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A Fellows to a Fellow: resources for cardiology fellows

The excitement continues as 3rd year general cardiology fellows wrap up their training in these last few months. Those pursuing advanced training in interventional cardiology find themselves at a crossroads as they begin a year of procedural training. Being one of those lucky fellows, I recently began searching for resources to help me get started with the transition. This list is definitely not exhaustive, but I hope you find it helpful for those going down this pathway.

Here are my go-to resources to help me get started in interventional cardiology training.

  • CRF (Cardiovascular Research Foundation) Fellows Course Connect
    – This year, it will be presented in a virtual live-streamed format from May 7th-9th. One of the go-to courses every year that features key concepts in interventional cardiovascular medicine. Yes, it’s free for fellows.
    https://www.crf.org/fellows/register
  • ARCH (Advanced Revascularization) Course – Hybrid
    – Takes place both online and with limited in-person registration in St. Louis Missouri at the Ritz-Carlton Hotel. Has a dedicated Fellows course on Wednesday, April 14th, with the goal to prepare cardiology fellows for interventional practice. (Full scholarship included with registration)
    https://archsymposium.com/april-2021-fellows-course/
  • SCAI 2021 (Virtual) Scientific Sessions
    Can’t miss the scientific sessions from SCAI, it’ll be loaded with tons of educational content geared towards interventional cardiology. Dr. Quinn Capers is scheduled as a Keynote speaker discussing “Black Lives Matter….In the Cath Lab, Too! A Role for Interventional Cardiology in Combating Racism”
    https://scai.org/scai2021
  • SCAI Fall Fellows Course
    Tentatively scheduled for Dec 3-7th in Miami, Florida. Always considered one of the best interventional fellow courses to attend. Looking forward to this happening.
    https://scai.org/event/2021-fall-fellows-courses
  • Interventional, Early Career, & FIT Monthly Case Discussions: High Risk and Complex PCI and Mechanical Circulatory Support
    https://www.acc.org/Education-and-Meetings/Meetings/Meeting-Items/2021/02/18/19/44/Webinar-Int-EC-FIT-Monthly-Cath-Case-Discussions-High-Risk-PCI
  • CRT 2021 Virtual
    From Feb 13 – April 24, 2021, every Saturday Morning. From live-stream discussions with the latest in interventional cardiology to live cases. Free registration is a plus.
    http://www.crtmeeting.org
  • Emmanouil Brilakis’ youtube channel. The Manual of PCI (A Step-by-step approach) https://www.youtube.com/watch?v=ELu-yJ7USOU&list=PLrg6KBVL0GBqabghGLCgqbplSrGQEiHh4
    Probably one of the most important youtube channels for all interventional cardiology trainees. If you haven’t started watching these videos, you’re missing out. The accompanying textbook (https://www.pcimanual.org/) is also a must-have.

Now there are also plenty more resources out there, but I felt that this was a good starting place for me. Hopefully, it helps someone.

 

“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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Coronary Allograft Vasculopathy – The Achilles’ Heel of Heart Transplant

As a 3rd year medical student in the coronary care unit (CCU), I helped care for a patient whose story I will never forget. She had developed advanced heart failure due to peripartum cardiomyopathy in her 20s giving birth to her only child and required a heart transplant. She did well for a number of years, but I met her in her 30s when she was admitted post-MI in cardiogenic shock. Her coronary atherosclerosis was due to severe coronary allograft vasculopathy (CAV), an aggressive form of CAD transplant patients may develop. She got a LAD stent and was supported with a balloon pump but was tenuous at best. Some days after her PCI, in a moment seared into my memory, she let out an ear-piercing yell and suddenly arrested and died, her daughter at the bedside. I’ll always remember the pain on her child’s face when she passed, and I will always have a sincere appreciation for the misery CAV can cause. This blog is meant to provide some historical context to heart transplantation and the issue of CAV, as well as to discuss ways we can prevent it.

Since the first heart transplant in Cape Town, South Africa, there have been tremendous advances in cardiac transplantation with median survival now around 12 years. It didn’t always appear that this would be the case, with mortality so high in the early days that many felt heart transplant wasn’t worth it. The advent of calcineurin inhibitors with cyclosporine in the 1980s and tacrolimus in the 1990s were key (Figure 1). Steady improvements in infection prophylaxis, screening for and treating rejection, and surgical technique and expertise further helped the cause.

But as we addressed one set of problems, we found another. CAV is an aggressive form of coronary artery disease (CAD) present in 30% of heart transplant recipients at 5 years and 50% at 10 years. Those with it have worse survival. It shares some risk factors with classic CAD but has several of its own, and there are key pathophysiologic differences (Figures 2 and 3). Our patient was unique in that she had a true plaque rupture MI, typically occurring less often with CAV relative to classic CAD, but this may have been related to a donor transmitted lesion acting more as typical CAD would.

Figure 2. Pathophysiologic Differences

Figure 3. Risk Factors

So how do we prevent CAV? Our best data comes from statin trials in the 1990s-2000s (pravastatin, simvastatin, and atorvastatin studied), showing lower rates of rejection and CAV with improved survival in transplant patients treated with statins. This makes intuitive sense, as dyslipidemia is a rock-solid risk factor for classic CAD and nearly universally seen post solid organ transplantation due to the metabolic consequences of common immunosuppressives. These immunosuppressives, while life-saving in their own right, also lead to worsening glucose control, hypertension, obesity, and kidney disease. Addressing each of these while encouraging a heart-healthy diet and routine exercise is of paramount importance in keeping our transplant patients healthy. Finally, a reminder that there are many drug-drug interactions with transplant medications. Figure 4 is adapted from Warden et al and shows the relative degree of interactions between immunosuppressives and common lipid-lowering drugs.

Figure 4. Drug-Drug Interactions

While this story was tragic for the patient and her family, it’s given me a profound respect for CAV that I will carry forward when I eventually care for heart transplant patients in my career.  Below are the references for this article from which parts of the figures were taken. Each of these is a fantastic resource for further learning.

