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Cardiac Critical Care Fellowship: Insights From a Fellow Who Recently Completed Her Training

I am pleased to have the opportunity to share the experiences of Dr. Alejandra Gutierrez-Bernal who was one of my general cardiology chief fellows and she recently completed her cardiac critical care fellowship!

Please describe yourself and your prior training.
I am a Latin American woman who loves cardiology, spending time outside, running, swimming, painting, and reading novels. I am the youngest of three and have a baby niece who brightens my days. I was born in Colombia and was fortunate enough to live in different places growing up including Mexico, here in the US and my native Colombia. I did my medical school training in Colombia and then spent some time doing research with my great mentor, Dr. Mina Chung, and Dr. Van Wagoner at the Cleveland Clinic. We studied the molecular mechanisms leading to atrial fibrillation which increased my interest in cardiology as a field. I then did my internal medicine residency at CCF and moved on for my cardiology fellowship at the University of Minnesota. I am currently finishing my critical care fellowship here too.

When and why did you decide to pursue cardiac critical care training?
As a medical student, I was fascinated by cardiology, specifically electrophysiology. I loved to look at ECG’s and try to figure out the exact origin of different PVC’s or arrhythmias. By the end of the residency, I was sure I was going to do electrophysiology. However, during my first year of fellowship, I spent a lot of time in the intensive care unit and everything it involved including VA ECMO, cardiogenic shock, and acute heart failure, and was given enormous autonomy. I found that at the end of the day, I was very tired but felt extremely accomplished and happy. I have had great mentors during my training and one of the people that has influenced me as a person and as a doctor, the most is Dr. Bartos. He is an interventional cardiologist and an intensivist. One day he told me I should think about this as a career and the thought had not occurred to me. The idea stuck with me and now after completing my training I wouldn’t have it any other way.  I have the opportunity to make a difference, establish connections with families and help them when they are most vulnerable. I couldn’t be happier with the choice I have made.

What unique experiences does a cardiac critical care physician who completed a cardiology fellowship have compared to those who pursue cardiac critical care training after completing an anesthesiology residency?
Critical care training is interesting because you work with various specialties. We all have very different perspectives which has made this past year of training so much more enjoyable.  When I approach a patient, I can’t stop myself from looking through the ECG, echocardiogram and think through their hemodynamics imagining what their numbers would be if I had a swan. I manage shock, assess volume responsiveness and fluid status, and use inotropes a little differently given my general cardiology training. My pulmonary critical care colleagues taught me to look at the chest CT and make a mental picture of their pulmonary status and my anesthesia colleagues play with the medications differently. As a cardiologist, the critical care field is very exciting. Our older cardiac patients often have multiple organ systems involved and patients in the other units have more cardiac disease.  This year has been an amazing journey as I go around the other units and look at them from different perspectives, critical care cardiologists fill a gap that was missing.

Why did you choose to stay at the University of Minnesota for cardiac critical care training?
There are three main reasons I wanted to stay here. First and foremost is mentorship. The field of critical care cardiology is newer and having someone to guide me and to aspire to was very important to me. Here I had the opportunity to train with great people who since the early stages of my training pushed me to think out of the box and practice independently, transforming me into a better person and doctor.  The second was the patient population. The University of Minnesota has a great resuscitation team, and we see a multitude of cardiac arrest patients many of whom are treated with VA ECMO. I wanted to have the first-hand experience treating these patients since I believe this is the future of cardiology. And lastly, the research experience. I had protected research time last year which was important to me as I wanted to stay at an academic center and wanted to start building my portfolio in critical care given that my prior research experience had been focused on electrophysiology. Overall, it has been a great experience and I wouldn’t do it any other way.

What are some of the unique aspects of cardiac critical care and general cardiology training at the University of Minnesota?We are lucky enough to have a lot of exposure to mechanical circulatory support. During our general cardiology training, we have several rotations in our intensive care units with our cardiac structural and interventional team which includes our post-arrest patients and the heart failure service with LVAD and transplant patients. We are given a lot of independence with these very sick patients, and I believe that this is what taught me the most and reinforced my decision to pursue critical care. Our cardiothoracic surgeons are very approachable and wonderful team players which makes work so enjoyable and patient care seamless.

What is the balance of your time during your first faculty position (e.g. how many weeks are you on service, do you get protected academic time, etc.)?
I am very excited about starting my first job. I think the balance is perfect for me to start my career. My appointment is 80% clinical and 20% academic. I will have around 13 weeks of service and will be only in the intensive care unit while on service. On my time off service, I will be in the echocardiography lab and will have some clinic. With this, I hope to have a great balance between the sick patients in the ICU and the more relaxing setting  of imaging and general cardiology.

What were you looking for when you were searching for your first attending position?
It was very important for me to be in an academic institution. I like clinical research and the idea of furthering the field is fascinating to me. I was looking for a place that would push me in terms of clinical experience to continue learning and had challenging patients yet provided support and mentorship. The University of Minnesota seemed like the perfect fit. I truly think that what I will be part of, will change the field of resuscitation and save lives, that is why we all signed up for medicine.

What advice do you have for other early career cardiologists?
I think the most important thing is to find and do what makes you happy. If the days are long and tiring but you feel fulfilled at the end of the day, then that is what you should be working for.

Thanks so much for the great advice, Dr. Gutierrez-Bernal!

 

“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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An Experiment with an A.I. Blogging Partner!

This week I wanted to try some new ideas for a blog. Instead of writing it myself, I wanted to test out a new class of artificial intelligence that’s already available, and rapidly expanding in the domain of online media writing. As a blogger, I think it is important to demonstrate what this space is going through in terms of evolution. Therefore, for this monthly blog post, I will be using one of the relatively new Artificial Intelligence (AI) writing generators.

These are applications built on algorithms requiring you to only input a few keywords, or sentences, and then clicking a button and letting the AI generator initiate its programming. The AI will spend some time (only a handful of minutes) and search all over the internet for data, producing a 100% guaranteed unique written article. This type of technology is right now in its infancy stages, and is useful in a limited capacity. But in the next five to ten years, AI of this sort will be immensely more integrated, not just in blogging, but in all types of professional fields.

As a biomedical scientist, I can imagine using an AI generator as an assistant in writing scientific articles that I aim to publish when I generate new research, finalize studies, and have results to share. A medical doctor could use AI writers to assist in composing case reports, as well as discussing details of specific medical treatments, or any other writing task. It’s not hard to imagine a future where many professionals, within academia, or the healthcare system, will be using AI generators to assist them in enhancing, and speeding up content sharing while reducing the time consumption required for writing reports, articles or any other original content.

This is an exciting new technology to embrace as an early career professional. Knowing that my readers (as always, thanks for reading!) are mostly early-career scientists and professionals, I think it’s prudent for me to expose and bring awareness to this emerging technology. With that, I will now share the stage on this blog with the artificial intelligence writing generator called Writesonic. This specific AI generator was picked by me because of its simplicity and affordability. The application only requires me to provide a few keywords, and then provide it time to search and produce a short article that is guaranteed to be unique. There is no “copy-pasting” from somewhere else. And it’s up to me to accept it, and make any changes necessary.

The keywords I provided to seed Writesonic are Heart disease burden novel treatments & prevention strategies. The primer intro I was prompted to provide was this: Heart disease is the number one cause of mortality worldwide. The burden of this disease is set to increase in the coming decades due to longer lifespans, more prevalent sedentary lifestyles, as well as the changing type of diet and food choices that the global population is adapting to. Research towards new preventative measures, as well as new treatment options is of great importance in order to reduce the burden of heart disease on the overall society.

