hidden

11 Women Cardiology Leaders – How to Overcome Adversity & Thrive

Summarized by Nidhi Madan MD Sarah Rosanel, MD; Cynthia Kos DO, Renee P. Bullock-Palmer MD, Kamala P. Tamirisa MD and Purvi Parwani MBBS MPH. Edited by Marissa Bergman.

Presented by the ACC Women in Cardiology (WIC) Section, AHA WIC Section and Women as One, this webinar highlighted a panel of female cardiologists with leadership roles in the field. The opportunity of gathering 11 female leaders of international Cardiology organizations comes rarely and the webinar was incredibly inspirational. It was co-moderated by ACC WIC Chair Dr. Toniya Singh, MD, Cardiologist at St. Louis Heart & Vascular and AHA WIC Chair, Dr. Annabelle Volgman, MD, Professor of Medicine, Rush College of Medicine;

The webinar focused on providing guidance, empowerment and optimism to women in cardiology through personal journeys and experiences. The presentations equipped attendees with the necessary skills and qualities to more than just survive, but, rather, thrive, during the ongoing pandemic and racial crisis.

Cindy Grines, MD, FACC, MSCAI

President of the Society of Cardiac Angiography & Interventions.

                                    “Accept the situation and have a game plan.”

Dr. Grines began the presentation with her personal journey. She had an extremely successful cardiology career in Michigan for over 25 years. Then, she decided to move, for family reasons, and began a new position as Academic Chair of Cardiology in New York. She was told during the interview process that her focus needed to be 90% on academics, research productivity, mentoring the faculty, and gaining the program a national presence. Over the next 1.5 years, she worked hard towards these goals and exceeded the expectations. Yet, despite going above and beyond in her professional duties, Dr. Grines was terminated from her position without a valid reason – with claims that it was a “business decision” and “trying to merge some roles.” She alluded to how she handled this unprecedented situation, and formulated a game plan. She negotiated a severance package and found her current position, with which she is very happy. Her presentation emphasized the importance of networking and  destigmatizing what might feel like a humiliating and isolating situation. Dr. Grines concluded with words of motivation:

“You need to pick yourself up, brush yourself off and get back in the saddle and ride that horse again. The bottom line is change is good and when these things happen to you it’s going to motivate you to do something different and to prove yourself.”

Roxana Mehran, MD, FACC, FACP, FCCP, FESC, FAHA, FSCAI  

 The Cofounder of “Woman As One.”

“Don’t give up on your goals.”

Dr. Mehran’s presentation started with a bang: “Celebrate Women!” She continued with powerful words, “When we focus on our goals, we can achieve everything and we should never give up on our goals. They are yours, cherish them, fight for it, you will achieve it.”

Dr. Mehran was born in Iran and she dreamt of being a doctor since she was quite young. Amidst the hostage crisis in Iran, her family immigrated to Queens, NY. Despite facing poverty and restarting her life as an outsider, she never lost sight of her aspirations and eventually became an interventional cardiologist. With her determination and strong will, Dr. Mehran was one of the first female fellows at Mount Sinai. She pursued her career and continued her mission to contribute to science and clinical outcomes. As a woman in a male dominated field, she felt the inequalities in interventional cardiology, and she made it her new goal to ensure women are heard. Ultimately, she co-founded “Women As One” to encourage women not to accept inequalities or harassment in any form. As she explained, “You just have to see it all, keep your eye on the ball just like they tell you in baseball and in tennis… and make sure you hit that bull’s eye. Work hard and it will come to you.”  She concluded with her favorite quote by Maya Angelou,

 “Do your best you can until you know better, then when you know better, do better.”

Athena Poppas, MD, FACC, FASE

President of the American College of Cardiology

 “Strategic Leadership & Change Management”

Strategic leadership has never been as important as it is during the challenging times of the pandemic. Dr. Poppas referred to the importance of influential leadership and emphasized that one does not need a title to lead. These times are an incredible opportunity for everyone to step up and contribute. She explained that strategic leadership is not linear, but mostly circular – anticipating, recognizing challenges, interpreting and making decisions, staying aligned but learning along the way. She then shared some of the key tools from her leadership toolbox:

  1. Authenticity is essential.
  2. Use influential skills rather than just telling someone what to do – utilize the tools of change management to bring people along.
  3. Manage conflict and work together.
  4. Realize one’s own strengths, be honest about those strengths and bounce ideas off friends and allies. Be cognizant about weaknesses with a goal to improve them.
  5. Put yourself out there and seize opportunities.

Dr. Poppas concluded by reiterating that change management and strategic leadership is a continuum and a continuous cycle of learning. At the same time, succession planning with mentoring and helping others is key, so that there is an entire group capable of replacing you.

Andrea Russo, MD, FHRS

Immediate past President of Heart Rhythm Society (HRS)

                                                               “Resilience”

 In Dr. Russo’s first week as President of HRS, a controversial topic of Maintenance od Certificate (MOC) surfaced. HRS was looking into ways to create a less disruptive and  more customizable educational program and certification. Therefore, HRS put together an MOC Task Force and conducted a member survey assessing the feasibility of other options. Throughout this battle, resilience helped her look into options that would be relevant to the HRS members. The COVID-19 pandemic put the annual HRS meeting in jeopardy. She led the team, which considered the safety of travel and alternate ways to deliver education. Arrhythmias related to the coronavirus needed attention with protocols; how to deliver EP care to patients in the COVID era while also protecting the EP team by reducing their exposure became a priority. To answer these questions, HRS put together a group called the COVID-19 Rapid Response Task Force to collate the major information and provide guidance. There was an outpouring of volunteers and these documents were prepared in record time. This experience emphasized  the resilience of a collective resolve from the volunteers who contributed to the HRS staff. Dr. Russo concluded by saying that COVID did jump start the utilization of online educational platforms and digital health to successfully deliver the HRS 2020 content online.   She explained that one of the most rewarding experiences of her presidency was the ability to share ideas, work together with leaders from around the globe and improve knowledge.