References:

  1. Stehlik, J., et al. (2018). “Honoring 50 Years of Clinical Heart Transplantation in Circulation: In-Depth State-of-the-Art Review.” Circulation 137(1): 71-87.
  2. Warden, B. A. and P. B. Duell (2019). “Management of dyslipidemia in adult solid organ transplant recipients.” J Clin Lipidol 13(2): 231-245.
  3. Costanzo, M. R., et al. (2010). “The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients.” J Heart Lung Transplant 29(8): 914-956.

 

 

 

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Equity & Inclusion in Medicine – Part III: How to Create a Diverse Cardiology Workforce

In Part I, I discussed experiences of BIPOC in medicine as well as those underrepresented in cardiology as a framework to build understanding. In Part II, I made a good case for why diversity will help cultivate innovation and improve health disparities. In the final part of this blog series, I will review how cardiology programs can improve diversity.

We are in an era of great reflection and growth as we endure the extreme pressures of the COVID19 pandemic. This horrendous experience has fostered some positivity which is the strong motivation towards racial harmony and equity. This is a special time of modernity and we can capitalize on this momentum by amplifying initiatives towards increasing diversity in cardiology.

The Duke cardiology group published a data-driven manual on how cardiology fellowships can improve diversity, especially for those who are underrepresented. In this article, Rymer et al. 1 designed a quality improvement study from 2017-2019 with the aim of increasing the numbers of underrepresented cardiology fellows in their training program. This initiative included reorganizing the fellowship recruitment committee, changing the applicant process and interview day, as well as making changes to the applicant ranking process. Finally, there was a postmatch intervention. This involved developing a diversity and inclusion task force to spearhead these initiatives. Comparing applicants 10 years before and during the intervention period, there was a significant increase in women and underrepresented applicants. Women increased from a 5-year mean of 27% to 54.2% after the intervention and underrepresented fellows increased from 5.6% to 33.3%. After the intervention, the fellowship population was 2/3rds either women or members from an underrepresented ethnic group!

Williams et al. further pushed toward cultivating an antiracist cardiology culture in their article entitled: How to Build an Antiracist Cardiovascular Culture, Community, and Profession 2. The authors took a deep dive into several ways to build a diverse team. They state that to purposely create a culture of diversity, especially for those that lack diversity; programs should aim to share their objectives in creating a less biased training program for applicants. This strategy also includes having a diversity and inclusion committee to evaluate promotional materials to ensure they do not include racially biased language. Once trainees are there, they recommend continuing this initiative by having structured teaching sessions that include implicit bias training. They further recommend allowing for space for underrepresented trainees to share microaggressions. One example of a microaggression expressed by underrepresented physicians is constant questioning regarding country of origin or ability to speak English with a condescending tone. These stories can be shared on a personal level to help each other understand and appreciate different experiences.

There are professional ways to support trainees and create an inclusive environment. The authors suggest encouraging respect by introducing fellows as “Dr.” and leaders of the team. They emphasize intentional mentorship for underrepresented trainees shared amongst faculty. They further warn against perpetuating the “minority tax”, which puts the entire onus of diversity and inclusion on faculty of color with often a lack of compensation. In addition, the authors encourage all faculty to help introduce trainees into a network and provide a platform for successful promotion by nominating under-represented minority members to appropriate positions. Certainly, this can extend beyond fellowship. It goes without saying, that nomination and promotion is suggested for those who earn it; however, not uncommonly underrepresented fellows meet this criterion and may be overlooked.

The future of this country is one in which there may not be a majority. It is important that we understand one another and work together to move forward. Diversifying cardiology will bring about innovation and growth in the field. The patient experience can improve as well with more physicians who share their personal experiences. This can build communication and preventative measures. I hope that we continue this momentum and cultivate a better experience for all.

References:

  1. Rymer et al. Evaluation of Women and Underrepresented Racial and Ehnic Group Representation in a General Cardiology Fellowship After a Systematic Recruitment Initiative. JAMA Netw Open. 2021; 4(1)
  2. Williams et al. How to Build an Antiracist Cardiovascular Culture, Community, and Profession. JACC 2021 77 (9)

“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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Alcohol Consumption and Cardiovascular Disease: How much is too much?

Most enjoy sipping on a glass of wine, a beer, or cocktail from time to time on their own, or with a group of others. And in more of these occasions than not, the individual determines how much he or she could or could drink given future plans (e.g. driving a vehicle).

But, why don’t people consider the impact a drink of alcohol consumption could have on their health more?

This is likely because of the recommendations of drinking alcohol in moderation. Alcohol has been shown to have protective effects regarding how we use our fats in our blood (3). There is even data that shows a reduction in the incidence of heart attacks related to alcohol consumption (4).

In 2019, about 26%  of people ages 18 and older (29.7 percent of men in this age group and 22.2 percent of women in this age group) reported that they engaged in binge drinking in the past month (1). Binge drinking is 5 or more drinks for men and 4 or more drinks for women in about 2 hours (2). The Dietary Guidelines of 2020-2025 define Alcoholic beverages as the following:

“Adults of legal drinking age can choose not to drink, or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more.”

It is important to define what one alcoholic drink equivalent. About 14 grams (0.6 fl oz) of pure alcohol is one drink, 12 fluid ounces of regular beer (5% alcohol), 5 fluid ounces of wine (12% alcohol), or 1.5 fluid ounces of 80 proof distilled spirits (40% alcohol) (2).

Benefits of Alcohol Consumption Source: https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials

Most importantly, what is a moderate amount of alcohol consumption?

A moderate amount is 2 drinks of less a day for men and 1 drink of less a day for women. Okay, what if we drink alcohol above the defined moderation?

Well, the National Institute on Alcohol Abuse and Alcoholism reported that people who drank alcohol two times the gender-specific binge drinking thresholds were 70 times more likely to have an alcohol-related visit to the emergency department. Furthermore, those who consumed alcohol at three times the gender-specific binge thresholds were 93 times more likely to have an emergency department visit.

Perception of a lot and little:

How good are we in determining moderation? In a 2015, a cross-sectionally analysis from the eHeart Health Study dataset had participants answer the following questions (5):

Source: https://www.sciencedirect.com/science/article/pii/S0002914915013533?casa_token=6RqulqCY-doAAAAA:mQDOG8ZbJEp_w4WXk4v7p4cDLT3R3LT8lIzAMQBrUxLx0giLTI0g67EhdTXksWvsLCNAsQ6d

Do you believe alcohol is good for your heart?” – “Yes,”“No,”or“I don’t know.”