Let’s see what Writesonic produced:

[New Treatments And Prevention Strategies For Heart Disease: A Comprehensive Update

Heart disease is the number one cause of mortality worldwide. The burden of this disease is set to increase in the coming decades due to longer lifespans, more prevalent sedentary lifestyles, as well as the changing type of diet and food choices that the global population is adapting to. Research towards new preventative measures, as well as new treatment options is of great importance in order to reduce the burden of heart disease on the overall society.

What is heart disease?

Heart disease is a term that is used to describe conditions that affect the heart and its chambers (cardiac chamber). Heart disease can be classified as either coronary artery disease or ventricular heart disease. Coronary artery disease is the narrowing of the coronary arteries and the accumulation of plaque, which can lead to a heart attack. Ventricular heart disease is the weakening or malformation of the chambers that give the heart its ability to pump blood, leading to a similar heart attack or a stroke. Approximately 50% of heart disease is due to coronary artery disease. Of this group of diseases, only 50% will progress to cause a heart attack. The remainder are considered non-major conditions, but the symptoms and outcomes can be much worse.

Prevention Strategies

Heart disease is often prevented in its early stages, where the average life expectancy is around 5 years. The first step in the prevention strategies is to prevent a number of risk factors that can cause heart disease, such as high blood pressure, obesity, diabetes, smoking and an unhealthy diet. Some of the proposed strategies for the prevention of heart disease are: Studies show that the common components of heart healthy diets include: vegetables, whole grains, fruit, nuts, low fat dairy products, tea and coffee. Progression to clinical cardiovascular disease can be delayed and even reversed if found in the earlier stages of the disease. Weight gain to obesity may cause a number of health problems, Weight loss is the most important factor in the prevention of heart disease.

Diagnosis and treatment

Heart disease is a major risk factor for death, in both men and women. It is also considered a major cause of morbidity and mortality. Heart disease encompasses all types of conditions in which the heart is significantly damaged. Conventionally, the most common approaches for the treatment of heart disease are drug therapy and surgical intervention. In general, heart disease is caused due to a build-up of atherosclerosis.

Conclusion

Heart disease is a major cause of death worldwide. New therapies and preventative strategies are being developed to reduce the risk of heart disease, as well as new targeted therapies to treat certain forms of the disease. Heart disease is highly complex and the available knowledge and research on the condition is constantly changing.]

 

Alright, I’m back! Here’s my review: Writesonic is one of the better, but not top of the line, expensive options, so presumably there is a level of competence above what we saw here. The user-friendly and low threshold to entry and use of this AI content generator is very attractive. It allows folks like us, outside of the daily need for such a product, to actually jump in and try this stuff out. The actual end-product, the content, is however way below our “subject matter experts” viewpoints, and for many of us, our “technical precision” will quickly find the overly generalized way the AI writes leaves a lot to be desired.

Without burdening you with another example, I did the same exercise with a different AI writing generator called Rytr, which functions similarly to Writesonic. The final content output was remarkably similar in length and depth of information. This research provided me with enough data to understand where the technology has broadly reached. I see no way for these AI assistants and algorithms to be sufficiently up to date with scientific literature and novel science at this moment. Being able to scan and extract information from original research articles and academic publications is a step (or a mile) out of the general AI writer mandate, for the time being (but surely in a few years this will not be the case).

So, in the end, I’ll say this: AI writers have a great potential to be useful in fields of research and medical writing, but for now, they’re a few years away from that utility. Having said that, for early-career professionals, I say keep an eye on this, you’ll probably be using it by the time you’re at a later stage in the career path you’re on currently!

 

“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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I May Have Finished My Training but the Learning Will Never End

Today, as I write this, it’s my last month in the formal term of being a ‘trainee.’ And not just any old trainee but a critical care fellow who’s had 6 years of training under his belt. I started my internal medicine residency in Worcester, Massachusetts – roughly 3000 miles from where I grew up. The population was diverse, the hospital life seemed incredibly exciting (and nerve-racking)

Day of 1 of the intern year with Dr. Deeqo Mohamud who become of my best friends.

and I was far from my family. But, I quickly had a new family – those that I would spend the next 3 years together with.

There is a general feeling and oftentimes unspoken trauma with training. We have endless shifts spanning weekends/holidays, fear of failing, fear of harming our patients, and at times knowing our best efforts may not help save a life. These feelings are often not discussed in residency but I was fortunate to have trained in a place that helped provide me with the support I needed to become the best doctor I could. In fact, I stayed at the University of Massachusetts for an additional 3 years for cardiology training.

I could feel myself growing as a provider during my cardiology training. The responsibilities grew, the fear of mistreating a patient having a heart attack was always on the forefront of my mind, and the expectation that I would be a master of all things related to the heart was

Dr. Noami Botkin (PD) plus my amazing co-fellows, 2 couldn’t make it for the picture.

overwhelming – and still is to this day. I was fortunate to have mentors who helped me grow clinically, academically, and personally. I saw the type of doctor I wanted to become, the changes in medicine that inspired me, and the continued inequalities that broke my heart. The end of my fellowship was marked with a more somber mood due to the COVID-19 pandemic. The ceremonious feeling of finishing residency wasn’t there for any of the trainees who were graduating but true to form, UMass continued to make us feel like family. With the resolve to not let a global pandemic dampen my spirits, I headed back to California after nearly a decade of not living in my home state.

I started yet another fellowship – more training, more weekends, more holidays, and more rewards. I was growing and gaining new skills that were making me a better physician. I was working in various intensive care units across the Stanford Hospital system and all the while, meeting colleagues who become family. COVID was unrelenting and we were all feeling the fatigue of it. The reduced social interactions, the hostile political environment, and our own uncertainty of when things would be back to “normal.” We banded together to provide the support and encouragement needed to get through our shifts.

Stanford Critical Care Fellows posing for the camera

The cumulation of my training has led me to become a critical care cardiologist – a doctor who works in ICUs to take care of any and all aspects of a patient’s heart. As I reflect on my years as a trainee, I’ve realized that the learning will never stop. Not only the science of medicine but the humanity, humility, and courage to do our best daily.

As Dr. Louis Weinstein stated: “At the initiation of your residency, after having received a medical degree, you were legally a medical doctor. Now that you have finished your formal training, you have the potential to become a true Healer.” Having completed my short-term goals of finishing my training, I am now looking to how I can harness Dr. Weinstein’s teachings, to combine elegance into the art and science of medicine. As I start my new position as an attending at the University of Pittsburgh Medical Center, I may no longer be a trainee but I will be a life-long learner.

 

“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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Summary of COVID-19 Medications

The past year has seen tremendous changes due to the coronavirus 2019 (COVID-19) pandemic across multiple levels. While behavioral changes and social isolation helped with limiting the spread of the disease, certain medications were studied and have been shown to be of benefit in COVID-19 patients. In this article, we summarize some of these medications, the mechanism of action and add references to the major studies supporting them.

1-Glucocorticoids — Steroids are recommended for severely ill patients with COVID-19 who are on supplemental oxygen or ventilatory support [1,2].

2-Baricitinib is a selective JAK1 and JAK2 inhibitor used for the treatment of rheumatoid arthritis, and has been used in COVID-19 patients on the basis that it disrupts the activation of downstream signaling molecules and proinflammatory mediators[ 3].

