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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?

 

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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!

 

 

 

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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.
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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.

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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.

 

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Fellow Focus: Peer Mentorship Program

During my first year of general cardiology fellowship, our program underwent an exciting transition – our incoming fellowship class increased from 6 fellows the previous year to 10 fellows in my class, nearly doubling the size of the fellowship. This growth was necessitated by the welcome addition of the West LA VA as a rotation site for house staff, which meant spreading our fellowship across 4 different clinical sites. While this gives our fellows the opportunity to train in a wide variety of clinical settings with different patient populations and pathologies, it also creates a very large fellowship program, with 30 fellows altogether. Although there are advantages to having a large program, a program this size poses the risk that fellows ultimately may not get to build the camaraderie that many acknowledge is a pivotal aspect of their medical training. Indeed, much of the education received during clinical training occurs through our peers.

At the beginning of my chief fellowship year, my co-chiefs and I chose to implement a new program within our fellowship to promote peer mentorship among our fellows. Inspired by an outstanding JACC article describing a peer mentorship program that was instituted in Columbia University’s Pediatric Cardiology fellowship,1 we created a similar program in which “Houses” were formed consisting of one fellow from each class. Each House would be led by its senior 3rd year fellow, who would also choose a faculty mentor for the group (Figure 1).

Figure 1: Schematic representation of the House system. Each pillar represents one “House” consistent of 3 fellows and 1 faculty mentor. Adapted from Reference 1.

Each House was advised to meet at least once each quarter, with each meeting organized by the senior fellow. Meetings were suggested to be informal, but discussion items, such as research opportunities, balancing family and fellowship, and exploring career paths, were recommended. Further, senior fellows were encouraged to take ownership of mentoring their respective 1st year fellows, particularly during the first half of the year.

After surveying fellows before and after the implementation of the House program, the results of the program were rather impressive. For instance, prior to the program, only 44% (4/9) first-year fellows said a senior fellow helped them during an early-year overnight call. Post-implementation, this number improved to 100% (10/10 first-year fellows from the next class). Further, first-year fellows were asked to assess their satisfaction with “Peer Mentorship” within the fellowship, and these ratings improved significantly after the House program implementation (Figure 2).

Figure 2: First-year fellow satisfaction for peer mentorship within the fellowship program.

Many more aspects were assessed in these surveys, as well as in surveys given to senior fellows and faculty members. These included measures of feedback frequency given by senior fellows and faculty on conference presentations and measures of academic productivity (abstract submissions to national meetings, peer-reviewed publications). While many other factors besides the House program may have contributed to the improved scores we observed on these surveys (perhaps even a placebo effect), the feedback we received on this program from fellows and faculty were overwhelmingly positive. As the program is far from perfect, we have found that it was easy to implement, sustainable, and effective at improving fellow satisfaction with our training program. As it continues into its second year, we hope that it will continue to improve, and more importantly, that it will further improve the fellowship experience within our program.

This past weekend, I shared our experience with this peer mentorship program with others as a moderated poster abstract at ACC.19 in New Orleans, Louisiana.2 For other large training programs looking for methods to improve peer mentorship, we believe our House system was effective and would be happy to share more details from our experience with those who are interested.

 

References:

  1. Flyer JN and Joong AN. Improving Peer Mentorship: A Novel Fellow “House” Program. J Am Coll Cardiol. 68:2907-10. 2016
  2. Hsu JJ, Flyer JN, Joong A, Small A, Vampola S, Yang EH, Watson KE. House of Cards: Implementation of a Formal Peer Mentorship System in an Adult Cardiology Fellowship Program. American College of Cardiology, Cardiovascular Training Section, New Orleans, LA. March 2019

 

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Tech in Cardiology

Tech in Cardiology

On a recent flight from San Francisco, I found myself sitting in a dreaded middle seat.  To my left was a programmer typing way in Python, and to my right was an oncologist flipping through a slide set on chemotherapy trials.  While this may sound like the beginning of a bad joke, I remember this moment because it got me thinking about the influence of tech on medicine.  The purpose of my trip, by the way, was to interview for a fellowship position in cardiology, a specialty with arguably some of the most impressive tech.