You believe alcohol is good for your heart because?” –“ Your doctor told you,” “You learned this in school,” “You learned from reading lay press,” “You learned this from friends, colleagues, or word of mouth, ”or “Other [free text]. Over 5,000 people answered the questions and approximately 30% felt alcohol consumption was health healthy, 39% felt it was unhealthy and 31% were unsure. The majority of the perceptions were related to information retained from the lay press.

The lay press giving us some health guidance! Shocking, I know.

More importantly, it is important to determine the causal effects we see in observational studies. Those are studies that conclude “x” amount of alcohol is related or associated “y” outcome of health. So researchers design studies termed “Mendelian Randomization”. The study looks at genes known to function to look at modifiable (lifestyle) exposure to disease. Larsson et al. published a Mendelian Randomization study in 2020 that investigated the effect of alcohol consumption on 8 cardiovascular diseases (6). The authors found that high alcohol consumption may be causally associated with an increased risk of stroke and peripheral artery disease. Furthermore, the link may occur through blood pressure changes.

Source: https://www.cvphysiology.com/Hemodynamics/H014

Blood pressure changes are controlled by our nervous system. A recent study from Greenlund et al. investigated the effects of night binge alcohol consumption on sleep, morning-after blood pressure, and muscle sympathetic activity (7).  Twelve men and ten women were included in this randomized cross-over design. The alcohol had a 1:3 ratio of 95% ethanol mixed orange or cranberry juice. Sounds pretty yummy. The alcohol dose was a 1 g/kg dose for men and a 0.85 g/kg dose for women.. The authors utilize the Valsalva maneuver to observe the changes in blood pressure after the night of binge drinking.  The Valsalva maneuver leads to a decrease in heart rate and blood pressure, which then stimulates the sympathetic nervous system and allowing the investigators to examine changes in sympathetic function.

There were increases in resting heart rate the next morning, but blood pressure remained unchanged compared to the fluid control condition. During the Valsalva maneuver, there was a heightened sympathoexcitatory response and a reduced baroreflex response. Furthermore, a night of binge drinking disrupted sleep quality (reduced REM sleep).

Studies that use Mendelian randomization, or have a practical approach of viewing the morning effect effects have significant roles in improving the comprehension of the information received from the lay news. Alcohol consumption is certainly linked with cardiovascular disease. The idea of everything in moderation seems to prevail. However, the amount that is perceived to be a lot person to person varies, making alcohol consumption a known risk to health. People’s perceptions of themselves could change the amount of alcohol consumed in one sitting, which could increase the risk of binge drinking (8).

References

  1. Alcohol Facts and Statistics | National Institute on Alcohol Abuse and Alcoholism (NIAAA) [Internet]. [cited 2021 Mar 14]. Available from: https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-facts-and-statistics
  2. Dietary Guidelines for Americans, 2020-2025 and Online Materials | Dietary Guidelines for Americans [Internet]. [cited 2021 Mar 14]. Available from: https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials
  3. Gaziano JM, Buring JE, Breslow JL, Goldhaber SZ, Rosner B, Vandenburgh M, et al. Moderate Alcohol Intake, Increased Levels of High-Density Lipoprotein and Its Subfractions, and Decreased Risk of Myocardial Infarction. New England Journal of Medicine. 1993;329(25):1829–34.
  4. Camargo Jr. CA, Stampfer MJ, Glynn RJ, Grodstein F, Gaziano JM, Manson JE, et al. Moderate Alcohol Consumption and Risk for Angina Pectoris or Myocardial Infarction in U.S. Male Physicians. Ann Intern Med. 1997 Mar 1;126(5):372–5.
  5. Whitman IR, Pletcher MJ, Vittinghoff E, Imburgia KE, Maguire C, Bettencourt L, et al. Perceptions, Information Sources, and Behavior Regarding Alcohol and Heart Health. The American Journal of Cardiology. 2015 Aug 15;116(4):642–6.
  6. Larsson Susanna C., Burgess Stephen, Mason Amy M., Michaëlsson Karl. Alcohol Consumption and Cardiovascular Disease. Circulation: Genomic and Precision Medicine. 2020 Jun 1;13(3):e002814.
  7. Greenlund IM, Cunningham HA, Tikkanen AL, Bigalke JA, Smoot CA, Durocher JJ, et al. Morning sympathetic activity after evening binge alcohol consumption. Am J Physiol Heart Circ Physiol. 2021 Jan 1;320(1):H305–15.
  8. Cromer JR, Cromer JA, Maruff P, Snyder PJ. Perception of alcohol intoxication shows acute tolerance while executive functions remain impaired. Experimental and Clinical Psychopharmacology. 2010;18(4):329–39.

“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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PFO Closure in PFO-related Stroke

Last week, Gore REDUCE study, a randomized open-label trial with a median duration of follow-up of 5.0 years [4.8 to 5.2] demonstrated that 1.8% of patients with PFO closure had recurrent ischemic strokes (hazard ratio, 0.31; 95% confidence interval, 0.13 to 0.76), compared with 5.4% patients who treated with an antiplatelet-only group (Figure).1 A patent foramen ovale (PFO) is far and away from the most common congenital heart defect with an estimated prevalence of 1 in 4 adults.  The FDA has previously approved the Amplatzer PFO Occluder device in 2016, however initial trials such as the RESPECT, PC, and CLOSER I trials did not show any benefit for PFO closure in the reduction of recurrent embolic stroke, compared to medical therapy. Interestingly, more recent trials conducted within the last 5 years, such as the DEFENSE‐PFO, REDUCE, CLOSE and RESPECT trials, demonstrated that PFO closure had reduced incidence of stroke compared to medical therapy. Given this influx of new evidence from recent trials, it has been suggested that PFO closure be considered in patients 60 years or younger with a PFO-related stroke. However, other potential etiologies such as atrial fibrillation (AF, requires at least 30 days of cardiac monitoring based on recent trials), autoimmune disorders, uncontrolled diabetes or hypertension must first be ruled out.