3- Tocilizumab  — Markedly elevated inflammatory markers (including interleukin [IL]-6) are associated with critical and severe COVID-19, and blocking these it may prevent disease progression. Tocilizumab is a recombinant humanized monoclonal antibody that competitively inhibits the binding of interleukin-6 (IL-6) to its receptor (IL-6R) [4].

4Favipiravir is an RNA polymerase inhibitor available in some Asian countries for the treatment of influenza and mild COVID-19, and it is being evaluated in clinical trials for the treatment of COVID-19 in the United States and elsewhere [5].

5-Remdesivir — is an adenosine triphosphate analogue, which stops replication of the virus. It was first described in the literature in 2016 as a potential treatment for Ebola. The FDA granted full approval as a COVID-19 treatment on October 22, 2020, for hospitalized children ≥12 years and adults with COVID-19, regardless of disease severity [6]. 

6Hydroxychloroquine/chloroquine is not recommended in hospitalized patients given the lack of clear benefit and potential for toxicity. There is also for QTc prolongation and arrhythmias with the use of this medication [7].

7Monoclonal antibody therapy –In the United States, the following monoclonal antibody therapies are available for patients with mild to moderate infection in the outpatient setting [8,9]:

Bamlanivimab-etesevimab
Casirivimab-imdevimab
Sotrovimab

8Interferons – Interferon beta has been reported in the literature to inhibit COVID-19 replication in vitro. Defects in type 1 interferon production (which include interferon beta), have been associated with severe COVID-19 infections. However, clinical data so far do not support a clear benefit of interferon beta for severe COVID-19 [10].

9- IL-1 inhibitors – Interleukin-1 (IL-1) is a pro-inflammatory cytokine that has been associated with severe COVID-19, and several observational studies have suggested that IL-1 inhibitors, for example, Anakinra, is associated with reduced COVID-19-associated mortality [11].

10- Colchicine – Although there are some data demonstrating a benefit from Colchicine in mild to moderate COVID-19, the benefit is modest without a reduction in mortality, and adverse effects are common [12].

This is a brief summary of some of these medications. A registry of international clinical trials can be found at covid-trials.org.

A special thank you to my sister, Rawan Ya’acoub, a clinical pharmacist and an assistant professor at the University of Jordan in Amman, Jordan.

References

[1] WHO Rapid Evidence Appraisal for COVID-19 Therapies (REACT) Working Group, Sterne JAC, Murthy S, Diaz JV, Slutsky AS, Villar J, Angus DC, Annane D, Azevedo LCP, Berwanger O, Cavalcanti AB, Dequin PF, Du B, Emberson J, Fisher D, Giraudeau B, Gordon AC, Granholm A, Green C, Haynes R, Heming N, Higgins JPT, Horby P, Jüni P, Landray MJ, Le Gouge A, Leclerc M, Lim WS, Machado FR, McArthur C, Meziani F, Møller MH, Perner A, Petersen MW, Savovic J, Tomazini B, Veiga VC, Webb S, Marshall JC. Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis. JAMA. 2020 Oct 6;324(13):1330-1341. doi: 10.1001/jama.2020.17023. PMID: 32876694; PMCID: PMC7489434.

[2] Rochwerg B, Siemieniuk RA, Agoritsas T, Lamontagne F, Askie L, Lytvyn L, Agarwal A, Leo YS, Macdonald H, Zeng L, Amin W, Burhan E, Bausch FJ, Calfee CS, Cecconi M, Chanda D, Du B, Geduld H, Gee P, Harley N, Hashimi M, Hunt B, Kabra SK, Kanda S, Kawano-Dourado L, Kim YJ, Kissoon N, Kwizera A, Mahaka I, Manai H, Mino G, Nsutebu E, Pshenichnaya N, Qadir N, Sabzwari S, Sarin R, Shankar-Hari M, Sharland M, Shen Y, Ranganathan SS, Souza JP, Stegemann M, De Sutter A, Ugarte S, Venkatapuram S, Dat VQ, Vuyiseka D, Wijewickrama A, Maguire B, Zeraatkar D, Bartoszko JJ, Ge L, Brignardello-Petersen R, Owen A, Guyatt G, Diaz J, Jacobs M, Vandvik PO. A living WHO guideline on drugs for covid-19. BMJ. 2020 Sep 4;370:m3379. doi: 10.1136/bmj.m3379. Update in: BMJ. 2020 Nov 19;371:m4475. Update in: BMJ. 2021 Mar 31;372:n860. PMID: 32887691.

[3] Kalil AC, Patterson TF, Mehta AK, Tomashek KM, Wolfe CR, Ghazaryan V, Marconi VC, Ruiz-Palacios GM, Hsieh L, Kline S, Tapson V, Iovine NM, Jain MK, Sweeney DA, El Sahly HM, Branche AR, Regalado Pineda J, Lye DC, Sandkovsky U, Luetkemeyer AF, Cohen SH, Finberg RW, Jackson PEH, Taiwo B, Paules CI, Arguinchona H, Erdmann N, Ahuja N, Frank M, Oh MD, Kim ES, Tan SY, Mularski RA, Nielsen H, Ponce PO, Taylor BS, Larson L, Rouphael NG, Saklawi Y, Cantos VD, Ko ER, Engemann JJ, Amin AN, Watanabe M, Billings J, Elie MC, Davey RT, Burgess TH, Ferreira J, Green M, Makowski M, Cardoso A, de Bono S, Bonnett T, Proschan M, Deye GA, Dempsey W, Nayak SU, Dodd LE, Beigel JH; ACTT-2 Study Group Members. Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19. N Engl J Med. 2021 Mar 4;384(9):795-807. doi: 10.1056/NEJMoa2031994. Epub 2020 Dec 11. PMID: 33306283; PMCID: PMC7745180.

[4] Ghosn L, Chaimani A, Evrenoglou T, Davidson M, Graña C, Schmucker C, Bollig C, Henschke N, Sguassero Y, Nejstgaard CH, Menon S, Nguyen TV, Ferrand G, Kapp P, Riveros C, Ávila C, Devane D, Meerpohl JJ, Rada G, Hróbjartsson A, Grasselli G, Tovey D, Ravaud P, Boutron I. Interleukin-6 blocking agents for treating COVID-19: a living systematic review. Cochrane Database Syst Rev. 2021 Mar 18;3:CD013881. doi: 10.1002/14651858.CD013881. PMID: 33734435.

[5] Udwadia ZF, Singh P, Barkate H, Patil S, Rangwala S, Pendse A, Kadam J, Wu W, Caracta CF, Tandon M. Efficacy and safety of favipiravir, an oral RNA-dependent RNA polymerase inhibitor, in mild-to-moderate COVID-19: A randomized, comparative, open-label, multicenter, phase 3 clinical trial. Int J Infect Dis. 2021 Feb;103:62-71. doi: 10.1016/j.ijid.2020.11.142. Epub 2020 Nov 16. PMID: 33212256; PMCID: PMC7668212.