 

Wearables

Not to discount advances in medical devices (e.g. leadless pacemakers, bioprosthetic valves), the emergence of consumer-facing wearable devices is as trendy as ever.  Google recently collaborated with AHA to build its fitness app (Google Fit), which uses algorithms to quantify physical activity in terms of “heart points.”1  The Apple Health app now incorporates EKG capabilities, allowing patients to record episodes of arrhythmias—something I have certainly witnessed in cardiology clinic.2

 

Big data

Big data is an increasingly prominent component of clinical research, and a number of joint ventures with medical and tech leaders have emerged.  One Brave Idea3 is a research collaboration between AHA and Verily (Alphabet’s life sciences division) which uses genomics to study coronary artery disease.  Meanwhile, Verily’s Project Baseline4 is a massive longitudinal observational study—a modern version of the Framingham Heart Study.

 

Artificial intelligence

AI could eventually play a prominent role in medical diagnosis and decision-making.  The Stanford Machine Learning Group5 has developed a neural network that outperforms cardiologists in diagnosing arrhythmias on EKG—a significant improvement on existing algorithms which are often unreliable.  AI also carries vast potential in radiologic interpretation.  Already, Veril is using machine learning to interpret retinal images not only to detect diabetic retinopathy and macular edema but also to extrapolate information about cardiovascular risk.6

 

EMR

Electronic medical records represent an obvious space for tech innovation.  Fast Healthcare Interoperability Resources (FHIR) are making it easier to share health information across our disjointed EMR systems.  Providers are now able to push health data directly to patients’ iPhones using Apple Health Records.7  One can only speculate whether we will see a legacy software giant compete directly in the EMR space.

 

Cardiology and the rest of medicine has long excelled at basic science and translational research, but digital tech is increasingly creeping in.  We are in a tech zeitgeist, and this is good for both patients and providers.

 

References:

  1. https://www.heart.org/en/news/2018/08/21/google-just-launched-heart-points-here-are-5-things-you-need-to-know
  2. https://www.apple.com/healthcare/site/docs/Apple_Watch_Arrhythmia_Detection.pdf
  3. https://www.onebraveidea.org/
  4. https://verily.com/projects/precision-medicine/baseline-study/
  5. https://stanfordmlgroup.github.io/projects/ecg/
  6. https://blog.verily.com/2018/02/eyes-window-into-heart-health.htm
  7. https://www.apple.com/healthcare/health-records/
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Behind Our Backs: A Flurry of Complementary Health Approaches 

As a cardiologist who trained in a quaternary care hospital, I am used to treating the sickest patients, such as those with large heart attacks, shock and cardiac arrest.  When I go to my weekly clinic, I have to suddenly shift my focus. Much healthier people walk through the door and we spend the majority of the time discussing preventive strategies to reduce their risk of future heart events through prescription treatments and lifestyle changes.

In my clinic, I am exclusively focused on treating or preventing heart disease using a defined armamentarium of evidence-based approaches that I’ve learned over my years of training.  As healthcare providers, we set a cut-off of patient conditions and respective treatments that are “doctor-worthy.” Those are health complaints that are serious enough for us to treat, and their treatments have met high thresholds of evidence to make recommendation guidelines. The reality however is that health is not merely the absence of disease, and patient priorities regarding their health are not always aligned with our recommended item list. They realize that their priorities might be “non-doctor worthy,” so they turn behind our backs to online and community resources for guidance.

If you’re a healthcare provider, the next time you review a patient’s medication list, I encourage you to look at the number of naturals, vitamins, and supplements on it. When I did this exercise myself, I found that around 90% of my patients take at least one non-prescribed item, and often several of them. I then researched the statistics and found that my patients are not far off from the general U.S. population. More than two-thirds of Americans take a vitamin, mineral or supplement. Nearly half of older Americans take vitamins and minerals. Almost 18% of adults take a natural product, including the 7.8% of Americans who take fish oil.  This does not include complementary therapies such as acupuncture, massage, and mind-body practices which are used by more than 30% of adults.

This flurry of complementary health approaches is happening behind our backs. As a result, people are left unguided and sometimes misguided by a flourishing market. For example, there are thousands of ingredients, each being packaged and marketed in hundreds of products. For a single health condition, people can choose from a list of nearly a thousand products. The result is a fruit salad containing the effective and the ineffective, the safe and the unsafe, the appropriate and the inappropriate…

https://nccih.nih.gov/health/meditation/overview.htm

https://nccih.nih.gov/health/meditation/overview.htm

Turning our backs is not the answer. Complementary health approaches could be powerful resource to help with patient’s wellness. Integrating those approaches into mainstream medicine is key. This is why many top academic centers now have integrative medicine departments, and the NIH dedicates an agency for scientific research on the subject.