Last year, the 2020 practice advisory update summary by the American Academy of Neurology suggested that PFO closure probably reduces the risk of stroke recurrence with an HR of 0.41 with acceptable heterogeneity (I2 = 12%) and an absolute risk reduction of 3.4% at 5 years for patients with cryptogenic stroke and presence of a PFO based on meta-analyses using fixed-effect.2 This was unsurprising to me given the trends seen in the RESPECT and CLOSE trials. Interestingly, the report suggested an increased risk of developing AF with RR 3.12 in participants who received closure compared with those receiving medical treatment. This raised an interesting causality dilemma similar to the story of the chicken and the egg. Did these trials capture paroxysmal AF using 30 days of ambulatory monitoring and exclude those with paroxysmal AF prior to PFO closure? If that is the case, what was the primary mechanism for the development of AF after PFO closure? Atrial stunning? If a patient were to develop AF following PFO closure would that increase their risk of recurrent stroke?  And if so, is the risk of recurrent stroke higher or lower with PFO closure compared to those without PFO closure? Indeed, it would be interesting see which echo parameters are independent predictors of developing AF in PFO closure (after adjustment for potential confounders). Moreover, the American Academy of Neurology recommends (level C) that aspirin or anticoagulation may be considered in patients who opt to receive medical therapy alone without PFO closure.2 In fact, the comparison between PFO closure and systemic anticoagulation (e.g., DOAC) to prevent recurrent ischemic stroke remains unknown.

Switching gears, let us look at post-PFO closure management. Again, very limited data currently exists on the optimal duration of DAPT (dual antiplatelet therapy) after PFO closure. RESPECT and CLOSE used DAPT for 1 and 3 months, respectively, while some experts recommend ranges DAPT anywhere from 1 to 6 months. A European position paper on the management of PFO, suggested that following PFO closure patients should be on DAPT for 1-6 months followed by antiplatelet monotherapy for ≥5 years.3

In a nutshell, PFO closure should be considered for patients 60 years or younger with PFO-related stroke patients without the comorbidities of the previously mentioned risk factors.  A multidisciplinary discussion between neurology, geriatrics, and interventional cardiology are key in decision-making regarding PFO management.  Further research should include a randomized controlled trial regarding DAPT duration and the use of DOACs (direct oral anticoagulants) following PFO closure in patients with PFO-related left circulation embolism.

Credit: Figure from the New England Journal of Medicine 2021; 384:970-971

Reference

  1. Kasner SE, Rhodes JF, Andersen G, Iversen HK, Nielsen-Kudsk JE, Settergren M, Sjöstrand C, Roine RO, Hildick-Smith D, Spence JD, Søndergaard L; Gore REDUCE Clinical Study Investigators. Five-Year Outcomes of PFO Closure or Antiplatelet Therapy for Cryptogenic Stroke. N Engl J Med. 2021 Mar 11;384(10):970-971. doi: 10.1056/NEJMc2033779.
  2. Messé SR, Gronseth GS, Kent DM, Kizer JR, Homma S, Rosterman L, Carroll JD, Ishida K, Sangha N, Kasner SE. Practice advisory update summary: Patent foramen ovale and secondary stroke prevention: Report of the Guideline Subcommittee of the American Academy of Neurology. Neurology. 2020 May 19;94(20):876-885. doi: 10.1212/WNL.0000000000009443. Epub 2020 Apr 29.
  3. Pristipino C, Sievert H, D’Ascenzo F, Louis Mas J, Meier B, Scacciatella P, Hildick-Smith D, Gaita F, Toni D, Kyrle P, Thomson J, Derumeaux G, Onorato E, Sibbing D, Germonpré P, Berti S, Chessa M, Bedogni F, Dudek D, Hornung M, Zamorano J; Evidence Synthesis Team; Eapci Scientific Documents and Initiatives Committee; International Experts. European position paper on the management of patients with patent foramen ovale. General approach and left circulation thromboembolism. Eur Heart J. 2019 Oct 7;40(38):3182-3195. doi: 10.1093/eurheartj/ehy649.
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From “Medicare for All” to “Health for All”: Redefining the Who and Where of Care Delivery (Part 2 of 3)

In my last post, I discussed the need for physicians to engage in discussions of meaningful health systems reform in order to help realize the ideal of a healthier society for all Americans. However, innovative solutions addressing the shortcomings of our current care-delivery model designed and tested within the United States are few and far between. Instead, over the next two posts, I describe some of the strategies developed in and for resource-limited settings that may have applicability to the U.S. context.

The current post details two categories of interventions with the potential to provide expanded access to healthcare providers that may be particularly valuable for the provision of preventive cardiac services. Task-shifting interventions, which comprise the first category of this discussion, are defined by the Centers for Disease Control and Prevention as “the process of delegation” of health responsibilities and duties from skilled to less specialized healthcare workers and operate by means of rapid expansion of the healthcare workforce with the inclusion of a new cadre of providers.1 The second category includes mobile health interventions, which range from low-tech appointment reminders to more technologically advanced home cardiac rehabilitation programs and medical counseling curricula. The combined anticipated effect of both groups of interventions is to simultaneously grow the workforce able to provide high-value cardiac care, while also redefining the clinical setting in order to enhance the accessibility of health services. Below, we briefly explore potential applications of both categories of interventions to cardiac care in the U.S., highlighting existing experience with each.

Task-shifting interventions for cardiovascular care:

Although the COVID-19 pandemic exacerbated shortages in the healthcare workforce globally, the problem can be traced back long before the current crisis, with devastating consequences in rural and low-income communities. Assuming no expansion of health services beyond current levels, the American Association of Medical Colleges (AAMC) projects that by 2033 the United States will face a shortage of between 55 and 139 thousand physicians, up from prior years and including both primary care providers and specialists.2 Should universal health coverage become a reality in the coming decade, this gap in providers is likely to balloon as individuals previously excluded from health services attempt to gain access to the system. The solutions proposed to this problem have long focused on increasing the training capacity of the current medical education system and aggressive recruitment of skilled providers from outside the U.S., however, both strategies are costly and may take years—if not longer—to realize gains.