Christine Albert, MD, MPH, FHRS

President of Heart Rhythm Society

“Embrace Change, Be Creative”

 Dr. Albert’s advice is, when one cannot change the adversity, it is important to change gears and embrace the new opportunity. Listening to new suggestions, moving forward and ultimately bringing the group along as a leader are an integral part of being creative. Advances in digital forms of communication in COVID times are one such example of embracing the change.  She ended with these empowering words, “Don’t be afraid to forge ahead in adversity.”

                                                  Mariell Jessup, MD, FAHA

                Chief Science & Medical Officer of American Heart Association

                                               “Believe in your Capabilities”

 Dr. Jessup’s presentation focused on how it takes courage to overpower impostor syndrome and its nagging question, “Are you capable?” She pointed to Michelle Obama’s comments as a guiding example: “Am I good enough?” “Of course!” She argued that courage might not be easy to find every moment, and that friends and mentors play an important role against a doubtful mind.

She referred to Eleanor Roosevelt’s challenging life and quoted, “You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, ‘I have lived through this horror. I can take the next thing that comes along.’ You must do the thing you think you cannot do.”

Dr. Jessup offered several more phrases and quotes to empower and remind women that it is vital to focus on courage to lift up mentees. She was reminded of Queen Elizabeth’s quote, “When life seems hard, the courageous do not lie down and accept defeat; instead, they are all the more determined to struggle for a better future.” Another voice of reason she found very relevant is Winston Churchill, regarding sharing courage “I never gave them courage; I was able to focus theirs.” She concluded her presentation on an uplifting note – “Have the courage!”

 Michelle Albert, MD, MPH, FAHA, FACC

President, Association of Black Cardiologists (ABC)

 “Remembering your purpose”

 Dr. Albert emphasized being innovative and creative while also being kind and compassionate in a society facing healthcare disparities. It is important to remember the purpose, when attempting to have an impact. She also emphasized harnessing one’s background to help focus on one’s individual passion and follow that purpose.

Raised by her grandparents, Dr. Albert witnessed hardship and segregation, and she perceived how the socioeconomic background of the patients influenced healthcare. As she explained, “The largest gap in healthcare is in cardiovascular medicine”.

Dr. Albert further highlighted the importance of appropriate support, including key mentorship and faith to overcome adversity. She stressed that being disciplined; bold, collaborative and always thinking outside of the box are key for achieving ultimate professional purpose.

She concluded by warning against transactional relationships or being predatory in the professional setting.

Chiara Bucciarelli-Ducci, MD, PhD, FESC, FRCP

CEO, Society of Cardiac Magnetic Resonance (SCMR)

What opportunities can this adversity bring?”

 Dr. Bucciarelli-Ducci believes there are endless opportunities and each challenge simply leads to more opportunities. She is a transformational leader, someone who tries to identify the need for change, create a vision, guide change through inspiration and work collaboratively. She always aspired to be that woman in cardiology and her experience has taught that with change always comes resistance. She stressed the importance of listening to all parties while honing the power of negotiation. She quoted Socrates, in emphasizing the power of a collaborative team, “The secret of change is to focus all of your energy, not on fighting the old, but on building the new.”

Her Italian background, upbringing and world history inspire her tremendously. To Dr. Bucciarelli-Ducci, the COVID-19 pandemic parallels what happened during World War II (WWII). Just like WWII, she believes that this pandemic is creating new ways of thinking, working and connecting with people across the globe.

Sharmila Dorbala, MD, MPH, FASNC

President, American Society of Nuclear Cardiology (ASNAC)

“Be Optimistic”

In Dr. Dorbala’s experience, “Optimism is one of the keys to success.” She believes that whether one looks at the glass as half-full or half-empty is a matter of perspective and choice. One can choose to be an optimist and train oneself to focus on the positives, and that optimism gives one confidence to take risks and then becomes contagious.

She provided an example of contrasting optimists and pessimists and how they view the world differently. Optimists see challenges as being temporary, something that can be conquered and used as a stepping-stone to better solutions, whereas pessimists view challenges as insurmountable obstacles. She referenced her research interest in cardiac amyloidosis to illustrate how optimism has influenced her own career. Dr. Dorbala actively chose to be optimistic and stayed in this field despite the hurdles she encountered. She always remained passionate about her field and confident that her hard work would lead to opportunities. She believes that the advances in medicine seen today are because the medical community chose to focus on the potential of the future.

Her overall advice for professional life is to have the integrity to do what is right, irrespective of the consequences, focus on excellence and be passionate about the cause. She reminds us to never underestimate the importance of having an optimistic outlook to gain confidence and to look for opportunities by embracing risks.

Judy Hung, MD, FASE

Incoming President, American Society of Echocardiography (ASE)

Forget the noise and forge ahead”

Dr. Hung emphasized that during one’s medical career there will be many instances of biases and inequality, intentional or unconscious. She advised that these injustices should not distract one from pursuing their goals.  To her, it is important to always stay in the lane. Dr. Hung explained that one could transform anger and sadness into positive energy, and make an impact professionally. Her strongest advice to women in cardiology is to stay focused and not let negative attributes of mental energy sway one away from their focus.

Biykem Bozkurt, MD, PhD, FHFSA, FACC, FAHA

President of Heart Failure Society of North America

“Create Change and acknowledge the ‘never-evers’ ”

 In a time that has left everyone grappling with unprecedented personal and professional challenges, how can do you thrive as leaders? Dr. Bozkurt argued, “most advancements come from acknowledgement of the ‘never-evers’”. “You have to face obstacles head on” or else face “stagnation and complacency.” She offered words of wisdom that adversity creates opportunity for resilience to get out of one’s comfort zone and create a meaningful change.

The COVID-19 pandemic has exacerbated a constant truth of the profession – doctors are witness to human suffering, but, at the same time, healing. “Do not sanitize suffering…learn from it… and teach the next generation,” said Dr. Bozkurt.  She cautioned against disinfecting the truth out of uncomfortable realities.  Amongst the suffering and sacrifice lies empathy, humility, and growth.

