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Johnson & Johnson COVID-19 Vaccine

On February 27, 2021, the Johnson & Johnson COVID-19 Vaccine has been Authorized by the FDA for emergency use. Which makes it the third vaccine to be authorized in the United States. The emergency use authorization was granted after 43,783 participants (18 years of age and older) with no evidence of prior COVID-19 infection were randomized to the vaccine group versus the placebo (saline) group. The trial was conducted in eight countries across three continents with a diverse and broad population. Overall, the vaccine was 66% and 67% effective in preventing moderate to severe/critical COVID-19 occurring after 2 and 4 weeks respectively. Moreover, it provided a 77% and 85% in preventing severe/critical COVID-19 occurring after 2 and 4 weeks respectively. Similar to the other vaccines, the most commonly reported side effects were pain at the injection site, headache, fatigue, muscle aches, and nausea. It is still unclear whether the vaccine will decrease transmission of the virus. Additionally, the participants were only followed up for a median of 8 weeks, so long-term efficiency or safety is not available. One of the main advantages of this vaccine is that it is administered as a single shot.

In contrast to the Pfizer and Moderna vaccines which utilized messenger RNA. Johnson & Johnson’s vaccine used existing technology to add the gene for the COVID-19 spike protein to a modified Adenovirus. After receiving the vaccine, the body will be able to produce the COVID-19 spike protein to trigger the immune system to mount an immune response without causing the disease.

(Figure from Livingston EH, Malani PN, Creech CB. The Johnson & Johnson Vaccine for COVID-19. JAMA. Published online March 01, 2021. doi:10.1001/jama.2021.2927)

Although the Pfizer and Moderna Vaccines are very effective. Having an additional vaccine will accelerate the vaccination speed. Johnson and Johnson has begun shipping its COVID-19 vaccine and expects to deliver enough single-shot vaccines by the end of March to enable the full vaccination of more than 20 million people. Additionally, Merck will be manufacturing this vaccine which will ramp up the production speed. So far, more than 50 million people have received at least one dose of the vaccine. It is expected that by the end of May 2021, vaccines will be available for the entire adult population in the United States. For the time being, we have to practice social distancing, wear a mask, and hope for the best!

References:

1) Livingston EH, Malani PN, Creech CB. The Johnson & Johnson Vaccine for COVID-19. JAMA. Published online March 01, 2021. doi:10.1001/jama.2021.2927

2)https://www.fda.gov/news-events/press-announcements/fda-issues-emergency-use-authorization-third-covid-19-vaccine

3)https://www.jnj.com/johnson-johnson-covid-19-vaccine-authorized-by-u-s-fda-for-emergency-usefirst-single-shot-vaccine-in-fight-against-global-pandemic

 

“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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Eating To Live Or Living To Eat? The Weight-Gain Struggle During a Pandemic

To my fellow physicians and patient providers, how many of your patients have gained weight and blamed it on the pandemic due to limited options for physical activity outside of the home?

Unsurprisingly, almost all of my patients I’ve seen over the past year have fallen victim to this, with good reason. They are protecting their health by avoiding exposure to COVID-19 but at the same time are unconsciously neglecting their health by not having the means or green light to engage in healthy behaviors such as going to the gym, walking in public spaces, and engaging in aerobic exercise and strength training. Our current restrictive environment combined with more time at home to eat and indulge is a fail-proof setup for adding on these harmful extra pounds.

So what can our patients control and how do we motivate them? This reminds me of my roommate in medical school who once told me that I “live to eat” because I would act immediately on a food craving and would also plan my next meal while actively eating a meal in front of me. I asked him if he also followed this same dogma of being an “emotional eater” and acted impulsively on energy-dense, nutritionally lacking foods. He responded with “I eat to live” because he only thinks about food when his body sends him the appropriate signals. I had to think about this. Yes, “stress-eating” is a habit that many of us are using as a coping mechanism during the COVID-19 pandemic.

Food culture is central in many cultures across the world. Food brings people together, establishes common ground amongst strangers, and provides satisfaction and emotional fulfillment while traveling, learning, and growing. We’re social creatures who naturally select to build connections that many times are centered around meals. But when the balance tips towards overindulgence and away from physical activity and healthy mindfulness is when chronic diseases such as coronary artery disease and its associated comorbidities arise.

For many of us, we understand what we should eat to become healthier, however, that does not mean we will actually follow this rationale to maintain a heart-healthy diet, especially during a pandemic when most of our day is spent sedentary in isolation at home. Despite having a master’s degree in Nutrition as part of my training, I can admit that I have invariably fell victim to the vices of food comfort at home. I was eating a lot of baked desserts after dinner but recently decided to replace this habit with a cup of hot chocolate made with soy milk and sugarless cocoa powder.