Developed in low- and middle-income countries (LMIC), task-shifting—which incorporates greater numbers of non-physician healthcare workers (NPHW) and minimally trained community healthcare workers into the medical workforce—may provide a pragmatic and low-cost solution to shortages in the U.S, just as it has done in LMIC. Demonstrating potential applications to cardiac care, a 2019 Lancet meta-analysis including task-shifting interventions where community healthcare workers, dietitians, nurses, and pharmacists delivered versions of algorithm-driven hypertension care and lifestyle counseling found that the strategy led to a statistically significant 5-point reduction in systolic blood pressure. Moreover, recent randomized trials in low-income settings have employed non-physician health workers to achieve both blood pressure improvements and reductions in mortality.3-5 Such interventions have effectively implemented short training periods (ranging from 3-7 days in many cases with periodic ‘refresher’ training) combined with clinical decision support tools to guide algorithm-driven care for screening, counseling, and treatment of basic cardiac conditions, all at low cost to the system.6

Yet uptake of such interventions in resource-limited settings within high-income countries such as the U.S. has been minimal. A 2019 JAMA Surgery editorial highlights this contradiction: commending the innovative use of NPHWs and non-surgically trained physicians in performing low-complexity surgeries such as hernia repairs in low-income countries, while acknowledging the failure to translate such benefits to communities in need in the U.S.7 One notable example within cardiovascular prevention in the U.S. bears remembering, however. The barbershop-based blood pressure study, led by Dr. Ronald Victor and published in the New England Journal of Medicine in 2018, evaluated the effect of a pharmacist-led hypertension treatment based in community barbershops in improving blood pressure among Black men when compared to counseling in the barbershops alone.8 The study demonstrated a whopping mean systolic blood pressure reduction of 27 points among those receiving the pharmacist-led intervention, with more than two-thirds of intervention participants achieving blood pressure control by the end of the study. The takeaway? With innovative adaptation of task-shifting approaches to local contexts in the U.S., such strategies have the potential to transform the model for care-delivery, reduce gaps in access to care and drive meaningful reductions in cardiovascular disease.

Mobile & virtual health interventions:

Over the past year, virtual and telehealth medical services have rapidly expanded, propelled by the desire to protect patients and providers alike during the height of pandemic lockdowns. The shift is likely to be one of the longest-lasting impacts of the pandemic on the way we practice medicine, but calls to incorporate mobile and virtual health services are not new within the pandemic era. Prior studies have demonstrated potential applications of mobile health or mHealth interventions to provide patient-centered education, communicate clinical reminders and advice, and perform complex health training, including cardiac rehabilitation, though mHealth tools can be more broadly categorized as patient-facing, provider-facing, and communication oriented.9-11 Additional applications in the treatment and counseling of high-risk conditions, including heart failure, hypertension, hyperlipidemia and coronary artery disease  have additionally been proposed, though implementation in these instances has lagged. Nonetheless, such interventions have demonstrated potentially dramatic results in LMIC with significant and sustained reductions in blood pressure, LDL levels, and improvements in metrics such as 6-minute walk distance with physical activity training, at little cost to the health system.12-14

Three recent developments and trends do bode well for the future of mobile and virtual health expansion in cardiovascular care. First, smartphones and wearable mobile health devices have become increasingly common in the U.S., with more than three-quarters of the U.S. population reporting use of a smartphone and wearable technology rapidly advancing to gain FDA-approval for detection of atrial fibrillation and in the near future likely continuous blood pressure and glucose monitoring.11,15 As such technology becomes more ubiquitous, moreover, the potential for such interventions to be used to reach under-resourced populations, including low-income and elderly individuals, is far more likely, expanding the potential reach of the healthcare system. Second, although high-quality evidence for mHealth interventions is lacking currently, the ability for mHealth applications to rapidly enroll large numbers of participants at low cost suggests an opportunity to grow the evidence base rapidly.16 Recent partnerships between academia and tech companies, including an ongoing study led by Yale University and Boehringer Ingelheim evaluating multiple mHealth based interventions for the management of heart failure, demonstrate the potential to generate new, high-quality evidence to guide future interventions.17 Finally, the past decade has been a time of tremendous investment in digital health, with venture capital investment exceeding $4 billion in 2014 alone and new startups emerging monthly.11

The result of this innovation and investment could be ground-shifting for low-income populations. What mobile and virtual technology ultimately offer is a means for redefining the clinic and hospital to bring healthcare directly into homes within underserved communities. Done well, mHealth interventions could address numerous barriers to care in under-resourced communities, improving health literacy, removing the financial and time cost of transportation to brick and mortar health institutions, and guiding care via simple and easy-to-access applications. This will require thoughtful application of technology to the goal of expanded care, however, as residual high costs of such services could ultimately undermine efforts at equity.

The bottom line: innovative approaches to care delivery that focus on both the who and where of healthcare have the potential to meaningfully alter care for low-income populations in the United States. Many such interventions have demonstrated efficacy already on a small-scale, but incorporation of such strategies into a new national approach to healthcare could go beyond these efforts in pairing an expanded vision of healthcare with universal health coverage. The potential for change is there, we just need the creativity and willpower to utilize it.

