Strachan FE, Mooney L, Stewart SD, Marshall L, et al. Presenting Symptoms in Men and Women Diagnosed With Myocardial Infarction Using Sex-Specific Criteria. J Am Heart Assoc. 2019 Sep 3;8(17):e012307.
  5. Dreyer RP, Smolderen KG, Strait KM, Beltrame JF, Lichtman JH, Lorenze NP, et al. Gender differences in prevent health status of young patients with acute myocardial infarction: a VIRGO study analysis. Eur Heart J Acute Cardiovasc Care 2016;5:43–54.
  6. Arora S, Stouffer GA, Kucharska-Newton AM, Qamar A, Vaduganathan M, Pandey A, et al. Twenty year trends and sex differences in young adults hospitalized acute myocardial infarction: the ARIC Community Surveillance Study. Circulation. 2019;139:1047–1056.
  7. 037137Jespersen L, Hvelplund A, Abildstrom SZ, Pedersen F, Galatius S, Madsen JK, et al. Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events. Eur Heart J 2012;33:734–744.
  8. Ong P, Camici PG, Beltrame JF, Crea F, Shimokawa H, Sechtem U,et al. International standardization of diagnostic criteria for microvascular angina. Int J Cardiol 2018;250:16–20.
  9. Srivaratharajah K1 Coutinho T, deKemp R, Liu P, Haddad H, Stadnick E, et al. Reduced Myocardial Flow in Heart Failure Patients With Preserved Ejection Fraction. Circ Heart Fail. 2016;9(7).
  10. Scott PE, Unger EF, Jenkins MR, Southworth MR, McDowell TY, Geller RJ, et al. Participation of Women in Clinical Trials Supporting FDA Approval of Cardiovascular Drugs. J Am Coll Cardiol. 2018;71(18):1960-1969.
  11. Pilote L, Raparelli V. Participation of Women in Clinical Trials: Not Yet Time to Rest Our Laurels. J Am Coll Cardiol. 2018;71(18):1970-1972.
  12. Mehran R, Baber U, Sharma SK, Cohen DJ, Angiolillo DJ, Briguori C, et al. Ticagrelor with or without Aspirin in High-Risk Patients after PCI. N Engl J Med. 2019;381(21):2032-2042.
  13. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, et al; DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019;381(21):1995-2008.
  14. Schüpke S, Neumann FJ, Menichelli M, Mayer K, Bernlochner I, Wöhrle J, et al; ISAR-REACT 5 Trial Investigators. Ticagrelor or Prasugrel in Patients with Acute Coronary Syndromes. N Engl J Med. 2019 ;381(16):1524-1534.
  15. Presented by Dr Judith S. Hochman at the American Heart Association Scientific Sessions (AHA 2019), Philadelphia, PA, November 2019. https://www.ischemiatrial.org/system/files/attachments/ISCHEMIA%20MAIN%2012.03.19%20MASTER.pdf

 

“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.”