So how do we combat this? We know the right food prescriptions of diet to provide our patients and have all heard the saying of “you are what you eat.”

Let me quickly review the 4 strategies of motivational interviewing (OARS) and a few quick tips to help our patients (and ourselves) make gradual and achievable nutritional changes:

  • Open-ended questions- this allows your patient to explore and think more deeply about personal goals.
  • Affirmations- highlight your patient’s strengths and skills to support self-efficacy
  • Reflections– reflective listening and providing empathy deepens the trust with your patient; avoid making judgments as patients become may become defensive
  • Summaries- summarizing the above then allows you to move on to making a specific plan with your patient

Here are 5 tips to help your patients make healthier food choices during the pandemic:

  • Allow your patient to decide on 1-2 specific food goals per week (this can involve eliminating one food item they are able to identify that is unhealthy or decreasing the amount of this food item per day or week).
  • Empathize with the difficulty of being at home and that boredom by itself can cause overeating. Prior to eating, challenge them to take a few seconds to determine whether or not they are hungry or are deciding to eat because they are bored.
  • Make a goal of drinking at least 8 glasses of water a day- being underhydrated can in turn cause overeating of salt-laden foods.
  • “Eat your calories, don’t drink them.” Ensure that your patient is avoiding caloric beverages. If they enjoy fruit juices, ask that they try eating fruits as the fiber benefits are much more plentiful with less additive sugars.
  • Lastly, congratulate them on their decision to make a change and have a specific follow up plan to continue building on the changes they are making.

Be well,

Kyla Lara-Breitinger, MD, MS

References:

https://psycnet.apa.org/record/1998-04654-001

 

“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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Evaluating ML/AI Models in Clinical Research

The number of machine learning (ML) and artificial intelligence (AI) models published in clinical research is increasing yearly. Whether clinicians choose to dive deep into the mathematical and computer science underpinnings of these algorithms or simply want to be conscientious consumers of new and relevant research to their line of work, it is important to become familiar with reading literature in this field.

To that end, Quer et al. recently wrote a State-of-the-Art Review in the Journal of The American College of Cardiology detailing the research landscape for ML and AI within cardiology including concrete tips on how a non-ML expert can interpret these studies. At its core, ML is about prediction, and models are created to make accurate predictions on new or unseen data. Inspired by their work and incorporating many of their recommendations, below is a list of considerations for when you are critically evaluating an ML/AI model in clinical research:

  1. What question is addressed and what problem tackled? How important is it? Regardless of a model’s performance or the accuracy, its usefulness is determined by its clinical application. Everything must go back to the patient.
  2. How does the ML/AI model compare to traditional models for the given task? Many studies have shown little additional benefit when comparing ML/AI models to standard statistical approaches including logistic regression for clinical questions that have been extensively researched in the past with key predictors of the outcome of interest identified. The promise of ML/AI really exists in incorporating novel data sources and data structures, including time-series information and continuous input from wearable sensors, raw images and signals such as that from common studies including echos and ECGs, and harmonizing unique data types together.
  3. To which broad category does the model fall into? Most machine learning models fall into buckets of supervised learning algorithms, unsupervised learning algorithms, or reinforcement learning. Each approach is slightly different with a unique end product. Supervised learning algorithms learn patterns in the data that allow them to predict whether a specific observation falls within a specific class or category, for example determining if a photo is a cat or a dog. This requires data that is labeled for the algorithm to learn from, i.e. someone or something has provided data that is correctly tagged as a dog or cat. Unsupervised learning does not require observations with labels but instead combs through the observations to look for those that are similar to each other. Reinforcement learning a separate task in which an agent is trained to optimize choices made to attain a stated goal. All of these have been used clinically in recent literature.
  4. How were the data and labels generated? Garbage in = garbage out. Your model is only as good as the data it was trained on and the accuracy of the labels. It’s important to know where this information came from.
  5. Model training, validation/performance, generalizability. A common approach to training models is to split the data into a training set with unique observations left for the test set to validate the model. It is critical to train and test on different data with no overlap. Model performance is tracked with metrics similar to those used to evaluate clinical models, including sensitivity, specificity, positive predictive value, negative predictive value, and AUC, although the names associated with those measures may be different. Additional measures such as an F-score may be used. Arguably more important, however, is generalizability. This is how well the model performs in an entirely unique cohort, often from another center, although many of the currently published studies do not include this step.
  6. How clinically useful are these findings, and is the model interpretable? Basically, is the juice worth the squeeze? And can a human understand why the model made its conclusion? A common knock against deep learning neural networks for example is that although they are incredibly skilled at learning from data and making accurate predictions on new data, how they do so is a “black box,” although new ML/AI methods have started to account for this.
  7. How reproducible are the results? Did the authors share their code or dataset? If they used an EHR phenotype to generate their cohort, can you do the same thing at your institution?