REFERENCE

  1. Sharing and Shifting Tasks to Maintain Essential Healthcare During COVID-19 in Low Resource, Non-US Settings. Centers for DIsease Control and Prevention;2020.
  2. Boyle P. U.S. physician shortage growing. In: Colleges AAoM, ed2020:https://www.aamc.org/news-insights/us-physician-shortage-growing.
  3. Jeemon P, Joseph LM, Anand TN. Task sharing with non-physician health-care workers for management of blood pressure – Authors’ reply. Lancet Glob Health. 2019;7(10):e1327.
  4. He J, Irazola V, Mills KT, et al. Effect of a Community Health Worker-Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial. JAMA. 2017;318(11):1016-1025.
  5. Jafar TH, Gandhi M, de Silva HA, et al. A Community-Based Intervention for Managing Hypertension in Rural South Asia. N Engl J Med. 2020;382(8):717-726.
  6. Joshi R, Thrift AG, Smith C, et al. Task-shifting for cardiovascular risk factor management: lessons from the Global Alliance for Chronic Diseases. BMJ Glob Health. 2018;3(Suppl 3):e001092.
  7. Wren SM, Kushner AL. Task Shifting in Surgery-What US Health Care Can Learn From Ghana. JAMA Surg. 2019;154(9):860.
  8. Victor RG, Lynch K, Li N, et al. A Cluster-Randomized Trial of Blood-Pressure Reduction in Black Barbershops. N Engl J Med. 2018;378(14):1291-1301.
  9. Piette JD, List J, Rana GK, Townsend W, Striplin D, Heisler M. Mobile Health Devices as Tools for Worldwide Cardiovascular Risk Reduction and Disease Management. Circulation. 2015;132(21):2012-2027.
  10. Dorn SD. Digital Health: Hope, Hype, and Amara’s Law. Gastroenterology. 2015;149(3):516-520.
  11. Eapen ZJ, Turakhia MP, McConnell MV, et al. Defining a Mobile Health Roadmap for Cardiovascular Health and Disease. J Am Heart Assoc. 2016;5(7).
  12. Srinivasapura Venkateshmurthy N, Ajay VS, Mohan S, et al. m-Power Heart Project – a nurse care coordinator led, mHealth enabled intervention to improve the management of hypertension in India: study protocol for a cluster randomized trial. Trials. 2018;19(1):429.
  13. Prabhakaran D, Jha D, Prieto-Merino D, et al. Effectiveness of an mHealth-Based Electronic Decision Support System for Integrated Management of Chronic Conditions in Primary Care: The mWellcare Cluster-Randomized Controlled Trial. Circulation. 2018.
  14. Beratarrechea A, Abrahams-Gessel S, Irazola V, Gutierrez L, Moyano D, Gaziano TA. Using mH ealth Tools to Improve Access and Coverage of People With Public Health Insurance and High Cardiovascular Disease Risk in Argentina: A Pragmatic Cluster Randomized Trial. J Am Heart Assoc. 2019;8(8):e011799.
  15. Jia X, Kohli P. Telehelath and Cardiovascular Disease Prevention: A Discussion of the Why and How. American College of Cardiology2020.
  16. Rowland SP, Fitzgerald JE, Holme T, Powell J, McGregor A. What is the clinical value of mHealth for patients? NPJ Digit Med. 2020;3:4.
  17. Wicklund E. Yale Studies 3 Different Telehealth, mHealth Tools for Cardiac Care. mHealth Intelligence. 2020. https://mhealthintelligence.com/news/yale-studies-3-different-telehealth-mhealth-tools-for-cardiac-care.

“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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Protecting Your Peace- 5 Things to Consider Before Saying Yes

Early in my career, I jumped at nearly every opportunity that came along. I wanted to impress everyone, and I wanted to prove to them that I deserved to be there. At that point in my career, I felt it was important to seize every chance because, even though I had endured years of school and training, I hadn’t yet figured out exactly what I wanted to do with my life. Taking on every challenge that came along was extremely enlightening. It allowed me to realize what I loved, what I just liked, and what I could barely stand doing. This approach also connected me with many people from so many different specialties. Eventually, it simply became exhausting.

When I took on a task, and I took on a lot of them, I wanted to do everything to the very best of my ability. I would eventually learn that you have to put even more energy into doing things you do not actually like. While the networking and building human connections aspect of my work was incredible, it became very clear that I could not go on doing work I had no interest in.

Now I approach new opportunities a little differently. Instead of eagerly jumping in, I take some time to consider what this might mean for my schedule, my well-being, and my overall goals. Burnout is very real, and I’m already a very busy person. For new chances like this, I evaluate them in terms of my Five Ps: Pay, Promote, Passion, Push, and Purpose.

  1. Pay

What is the financial compensation? Is there a budget attached, and is it reasonable? For many opportunities I research the pay history to find out what my white, male counterparts would make for the same position. When it comes to pay, remember: If you don’t ask for it, you’ll never get it.

  1. Promote

Will this opportunity promote me? Some people are okay being right where they are in their career, but others are still eagerly climbing that ladder. Sometimes opportunities are exactly what you need to take you to the next level, regardless ofpay or how satisfying they might appear.

  1. Push

Will this opportunity push me? Will it challenge me? Will I learn something new, or will it force me out of my comfort zone? Opportunities that push you are often the ones that help you grow.

  1. Passion

Am I passionate about this opportunity? Is it something I love doing so much that I’d do it for free just because it enriches my life? In the past, opportunities like mentoring or health advocacy have been obvious choices simply because of my passion for them.

  1. Purpose

Does this opportunity align with my Purpose? We all have a purpose on this earth and opportunities that present themselves to us are the best when they align with our purpose.

After asking these five questions, if a given opportunity meets one or more of my Five Ps, I say yes! Otherwise, I have to pass. Just setting boundaries isn’t enough, you have to work to enforce those boundaries as well.

Protect your peace, Queens, and Kings.

 

“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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Finding your first job after training – what I learned from the process.

We all look forward to the day we can finish training and finally become attendings. For me, that day crept up faster than I was ready for. In the midst of a pandemic, not only was I juggling clinical responsibilities, I also had to figure out how to find “my perfect” first job. I tried a number of different strategies but here is what I learned from the process.

  1. Attending job searches is NOT the same as residency or fellowship positions. For many of us, we filled out an application and started clicking away on any and all programs that we thought would help us become physicians. We then interviewed all of the US in hopes a computer algorithm will match us to our first-choice program. This isn’t the approach I took for attending jobs. I only spoke to places I had an interest in working and felt would be a great fit for my first job. It’s important for us to shift away from thinking of a residency/fellowship position as the process is not the same and requires a different approach.
  2. What is my dream job? And more importantly, write it down! One of the most important things I learned is I need to have a clear vision of what type of job I am looking for. Specifically, I first had to decide if I want to work in an academic environment vs community setting vs private practice vs locum, etc etc. This was the key step to focus my target search. More importantly, employers will ask asked me “what are you looking to do?” By having a concrete answer, the process was much more smooth and fruitful.

Other things to consider are how much inpatient time I’d like to do, how to develop an outpatient clinic, and opportunities to be involved in trainee education. For those

who are wanting to do research, is having protected time important and if so, how much time would you

want. By having this road map of your “dream job” before talking to employers will show you are prepared and have done adequate research for your first attending job. It will be up to the employers to then help your roadmap become a reality.