[6] Antinori S, Cossu MV, Ridolfo AL, Rech R, Bonazzetti C, Pagani G, Gubertini G, Coen M, Magni C, Castelli A, Borghi B, Colombo R, Giorgi R, Angeli E, Mileto D, Milazzo L, Vimercati S, Pellicciotta M, Corbellino M, Torre A, Rusconi S, Oreni L, Gismondo MR, Giacomelli A, Meroni L, Rizzardini G, Galli M. Compassionate remdesivir treatment of severe Covid-19 pneumonia in intensive care unit (ICU) and Non-ICU patients: Clinical outcome and differences in post-treatment hospitalisation status. Pharmacol Res. 2020 Aug;158:104899. doi: 10.1016/j.phrs.2020.104899. Epub 2020 May 11. PMID: 32407959; PMCID: PMC7212963.

[7] Rochwerg B, Siemieniuk RA, Agoritsas T, Lamontagne F, Askie L, Lytvyn L, Agarwal A, Leo YS, Macdonald H, Zeng L, Amin W, Burhan E, Bausch FJ, Calfee CS, Cecconi M, Chanda D, Du B, Geduld H, Gee P, Harley N, Hashimi M, Hunt B, Kabra SK, Kanda S, Kawano-Dourado L, Kim YJ, Kissoon N, Kwizera A, Mahaka I, Manai H, Mino G, Nsutebu E, Pshenichnaya N, Qadir N, Sabzwari S, Sarin R, Shankar-Hari M, Sharland M, Shen Y, Ranganathan SS, Souza JP, Stegemann M, De Sutter A, Ugarte S, Venkatapuram S, Dat VQ, Vuyiseka D, Wijewickrama A, Maguire B, Zeraatkar D, Bartoszko JJ, Ge L, Brignardello-Petersen R, Owen A, Guyatt G, Diaz J, Jacobs M, Vandvik PO. A living WHO guideline on drugs for covid-19. BMJ. 2020 Sep 4;370:m3379. doi: 10.1136/bmj.m3379. Update in: BMJ. 2020 Nov 19;371:m4475. Update in: BMJ. 2021 Mar 31;372:n860. PMID: 32887691.

[8] Chen P, Nirula A, Heller B, Gottlieb RL, Boscia J, Morris J, Huhn G, Cardona J, Mocherla B, Stosor V, Shawa I, Adams AC, Van Naarden J, Custer KL, Shen L, Durante M, Oakley G, Schade AE, Sabo J, Patel DR, Klekotka P, Skovronsky DM; BLAZE-1 Investigators. SARS-CoV-2 Neutralizing Antibody LY-CoV555 in Outpatients with Covid-19. N Engl J Med. 2021 Jan 21;384(3):229-237. doi: 10.1056/NEJMoa2029849. Epub 2020 Oct 28. PMID: 33113295; PMCID: PMC7646625.

[9] Weinreich DM, Sivapalasingam S, Norton T, Ali S, Gao H, Bhore R, Musser BJ, Soo Y, Rofail D, Im J, Perry C, Pan C, Hosain R, Mahmood A, Davis JD, Turner KC, Hooper AT, Hamilton JD, Baum A, Kyratsous CA, Kim Y, Cook A, Kampman W, Kohli A, Sachdeva Y, Graber X, Kowal B, DiCioccio T, Stahl N, Lipsich L, Braunstein N, Herman G, Yancopoulos GD; Trial Investigators. REGN-COV2, a Neutralizing Antibody Cocktail, in Outpatients with Covid-19. N Engl J Med. 2021 Jan 21;384(3):238-251. doi: 10.1056/NEJMoa2035002. Epub 2020 Dec 17. PMID: 33332778; PMCID: PMC7781102.

[10] WHO Solidarity Trial Consortium, Pan H, Peto R, Henao-Restrepo AM, Preziosi MP, Sathiyamoorthy V, Abdool Karim Q, Alejandria MM, Hernández García C, Kieny MP, Malekzadeh R, Murthy S, Reddy KS, Roses Periago M, Abi Hanna P, Ader F, Al-Bader AM, Alhasawi A, Allum E, Alotaibi A, Alvarez-Moreno CA, Appadoo S, Asiri A, Aukrust P, Barratt-Due A, Bellani S, Branca M, Cappel-Porter HBC, Cerrato N, Chow TS, Como N, Eustace J, García PJ, Godbole S, Gotuzzo E, Griskevicius L, Hamra R, Hassan M, Hassany M, Hutton D, Irmansyah I, Jancoriene L, Kirwan J, Kumar S, Lennon P, Lopardo G, Lydon P, Magrini N, Maguire T, Manevska S, Manuel O, McGinty S, Medina MT, Mesa Rubio ML, Miranda-Montoya MC, Nel J, Nunes EP, Perola M, Portolés A, Rasmin MR, Raza A, Rees H, Reges PPS, Rogers CA, Salami K, Salvadori MI, Sinani N, Sterne JAC, Stevanovikj M, Tacconelli E, Tikkinen KAO, Trelle S, Zaid H, Røttingen JA, Swaminathan S. Repurposed Antiviral Drugs for Covid-19 – Interim WHO Solidarity Trial Results. N Engl J Med. 2021 Feb 11;384(6):497-511. doi: 10.1056/NEJMoa2023184. Epub 2020 Dec 2. PMID: 33264556; PMCID: PMC7727327.

[11] Huet T, Beaussier H, Voisin O, Jouveshomme S, Dauriat G, Lazareth I, Sacco E, Naccache JM, Bézie Y, Laplanche S, Le Berre A, Le Pavec J, Salmeron S, Emmerich J, Mourad JJ, Chatellier G, Hayem G. Anakinra for severe forms of COVID-19: a cohort study. Lancet Rheumatol. 2020 Jul;2(7):e393-e400. doi: 10.1016/S2665-9913(20)30164-8. Epub 2020 May 29. PMID: 32835245; PMCID: PMC7259909.

[12] Deftereos SG, Giannopoulos G, Vrachatis DA, Siasos GD, Giotaki SG, Gargalianos P, Metallidis S, Sianos G, Baltagiannis S, Panagopoulos P, Dolianitis K, Randou E, Syrigos K, Kotanidou A, Koulouris NG, Milionis H, Sipsas N, Gogos C, Tsoukalas G, Olympios CD, Tsagalou E, Migdalis I, Gerakari S, Angelidis C, Alexopoulos D, Davlouros P, Hahalis G, Kanonidis I, Katritsis D, Kolettis T, Manolis AS, Michalis L, Naka KK, Pyrgakis VN, Toutouzas KP, Triposkiadis F, Tsioufis K, Vavouranakis E, Martinèz-Dolz L, Reimers B, Stefanini GG, Cleman M, Goudevenos J, Tsiodras S, Tousoulis D, Iliodromitis E, Mehran R, Dangas G, Stefanadis C; GRECCO-19 investigators. Effect of Colchicine vs Standard Care on Cardiac and Inflammatory Biomarkers and Clinical Outcomes in Patients Hospitalized With Coronavirus Disease 2019: The GRECCO-19 Randomized Clinical Trial. JAMA Netw Open. 2020 Jun 1;3(6):e2013136. doi: 10.1001/jamanetworkopen.2020.13136. PMID: 32579195; PMCID: PMC7315286.

“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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Top tips for getting involved in editorial boards – Insights from #QCOR21

QCOR Summer Meet Up 2021 was a fabulous one-day event of networking, mentorship and sharing experiences. There was something for everyone across the spectra of careers, especially for early and mid-career physicians and researchers in the cardiovascular outcomes space.

The sessions were interactive, with opportunities for questions to be fielded to expert moderators. One such meeting with doctors Ann Marie Navar, MD, PhD and Dennis Ko, MD, FRCPC, MSc on How to get invited onto editorial boards had some superb insights, a few of which I’ve penned down on this blog.