These points are meant to summarize and add to some important aspects of this recently published article, but it is an excellent read and I encourage everyone to review it in its entirety.

Reference:

Quer, G., et al. (2021). “Machine Learning and the Future of Cardiovascular Care.” Journal of the American College of Cardiology 77(3): 300-313.

 

“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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Black Lives Matter in Heart Transplant Too

Written by Isaiah A. Peoples MD, MS, Christy N. Taylor MD, MPH, and Nasrien E. Ibrahim MD

The current climate in America has taken the rose-colored lens off society and allowed the world to see the gross disparities faced by Black Americans and other marginalized groups. Initiated by the multiple murders of unarmed Black Americans by police officers to the unprecedented dissimilarities in the death rate of Black and brown people due to COVID-19. This has given pause to the medical community; forcing us to reflect on the ever-increasing health disparities facilitated by institutional racism, which has sadly been perpetuated in medicine including in heart transplants. This is partially reflected by the low number of hearts being transplanted to people of color even when medically indicated. Often the factors of financial and social “requirements” are what lead to many being turned down for transplantation. These are young patients, Black patients, brown patients, patients with young children, patients without financial means, patients without caregivers, patients neglected in the healthcare system; souls that will haunt us forever. Our healthcare system is broken.

Heart transplantation is one of the greatest innovations in medicine to date. Helping patients with end-stage heart failure (HF) and New York Heart Association IV symptoms have a second chance at life, hiking the Grand Canyon, or keeping up with their young children- nothing comes close. However, along the continuum of HF from the prescription of guideline-directed medical therapies (GDMT) including internal cardioverters defibrillators to advanced therapies including heart transplant, Black patients are undertreated.

Transplant selection is a complicated process where ethics, emotions, and implicit biases occasionally muddle the process further. A study by Dr. Khadijah A. Breathett and colleagues examining racial bias in the allocation of advanced HF therapies found Black women were judged more harshly by appearance and adequacy of social support.1 In transplant selection there are non-modifiable factors as well as modifiable factors to consider, with modifiable factors carrying the greatest risk for bias and inequitable listing and organ allocation decisions. Patients too sick to survive, for example, a patient with multi-organ failure intubated and on extracorporeal membrane oxygenation or patients with active cancer have absolute contraindications- these are non-modifiable. Age cut-offs vary across transplant centers, but in all cases, the same standards must be held for all patients to ensure equity.

Modifiable risk factors are where decisions are more likely to be influenced by implicit biases and where the greyest zones exist. When patients are asked to identify social support systems do we consider a group of church members who agree to care for the patient in a rotating fashion adequate support or does a family member or partner need to be identified? What about patients with insurance but limited finances to the extent co-payments are unaffordable? Do we expect patients to fundraise or does the transplant institution assist in some costs for a prespecified number of patients each year? Do we expand insurance coverage? What about undocumented patients, patients without insurance, and patients in prison? What about patients with substance use disorders? Are we morally obligated to assist them to ensure future transplant candidacy? Modifiable is where things get murky.

We wanted to examine the percentage of Black patients who received heart transplants in the highest volume transplant centers in the United States relative to the demographics of the cities where these transplant centers reside; we looked at 2019 data for sake of completeness (Table 1). We recognize this is merely a snapshot in the history of transplant programs from a bird’s eye view, that cities may have multiple transplant centers, Black patients may prefer certain centers, and finally, the city demographics are from 7/1/2019 and may differ if we had year’s end demographics. HF is more prevalent and is associated with higher mortality and morbidity in Black individuals than in white individuals2 and once it has developed, Black patients have more events and worse health status compared to white patients. As such, the proportion of Black patients transplanted at each center should in theory at the very least match demographics of the city where the transplant center is located, but without granular data, we cannot be certain.

What we are certain of is the need for improving the care Black patients with HF receive. The first and most important is earning trust amongst Black communities and reestablishing the doctor-patient relationship through community engagement. This will allow us to inform Black communities about the transplant process and when a transplant should be considered and what to expect. We must develop GDMT optimization programs in Black communities to reduce morbidity and mortality, identify patients who need device therapies, and identify those who do not improve and require evaluation for transplant earlier since Black patients are sicker when listed and more likely to die waiting with longer wait times.3 Additionally, transplant centers should be tasked to develop outreach programs to Black, Hispanic, minoritized, and marginalized communities and perform a prespecified number of transplants in patients who lack financial means based on transplant center volume. Implicit bias and antiracist training for all team members involved in transplant selection must be required and transplant selection teams must be diversified by concerted efforts in hiring diverse faculty but also improving the diversity of the pipeline. And for modifiable factors, rigorous efforts such as substance treatment programs and involvement of weight loss clinics must be attempted consistently with our moral obligation to assist patients in becoming eligible for transplant.