Guidance is critical for three reasons. First, it ensures that people only use complementary approaches when appropriate. This means that they do not replace treatments by their doctors with less potent or effective approaches and they do not not delay seeking medical care when necessary. Second, it is important to distinguish ingredients and practices with the highest level of evidence for effectiveness for a condition (the minority), from those with evidence for lack of effectiveness or those with insufficient evidence (the majority). Third, guidance regarding safety of naturals, vitamins, and supplements as well as their interactions with prescription medications would help avoid detrimental consequences.

Climbing the ladder starts with a first step. I recently started asking my patients about their vitamins, naturals, and supplements, including why they take them, how they learned about them, and what are the results they’re achieving. You should do the same. You’ll be surprised!

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Precision Medicine: Is It The Future For Heart Diseases?

Cardiovascular disease is famously known as a disease that “rose from relative oblivion to the uno numero killer worldwide.” Globally, there were an estimated 422.7 million cases of cardiovascular diseases (CVD) and 17.92 million deaths in 2015. Over the past 50 years, significant efforts have been made to suppress or even eradicate cardiovascular diseases. The figure1 to the left is adopted from Havlik and Feinleib illustrates the various strategies applied to reduce the deaths associated with coronary heart disease, which are also relevant for CVD more broadly.

While discussions are aimed towards who or what deserves the credit for this decline, the prevention and cure still remain obscure, highlighting that we need a shift in management of these patients. Currently, the approach to CVD treatment is evidence-based medicine. This supposes “one size fits all,” that individuals with common symptoms share the same disease and will respond to similar management strategies, and ignores that patients are unique at large. Moreover, current healthcare is expensive and inefficient at most part.

 

Precision Medicine

Precision medicine represents a new approach where patient care is targeted towards prevention and cure considering individual differences of patients. The goal is to identify what’s best for a particular patient than what benefits the average population. As figure to the left shows, it is aimed to achieve through the accumulation of personalised data (clinical, biological, environmental & genetic) and computed predictive models that will inform logical therapy for each patient2.

The success of precision medicine relies on extensive clinical testing, electronic health records, genetic profiling, big data sets, and novel analytical and implementation methods to create a person-specific information that can then be used to identify an optimal intervention with minimal risk.

The benefits of precision medicine included better medical management, safer dosing options, reduced adverse events, reduce inappropriate procedures and medical interventions, and improved patient management.

 

Precision Medicine in Cardiology and Challenges

Cardiology has been slower than other disciplines in pursuing precision medicine. This is now changing as several attempts are beginning to take shape. Efforts are in place to define distinctive patient groups, identify molecular targets, develop risk models and evaluate the effects of drugs through genome scale metabolic models.  But there are several barriers in precision medicine that also limits the widespread application and advancement of it in modern medicine. First of all, the multidisciplinary approach requires synchronisation between several departments, calls for advances in technology, regulatory oversights, big data storage, and ethical concerns with the use of genetic information storage.

There is also a large concern that precision medicine is just like stem cell revolution, where the promise to become what it is may not be achievable but will have incremental gains on a case by case basis. But by comprehensive understanding, united efforts, clinical application, evidence-based practices and technological advancements, precision medicine could change the entire landscape of cardiovascular health care system in the near future.

 

References:

  1. Jones DS and Greene JA. The decline and rise of coronary heart disease: understanding public health catastrophism. American journal of public health. 2013;103:1207-1218.
  2. Duffy DJ. Problems, challenges and promises: perspectives on precision medicine. Briefings in Bioinformatics. 2015;17:494-504.