Write well and publish: Editors look at your prior academic publishing footprint. This can be any previous writing experience: manuscripts, book chapters, publications, even blogging work – that proves you can write and can get your name out there.  If not original science, one can always write editorials, viewpoints or comments to scientific articles in the form of correspondence.

Be a good reviewer: The first step to joining an editorial board and indeed becoming a good editor, is to become a good reviewer. Advantages to reviewing articles for journals are many – good reviewers are eventually recognised, and when known as a high-quality reviewer, even considered for a position on the editorial board when there is an opening. A well-done review also affords the potential to be invited to write an editorial on the content reviewed. Further, some journals let you self-nominate to write an editorial – including an accompanying sentence or two on why you should be writing it is a good idea.

Top tips for writing a good review: Journals look for someone who understands critical appraisal, especially methodology and bias in the outcomes world. A good review is a structured, concise review. It is not the reviewers’ job to nitpick every detail or re-write the manuscript for the authors. It’s important to assess the integrity of the paper for its scientific value.  Brevity is key, with a focus on what the paper is about, if indeed it is worth publishing, what is novel or interesting about it, and how it will add to the literature. Comments on major flaws if any, are absolutely necessary, as well as priority of publication. Be professional in comments to the authors, as an overly negative/ harsh attitude is not well-received.

Good reviewing etiquette: Too many requests for reviews can sometimes be overwhelming. Even so, it’s not the best idea to decline a review request from a top tier journal or one with a high impact factor, as these might constitute missed opportunities. It’s also good etiquette to review for a journal in which you’ve just published. However, if you absolutely do not have the bandwidth, decline with good reason and mention them in the checkbox. Having agreed to review an article, it should be done expeditiously. Speedy reviews are efficient and always appreciated, as they help speed up turnover and clear article backlogs.

Seek feedback: A great way to self-assess one’s reviews as a junior reviewer, is to read more senior reviewers’ comments on the same manuscript, as well as the editors’ comments. One can also reach out to the associate editors for suggestions on improvements, who might be able to provide feedback, time-permitting.

Watch out for calls: An increasing effort is being made to improve diversity in editorial boards, with open calls to fill vacant positions. Such openings in editorial boards are often advertised on social media, or via emails sent to society member mailing lists. For more junior researchers, some journals offer editorial internships or assistant reviewer programs, with assigned associate editors that provide feedback on reviews. This is a great place to start, and depending on performance, might eventually lead to a permanent spot on the editorial board too.

Networking and reaching out: And finally, a combination of good skills, clever presentation of one’s abilities, and good networking might just be what lands you your next opportunity. Reach out to peers, mentors and sponsors for support and opportunities. Let your work and your name be known, so that when a suitable opportunity avails itself, you are invited to be a part of it.

I’d like to thank doctors Ann Marie Navar, MD, PhD and Dennis Ko, MD, FRCPC, MSc for sharing these really insightful tips on good reviewing, scientific writing and eventually getting invited to editorial boards. #QCOR21 continues at Scientific Sessions which will be held on November 13–15, 2021 at Boston, MA.

“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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Speak to Me: effective scientific communication

What is science communication? What are the differences between a research seminar and a TED-style talk? I recently had a chance to present my research discoveries in a very short (3min) format to fellow colleagues. It didn’t go as well as I planned. I noticed the varieties of styles and topics, so I decided to look into effective ways for science communication. “Science communication is defined as the use of appropriate skills, media, activities, and dialogue to produce one or more of the following personal responses to science: Awareness, Enjoyment, Interest, Opinion-forming, and Understanding”, a contemporary definition of science communication1. Scientists are more aware of the importance of scientific communication in recent decades. The reasons for science communications range from grant requirements, public engagement, to feelings of moral obligation2. Audiences are also very diverse such as interested/non-interested laypeople, engaged stakeholders and policymakers, and scientific colleagues from other disciplines.

Many articles discussed the techniques for effective science communication. They are very accessible through websites. An article published by Steven J. Cooke and colleagues shared a nice collection of useful websites in a table format with emphasis on key resources on science communication for scientists3. With a great wealth of information online, I’m going to share some major points regarding effective science communication.

Know your audiences

For any kind of effective science communication, the first step is to set objectives. Why are you interested in sharing what you know? What do you want your audiences to take home? Then the next question naturally will be who are your audiences? The knowledge depth of your audience decides how you want to present your story. Imagine a nuclear scientist tries to tell a government official that what is radioactive. Think critically about what aspect of your science will reach the target audience. It’s paramount that the information you share is of appropriate complexity. For example, you would describe your research differently to a group of colleagues than to high school students– and even specialized audiences like colleagues are not homogeneous. Some may specialize in a different field.

Avoid acronyms and jargons

One of the biggest obstacles to effective communication is acronyms and jargon. Imagine if you hear a spy uses morse code to communicate. It’s basically the same when a scientist uses his/her “comfortable languages” to talk to “insiders”. Sometimes it forms a special bond and feels very exclusive. Most of the time it saves lots of time and energy to repeat some concepts over and over. Scientific concepts sometimes could be less institutional. Avoid acronyms that could reach a broader audience. Regardless of what forms of communication, acronyms should be critically scrutinized based on necessity and commonality. Multidisciplinary studies embrace effective communication among scientists and acronyms are not going to make it easier. Jargon is a similar but different issue. If you look at the word panel in Fig14. You might find some commonly used words by in the jargon category. When you bury yourself in your specialized field long enough, you might find it harder to distinguish what is jargon and what is not. A group scientists developed a program to help scientists identify jargons4 and there might be other resources online to achieve a similar goal.

Fig1: Screen shot showing words after de-jargoning4.

Focus on the science

It’s not a big surprise for scientists to think and talk about science all the time. Avoiding granular details is one of the top lessons I learned as a graduate student. If you practice this fashion in an extreme way, if could be counterproductive. Good science is the foundation of quality science communication. Don’t lose sight that people are interested in your talk/post because you have a unique science-based perspective. “Avoid patronizing an audience by oversimplifying or glossing over important scientific details, as interested people want to hear about the scientific process and see the data themselves.”3. An effective science communication should include appropriate details which covers significance, background, challenges, as well as results. Be creative, be relatable and be interesting. Most importantly, be true to the data and don’t oversell or overstate the results. Share with the audiences your enthusiasm based on the science, don’t sensationalize and overpromise research outcomes.

Most scientists don’t have formal training in science communication. Universities and government agencies are starting to realize the importance and are working on to incorporating proper training for the next generation scientists. Some universities opened graduate program in science communication major. It’s a fast-growing field that we should all consider improving our science communication skill in the future.

 

References

  1. Burns TW, O’Connor DJ, Stocklmayer SM. Science Communication: A Contemporary Definition. Public Understanding of Science. 2003;12(2):183–202.
  2. Poliakoff E, Webb TL. What Factors Predict Scientists’ Intentions to Participate in Public Engagement of Science Activities? Science Communication. 2007;29(2):242–263.
  3. Cooke S, Gallagher AJ, Sopinka N, Nguyen VM, Skubel R, Hammerschlag N, Boon S, Young N, Danylchuk A. Considerations for effective science communication. In: ; 2017.
  4. Rakedzon T, Segev E, Chapnik N, Yosef R, Baram-Tsabari A. Automatic jargon identifier for scientists engaging with the public and science communication educators. PLOS ONE. 2017;12(8):e0181742.