Heart transplant is one of the most incredible things in medicine, we must ensure it is accessible to all by dismantling the oppressive systems in place that have made access to organs inequitable. Black Lives Matter in Heart Transplant Too.

References

  1. Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Yee RH, Knapp SM, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E and Sweitzer NK. Association of Gender and Race With Allocation of Advanced Heart Failure Therapies. JAMA Network Open. 2020;3:e2011044-e2011044.
  2. Sharma A, Colvin-Adams M and Yancy CW. Heart failure in African Americans: Disparities can be overcome. Cleveland Clinic Journal of Medicine. 2014;81:301-311.
  3. Lala A, Ferket BS, Rowland J, Pagani FD, Gelijns AC, Moskowitz AJ, Horowitz CR, Pinney SP, Bagiella E and Mancini DM. Abstract 17340: Disparities in Wait Times for Heart Transplant by Racial and Ethnic Minorities. Circulation. 2018;138:A17340-A17340.
  4. United States Census Bureau https://www.census.gov/quickfacts/fact/table/US/PST045219 accessed 12/20/2020.
  5. United Network for Organ Sharing https://optn.transplant.hrsa.gov/data/view-data-reports/center-data/ accessed 12/20/2020.

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

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Art in Science

In 2020, my resolution/quarantine hobby was learning how to draw and paint. The year before, I had to make a figure for a review paper, but I was paralyzed for weeks because I didn’t know what to make, and I thought I was bad at drawing. Determined not to let that happen again, I started figure drawing and soon delved into the intricacies of portraying plants and animals in watercolor. It reminded me of the botany class I took in college where every week we trekked through the Illinois forest and made anatomically accurate sketches of the plants we saw.

Art and science have always gone hand in hand. Leonardo da Vinci was skilled in dissection and was one of the first to create detailed drawings of the human heart and describe coronary artery disease. Current science and medical illustrators use a mix of photorealism, illustrative diagrams, and data visualizations as teaching tools. Other times, art is used to tell a story or promote the public interest, as Ashley Cecil did during her time as artist-in-residence at the Carnegie Museum of Natural History and the Richards-Zawacki lab at the University of Pittsburgh.

Illustrations have been essential during the COVID-19 pandemic, starting with the spiky blob that has been the face of the virus. Everywhere we go, there are images of proper mask-wearing, hand-washing, social distancing, COVID-19 symptoms to watch for, nasal swab testing procedures, and now, vaccination information. Data visualizations (less artsy) such as the Johns Hopkins COVID-19 dashboard have also helped us to keep track of infection trends.

CDC/ Alissa Eckert, MSMI; Dan Higgins, MAMS

Although text and graphs get the point across, there are many opportunities for scientists and physicians to incorporate illustrations:

  • When you want to grab or keep people’s attention. Even simple graphics can add humor and visual interest.
  • When talking to people outside of your field. People may not know the same jargon that you do, it can be easier to convey information with images.
  • For complex ideas, pathways, and processes that are difficult to digest with long, dense paragraphs. Graphical abstracts are also becoming a more popular way to summarize papers.
  • When photographs are too detailed or not possible to take. Anything from a simple sketch to a full color drawing can fill the void.
  • For emphasis. Some points may need to be repeated in different formats.

For future papers and presentations, I’ll be less hesitant to incorporate illustrations of my own. Even if you don’t consider yourself an artist, images and illustrations are freely available from sites such as Smart Servier Medical Art or the CDC’s Public Health Image Library. Or make drawing your newest hobby, too, to gain a greater understanding of your work and the world around you.

“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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February: Black History and American Heart Month

The month of February celebrates Black history and cardiovascular disease – both of which offer unique opportunities. Black History Month celebrates the contributions of African Americans while American Heart Month provides opportunities to highlight the burden of cardiovascular disease. This is no way an exhaustive list, but who have contributed to the history of medicine.

James Derham (or perhaps it was Durham) is believed to be the first Black person to officially practice medicine in the U.S and without a medical degree. It is believed he learned by way of apprenticeships which was a major form of passing skills to those who didn’t (or couldn’t) attend university. He was born a slave and worked for many doctors. He was able to buy his freedom and continue to practice, but by the early 1800s, James disappears from history. Some say he was murdered and others believe he left Philadelphia to practice medicine elsewhere.

 

Vivien Theodore Thomas was born in New Iberia, Louisiana and attending high school in Nashville in the 1920s. Vivien always wanted to be a doctor but due to the Great Depression he was forced to work instead. He eventually, became an assistant to surgeon Alfred Blalcok – most noted for his work in shock and Tetralogy of Fallot. Their hard work (along with Dr. Helen Taussig) created the Blalock-Thomas-Taussig Shunt, an operation that ushered in the modern era of cardiac surgery. In 1976, Vivien was awarded an honorary doctorate and named an instructor for surgery at Johns Hopkins School of Medicine. A great movie I saw about Vivien was Something the Lord Made and highly recommend it.