Dr. Bozkurt cited the story of Marguerite Matisse as a compelling example. Marguerite suffered from severe illness at a young age, requiring a tracheostomy. Despite poor health and a prominent scar, she became a lifelong muse for her father, the renowned artist Henri Matisse. As he once explained, “I don’t remember adversity, I remember resilience.” Dr. Bozkurt hopes that when the world looks back on the current healthcare, economic, racial, and political situations, Matisse’s quote will ring true.

Visit this website for access to this important webinar.

Summarized by Nidhi Madan MD Sarah Rosanel, MD; Cynthia Kos DO, Renee P. Bullock-Palmer MD, Kamala P. Tamirisa MD and Purvi Parwani MBBS MPH. Edited by Marissa Bergman.

“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.”

hidden

My Professional Journey

I was fascinated by the body’s circulatory system in high school. I was also concerned about heart disease being the number one killer of adults in the world. I figured I would become a cardiologist and help save hundreds, thousands, or even millions of people over time in personalized and public health care from fatal heart conditions. I suspected then that I would one day be a physician in cardiovascular diseases.

In college, everyone knew. I majored in Physics, spent lots of time in Spanish, and met my humanities and social sciences requirements, yet everyone knew I was destined for medical school. I completed all my premedical studies, volunteered at a local hospital, and shadowed doctors, and pursued research. My high honors senior thesis for the Bachelor’s and my excellent Master’s thesis were ultimately based on analyzing blood samples to determine health and disease and make predictions, using quantitative analytical methods in genomics and transcriptomics (gene expression profiles). Those studies in the blood were the closest I could get to the circulatory system as a physics major doing biomedical research at that time. It was fantastic!

By the time I started medical school, I figured that if I didn’t become a cardiologist, then I would be an oncologist or practice medical genetics (thinking that would be the closest thing to genomics). In medical school didactics, I quickly learned that medical genetics back then wasn’t what I thought it would be, and it didn’t focus on adults as much as I would have liked. Oncology lectures focused less on the conversation with the patient and more on signaling pathways that I had not yet begun to understand. I decided maybe that was not for me either. The physiology of the heart indeed captured my heart; the lungs and kidney were great too. So there I was, back to the heart and its circulatory system.

In my third year of medical school, I faced a dilemma. I enjoyed Psychiatry, Radiology, General Surgery, Orthopedic Surgery, Family Medicine, and Pediatrics, among other rotations, as well as my electives in Cardiology. What was I to do with my life as a doctor? I could almost see myself doing any of those! Almost.

During the PhD of my MD/PhD program, I shadowed a general cardiologist. I noticed that most of his patients were older and already in atrial fibrillation or heart failure. I asked myself, “Where are the 40-60 year olds before this happens?” I decided to create Preventive Cardiology. That was in 2006. I googled and saw that it already existed! In fact, we had just recruited a brand new faculty cardiologist, whose focus was prevention. I quickly became her mentee and spent some time in clinic with her. I realized that when it really came down to it, I saw myself managing and even more so preventing heart disease.

Then one day, I saw an email about a pilot research study in cardio-oncology. Thankfully, I was able to be a part of the study and learn more about this emerging field. This was in 2010. Almost a decade ago, I realized that my calling in medicine was to practice preventive cardiology and cardio-oncology and pioneer the merging of the two.

So, in my fourth year of medical school, I spent lots of time in various Cardiology clinics, to gain knowledge and exposure in other fields within Cardiology. I also had the opportunity to spend time in Medical Oncology and Radiation Oncology clinics, as well as with the radiation therapy technicians, treatment planners, and medical physicists. I performed literature reviews on my own and brought in articles to discuss with the Cardiologists, Medical Oncologists, and Radiation Oncologists. My favorite paper then is still quoted today in many experts’ presentations on ischemic heart disease risk resulting from radiation therapy.

With such incredible exposure to Cardiology, Oncology, and Cardio-Oncology patient care, research, and education, I thought about what I wanted to do most in the world as a professional. It became clear to me in my fourth year of medical school that I wanted to manage and, even more profoundly, prevent heart disease in the general population and in individuals with a current or prior history of cancer, and especially too in women. During that year, I got to present on my learning experiences in patient care, research, and education to the entire Cardiology department.

In 2012, in my last year of medical school and the MD/PhD program, I matched into the highly selective clinician investigator program at Mayo Clinic in Rochester, MN. I signed on the dotted line in advance for Internal Medicine Residency, Cardiology Fellowship, and Postdoctoral Research Fellowship. Everyone, therefore, knew I was for sure destined to #ChooseCardiology.

During my second year of residency, during my Oncology rotation, I cared for a woman with congestive heart failure thought to be due to anthracycline therapy administered many years before. That blew the whole thing open. I informed my faculty and advisors in Oncology, Preventive Cardiology, and Cardio-Oncology that I desired and planned to pursue both Preventive Cardiology and Cardio-Oncology and find ways to merge the two.

Over seven years at Mayo Clinic, I was, therefore, able to focus much of my research and subspecialty training and learning efforts in Preventive Cardiology and Cardio-Oncology (see CardioOncTrain.com). I also had the privilege of several clinic sessions in Heart Disease in Women. To me, all three are related, in so many ways.

My mission, therefore, is to protect the heart from ischemia, arrhythmia, cardiomyopathy, and other ailments in the general population, and particularly those individuals with a current or prior history of cancer (and especially in women).

Thus, I am now a cardiologist, with special emphases in preventive cardiology and cardio-oncology, especially in women. I am also a poet, and writing poetry about science, medicine, and now the heart has truly become one of my greatest joys (see LyricalMezzanine.com).

I share this story with you as an example of an individualized pathway in #ChooseCardiology. Perhaps you too are leaning towards areas in Cardiology to which you have not had much exposure, yet you know somebody has to do it, and that it must be created. Don’t let the unknown obscure the certainty of your calling. Find mentors and advisors who will believe in your potential and vision and spur you on, and who will one day be proud and excited to see your passion become reality.