“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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Studying for Medical Boards as a Foreign International Graduate While Working: tips and experience

When I decided I wanted to take the steps, in January of 2019, to pursue a residency in neurosurgery in the United States, I did what most of us do, I went to Youtube and saw how other people have studied. After a couple of days watching various videos, I felt overwhelmed since most of the videos entailed studying >9 hours, having a dedicated period exclusive for studying, and some of them suggested doing them during medical school.

All of those suggestions were not possible at the time for me, I had just graduated from medical school in December of 2018, and I had accepted a full-time job at Cedars-Sinai. Though I did question if I was going to be able to manage a full-time job on research and study for this life-defining exam, in the end, I pulled it off, and I took step1 in October of 2019 and step2 CK in may of 2020.

Before starting with my personal story of how I studied and managed my time to finish both USMLE while working, I just want to give you peace of mind to all of you that are not in the ideal situation of studying full time or that cant dedicate enormous time of study due to personal responsibilities. All roads lead to Rome; everyone is in a particular economic, social, and educational situation and what each one of us must do is to adapt and make the most out of our conditions!

So, let’s begin.

What was your approach to work and study at the same time?

When I faced this challenge, the first thing I did was to talk to my boss, Dr. Nestor Gonzalez, and my coworker Juan Toscano. I let them both know that while I was going to fulfill my job to the best extent of my abilities, they should know that I was also dedicating all my spare time both at work and outside from work to study.

I believe it’s crucial to the people you work with know what you are going through, and to me, this was extremely helpful, as there were times my coworker took over simple tasks and was very understandable to give me as much time as I could to study. Since my boss knew that I was taking this exam, I was able to take 2 weeks off before my exam date to dedicate 100% of my time to study.

For how long and how did you prepare for step1 and step2?

I started my step1 preparation on the third week of January 2019, when I started my job. During the first three weeks, I tried to get a sense of how my day to day was going to be at work, identify which hours would be ideal for studying either after work, before work, and also determine what the best time to do questions was, watch videos, read the first aid, etc.

After finishing the First Aid’s first pass (not extremely thorough, just a glimpse to see and get familiarized with the material), I outlined 3 phases of the study.

  • The first (from Feb-April) would be dedicated to learn and review the theory, so 90% of my study day was to read the first aid, watch pathoma/Kaplan/sketchy, and a 10% was to do questions from different banks.
  • The second (may-sept), Was dedicated 90% to Uworld and their respective review, and 10% to review the FA, pathoma, or any gap in my knowledge.
  • The third and last (last week of sept-first of October), I only did questions. These were the 2 weeks my boss gave me to dedicate full time to study. I was able to do during this first week > 4 blocks a day with their respective review, and the last 5 days, I did practice 7 blocks as if I were taking  Step1 (based on the recommendation of my friends Sandra Saade and Andre Monteiro), which was extremely helpful to gain endurance.

Total study time for Step1: From February-October

For step2 was easier to get organized since I would follow the same schedule and balance of work/study. I took a month’s break from step1 and started to study for step2 at the end of November. I studied from November until May 28, 2020 (one day after my birthday).

The approach was pretty similar to that of step1 with the caveat that I started from day 1 to do questions, and I also took one week off from my vacations to dedicate full time to prepare step2. The pandemic changed my preparation timing since we had to deal with the Prometric cancelations due to covid.  

How was a regular workday during step1 and step2 preparation?

I would wake up at 6 am in the morning, and during the first 3 months, I commuted on the bus to my workplace, which was approximately 2 hours away. During these bus rides, I would read first aid; of course, I needed some noise-canceling headphones. I would highlight or repeat the things that I thought were most important. By the time I got to work, depending on the time, I would do 10 questions from any qbank before starting to work at 9 am. Usually, I would leave work by 4-4:30 pm to head back to my place.

On the way back, the commuting was equally long, sometimes a bit longer depending on traffic, so by the time I got to my home, I would have already read first aid on average 3 hours/day from Monday-Friday. I used to get home at around 7:00-7:30, cook dinner and my lunch for the next day, and after an appropriate break watching friends (I had just started to watch it), I would start my night study routine at 9:00 pm. From 9 pm until 1 am, I would watch pathoma, Kaplan, or sketchy videos. My goal from Monday to Friday was to study at least 6 hours per day, and I usually slept from 1 to 6 am (since med school, I had slept 5 hours a day)

In March, to make my commute more manageable, I got a bicycle, so I was biking halfway to work and the other half on the bus.  This allowed me to get some exercise done, which I realized I was missing, and helped me to be more relaxed during this study/work period.  From March until mid-June, I followed the same routine of reading first aid or doing my Anki cards on the bus and then studying at home until 1 am (or if I felt tired before 1 am).  Some days, I had some spare time at work, so I tried to get some study done either by reviewing questions or reading the first aid.

From June-September, I wanted to increase my study time and try to use any free time to study. This routine of study/work with no other activities was highly tiring and stressful, and I knew that I needed something for my mental health, so I decided to join the gym. During this period, I wanted to use my time on my bicycle rides which were more than 50 min a day, so I converted all the pathoma videos into mp3 so I could listen to pathoma while I was riding my bike. Then I would do Anki or read FA on the bus, and at work would still review any question I didn’t finish the night before. Anki became my favorite and most used application, as during any break, at lunchtime, waiting for a meeting to start, or on the bus, I would do a couple of cards, and in the end, this helped me a lot. After work, I would get home at the same time (around 7 pm), eat dinner, and study until 9 pm. Then I would go to the gym and disconnect myself from anything related to the step.  After my workout, I would study again until 1 am.  Since I was increasing my study time during my former free time, I was trying to aim to have more than 6 hours of study a day, even though I had added the gym to my schedule.

I continued this pace until September before my 2 weeks of dedicated, with a few modifications. The closest I was getting to the date of my exam on October 8, I cut back even more from my free time, so once I finished listening pathoma, I transformed to Mp3 all the videos from Boards and Beyond (per Sebastian Gallo suggestion), and I would listen to them instead of listening to music, during my bike rides, while walking and even at the gym. This passive learning was a way of trying to make the most of the time during a working day.

I took 2 weeks off work, and I had the most significant visit at the worst time, from my mother Patricia, but it did give me an energy boost to finish up my studies. I stayed with my aunt Cristina and uncle mike in San Diego for the 2 most stressful weeks of my life so far, where I was studying from 9 to 11 hours a day before the test.

For step2, things were more manageable since I moved 15 min away from the hospital, and not commuting for more than 3 hours a day improved my life and study style a lot. My working schedule did not change, but my study times did. Since I was living so close to the hospital, I arrived at 6:40 am to the hospital and headed to the library to do a block of uworld and study until 9. I would work until 4:30 pm and then head to the library until 9:00 pm to keep doing questions or reviewing questions and then heading to the gym until 11-11:30. I would head back to my place and go to bed at around 12:30 to 1 am and then repeat the same schedule before the pandemic hit.

When the pandemic hit, we were sent to work from home. To adapt to working and studying in the same place as my roommates, that weren’t particularly quiet, I shifted my schedules to go to bed at 6:00 pm and wake up and begin my day at 11:00 pm. This allowed me to have enough space and time to study from 11:00 pm until my workday began at 8 am.  After finishing work at around 4 pm, I would run 3 miles while listening to mp3 of MedEd, then had dinner and go to bed. After 3 cancelations from Prometric, I was able to schedule my step2 for the end of May.