 

Rebecca Lee Crumpler was an American nurse, physician, and later turned author. She is believed to be the first African American woman to become a doctor of medicine in the U.S, studying at New England Female Medical College. In 1883, she wrote Book of Medical Discourses dedicated to maternal and pediatric medical care. It was the first publications written by an African American about medicine. After the Civil War, she continued to treat women and children in Virgina. She also worked for the Freedmen’s Bureau to provide medical care for freed slaves.

 

Edith Mae Irby was inspired to become a physician after unfortunately seeing her sister pass from typhoid fever. At a young age, she saw health care disparities first hand and believed her sister passed prematurely due to lack of care because her family was poor. This sparked a fire for Edith to become a physician that found her reward in service not wealth. Edith was the first African-American student admitted to the University of Arkansas Medical School in 1948 and believed to be the first black student enrolled in any all-white medical school in the South. This comes 6 years before the Supreme Court’s decision on Brown v Board of Education.

In the words of poet laureate Amanda Gorman in the poem titled “The Hill We Climb” she states “we will not march back to what was, but move to what shall be.” This exemplifies both Black History and American Heart Month. Knowing where we came from helps us better see where we are going and I look forward to see where we go.

 

“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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So You Want To Apply To Cardiology Fellowship: Tips From the 2020 Application Cycle

The fellowship match process for Cardiology, an increasingly saturated subspecialty with an ever-expanding applicant pool, is extremely competitive. However, the 2020 application cycle proved to be an entirely different beast, with the COVID-19 pandemic and the inability to interview in-person adding layers of complexity to an already confusing process.

Applicants and fellowship program directors alike wrung their hands over the impersonal nature of Zoom interviews (how could you really feel the “vibe” of a place from a Zoom?). Sure, costs decreased because programs were not “wining and dining” applicants and applicants did not have to travel while working full-time. But this democratization of the application process had the adverse effect of leading many applicants to apply to many more programs. Cardiology program directors were overwhelmed by record numbers of applications. Concurrently, applicants were distressed about not receiving interview invitations. It was tough.

As someone that just matched into Cardiology, I would like to offer some unsolicited advice for future fellowship applicants:

DO be judicious in how you build your Cardiology resume

Fellowship applicants are told that they need to join projects or produce manuscripts to “show interest” in Cardiology. While it is important that you explore Cardiology outside of your clinical rotations, it is also important to choose quality over quantity and not over-commit to projects for the sole purpose of buffing your resume. For each possible project or extracurricular activity, be a little bit selfish and ask yourself, what will I get out of this experience? Will you acquire new skills? Will you gain valuable new insight or knowledge? Will you build relationships with great mentors? How will that project fit into your personal narrative or your career interests within Cardiology? Your time is precious. Spend it developing meaningful, in-depth experiences that help you grow as a future cardiologist, not just checking off boxes.

DO give yourself time to make your personal statement about YOU

Writing is hard. I love writing, but I find it uniquely painful and time-consuming. My first drafts are awful; I go through countless edits before landing on a final product that I can tolerate. Writing personal statements is EXTRA hard because we are bad at writing about ourselves and framing our lives and career goals into a short, neat narrative. Instead, we resort to narratives about patients (nice, but says nothing about who YOU are) or generic maxims (ditto). Your personal statement needs to be PERSONAL. It should be about YOU, the journey you took to get to where you are today, and the journey you hope to embark on next. What MUST the reader absolutely know about you by the time they get to the end of the essay? Does a sentence or paragraph reveal anything about you or does it serve a purpose in telling your story? If the answer to either of these questions is “No,” cut that sentence/paragraph out. Be brutal. Lastly, find out who in your life is a good editor and ask them for lots of feedback.

DO be realistic / DON’T take away opportunities from other people

Some applicants are overly confident and do not apply to enough programs. Some apply to way too many, ultimately interviewing at programs in which they are not truly interested, thus shutting out other applicants who would have loved to interview at those programs. How do I know if I am a competitive applicant? How many applications is too many?, you might ask. The only way to know is to make a list of programs to which you’d like to apply and show it to trusted advisors (e.g. your program director). Solicit their honest feedback so that you can make an informed decision about what you need to do to be able to match.

DO research the institutions to which you apply and interview

There are many great Cardiology fellowship programs. There are no “best” programs. The best program for you is one that aligns with your career goals. Different programs have different flavors, strengths, and weaknesses. While interviewing, I realized that some programs were a great fit for me and my specific interests, while other, equally amazing programs were not. The only way to figure out whether a program might be well-tailored to your interests is to research programs before you apply (search online, talk to people that know the program), research them again before your interview, and ask lots of questions during your interview day. If you know before you even apply that a program would not be a good fit for you, why apply there?

