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WELLNESS MATTERS

American Heart Association Early Career Guest Blog

Sherry-Ann Brown MD PhD FAHA

WELLNESS

The World Health Organization defines wellness as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity”. The terms in this definition inspire similar words such as continuous (state), whole (complete), tangible (physical) and intangible (mental), as well as togetherness or community (social).

 PANDEMIC WELLNESS

Indeed, during the pandemic, we often say or hear, “We are all in this together”. The global community has rallied around each other to get through the coronavirus disease of 2019 (COVID-19) well. In the midst of a nation in turmoil with pandemics juxtaposed (coronavirus and racial and ethnic inequities), we find ourselves in the middle of it all as physicians.

SAFETY & WELLNESS

Along with everyone else in medical authority, we encourage those around us and all we serve to distance physically more so than socially. We want people to remain social, to enhance wellness. Yet, we need that socialization to be safe and physically distant, to foster tangible wellness.

 WELLNESS NOT CANCELLED

We encourage everyone to recognize that conversations, relationships, love, songs, reading, hope, joy, getting outdoors, music, family, and self-care should not and will not be canceled. This is the good stuff. The intangible components of wellness.

WELLNESS HEROES

So many of us in health care are sacrificing this period of our lives or in fact our very lives so that our patients can be whole. This altruism that led us here is continuous and indestructible by the #rona. Many of us turn to visual wellness inspired by COVID-19 to help capture the essence and sentiments of these challenging times. Art and other forms of creative expression of what’s inside of us or in society can motivate us to see more, be more, and serve more.

These matters at hand are crucial to help maintain our state of complete physical, mental, and social well-being. If we are honest with ourselves, we recognize that most of us live at best in a state of incomplete well-being. Yet, we can stand together against cancellation of our will and empower each other on this journey to wellness. It’s never been a destination. It’s always been a process that we continue to learn daily.

 

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

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Work life balance- Is This a Myth?

Work-life balance: for many in Cardiology it’s an elusive idea. Now, our worlds of work and “life outside of work” are even more blurred among Zoom meetings and facemasks.  However, over the years, I have learned 3 important concepts (Figure 1) that has made work-life balance POSSIBLE, not just a myth.

Figure 1. Outlining the three key concepts of work-life balance.

Concept #1: Who are you outside of work?

As Cardiologists, researchers, educators, and team members we know the day, night, and weekend hours that define our careers. However, how do you describe yourself outside of work? Who are “you” after shedding the scrubs and white coat, away from the office, hospital, and lab?   Beyond Cardiology, what are your interests?  The answers to these questions help to define you and an important part of your life. When we lose our work-life balance, we are losing a part of ourselves.

To begin recapturing your interests, look at your calendar over the next month, and schedule small increments of time (just 5-10 minutes!) to reconnect with your personal interests (of course staying safely physically distant for now).  These baby steps will move you closer to capturing the “life” in work-life balance.

Concept #2: “Balance” is dynamic.

How do you define “work-life balance”? Is it an equal distribution of time? Is it a certain quantity of time for specific activities?

Work-life balance is very similar to the field of Cardiology – it is constantly changing. For most people, work-life balance will not mean that there is “equal” or balanced time between work and personal life. Especially in Cardiology, our job usually engulfs the majority of hours in a week – clinical duties, grant deadlines, presentations, emails… and the list continues.  However, for work-life balance, one of the goals is to “balance” the transition from work to “life outside of work”. This means your presence, attention, and focus should completely shift from work to your personal interests and interactions. Work-life balance is beyond physically leaving the job, but balancing the mental transition to fully shift away from work.  It will take practice to avoid checking email or mulling over work.  The amount of time between work and your personal life will remain dynamic; but the “balance” is your ability to commit your focus and attention to those precious personal moments, just as you do for work.

Concept #3:   You are Responsible for You! 

Cardiology requires you to constantly learn and practice to achieve and maintain competency. You are upholding a professional commitment. The same commitment is required to grasp work-life balance.  You have to make a personal commitment to you!!  It is not sufficient to just “wish for it”.  We cannot expect anyone else to understand our needs or create our work-life balance.