 

“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.”

hidden

Why Cardiology?

“Why Cardiology?” is one of the most common questions I have been asked by friends, family, interns, residents, and even the occasional stranger sitting next to me on a flight. Despite being a simple question, the answer is very complex. I initially started residency thinking I would pursue a career in pulmonary/critical care – I loved the acuity, broad differential diagnoses, and the bond created with families. However, after my first month in the unit, I quickly abandoned this career path for multiple reasons. Shortly thereafter, I did my first rotation on the cardiology wards service with Dr. Matthew McGuiness (who is still one of my closest mentors) and I saw the light.

The month on the cardiology wards service is best described as “finding the missing piece of the puzzle.” I loved the anatomy, physiology, patient population, subtle differences in presentations, and my interactions even as an intern with patients. I also loved the depth of cardiology – including both clinical and basic science research opportunities, advanced fellowships options, and the ability to create my niche in cardiology. I learned cardiologists were pursuing careers in preventative cardiology, cardio-oncology, cardiac critical care, and cardio-obstetrics. I was blown away at the possibilities of a career in cardiology and having the ability to create my perfect dream job.

As I mentioned earlier, I was very interested in critical care when I started residency but did not want to be in the medical ICUs. The cardiac intensive care units were much more interesting to me with advanced hemodynamics, malignant arrhythmias, various mechanical circulatory devices, and seeing how quickly the realm of the cardiac ICUs were changing. The CCUs are no longer filled with patients who have had a STEMI requiring a week-long admission, but rather those with decompensated heart failure/cardiogenic shock requiring mechanical circulatory support (MCS) with LVADs, Impella, or ECMO.

I am now combining all of my loves – cardiology, critical care, and obstetrics (yes, I at one point wanted to go into OBGYN) for my job as an attending. With the help of my mentors, I have been able to combine all my passions into one. I will be attending in the cardiac intensive care unit and have a predominantly general cardiology clinic with a focus on cardio-obstetric patients. And the best part, every cardiology fellow can create his/her dream job.

A few key questions to ask yourself are:

  • Do I see myself as someone who enjoys the in-patient or the out-patient setting? This will help focus career options and set the stage for your career.
  • Am I a proceduralist or not? For me, I hate wearing lead, so it was a simple decision to not go into interventional or EP.
  • What type of patients do I get the most joy of taking care of. In my case, it was the critically ill and women who are pregnant with cardiovascular disease.
  • Who is 5-10 years ahead of me career-wise and has my ideal job? This has helped me be more active with research, clinics, conferences, and improve my fund of knowledge. It also gave me a roadmap to follow – no need to reinvent the wheel.

Of course, these are starting points and it’s a vast topic that takes time to explore. My journey of “why cardiology” has been filled with highs and low, but with the help of various mentors I have a clear vision of what I envision for my future career.

 

“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.”

hidden

Learning on the Go – Some Podcast Recommendations

As researchers, clinicians, and/or trainees, there never seems to be enough time in the day to get all the stuff done that we want to get done. There seems to always be more papers that we want or should read. One of my favorite ways to try to stay up to date with the latest research publications is listening to podcasts. I enjoy listening to podcasts while commuting and doing chores, and sometimes while working in the lab when no one else is around. Depends on my mood whether I can listen to a podcast while exercising or would prefer to listen to more energetic music.

Below is a list of some of my favorite cardiology podcasts. This is not a comprehensive list and I am not affiliated with any of these podcasts. I also am not endorsing any of the content discussed in the below podcasts. This list is also biased towards those podcasts that are easily accessible via smartphone podcast/listening applications and do not require downloading individual episodes from specific websites. These podcasts are not listed in any particular order.

  • Circulation on the Run: Summarizes the articles published in a specific issue of Circulation and has a more in-depth discussion of a featured article.
  • Discover CircRes: Summarizes the articles published in a specific issue of Circulation Research and also has a more in-depth discussion of a featured article often with the article’s corresponding author as well as the trainee involved in the article.
  • The Bob Harrington Show: Interviews and discussions of various topics in cardiology and the practice of medicine.
  • This Week in Cardiology: Dr. John Mandrola summarizes and provides his insight on some of the top news in cardiology for the week.
  • JACC Podcast: Dr. Valentin Fuster, editor-in-chief of the Journal of American College of College (JACC) provides an overview and summary of the articles published in a specific issue of JACC.
  • Eagle’s Eye View Your Weekly CV Update from ACC.org: A weekly cardiovascular update from Dr. Kim Eagle, editor-in-chief of ACC.org.
  • ACCEL Lite Features ACCEL Interview on Exciting CV Research: Interviews and summaries of some of cardiology’s most interesting research topics, hosted by Dr. Spencer King III.
  • Heart: Summaries of original research, editorials, and reviews from the BMJ’s Heart
  • Heart Sounds with Shelley Wood: Discusses some of the top stories in cardiology covered by the TCTMD reporters.
  • CardioNerds: This is a podcast that I just started listening to. It discusses high yield cardiovascular topics in a case discussion format.
  • AP Cardiology, ACC CardiaCast, Cardiac Consult A Cleveland Clinic Podcast for Healthcare Professionals: Three different podcasts that provide summaries of various cardiology topics.
  • JAMA Editors’ Summary, JAMA Clinical Reviews, JAMA Medical News Interviews and Summaries: Three different podcasts which provide summaries of various medical topics.
  • Annals of Internal Medicine Podcast: Highlights and interviews from a specific issue of Annals of Internal Medicine. The American College of Physicians has another podcast, Annals On Call Podcast, which features Dr. Bob Centor discussing influential articles that are published in Annals of Internal Medicine. I have not yet started listening to Annals on Call, but hope to do so in the near future.
  • ED ECMO: Discusses resuscitative extra-corporeal membrane oxygenation (ECMO) and extra-corporeal life support (ELS). At the University of Minnesota, cardiologists manage veno-arterial ECMO (VA-ECMO). More to come about this during an upcoming blog!