 

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The Invaluable Importance of Mentorship Throughout Your Career as a Female Cardiologist

Featuring an Interview with Dr. Stacey Rosen recipient of the American Heart Association (AHA) 2018 “Women in Cardiology Mentoring Award”

 

Lack of Females in the Cardiology Field

Over 36% percent of Internal Medicine residents are females. Despite this fact, females account for less than 20% of the Adult Cardiologist workforce in the United States and account of less than 10% of Interventional Cardiologists in the United States1. Recruitment and retention of many talented female cardiologists remain a constant challenge and is due to a variety of reasons. Some of these reasons include the thought that cardiology is a grueling field that does not allow for work life balance and is often inhospitable for females desiring to start a family. There is also difficulty in retaining females in the field due to increased gender discrimination in the field1. In fact the Professional Life Survey conducted by the American College of Cardiology had reported that many female cardiologists in the field report a high level of career satisfaction which has not changed over the last 20 years1. However, there are many challenges that have remained the same for female cardiologists over the last 2 decades, such as gender discrimination, the need to arrange for paid or unpaid childcare, being single and not having any children1. In addition, there has been aging of the workforce and there are increasingly more female cardiologists practicing in an academic and/or hospital employed setting rather than in private practiceand therefore having less autonomy over their work schedule and environment.

 

Need for Effective Mentorship For Female Cardiologists and the American Heart Association Women in Cardiology Mentoring Award

 

There is an ever increasing need to not only recruit more females in the field of Cardiology, but to also retain many talented female cardiologists in the field. Finding a good mentor and fostering good mentorship is invaluable for many females throughout their career in Cardiology. The Women in Cardiology Committee of the American Heart Association (AHA) values the importance of good mentorship and as such bestows the Women in Cardiology Mentor Award that is sponsored by the AHA Council on Clinical Cardiology to Cardiologists who have been recognised as having an outstanding record of effectively mentoring and supporting female cardiologists. Dr. Stacey E. Rosen,  Endowed Chair and Vice President for the Katz Institute for Women’s Health at Northwell Health, Partners Council Professor of Women’s Health at Hofstra North Shore-LIJ School of Medicine at Hofstra University and Professor of Cardiology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell is the recipient of the 2018 AHA Women in Cardiology Mentoring Award. She has mentored and supported numerous female cardiologists, and in the following interview, I had the honor of discussing the following questions with Dr. Rosen.

Courtney could we add a hyperlink to the AHA WIC mentor award nomination site?

 

What attracted you to the field of Cardiology?

Dr. Rosen: “I am the first member of my family to become a doctor. I am the daughter of educators and while in high school , I volunteered at Memorial Sloan Kettering in the pediatric child-life center. I thought that the medical field would allow me to pursue various professional options including clinical care, education, advocacy and research. I felt one could never be bored in medicine! As a student in the 6-year medical program at Boston University, we dissected a bovine heart and I was so amazed by the “simplicity” of the structure. Nothing else seemed intriguing after that – my only important decision was between pediatric cardiology and adult cardiology.”

Who were the inspirational persons that influenced this decision?

Dr. Rosen: “The Division of Cardiology at Boston University School of Medicine in the 1980’s – and ever since – was extraordinary. The faculty at Boston City Hospital (BCH) demonstrated commitment and passion for those in the underserved neighborhoods near BCH and the faculty at University Hospital were national respected clinicians , investigators and educators.”

Who were your mentors in Cardiology and how did they contribute to the advancement of your career?

Dr. Rosen: I completed Internal Medicine residency and a chief resident year at Montefiore Medical Center in the Bronx, and was privileged to work with an impressive Division of Cardiology. Hildrud S. Mueller, MD and James Scheuer , MD taught me the importance of rigor and attention to detail in both clinical work and research. I presented my first oral presentation with John Fisher, MD – the recently retired division chief – and learned to perform a complete and thorough cardiac exam with Mark Menegus, MD.

As a fellow at Cornell – New York Hospital, Mary Roman, MD, Peter Okin, MD, Paul Kligfiled, MD, and Richard Devereux, MD fostered my fascination with imaging and non-invasive cardiology. Doppler physics was replacing hemodynamic assessment in the cardiac catheterization lab and I was hooked!

Finally, my first faculty position was at Mount Sinai Medical Center. Working in the echo lab with Martin Goldman, MD was an extraordinary opportunity. He inspired me to view echocardiography as a critical tool to enhance optimal patient care and helped me to develop the skills to become a lab director in my next position.

You have mentored many colleagues in the Cardiology field and have been valued by many as a great mentor, which led to your selection for the 2018 AHA Women in Cardiology Mentorship Award. What are the factors that mentees should consider when selecting a mentor?