To reframe this important concept, consider your self-care and work-life balance as critical as filling your car with gas (or charging your car):  you cannot function without it!  Your personal commitment has to be as strong as your professional commitment.   No, it’s not easy, but it is possible.  Some find it helpful to be accountable to a colleague or friend, check-in regularly (set a reminder) about small steps to promote work-life balance. We understand our responsibility to patients.  Now, it’s time understand your responsibility to you!

During these uncertain times of the COVID-19 pandemic, healthcare workers are working longer hours and under even greater stress. It is normal to feel overwhelmed. Now, more than ever, it is important to find creative ways to focus on precious moments and commit to your well-being!  Below are 5 tips to stay committed to yourself and safely connect with others:

  1. Take three minutes.  Listen to your favorite song, dance while nobody’s watching, or take a few extra minutes in a hot shower. You do not need a long time to be kind to yourself.
  2. Join a Virtual group or class.  Physical distancing and long work hours can be very isolating. Take advantage of the numerous virtual options to safely connect with others who have similar interests.
  3. Share and listen.  Try moving beyond texting and talk on the phone. Commit to that moment, engage in the conversation and focus on listening.  The human connection remains very powerful to strengthen our mind and body.
  4. Protect Your Time. I know it is easier said than done. However, learning to set boundaries is critical to sustain your commitment to work and participate in the joys of life.
  5. Be Kind to Your Body. Find time to sleep, eat healthy snacks, and participate in small amounts of physical activity. Mental health and physical health are equally important.

In summary, work-life balance is a journey, not a destination.  Remember, that “balance” in work-life balance is dynamic – the amount of personal time will change, but your commitment and focus to that time should only grow.

 

About the Author:

Heather M. Johnson, MD, MMM, FAHA, FACC is a Cardiologist & Preventive Cardiologist at the Christine E. Lynn Women’s Health & Wellness Institute at Boca Raton Regional Hospital/Baptist Health South Florida.

 

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

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From Race-Based Medicine to Fighting Structural Racism

“Race is the child of racism, not the father.”

-Ta-Nehisi Coates, Between the World and Me.

BiDil, a combination of isosorbide dinitrate and hydralazine, was approved by the FDA in 2005 to treat heart failure in African Americans— the first race-based indication in the U.S. Though some groups lauded this move as a win for the underserved Black community, controversy soon emerged— and rightly so. Why did the researchers come to the conclusion that this combination of drugs worked better for one racial group than another? Why did the FDA take the action to approve it this way? The answers were not reassuring.

Did you know that there is no genetic basis for discrete racial categories? If not, this is likely because of what you were taught in training. It’s time to unlearn some falsehoods! The concept of race is not, in fact, biological, but social. It is not race, but racism that creates and perpetuates inequities.

Race-based medicine is bad medicine. Period. Dorothy Roberts gave a seminal TED talk in 2015 explaining this concept. The persistent myths that characteristics like pain tolerance vary by race are damaging and false. It is up to us, as clinicians and scientists, to dismantle the racist structures and processes within health care and within our larger communities that harm people of color. We cannot allow the fiction of biological racial difference to obscure the reality of racism.

Race can be an important variable to include, analyze, and understand in science and medicine, but not because of biology— because of structural racism. Diagnosis and treatment should not differ by race. Rather, social determinants of health must be part of all the care we provide, and all the research we conduct. We need to fundamentally reexamine the characteristics we use to ensure diversity and external validity. Yes, we need data on race, that that’s not enough.

As we see stark and alarming differences in COVID-19 among racial groups, the realities of racism’s health impacts are writ large. Living and working conditions, rather than biological differences, drive the differential infection and death rates. We, as the next generation of scientists and clinicians, can seize this moment to create lasting change and move toward health equity.

How?