Career development is important for all of us and working for a practice that will support our career goals is important. Having an idea of your 5-year (or 10-year) plan to discuss with an employer will help you gage if the employer can help you grow and develop to achieve those goals.

  1. Utilize your network. There was a point when I was getting nowhere with my job search. Emails were going unanswered, no new jobs had been posted at places I was interested, and everything felt very grim. I then spoke to my program director who was able to help me get in touch with former fellows (and now attendings) at different programs to see if they have something that would suit my dream job.

    I also spoke to several of my co-fellows which turned into all of us sharing where we have interviewed or places we think the other may find as a good fit. Don’t be afraid to reach out if you’re in this position – you have nothing to lose but a lot to gain! Reaching out to mentors is also important as they may have leads on jobs you may not have considered before.

Although this conversation can be extensive and this is not an exhaustive list, I’ll end with this: we put a lot of pressure on ourselves to find the perfect job right out of training. However, the first job doesn’t need to be the last job. You can always look for a better fit – but DO NOT burn any bridges with your current employer!

 

 

“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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You May Turn Off Your Cameras Now: Trials & Tribulations of the Cardiology Fellowship Zoom Interview Trail

Last month, I dedicated my blog post to tips for prospective Cardiology fellowship applicants. In this companion piece, I would like to share my experience on the Cardiology fellowship virtual interview trail. Part of my motivation is to provide additional information for Cardiology fellowship applicants, but also to shed light on various approaches – both successful and unsuccessful – to the virtual interviews. There was much hand-wringing this past year about the diminishment of the fellowship interview experience, which by necessity became all-virtual due to the COVID-19 pandemic. In some ways, it was better – the lack of travel made it more affordable and increased flexibility. In other ways, it was worse – being on camera for seemingly endless hours and feeling as if programs were invading your private space at home. Here are some takeaways from the 2020 Cardiology fellowship virtual interview season.

Virtual interviews are convenient

Say what you want about virtual interviews, but there is no denying that they are more affordable, convenient and flexible. Residents working 60-80 hours a week suddenly did not have to spend thousands of dollars traveling around the country. Applicants did not have to leave the comfort of their own home or office to interview around the country and as a result did not have to work as hard to find extra coverage. These decreased barriers democratized the interview process. However, virtual interviews also encouraged applicants to apply to more programs, clogging up the application pile and making it harder for fellowship program directors select among many highly qualified applicants.

Virtual interviews are surprisingly exhausting

Although Zoom interviews were convenient, many applicants found them to be mentally and emotionally draining. No matter how hard you try, Zoom cannot replace a real-life social interaction that is influenced not just by the things that you say or your facial expressions, but by the environment around you and the participants’ body language. Much of this context is lost during a video interview. Instead you are left with the feeling that you must be “on” all the time, lest the person on the other side of the camera misperceive you as being uninterested. That is not to say that you are not being closely observed at an in-person interview, but that this feeling of being under the eye is heightened when you are staring at a blinking green camera dot on your laptop for hours on end. As a result, the overall experience ended up being more tiring than I anticipated.

We could all stand to spend less time on camera

Although I have always thought of myself as an extroverted person, I found it difficult to be on camera for more than a couple of hours at a time. In fact, I greatly appreciated when program directors or coordinators took care to encourage us to take a break and turn off our cameras during gaps in between interviews. During these breaks, I would get up, stretch, and in a few cases even left my apartment to go for a short walk around my neighborhood.

A virtual interview does not need to last an entire day

I grew to appreciate efficiency and brevity in a virtual interview day. One interview day lasted for nine hours. By the eighth hour, I felt exhausted and unable to retain any further information. I had heard what I needed to hear about the program; those last few hours did not augment my experience. The most memorable part of the day ended up being the relief I felt when I logged off as the sun was setting. That overall experience would have been more pleasant, and the same amount of information would still have been conveyed, if the day had ended a few hours earlier. Therefore, I would argue that the ideal interview day length is four to five hours: a program should be able to conduct interviews and transmit all key information to applicants in, at most, six hours.

It’s hard to get the “pre-interview dinner” right on Zoom

Some programs chose to host a pre-interview Zoom “dinner” the night(s) before the interview, while others did not. Looking back on it, this decision did not affect how I viewed individual programs. I found one-on-one conversations in which I could talk with current fellows, especially fellows with whom I had some kind of personal connection, to be much more helpful than stilted virtual “dinners.” The experience with these Zoom “dinners” was variable. Some were well-run, leaving little ambiguity about what we were supposed to do at any given time and controlling the pace of conversations in a way that avoided awkward pauses. Others were disorganized to the point of being uncomfortable to sit through. These sessions are challenging because while some people prefer to be very active participants, others wish to more passively observe and take in information. It is difficult to cater to both of these types of people in a way that feels natural.

My recommendation: if you are going to host a Zoom, the session should be heavily structured so that 1) participants know exactly what to do at any given time, 2) applicants are given the space to ask questions without having to compete with others (short, timed breakout room sessions help with this), 3) providing discussion topics to fellows in case a group of applicants is unusually quiet and 4) ending sessions in a timely fashion so that participants do not have to sit in excruciating silence when everyone has run out of things to discuss. Efficiency is your friend here, as well.

You CAN still get a “feel” for a place without physically being there

Program directors and applicants were concerned that we would not get a good “feel” for individual programs without physically being there. I found conversations with fellows and attendings at various programs to be incredibly helpful in filling this gap. To my own surprise, by the end of most interview days, I logged off feeling as though I had a pretty good sense of what each program valued and ways and whether it might be a good fit for me.

Virtual interviews should be an opportunity to re-think how we do interviews

Instead of perceiving it as a crutch, program directors should view the virtual aspect as a chance to revitalize the interview day and distill it to its essentials. In some interviews, it felt as though programs were trying to recreate the entire in-person interview day on Zoom. This is a flawed approach because not everything translates well to Zoom. For example, pre-produced videos about the program do not need to be played in real-time during the interview day – applicants can watch these on their own time. Likewise, some PowerPoint presentations could also be pre-recorded for applicants to view in advance. The end result would be a leaner, more efficient interview day in which the limited on-camera time is spent interacting with others, so that applicants come away with a more nuanced and comprehensive understanding of each program without spending an entire business day on camera.