DO pre-plan your Zoom interview space

Are you the kind of person that goes with the flow? Or do you get anxious and feel the need to exert control over your surroundings? If you are the former, then great! If you are more high-strung, however, plan your Zoom space out in advance so that there are no unpleasant surprises on Game Day. Where are you going to place the camera? Does your laptop need to be propped up so that the camera is in line with your eyesight? Do you need additional lighting so that others can see you well? Is there too much noise from your surrounding milieu? Does your location have a reliable internet connection? Do you wish to display anything behind you while you are on Zoom? Note that anything you display on screen [e.g. books, artwork] is an open invitation for the interviewer to ask you questions about said item.

DO talk to acquaintances at fellowship programs

Now that interviews are on Zoom, it is as important as ever to talk to current Cardiology fellows and solicit their honest opinions about programs. I found talking one-on-one with people I knew at various fellowship programs to be more helpful in giving me a sense of that program’s “vibe” than just about anything else I heard on interview day. Ask to talk one-on-one with a fellow at every program with which you interview (i.e. someone who attended your medical school or residency, who is from a similar area or who has something in common with you). After these conversations, I felt more confident that I knew what I needed to know in order to make informed decisions about where to place programs on my rank list.

DO think about your “5-10 year plan” and career goals

We all dread the interview question about our “5-10 year plan.” However, rest assured that you will be asked about it at virtually every interview. The fellowship is the final training ground before you launch into your career. Because many people often stay at their institution after fellowship, your fellowship interview in some ways doubles as a faculty interview. The program will view you as a long-term investment and they want to know what you would bring to the department. With that in mind, think about your narrative. How will you “package” yourself? Sure, everyone knows that things might change in the future, but as things stand right now, what niche will you carve out for yourself if you become faculty in the department after fellowship? You should be ready to answer these questions.

DON’T be afraid to preserve your spirit

Interviewing can be fun, but it can also be stressful when paired with an 80-hour-per-week job. Find ways to decompress before, after, or during your interview day. Exercise as needed, spend time with family, debrief with friends, take breaks. For self-care, on Zoom interview days, I would select a 30-60 minute window when I was not on camera and leave my apartment to grab a coffee (yes, I went to the coffee shop in a suit!). It broke up my day, reenergized me, and made me feel like I was at a real in-person interview.

DO be yourself
You should always be professional and courteous to others. However, that does not mean that you need to be a robot! Do not be afraid to let your personality shine. You will have more interesting interactions with others and you will come across as more relatable. More importantly, depending on how the people on the other side of the screen respond, it may help you decide if a program is the right fit for you. Never be anyone other than yourself. You deserve to be at a program that will welcome you for who you are.

 

“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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Update on ACC/AHA Valvular Heart Disease Guidelines 2020: Deep Dive into Aortic Stenosis Treatment Options

“2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease” was co-published in the Circulation and in the Journal of the American College of Cardiology on December 17th, 2020. In this article, I will provide the recommendations and updates from these guidelines particularly the new changes compared to the older valvular disease guideline statement from 2014 and a focused update from 2017 as it pertains to aortic stenosis. In developing these recommendations, the writing committee used the available research through March 1st, 2020. Given the explosion of trials and studies in aortic stenosis (AS) management, the guidelines serve as a one-stop-shop for clinicians to dive deep for some guidance while taking care of patients with AS.

Aortic valve Recommendations:

The major change from the previous guidelines is that for symptomatic patients with severe AS who are >80 years of age or for younger patients with a life expectancy <10 years, TAVI (transcatheter aortic valve implantation) is recommended (Class 1) while for symptomatic patients with severe AS between age 65-80 with no anatomic contraindication to transfemoral TAVI, shared decision-making is emphasized, and the recommendation is either SAVR (surgical aortic valve replacement) or TAVI (Class 1).  Timing of aortic stenosis treatment is still largely decided by symptoms; however, asymptomatic patients with severe AS and low EF <50% are considered Class 1 for treatment. Similarly asymptomatic patients with severe AS and decreased exercise tolerance, or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise, or very severe AS (V2 ≥5 m/s), a BNP level  >3 times normal, or serial testing shows an increase in V2 ≥0.3 m/s per year are a Class 2 indication for valve replacement. The guidelines note the evidence from low-risk PARTNER 3 and Evolut trials.