Dr. Rosen:Mentees should consider several critical factors:

  • Compatibility – Choose someone with whom you are compatible but not someone who is a “mini me“ of yourself. You do want a mentor who will challenge you, be comfortable providing feedback, and teach you to internalize and utilize feedback to advance your goals.
  • Trust – You want a mentor whom you can trust – you will likely be sharing important and perhaps confidential conversations. It is also critical to know that you must earn a sense of trust from your mentor.
  • Expertise – Your mentor does not have to have the most senior titles or positions, but should have the requisite expertise to help you advance your career and help navigate challenges.
  • Willingness – A great mentor is one who is devoted to helping you develop a vision and is delighted to share knowledge and wisdom. It should be someone who is a good listener and has sufficient time to commit to the relationship.

 

Would you recommend having more than one mentor?

Dr. Rosen:  “Absolutely! But do remember that the mentee needs to commit sufficient time to each relationship in order to optimize the value of the partnership

 

How can mentees truly harness the power of strong mentorship?

Dr. Rosen:First – choose your mentor wisely and respect the relationship. Meet with individuals who you think may be good mentors and ask questions that will help you make a decision and get advice from friends and colleagues. Networking is often the key to identifying good choices.

Second – do the work and always respect the relationship! Discuss the goals and expectations of the partnership, as well as the process for communication, meetings and feedback. Be respectful of your mentor’s time and build trust immediately.

 

What are the differences between mentorship and sponsorship?

Dr. Rosen: Simply put – mentors advise you, while sponsors advance your career. A mentor is someone who can offer support, guidance and feedback, and allow you to develop your personal vision. A sponsor is earned – not chosen. A sponsor connects us to opportunities and advocates for our career advancement. It has been said that women are over-mentored and under-sponsored.

 

 

How has the experience of being a great mentor for so many colleagues contributed to your own career and personal growth?

Dr. Rosen: My late father was a middle school principal and my mother is a retired school teacher who taught in an underserved community in Brooklyn, NY. I learned from them the deep satisfaction one gets from teaching and advancing someone’s skills and abilities. I am also so grateful to MY mentors and get great satisfaction from “paying it forward.”  I am certain that I have learned as much from my mentors as they have learned from me!

What have been the 3 most rewarding experiences you have had throughout your career?

Dr. Rosen: As the director of the fellowship program at Northwell, I have had the privilege to work with dozens of trainees. I have helped impact their professional success and hopefully, the joy they find from practicing cardiology.

As chief of cardiology at Long Island Jewish Medical Center, I was able to rebuild a division that had weathered a hospital merger. Together with my colleagues, we completely revamped the division.

As a lifelong advocate for women’s heart health, I get enormous pride seeing the impact we have had on women’s health through improved clinical care, advances in gender-specific investigation and through advocacy and changes in policy. I know that our work is not done and that we still need to continue to advance women’s heart health agenda.

How has the field of Cardiology evolved over the duration of your career with regards to gender diversity and inclusivity of women in Cardiology?

Dr. Rosen: Unfortunately, our field has not advanced sufficiently when it comes to gender diversity and inclusion in Cardiology. Currently, fewer than 25% of cardiology fellows are female and fewer than 15% of board-certified cardiologists are women. Now that women are 50% of medical school graduates, the importance of developing a strategic approach to this lack of diversity is critical, or we will see a true talent drain in the near future. The good news is that both the American Heart Association and the American College of Cardiology have focused on lessening this disparity by better understanding the barriers facing female cardiologists and by making changes that will encourage young women to choose Cardiology.

What advice would you give to females considering a career in Cardiology?

Dr. Rosen: I can honestly think of no better choice! As clinicians, we can develop long-term longitudinal relationships and have an enormous impact on health and longevity. I believe that cardiology combines the best features of primary care and subspecialty medicine. As investigators, we can have a lasting impact on individuals and communities. Cardiology is also a field that is perfect for those who enjoy advocacy and advancing health policy improvements. I urge women NOT to eliminate Cardiology as a possibility because of concern about the challenges. Find the area of the field that you love, without fear or compromise, and then make decisions that will allow you to fulfill your vision of work – life integration.

References:

  1. Lewis SJ, Mehta LS, Douglas PS, et al. Changes in the Professional Lives of
    Cardiologists Over 2 Decades on behalf of the American College of Cardiology Women in Cardiology Leadership Council. J Am Coll Cardiol 2017