I am always open to hearing suggestions for new podcasts related to science/medicine or other topics!

 

“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.”

 

hidden

What do Immunology and Impostor Syndrome Have In Common?

As an Advanced Heart Failure and Transplant Cardiology Fellow this year, transplantation immunology is an important part of my curriculum. While I try to stay up-to-date on the latest advances in care in heart failure, cardiogenic shock, and mechanical circulatory support, I recently took a deeper dive into the fascinating history of organ transplantation and immunology – which brought me to Sir Peter B. Medawar, widely regarded as the “father of transplantation”.

Sir Peter Brian Medawar

Sir Peter Brian Medawar: https://www.thefamouspeople.com/profiles/peter-medawar-7366.php

Medawar was a Brazilian-born British zoologist who received (with Sir Frank Macfarlane Burnet) the Nobel Prize for Physiology or Medicine in 1960 for developing and proving the theory of acquired immunological tolerance. His early training and studies in England were focused in zoology and comparative anatomy, and his initial research was on connective tissue cells and tissue culture.

He became interested in skin grafting during World War II after witnessing military pilots sustaining severe burns in plane crashes and moved to Glasgow to continue this work for the Medical Research Council. Over the 1940s-early 1950s, he performed and published a series of experiments on the behaviors of skin autografts and allografts in burn victims. He demonstrated that skin allografts (i.e. homografts), although initially successful, were rejected within two weeks. In his experiments, when a second allograft from the same donor was attempted, the allograft was rejected much more quickly. Thus, he established the idea that allograft reactions were immunological. In the conclusion of their paper The Fate of Skin Homografts in Man, Gibson and Medwar state that “The time relations of the process, the absence of a local cellular reaction, and the accelerated regression of the second set of homografts suggest that the destruction of the foreign epidermis was brought about by a mechanism of active immunization.”

He furthered the ideas of genetically determined immunologic systems and immunologic tolerance through additional studies in different model organisms, including cattle and mice. In 1951, he tested the effects of cortisone on survival of skin homografts in rabbits and found that the daily subcutaneous administration of 10 mg cortisone acetate to adult rabbits delayed graft healing and vascularization and lengthened the life of skin homografts by 3x-4x!

Figure 3 from Billingham RE, Krohn PL, Medawar PB. Effect of Cortisone or Survival of Skin Homografts in Rabbits. Br Med J. 1951

Figure 3 from Billingham RE, Krohn PL, Medawar PB. Effect of Cortisone or Survival of Skin Homografts in Rabbits. Br Med J. 1951. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2068993/pdf/brmedj03547-0003.pdf

As excited as I was to read about this fascinating history of immunology and transplantation, I was even more interested to find that Medawar was a supporter of women in science (#HeForShe). In 1979, he published a book called Advice to a Young Scientist, a book he says is “the kind of book I myself should have liked to have read when I began research…” In the eight short pages of his book’s fifth chapter entitled “Sexism and Racism in Science”, he addresses the concepts of impostor syndrome, gender equality in academic medicine, and the frequent invisibility of women in science – all concepts still at the forefront of our current dialogue 40 years later.

Excerpt from Advice to a Young Scientist by Peter B. Medawar

Excerpt from Advice to a Young Scientist by Peter B. Medawar

The history of medicine is full of fascinating personalities and stories like this one, and to quote Medawar himself, “I do not know any scientist of any age who does not exult in the opportunity continuously to learn.”

 

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.

hidden

Pursuing Cardiology As a Medical Student/Resident

As an Early Career blogger for the AHA, I wanted to write my final blog post on advice for those interested in pursuing cardiology. My interest in cardiology began during my first year of medical school, and now as I am applying to become a fellow, I wanted to look back at the last 7 years.

 

Medical school

As a medical student, it can be difficult to know what field you would like to pursue. Although some may know from the beginning what they would like to specialize in, the majority of students must use their time during their clinical years to explore different fields. Given this, I would advise students to focus on getting a good background in all aspects of medicine during medical school. Take as much in from your exposure to each field. Do well on your boards, take ownership of the patients you see and read as much as you can.

So as a first or second year how can you know if cardiology is a field you should consider? Well, what made me interested in the field during those years was the physiology behind the mechanics of the heart.  It made intuitive sense. The time I spent reading Lilly’s Pathophysiology of Heart Disease did not feel like studying. This inspired me to sign up for electives in cardiology later on in medical school. During third and fourth year, rotating on a cardiology consult service or a CCU service can help you see the day to day life of cardiologist. It exposes you to the common consults and admissions in the field. It also allows you to get to know the type of personalities in cardiology. If you are interested, get involved in research projects.

 

Internal Medicine Residency

In the beginning of my residency, my advisor told me that before one could become a great cardiologist, they must become a great internist. This is something that I heard echoed by cardiology program directors during this past year’s AHA Scientific Sessions. A passion for patient care and an understanding of the intricacies of internal medicine are paramount in the path of a future cardiology fellow.

Be a good citizen in your program. Complete all your administrative duties on time. Be the one that chiefs can rely on when scheduling difficulties occur. Residency is not just about being smart but being reliable and hardworking. This makes you stand out.

While on the wards, incorporate the use of ultrasound in your daily practice. Try and volunteer for procedure and make it a goal to become comfortable with central and arterial lines.

Depending on your interests in cardiology, as a medicine resident it is worthwhile to get involved in a research project. It is important to truly have a passion for the research topic you decide to study. Whether it is because a patient you saw was affected by what you are researching, or if you have background in that topic, it is important to have a connection with the research topic. This is what drives you to spend your time outside of the hospital working on the research project. Attempting to work on a project in the name of “just having research” is a recipe for burnout and you will likely not complete the project.

Show case your research either through presentations at the AHA Scientific Sessions poster session or the American College of Cardiology meeting. Recognize that the deadline for abstract submission for these conferences are months before the meeting. Besides presenting, networking and sitting in on lectures important topics in cardiology. It is inspiring and will further your aspiration to work hard.

Finally, make sure to begin working on your application, specifically the personal statement early.