How was your schedule on the weekends?

My weekends were the days that I studied the most and tried to make up for the study that I could not finish during the week and the sleep I did not get. I would do grocery shopping, take care of my place, and all the labor that entails with being an adult. I would study 8—9 hours on Saturday and Sunday. My goal per week was to study at least 42 hours. Some weeks were more brutal at work, or I was tired and couldn’t finish my 6 hours daily on the weekdays, making the weekends the perfect time to make up for the time that I did not study. The weekends were ideal for taking any assessment, whether Uworld Self-assessment or NBME.

When I joined the gym, I had another activity to do on the weekends, and I wish I had done it sooner to improve my mood at earlier stages of my study preparation.

How did you manage your time?

In the beginning, I was using just a regular clock and writing down how much I was studying per day on an excel sheet. This helped me keep track of how much I was studying, so I would stop the clock every time I grabbed my phone or took breaks. Then I found an app that changed my time management forever that is called aTimeLogger, which allowed me to set goals per day, week, and month depending on the activity that I was doing, that basically were studying, working, exercising, and wasting time (yes, to visually see how much time one wastes on Instagram, Facebook, youtube, is disturbing and helped me to reduce this screen time especially during quarantine).

As I said before, my goals were to reach a doable 6 hours per day or 42 hours of study per week and to do at least 6 hours of exercise per week for mental and physical health. Also to maintain a minumun of 5 hours of sleep per day which is used to be my normal sleeping time since medschool.

How did you balance your social life and working/studying?

Significant endeavors entail enormous sacrifices, so during this working/studying period for step1, I deleted all my social media (Facebook, Instagram, Twitter) and only kept Whats app to talk to my family and close relatives.  Not having the distraction of social media on my phone helped me keep my objective clear, which was to pass with a good score step1/2, and that instead of grabbing my phone to check Instagram, I grabbed it to do Anki.

My social life was nonexistent during my study period. I did go out with my friend and coworker Juan maybe 6 times from January-December, and I saw my family a couple of times for brief moments. Since I had moved to a new country and new city, isolating myself from people was doable and extremely helpful to focus my energy only on studying and working.  My first vacations during 2019 were for my dedicated 2 weeks for step1; they were not the ideal vacations but were necessary to study.

Any final suggestions for someone that is in a position similar to you?

These exams are complicated not only for the amount of time invested and information one has to learn but also the emotional pressure of having a test determining how feasible your dream of becoming a physician in the USA would be.

So, I would suggest:

  1. Committing thoroughly to studying and working, and trying to isolate yourself from most social engagements, talk to your family and friends; they will understand your absence in social engagements and not hold a grudge.
  2. Reducing, if possible, to zero social media from your phone and laptop. This helps you focus on the exam and not feel sad/anxious (which happened to me) because you see your friends and family partying or having fun while you are spending more time with Uworld than with another human being. Remember this is temporary; your life will get better after finishing the exams.
  3. Surround by people that are going through the same process and by those who already took the exam, we know how it feels, and we understand what you are and will go through. I have to say that talking out loud when I felt hopeless, tired, and overwhelmed was a vital pillar of this process of studying/working. So I want to give an enormous shout-out to my very patient friends and were there for me every step (Juan Velez, Sandra Saade, Sebastian Gallo, Andre Monteiro).
  4. Make time, even if little, to do your hobbies. In my case, it was going to the gym. It really changed my mood and gave me more mental stability, and to give yourself a break from studying.
  5. If you feel tired or burnout (because at some point you will), don’t be hard on yourself and take a break. I used to get very mad at myself when I was trying to study but could not focus, or I was falling asleep. Taking a break is also crucial to maintain sanity during difficult and extended periods of studying/working.

Last but not least is to look at the big picture and all that is at stake. While it is thought to work and study simultaneously, it taught me a lot of things, such as resilience, pushing my boundaries, and making the most out of a not ideal situation.  When situations or conditions cannot be changed, one must adapt, and I’m glad I was able to deal with long commutes, working/studying, moving to a new country, and living alone for the first time in my life at the same time. In the end, it was worth it. I passed Step1 (239) and Step2 (236), and I’m thrilled that my dream to become a neurosurgeon is still intact.

“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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Fighting for Health Equity and Social Justice during the COVID-19 pandemic: Insights from the 2021 Epi/Lifestyle Scientific Sessions

This year’s Epi/Lifestyle Scientific Session took place on May 20-21, 2021. Despite the change in venues to virtual mode because of the COVD-19 pandemic, the conference was a success! Many attendees had the opportunity to participate, network, and learn about the latest science on Epidemiology, prevention, lifestyle, and cardiometabolic health. The opening remarks and keynotes centered on two particularly important topics, health equity, and social justice, and the commitment of the American Heart Association to eliminate health disparities in underserved ethnic communities.

Dr. Mitchell S. V. Elkind, MD, MS, FAAN, FAHA, American Heart Association President, opened the conference, highlighting the commitment of the American Heart Association to health equity and structural racism research, driving systemic public health change, while focusing on removing barriers to equitable health for everyone, everywhere. He also provided updates on new scientific research programs to address health inequities and structural racism, and diversity research opportunities for underrepresented racial and ethnic groups.

From a healthcare provider standpoint, many of these programs offer opportunities to bridge the gap in preventive CVD measures in our communities. Other important contributions highlighted at the conference included the COVID-19 Registry, a hospital-based quality improvement program to explore the links between COVID-19, cardiovascular risk factors, and adverse cardiovascular outcomes.

In alignment with the lead topic of the conference, two keynote speakers, Dr. Olajide A Williams and Dr. Laprincess C. Brewer highlighted the effects of structural racism on the social determinants of health, and their relation to health equity and social justice.  Dr. Olajide A. Williams presented on the relationship between structural racism and poor health. He highlighted the importance of social determinants of health and primordial prevention from the perspective previously reported by Dr. Camara Jones.1

Dr. Jones’ “Cliff Analogy” gives a clear picture of the three dimensions of health interventions to help people who are falling off of the cliff of good health: providing health services, addressing the social determinants of health and equity.1 The deliberate movement of the population away from the edge of the cliff represents our efforts to improve on the social determinants of equity through interventions on the structures, policies, practices, norms, and values that differentially distribute resources and risks along the cliff. By doing so, we can improve health outcomes and eliminate health disparities.1   His presentation is also a call to continue efforts to overcome the long-term effects of structural racism and eliminate its associated disparities by organizations outside of government.

Another keynote speaker, Dr. Laprincess C. Brewer discussed the importance of community-based participatory research as a strategy to promote cardiovascular health for all. She highlighted the importance of diversity in clinical trials and research studies as well as the need to build and maintain community partnerships to dismantle structural inequities, racism, and consequently lead to cardiovascular health equity in our communities.  Innovative approaches through community-based participatory research, involving our communities and key stakeholders have the potential to support lifestyle change for cardiovascular disease (CVD) prevention, especially in ethnic minority groups, such as African Americans, who carry the largest CVD burden.