 

“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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Sexual Harassment in Medicine: reflections from the other side

The first week of March on Twitter was rather shocking for the entire medical community with news of a 45-million-dollar sexual harassment lawsuit against Oregon Health & Science University (OHSU) and a former anesthesia resident. Dr. Jason Campbell is accused in the suit of sending overtly sexual text messages and photos and sexually assaulting a social worker at the hospital. Women in Medicine (WIM) on different social media outlets (Twitter, Facebook, Instagram, and clubhouse) were outraged and shared their sexual harassment stories. For me, it was truly disheartening and took me back to my own experiences of sexual harassment since the early days in medical school. It bought back difficult memories as I was reminded of how over the years as this “stuff” happened, I had decided to hide it somewhere in my memory closet from where it couldn’t escape. This news and the other stories by WIM jolted my memory about all those painful experiences from back in the day to right in front of my eyes, whether I was ready to relive them or not. Like many other WIM expressed on social media I was numb to these happenings. I was sad for days. I feel vulnerable now writing about it since I never have shared any of these stories even with my family or parents. I just “dealt” with these incidences. It was part of my “normal” life as a woman, I had stopped recognizing how in my micro-conscious brain, this “small stuff” whether it was a remark about my body or an intentional touch by male colleagues or “unusual” and uncomfortable attention by men at work or by patients, bothered me over the years traumatizing me except I never wanted to give it any attention.

Our lives begin to end the day we become silent about things that matter!

–Martin Luther King Jr.

Years ago, in medical school during my final year in India, a tutor who would decide the patient subjects for the viva exam threatened to fail me in the exam if I didn’t “go” with him to his place on campus. I was frightened. I always ranked top in university and he blatantly had asked me if I didn’t follow what he said, I would lose my ranking. Thankfully, I was strong then as I am strong now and refused. I still remember those terrifying days leading up to the exams, I feared that he would follow me wherever I went, like an ominous dark shadow that was ever-present. I would sit in the library where I always remained visible to others rather than choosing my favorite quiet corners. I was given a completely normal patient during the exam but delivered a robust discussion about the normal anatomy and physiology of a women’s body. It was difficult to impress the examiner with a discussion focused on what is normal rather than around pathology, so my score was not as high as it may have been if I was given a more appropriate patient to discuss. Another time I had a patient who had an erection and asked me to touch him as I was examining his inguinal hernia. I was deeply affected by such incidences in medical school. This shaped my vision of coming to the United States for further training since I had heard that women in medicine in the US worked in better environments without such overt sexual harassment, but alas, I didn’t know how global the problem truly was. I would never forget getting stalked by the campus police officer as I was getting my passport to come to the US. I had to visit the police station to get the proof of identity and then found that police officer every day for a month outside my hostel, waiting to talk to me. Despite polite ways of telling him, I was not interested; he would show up the following day. How was I safe if the campus police officer was trying to stalk me? I still remember feeling terrified and thinking of being hurt every time I stepped outside the medical school hostel.

“When it’s “he said/she said,” the woman can’t win. But when it’s “he said/she said/she said/she said/she said/she said,” transparency has a chance, and light can flood the places where abusive behavior thrives.”

— Melinda Gates

More recently in the United States, I was asked by a leader in a medical organization (not my current institute) to meet over coffee. I genuinely thought it was for discussion of my career path as I received some “mentoring” from this individual. Midway during the meeting, he took something from my plate and said if it was allowed to eat from the plate of a date. My face went completely pale. How was this “meeting” and discussing my career a “date” that I never agreed to? I felt intensely uncomfortable and decided to leave after making an excuse. There are numerous other examples where I felt uncomfortable by colleagues, patients, or men at work that I just avoided- forget about confronting or reporting them. This “stuff” that made me uncomfortable back then and causes sympathetic overdrive even right now, while I am writing it, are examples of sexual harassment that makes me feel emotionally numb and forces me to hide it! Sexual harassment, stalking and discrimination is rampant during training for WIM even in 2021 in the United States. The power differential through the medical training makes it hard for our trainees to report it and as a result, the culture of chauvinism, and sexual harassment continues to grow.

“Sexual Harassment is not about attraction or desirability. It’s about exerting control over people whenever you can.”

— Anonymous

For anyone reading this post, I want to make one thing clear, any conversation or contact that makes the opposite person uncomfortable can be considered sexual harassment. Even in the cases where one may think they may have consented; the power differential NEVER gives the opposite person the freedom to consent. Sexual harassment is really not about sex. It’s about power and aggression and manipulation. It’s an abuse of power problem. We need to make sure that our trainees are empowered to report these incidences. We also need to make sure men start discussing these topics amongst themselves and identify the troubling language and behavior in fellow men and start calling them out. Men have to be interested in our safety for the culture to change. For either gender, we should acknowledge the bravery victims exhibit when they are sharing their story and thank them for confiding in us but more importantly give them the courage to report or do it for them. Medical organizations seriously need to understand that completing sexual harassment modules online does very little to prevent sexual harassment at the workplace. A stepwise approach that empowers the victim to report such incidences without fearing retaliation is a must.

I seriously cannot wait for a world of equity, equality, and accountability, where no one has the audacity to “accidentally” touch a woman without their permission, where women can thrive and are valued for their talent and brilliance and aren’t asked for sexual favors for a deserving opportunity, I cannot wait for a world where no one can utter the words “grab ‘em by their p****” and where the locker room talk isn’t about insulting womanhood.

This fight is difficult. I know there will be lots of disappointment and sadness like there was this month, which will be with us for a long time, but I am hopeful since these conversations are increasingly happening on social media openly and with candor!

“Self-respect by definition is a confidence and pride in knowing that your behavior is both honorable and dignified. When you harass or vilify someone, you not only disrespect them, but yourself also. Street harassment, sexual violence, sexual harassment, gender-based violence and racism, are all acts committed by a person who in fact has no self-respect.

Respect yourself by respecting others.”

— Miya Yamanouchi  

 

“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.”