Class 1 indication for SAVR
Class 1/A: Symptomatic severe AS
Class 1/B-NR: Symptomatic low flow low gradient severe AS with reduced LV EF (left ventricular ejection fraction)
Class 1/B-NR: Symptomatic low flow low gradient severe AS with normal EF when AS is the cause of the symptoms.
Class 1/B-NR: Asymptomatic severe AS and an LVEF <50%
Class1/B-NR: Asymptomatic going for other cardiac surgery
Class 1 for  SAVR or TAVI
Class 1/A: Symptomatic severe AS patients 65 to 80 with no contraindication to TAVI either SAVR or TAVI
Class 1 for TAVI (transcatheter aortic valve implantation)
Class 1/A: Symptomatic severe AS patients >80 or for younger patients with a life expectancy <10 years, TAVI recommended
Class 1/B-NR Asymptomatic patients with age >80 years with severe AS and an LVEF<50

 

The guidelines put much emphasis on “shared decision making with the patient” taking into account the patient’s values and preferences and include the discussion of the risk of anticoagulation therapy and the potential need for and risk associated with aortic valve interventions. Another point to note from the guidelines is that the differences in the treatment approaches are driven by the overall risk of the patient. Risk assessment involves but is not limited to the STS(Society of Thoracic Surgeons) score. Per the new guidelines, low risk is defined by an STS score of <3%. A risk assessment also includes the determination of frailty, cardiac and other system compromises, and procedure-specific impediments. These are nicely outlined in the guidelines, and in my opinion, every general cardiologist should dive deep into these risk assessment tools to determine the risk associated with aortic valve procedural treatment accurately for an individual patient. Table 9 in the guidelines includes examples of procedure-specific risk factors for interventions not incorporated into existing risk scores. As the options for the treatment of aortic valve heart disease has broadened, the value of the multidisciplinary heart valve team and heart valve centers has become apparent and this is clearly recognized in the guidelines. Primary and comprehensive heart valve centers are defined by the expertise and treatment options offered in the management of patients with valvular heart disease.

Another point to note is that asymptomatic severe AS category, SAVR versus TAVI options are only available for patients with severe AS and low EF <50%. For other factors that indirectly identify LV decompensation or faster progression of AS like decreased exercise tolerance or a fall in systolic blood pressure of ≥10 mmHg from baseline to peak exercise or a BNP level i>3 times normal or serial testing shows an increase in V2 ≥0.3 m/s per year, SAVR is recommended in preference to TAVI.  As the level of evidence builds up for role of TAVI in an asymptomatic category, it has the potential to be truly be a game changer treatment option for AS patients.

References:

Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP 3rd, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O’Gara PT, Rigolin VH, Sundt TM 3rd, Thompson A, Toly C. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published online ahead of print December 17, 2020]. Circulation. doi: 10.1161/CIR.0000000000000923

“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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Conquering the K99 (Part 1)

Greetings postdocs! I wanted to share my experience with postdoc fellowships and grants for this month’s blog. As a postdoctoral researcher, I applied to over 15 grants and fellowships. Getting funding as a postdoc is difficult, and I did not receive most of the grants I applied to. However, my research proposal improved with each subsequent application, and I eventually found success first with an American Heart Association Postdoctoral Fellowship (thanks AHA!) and later with a K99 Pathway to Independence Award. Over the past two years, I have been a grant-writing coach and in the next few blogs wanted to share the many things I learned about applying for NIH funding.

What is the K99/R00?
The K99/R00 Pathway to Independence Award is an NIH career development award that supports up to five years of research. The five years consist of up to 2 years of mentored postdoctoral training (K99) and 3 years of independent support that funds your brand-new laboratory (R00).

Who is eligible to apply?
Unlike most NIH grants, both US citizens and non-US citizens (with a research or clinical doctoral degree) are encouraged to apply! Typically postdocs have four years (after degree conferral) to apply for a K99. However, postdocs can request extensions for numerous reasons, including medical issues, disability, family care responsibilities, and natural disasters. Recently, the NIH released two new notices that allow postdocs to apply for a one-year extension for childbirth (NOT-OD-20-011) and a two-receipt cycle extension for disruptions due to the COVID-19 pandemic (NOT-OD-20-158).

Should I apply? 

If you are eligible and have any inkling that you want to pursue a career in academics, then go for it! In my experience, postdocs often build a wall of concerns that delay their application process. Let me address a few of the most common concerns I have heard here:

  1. “I don’t have a chance at getting a K99 because I do not have a first-author postdoc publication yet.” You don’t have any chance of receiving a K99 if you never apply. While it is true that having multiple publications will likely strengthen your application and that some reviewers are overly critical of a lack of publications, I have met postdocs that received a K99 without a first-author publication. Do not disqualify yourself! It is better to apply without a first-author publication and address this issue in your resubmission instead of applying late and not giving yourself sufficient time to reapply.        
  2. “I don’t have enough preliminary data to write a K99.”
    The K99/R00 is unique in that it is a transition grant. The research you propose to do for your K99 must have a substantial training component that will elevate your science-self. Thus, while the science is important, the NIH is looking to fund people, not projects. The preliminary data’s sole purpose is to convince the reviewers that your project is feasible. Instead of worrying about gathering more preliminary data, refocus this energy towards building a strong team (aka. your scientific committee) that will function as the foundation of your training plan.
  3. “NIH success rates are low. I don’t think I’ll get it, and it’s not worth trying.”