Dr. Brewer highlighted the ongoing disparities in CDV mortality for African Americans. Despite improvements in mortality rates over the past decades, CVD remains the leading cause of death for African-Americans. She further messaged the American Heart Association’s Life Simple 7 as important factors to address in the fight against cardiovascular disease in ethnic minorities experiencing greater health disparities. Her presentation also highlighted the importance of community stakeholders, including faith-based organizations and community members in the identification of the research problem, development of research questions, as well as interventions that may be relevant to these groups.2 The various types of programs she discussed, including Mobile Health, emergency preparedness, and COVID testing, through a partnership with a faith-based organizations, served as examples of trusted social networks and established stakeholders that underserved communities may be more likely to reach out for support during health crises. These may further contribute to the delivery of culturally sensitive resources through community partnerships aimed to achieve health equity among ethnic minorities.

As I reflect on the message from the speakers during the opening session, it reminds me of the opportunities available in my community for engagement in the prevention of CVD, especially in underserved minority groups, and the need to reach out to key stakeholders trusted by these underserved groups. It is also a call to engage with these stakeholders in the delivery of interventions aimed at disease prevention, setting up guardrails to prevent them from falling off the cliff of good health.

References

  1. Jones CP, Jones CY, Perry GS, Barclay G, Jones CA. Addressing the social determinants of children’s health: a cliff analogy. J Health Care Poor Underserved. 2009;20(4 Suppl):1-12. doi:10.1353/hpu.0.0228
  2. Brewer LC, Hayes SN, Caron AR, et al. Promoting cardiovascular health and wellness among African-Americans: Community participatory approach to design an innovative mobile-health intervention. PLoS One. 2019;14(8):e0218724. Published 2019 Aug 20. doi:10.1371/journal.pone.0218724

“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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Follow Your Dreams: An Inspiring Journey Of an Electrophysiologist Turned Motivational Speaker and Life Coach

 

I am excited to interview Dr. Deborah Lockwood who is an electrophysiologist but recently her life took a very interesting turn and she decided to follow her passion outside medicine. She is sharing her incredible life journey with us in this video blog.

 

“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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Trends in COVID-19 in-hospital mortality: Insights from the AHA COVID-19 CVD registry

Information on the survival trends of hospitalized COVID-19 patients is important for physicians to identify trends and track the efficacy of hospital-based care in real-world practice. The American Heart Association’s (AHA) COVID-19 Cardiovascular Disease (CVD) Registry was put in place in April 2020 with the objective of improving nation-wide surveillance of hospitalized patients with COVID-19.1 Early data derived from this registry were presented at scientific sessions #AHA20 last year. This blog summarizes a more recent analysis by Gregory A. Roth and colleagues, looking at trends in patient characteristics and COVID-19 in-hospital mortality in the United States during the pandemic.2

This retrospective study published in JAMA Network Open included 20 736 hospitalized patients from the AHA COVID-19 CVD registry at 107 hospitals in 31 states. Undertaken as part of the Global Burden of Disease Study, the objective was to quantify changes in in-hospital mortality rates during the first 9 months of the pandemic, and understand if any observed changes were associated with differences over time in the characteristics of presenting patients. The data were analyzed to show comparative trends across 4 periods in 2020: March and April; May and June; July and August; and September through November.

There was a gradual decline in the numbers of admitted patients in the registry, with 11 901 patients admitted in March or April, down to 2010 patients in September through November. In terms of the patient demographics, 45.9% were women, the proportion of which slightly increased over time. The mean age was 61.2 ±17.9 years which decreased from March -April through September-November. 58.4% of patients were hypertensive. 35% were diabetic, and 18.3% had pulmonary disease. The mean BMI was in the obese range (30.8 ± 8.5) and increased a small amount through November.

Almost a quarter of patients were receiving supplemental oxygen on admission. This proportion increased from 23% in March – April to 35.9% in September through November. This was despite the presence of interstitial infiltrates on admission decreasing from 70.7% of patients to 60.8% during the corresponding periods. In contrast to supplemental oxygen, however, the use of mechanical ventilation decreased substantially from 23.3% to 13.9% during the same periods. The use of glucocorticoids and remdesivir increased substantially, potentially reflecting the emergence of randomized evidence of its efficacy during that time and the US Food and Drug Administration (FDA) announcement of remdesivir emergency use authorization on May 1, 2020.3 The mean duration of hospital stay also showed a reduction from 10.7±12.1 days to 7.5 ± 6.8 days.

A total of 3271 in-hospital deaths recorded from March through November 2020, corresponding to overall in-hospital mortality of 15.8%. In-hospital mortality rates declined as time progressed, with 19.1% in March-April, 11.9% in May-June, 11% in July-August, and 10.8% in September- November. Adjusted odds for in-hospital death were also significantly lower for all 3 later time periods studied, compared with March-April. Increasing age was the factor most strongly associated with death, with the figure depicting the adjusted odds ratios across different age groups [Figure 1]. Male sex, BMI > 45, and presences of comorbidities, specifically cancer, cerebrovascular disease, diabetes, and heart failure were independently associated with in-hospital death.

The greatest reduction in the in-hospital mortality rates occurred between March and May 2020, with high mortality rates falling by a massive 38% from March and April 2020 by May and June, followed by a modest further decrease by November. Notably, this difference in mortality rates persisted even after adjusting for age, sex, medical history, and COVID-19 disease severity. In the face of only minor changes in the characteristics of admitted patients described above, the authors have thus put forward some hypotheses that might explain these trends of decreasing mortality rates over time.

One of them is the extremely high hospital census and rapid implementation of new measures (i.e. isolation and personal protection procedures) especially in locations with very high rates of COVID-19 in March and April. This is consistent with the observation of the most rapid declines in mortality rates between the months of March – April and May – June, when health care workers gradually became more familiar with new procedures.

Changes in treatment protocols may also have contributed to this decreased mortality. The observed increased use of supplemental oxygen and decreased use of mechanical ventilation in the registry data could be explained by trends in respiratory care that emerged as the pandemic progressed, particularly the efficacious modalities of noninvasive ventilation, high flow nasal oxygen, and prone positioning, although these modalities were not captured in the registry. Substantially increased use of steroids and remdesivir may also have contributed to better outcomes.

Few limitations exist: the analysis was retrospective, with varying sample sizes due to the voluntary nature of enrolment in the registry. Certain treatment modalities were not captured. There was potential for bias due to confounding from unobserved or unrecorded characteristics in the estimation of associations, and as such causality cannot be inferred. Furthermore, it is important to note that this analysis included data from before the rollout of vaccines, and it would be interesting to see these more contemporary trends from the AHA COVID-19 CVD registry in future analyses.

Needless to say, such registry-based analyses provide important data on trends in mortality and contemporary management practices in the face of rapidly evolving hospital dynamics during the pandemic. While randomized controlled trials are essential to investigate potential treatments and inform evidence-based practice, the utility of such registries in identifying mortality and treatment trends in real-world practice, and indeed using this information to implement best practices, cannot be understated.

References

  1. Alger HM, Rutan C, Williams JH IV, et al. American Heart Association COVID-19 CVD Registry powered by Get With The Guidelines. Circ Cardiovasc Qual Outcomes. 2020;13(8):e006967.
  2. Roth GA, Emmons-Bell S, Alger HM, et al. Trends in Patient Characteristics and COVID-19 In-Hospital Mortality in the United States During the COVID-19 Pandemic. JAMA Netw Open. 2021;4(5):e218828.
  3. US Food and Drug Administration. Emergency Use Authorization (EUA) for emergency use of Veklury® (remdesivir) for the treatment of hospitalized patients with severe 2019 coronavirus disease (COVID-19). Published October 22, 2020. Accessed June 4, 2021. https://www.fda.gov/media/137564/download

 

“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.”