 

What was your experience applying to cardiology?

 

hidden

Bigger Isn’t Always Better: My 3 Tips on Maximizing the Small Conference Experience

In my March blog, I wrote about a few of my tips to get involved in our cardiovascular professional societies. I received a lot of great questions and feedback from trainees across the spectrum of cardiovascular disease through Twitter, LinkedIn, and email, so I thought I would share some similar content this month.

As busy cardiology fellows in training (FIT), finding the free time to attend more than one professional conference in an academic year is tough. Trying to choose among the various local, regional, national, and international opportunities can be difficult, not to mention the financial and time commitments required to attend multiple meetings in a year. As I have become a more senior cardiology FIT, I have come to appreciate the value of attending smaller, disease or topic-specific conferences. Here are 3 of my tips to make the most of these opportunities.

MindTheGraph.com

1) Search the CME offerings of academic institutions around you: Most large academic medical centers host continuing medical education (CME) programs focused on specific topics or diseases throughout the year. They are often held on weekends but are usually less time-intensive than the national professional society meetings. Despite their smaller sizes, the organizers will still invite preeminent clinicians and scholars in the relevant fields, which make these meetings terrific opportunities for FITs to access thought leaders and craft collaborations. I recently attended a weekend-long CME course focused on hypertrophic cardiomyopathy at an academic institution in a neighboring state. At the conference, I reconnected with a long-distance mentor who was invited to give a lecture, met a junior faculty member and brainstormed cross-institutional collaborations, and learned about HCM from internationally renowned clinicians and scientists. In addition, taking a deep dive into a topic of your interest can be a welcome respite from the hectic cognitive shifting we are forced to do at larger conferences.

MindTheGraph.com

2) Find a way to participate: While smaller conferences usually do not have much room for flexibility in the programming, the organizers may allow FITs to present cases to accompany the didactics. Offer to present a case that ties into the talk of a speaker whom you are most interested in meeting. By doing so, you can “break the ice” with your case presentation and worry less about initiating interaction with the speaker. You may also have the course registration fee, if there is one for FITs, waived through participating. Along the way, stay responsive over email and telephone and obey the organizer’s deadlines for submission of your materials. If you notice that the conference does not have an avenue for FIT involvement, offer to contribute by presenting a case or submitting a poster. Last year, I advised one of my mentees to contact the organizers of a sports cardiology course she was interested in attending. Even though there were no publicized opportunities for FIT engagement, she let the organizers know about her interest in attending and enthusiasm to contribute. The organizers invited her to the course and extended discounted registration. This year, she is on the course planning committee and is spearheading the FIT case and poster presentation sessions!

MindTheGraph.com

3) Follow up after the course: Send an email to the course directors and your new contacts after the course. Let them know how much you enjoyed the experience and that you would be delighted to participate in the same or a similar conference again. Close the loop with new contacts and propose next steps to move those potential collaborations forward. Connect with each other through social media, as well.

 

What are your tips for maximizing the small conference experience? I would love to hear them over the next month – share them with other #AHAFIT and me on Twitter and LinkedIn!

 

 

 

hidden

Cardiac Intensivist – Just an Extension of an Interventionist?

Three pathways encompassing an intersection of the established subspecialties of critical care and cardiology have been proposed as a training framework for an aspiring ‘critical care cardiologist’ by the authors in a recent article1.  However, focusing specifically on the skill set outlined in the article,  a different and accelerated pathway for duly trained and interested interventionists may merit consideration.   With additional training in end of life/palliative care, intubation skills and advanced ventilator management a interventional cardiologist may likely fill the shoes in a modern ICU better than cardiologists from other subspecialties, including even those with additional critical care training.

Among the skill sets outlined in1, accredited interventional training likely prepares an individual to the greatest extent.  Issues of vascular access, sedation management and escalation of vasopressors for ‘crashing patients’ are daily routine in a busy catheterization suite.  Point-of-care ultrasounds (POCUS) should enhance the armamentarium of every thoughtful interventionist to identify regional wall motion abnormality and direct appropriate revascularization in area of myocardial dyskinesis/’stunning’. Additionally POCUS helps identify tamponade expediently,as well as potential advanced valvulopathy needing urgent invasive intervention. Pulmonary artery catheter insertion, monitoring of the hemodynamics, and management has gained resurgence in the era of valvular interventions and percutaneous mechanical circulatory support(MCS) for cardiogenic shock.  Post-procedure care for revascularized patients is one of the most important lesson for Fellowship trainees, as is early identification, and directed action in case of development of complications. Being integral to a heart team2 for complex decision making also allows contemporary interventional trainees to be involved in complex decision making, and working closely with the surgical team. With more patients requiring complex interventions in contemporary practice-often with need for atherectomy of a dominant coronary artery, and those with advanced conduction system disease-transvenous pacemaker placement is increasingly performed in the Cath Lab. Also pacemaker placement during transcatheter aortic valve replacements (TAVRs) forms an essential step of the procedure enabling deployment of the valve.  Assessment of managing patients with acute coronary syndrome including interpreting EKGs to identify hemodynamically significant arrhythmias emergently is definitely in the ‘day’s work’ for most interventional trainees,

When looking at structured training, the the COCATS 4 document3 has outlined some competencies for a budding cardiac critical care professional-and recognizes the importance of cath lab rotations in forming the foundation of solid procedural skills. The only skills outlined as those outside the realm of a general cardiology Fellowship were ‘Skill to place intra-aortic balloon pump emergently’-which most interventional trainees become competent at, and ‘Skill to perform endotracheal intubation’-which in most tertiary care institutions is done by anesthesia-and interventionists may acquire competency with additional training.

The Acute Cardiovascular Care Association (ACCA) of the European Society of Cardiology (ESC) have come-up with their own certification exam and a core curriculum4. In addition to the above, they have outlined need for identifying and appropriately managing renal dysfunction in critically ill patients. The focused interventional trainee gets ample exposure to preventing, identifying and treating acute kidney injury almost on a regular basis in this era of heightened awareness of limiting contrast, and contrast-sparing interventions. Also the document outlines the importance of early, aggressive and adequate treatment for pulmonary embolism(PE)-and most PE response teams across the nation are staffed and often led by an interventionist.