Compared to other grants and fellowships, the K99 success rate is relatively high (~24% in 2019, with significant variability depending on the institute). Admittedly, preparing a K99 does take a lot of time. However, there are many benefits, even if you don’t get the award. First, it’s an excellent exercise in thinking deeply about your research. Second, it’s great practice for writing NIH grants. Lastly, in organizing your scientific committee, you have the potential to gain additional mentors and build real collaborations that can help you and your research succeed.

In my next blog, I will cover how to get started writing a K99, 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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Equity & Inclusion in Medicine – Part II: Inclusion in Cardiology

In Part 1, I shared common experiences between myself and other BIPOC physicians in medicine and cardiology. In this piece, I will dive into the importance of why increasing diversity and inclusion in cardiology is so urgent. Cardiology is a coveted specialty and can incentivize a power dynamic that does not often include BIPOC. I would argue that for a progressive program, creating an inclusive workforce will help programs progress, be innovative, and positively impact patient care in the community. This change will be a win-win for all.

When reflecting on this topic, I am reminded of an African American woman who was crying on the cath table the other day, with a look of fear and helplessness. This was not long after a report of a physician of color, who was infected with COVID19, reported that her symptoms were dismissed, and later died. If a physician feels unheard, how can a woman of color who is not a physician feel safe? The cath team did a great job of comforting her, but it was hurtful to see her in such fear.

African Americans are significantly affected by heart disease risk factors; in fact, together these conditions contributed to >2.0 million years of life lost in the African American population between 1999 and 20101, with heart disease being the leading cause of mortality in African Americans. Unfortunately, there is a lack of African Americans in the physician workforce considering African Americans make up ~ 13% of the U.S population, but only 4% of U.S. doctors2. According to the Harvard Business Review, increasing the numbers may improve health outcomes. They described a study in Oakland that assigned African American male patients recruited from barbershops to African American and Non-African American physicians. What they found was that African American patients were more inclined to agree to more invasive and preventative services than those with non-African American doctors. This is not an argument for a segregated system, but certainly increasing the numbers and learning from colleagues can help BIPOC patient outcomes.

One historical change in medicine that impacts care in the African American community is likely rooted in the Abraham Flexner Report3. An African American medical student applying to medical school in 1900 had 10 choices which declined to approximately a quarter of that by 1920. The Flexner Report, which was meant to trim the medical workforce to only those with the greatest quality of training, decided that only two medical schools that trained African Americans (Howard University and Meharry Medical College) were worthy of staying open. His devastating comments terminated the rest4. My cousin, Dr. Hubert Eaton, wrote about this dilemma in his book Every Man Should Try5. He graduated from the University of Michigan School Medical School in 1942 and his father went to Leonard Medical School (see Table 14). He found his father’s exam scores and noted they matched his own. He was perplexed that Leonard was shut down and he wondered:  Who validated the Flexner report? Why was one individual able to create this modernity in medicine without any scrutiny?

By building diversity and increasing contact between those who have shared experiences, the field of cardiology could improve BIPOC patient trust and compliance as well as reduce cardiovascular disease outcomes. This change could lead to lower hospital admissions and increase prevention efforts. Many BIPOC is inspired by giving back to the community and being involved in community engagement. This community service is via BIPOC oriented organizations (e.g., The Divine 9 fraternity and sororities, the Boule, The Links, Incorporated, etc.) as well as the Black Churches.  As BIPOC cardiologists, we have the ability to teach important primary prevention to thousands of people and the message is stronger if that provider looks like the community they represent.

Cardiology is a prestigious field and as such should aim to set an example for leadership across the country. We know that inequities exist in all aspects of cardiovascular disease and one way to combat this issue is to build a diverse workforce. When we lost community physicians after the Flexner report, we lost the community itself; the field of cardiology has the resources to restore this relationship and improve heart disease outcomes.

References:

  1. Carnethon et al. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation 2017: 136(21)
  2. Research: Having a Black Doctor Led Black Men to Receive More-Effective Care by Nicole Torres. Harvard Business Review 2018
  3. Flexner A. Medical Education in the United States and Canada. Washington, DC: Science and Health Publications, Inc.; 1910.
  4. Savitt. Abraham Flexner and the Black Medical Schools.  Journal of the National Medical Association. 2006: 98 (9)
  5. Every Man Should Try by Dr. Hubert Eaton

 

“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.”