In summary, with additional training –interventional cardiologists, and those in-training, with appropriate interest should potentially be integral, and possibly in a leadership position in a critical care team of the future.

References:

  1. Miller PE, Kenigsberg BB, Wiley BM. Cardiac Critical Care: Training Pathways and Transition to Early Career. J Am Coll Cardiol. 2019 Apr 9;73(13):1726-1730.
  2. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization. EuroIntervention. 2019 Feb 20;14(14):1435-1534.
  3. O’Gara PT, Adams JE, Drazner MH, et al. Journal of the American College of Cardiology May 2015, 65 (17) 1877-1886.
  4. https://www.escardio.org/static_file/Escardio/Education-Subspecialty/Certification/ACCA/Documents/ACCA_Core_Curriculum.pdf . Last accessed April 19, 2019.
hidden

Cardiac CT: The Future of Diagnostic Cardiology?

As a medical student eyeing the field of radiology, the science of imaging of was all too seductive.  Ultimately, a love for cardiac physiology won me over, but an interest in imaging lingered.  As it turns out, cardiologists are part-time radiologists with expertise in a number of cardiac imaging modalities.

CT has become the latest frontier in cardiac imaging with a number of useful applications.

By now, coronary calcium scoring is a well-established tool for risk stratification in subclinical coronary artery disease.  Cross-sectional imaging is also useful for evaluating pericardial thickening in restrictive cardiomyopathy.  Beyond these traditional applications, newer techniques are poised to change the way we use CT to evaluate heart disease.

 

Coronary CT Angiography

Using fast, EKG-gated scanners, coronary CT angiography (CCTA) is a noninvasive means to detect coronary anomalies and obstructive plaque.  CCTA is a sensitive tool for excluding coronary disease, with a nearly perfect negative predictive value in the ACCURACY trial1.  However, specificity is poor and the presence of stents or calcium degrades image quality.

The specificity of CCTA is improved with FFR-CT (HeartFlow), a noninvasive method that mimics invasive fractional flow reserve measurements.  Computational fluid dynamics are applied to a 3D model of coronary anatomy in order to simulate the hemodynamic effects of stenotic lesions.  The PLATFORM trial2 showed how these technologies can safely reduce unnecessary catheterizations with no detriment to outcomes.

 

CT Myocardial Perfusion Imaging

CT myocardial perfusion imaging is also possible.  Indeed, a key advantage of CT is the ability to combine anatomic and physiologic evaluation in a single study.  However, exposure to radiation and iodinated contrast is an important consideration when comparing this to SPECT imaging.

 

As our diagnostic tools multiply, cardiac testing will become less invasive yet choosing the right study will become more complicated.  Cardiology is a fortunate field that controls much of its own imaging, but with the emergence of cardiac CT, we will need to collaborate with our radiology colleagues to push our fields forward in tandem.

 

References:

1Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol 2008;52:1724-32.

2Douglas PS, Pontone G, Hlatky MA, et al. Clinical outcomes of fractional flow reserve by computed tomographic angiography-guided diagnostic strategies vs. usual care in patients with suspected coronary artery disease: the prospective longitudinal trial of FFR(CT): outcome and resource impacts study. Eur Heart J. 2015;36:3359–3367. doi: 10.1093/eurheartj/ehv444.

hidden

Preventive Cardio-Oncology: The Rise of Prehabilitation

Figure 1 Prehabilitation: optimization of overall health, wellness, and fitness prior to initiation of therapies that might adversely alter fitness, strength, quality of life, or function.

Figure 1 Prehabilitation: optimization of overall health, wellness, and fitness prior to initiation of therapies that might adversely alter fitness, strength, quality of life, or function.

As I near the end of my job search process and prepare to review offers and sign a contract, it is absolutely incredible to me to consider that I am completing training at just the right time for me in cardiology. While sitting in a preventive cardiology team room, I overheard two exercise specialists describing a project that they plan to present in several weeks at a national conference. I overheard them use the word ‘prehabilitation’. While the word is not brand new in their professional world or even in cardiology, at that time the word was novel to me. I felt excitement rise within me as I recognized the word ‘prehabilitation’ as a concept that I have envisioned for quite some time to be key to what I would like to achieve and develop in the emerging field of preventive cardio-oncology. As a senior cardiology fellow, my training has been particularly enriched in cardio-oncology (see CardioOncTrain.Com), preventive cardiology, heart disease in women, and precision medicine. I plan to have a heavy emphasis on prevention in my practice, and with eventual incorporation of maturing tools in precision medicine. If you too are interested in preventive cardiology and cardio-oncology, you may want to consider a combined practice of preventive cardio-oncology.  If you are also interested in heart disease in women, then you may want to consider preventive cardio-oncology particularly in women, e.g., women with breast cancer.  Yes, that is quite focused, but can be an incredible niche.  Yet, let us take a step back from the idea of preventive cardio-oncology in breast cancer or any other cancer and first consider how far we have come in the broader field of cardio-oncology.

In the burgeoning field of cardio-oncology, one could argue that we are doing quite well as a community with epidemiology and management of cardiovascular toxicities from cancer therapies. Our ability to completely predict cardiovascular toxicity in individuals is still in progress. Nevertheless, the field has come so far regarding what we now understand about pathophysiology, risk factors, and incidence of cardiovascular toxicity. In particular, due to the continuous and rapid innovation in cancer therapies, cardio-oncology continues to grow exponentially. If you are interested in or planning to join the field, now is a great time!

While the main focus in cardio-oncology has been on secondary and tertiary prevention of cardiovascular toxicity and its sequelae, an era is approaching that may focus even more so on primordial and primary prevention of cardiovascular toxicity. What if we could figure out ways to prevent cardiovascular toxicity before it even happens? What if we can even avoid development of risk factors themselves? These two questions point towards a focus on primary and primordial prevention, respectively. Indeed, for decades we have been focusing largely on secondary and tertiary prevention in Cardio-Oncology. Perhaps it is now time to focus more on what would appropriately be termed preventive cardio-oncology, a merger between preventive cardiology and cardio-oncology.

A hallmark of preventive cardiology has long been cardiac – and in fact cardiopulmonary – rehabilitation. This usually would occur in the setting of secondary or tertiary prevention. As such, ‘rehab’ generally has at least a few purposes. One purpose is to help individuals get back to the level of cardiopulmonary function they had prior to their cardiovascular event. A second purpose is to actually optimize their cardiopulmonary function, regardless of their original preexisting starting point, and help them develop a sustainable lifestyle modification program that can hopefully help prevent another event. A third purpose is to provide support and camaraderie that can help individuals regain the confidence they need to develop and maintain heart healthy lifestyle habits, by knowing they’re not alone in the process. For young patients, such as young adult women with spontaneous coronary artery dissection, this third purpose can be particularly beneficial.

Studies are now showing that cardiopulmonary rehab can also be useful in patients who have completed cancer therapy – in a sense as their ‘event’1,2. This is in part because cancer therapies can impact the heart, vasculature, and lungs, as well as other organ systems. In addition, while undergoing therapy for cancer, individuals often tend to lose fitness, energy, strength, and motivation for lifestyle modification, which is entirely understandable. Studies are therefore also showing that individuals who pursue exercise in the form of ‘habilitation’ while undergoing cancer therapies will also often have improved fitness and cardiovascular function and outcomes following the completion of therapy1,3.

Notably, newer studies are suggesting that exercise prior to the initiation of cancer therapies can further improve fitness, strength, quality of life, and cardiovascular function during or upon completion of cancer therapy1,4. This concept of ‘prehabilitation’ is catching on and will most certainly become a centerpiece and hallmark of primary prevention and perhaps even primordial prevention of cardiovascular toxicities.

Essentially, we need to recognize the impact and power of hysteresis, which suggests that the cardiopulmonary fitness starting point for a patient diagnosed with cancer will determine their cardiopulmonary fitness endpoint after treatment for cancer. This of course is intuitive, but not usually the focus early on in cancer survivorship. Since one in three individuals develop cancer in their lifetime5, it would be reasonable to recommend that all individuals optimize their cardiopulmonary fitness and prioritize lifestyle modification to ensure a desirable cardiopulmonary starting point if ever one is unfortunately diagnosed with cancer. If we take a step back, we realize that is quite similar to the argument for optimizing cardiovascular health in the general population. One in three individuals dies from cardiovascular disease each year6. It is therefore reasonable to recommend that all individuals optimize their cardiovascular health and prioritize lifestyle modification to hopefully help avoid cardiovascular events. When we view (i) cardiopulmonary fitness after cancer therapies and (ii) cardiopulmonary fitness associated with cardiovascular health in the general population through similar lenses, it becomes clear that preventive cardiology and cardio-oncology could potentially come together in an emergent subspecialty of preventive cardio-oncology.

For all individuals, the overarching goal is optimal cardiovascular health based on life’s simple seven: diet, physical activity, obesity, cholesterol, diabetes, blood pressure, and cigarette smoking, in the context of non-modifiable and also nontraditional modifiable risk factors. For individuals with cancer, who become survivors at the moment of diagnosis7, additional goals are preserving  strength, endurance, quality of life, and function.

To achieve long-lasting success in preventive cardio-oncology, we will need to consider three Ps: protocols, partnerships, and payments. In this hot new field of preventive cardio-oncology in which you and I might be trailblazing, together we need to develop standard protocols that can be used across the nation – and in fact across the world – to provide the best care for our patients. We will need Scientific Statements and Guidelines as the backbone of our practice. To facilitate evidence-based prevention, we will need a combination of retrospective, cohort, and case studies, as well as clinical trials. We will need to be sure to practice team-based care and forge lasting partnerships among clinicians, exercise specialists, and others in order to guide patients along gentle, individualized pre-habilitation, habilitation, and rehabilitation care plans. Importantly, relevant payment structures will need to be developed and adequately compensated by government, state, and private insurance.

An exciting path is before us Early Career folks in preventive cardio-oncology, as we shape the opportunity to practice in cardio-oncology from the perspective of primordial, primary, secondary, and tertiary prevention in women and in everyone.

 

References

  1. SquiresRW, Shultz AM, HerrmannJ. Exercise Training and Cardiovascular Health in Cancer Patients. Curr Oncol Rep. 2018 Mar 10;20(3):27. doi: 10.1007/s11912-018-0681-2.
  2. Lee K, Tripathy D, Demark-Wahnefried W, Courneya KS, Sami N, Bernstein L, Spicer D, Buchanan TA, Mortimer JE, Dieli-Conwright CM. Effect of Aerobic and Resistance Exercise Intervention on Cardiovascular Disease Risk in Women With Early-Stage Breast Cancer: A Randomized Clinical Trial. JAMA Oncol. 2019 Mar 28. doi: 10.1001/jamaoncol.2019.0038.
  3. https://journals.lww.com/oncology-times/pages/articleviewer.aspx?year=2019&issue=02050&article=00014&type=Fulltext. Accessed April 4, 2019.
  4. https://www.acc.org/about-acc/press-releases/2017/03/08/14/42/history-of-exercise-helps-prevent-heart-disease-after-breast-cancer. Accessed April 4, 2019.
  5. https://www.cancer.org/cancer/cancer-basics/lifetime-probability-of-developing-or-dying-from-cancer.html. Accessed April 4, 2019.
  6. https://professional.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_503396.pdf. Accessed April 4, 2019.
  7. Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, Bandera EV, Hamilton KK, Grant B, McCullough M, Byers T, Gansler T. Nutritionand physical activity guidelines for cancer survivors. CA CancerJ Clin. 2012 Jul-Aug;62(4):243-74. doi: 10.3322/caac.21142.