  • Question assumptions. Race-based decisions in medicine are often due to force of habit, tradition, and education. Ask why and if there’s not a good reason, stop. Why do we give race as a defining characteristic in our case presentations? Why do we calculate creatinine clearance differently? Why do we prescribe differently?
  • Assess your biases. Try the Harvard bias test, for example. No one is without bias! Seek out training. Eradicate blind spots. Form accountability groups with colleagues. This work can be uncomfortable, but it’s necessary.
  • Solicit input. Whether you are a researcher or a clinician, the community you serve needs to be involved. Do not assume you always know what’s best. If you ask, and listen, you will discover the values and priorities of the community. Trust-building takes work and time. Demonstrate trustworthiness and remember that iatrophobia is justified by history.
  • In research, define race and specify the reason for its inclusion. Use a sociopolitical rather than biological framework, and name contributing factors. Name racism and related forms of oppression that may be operating[1].
  • In clinical care, assess and address social determinants of health. Advocate for equity-focused community practices: food banks, suspension of evictions, support for access to broadband internet to increase access to healthcare and education, and provision of paid time off for sick leave & quarantine, among other actions. Identify needed resources and provide them.[1]

 

Sustainable change is never straightforward, never easy, and rarely rapid. As early-career professionals, we have many years to fight this fight. Let’s not waste any of them.

 

References:

[1]Boyd, R., Lindo, E., Weeks, L., & McLemore, M. (2020). On Racism: A New Standard For Publishing On Racial Health Inequities. Health Affairs Blog.

https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/?utm_medium=social&utm_source=twitter&utm_campaign=blog&utm_content=Boyd&

[1] Haynes, N., Cooper, L., & Albert, N. (2020). At the Heart of the Matter: Unmasking and Addressing the Toll of COVID-19 on Diverse Populations. Circulation, 142 (2).

https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.048126

 

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

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A New Way To Participate

One of the characteristics of attending medium to large scientific sessions is the time-honored act of… running from room to room trying to catch glimpses of talks that interested you, but have of course ended up in different rooms, minutes apart. Many of us have done this, and to an extent, I don’t mind it! I can always count on being able to reach my daily step count targets whenever I’m attending a conference, without needing to set aside 30mins dedicated to a walk or morning run.

The current global health crisis has ushered in new and accelerated inevitable changes in the way science research is conducted, disseminated, and discussed within the community. Each one of these aspects has shown the malleable and highly valued ability for science, and society, to adapt to new paradigms of work. There have been many challenges and losses in the way research has been affected (a partial or total work-from-home status doesn’t translate to equal productivity for lab based work). But at the same time, this ongoing pandemic response has also provided a launching pad for some very innovative and future friendly adjustments.

Today I’ll focus on one of those changes, related specifically to conference attendance. This is by no means a novel idea, but I find myself thinking a lot about it, and I’d like to share some of those thoughts. Online based conferences have existed before Covid-19 became a house-hold idea and reality. Even more novel are Social Media “conferences”, an example being the Royal Society of Chemistry putting on the #RSCPoster Twitter Conference earlier this year (planned in early 2019, before covid).

The fact of the matter is, the movement to have scientific meetings and conferences be better adjusted within the online space has been gathering momentum for years. I for one, have served as “Twitter Ambassador” for a handful of conferences over the past couple of years, because conference organizers, participants, and various communities, have found tangible and positive effects of having conferences be more open, interactive, and far-reaching, beyond the walls of the hotel or center that brings together the in-real-life attendees.

(photo taken by Mo Al-Khalaf, 2020)

This year the Basic Cardiovascular Sciences headline annual meeting, better known this week as #BCVS20 is a fully virtual conference. As an early career molecular biologist researching mechanisms of heart disease, this is one of the “can’t miss” events on my calendar. My previous experiences for these type of conferences has been very rewarding, and advantageous in propelling my research and career. Before Covid-19, I was very much looking forward to this meeting scheduled to be in Chicago. When it was announced that the meeting will become fully virtual, I knew that there will be some experience that’ll get lost in the format change. But I also appreciated the diligent and effective leadership that made this call, because this was definitively the right call, for the safety of the attendees, and all the workers that would be involved in administering and pulling off a successful meeting (a meeting that brings 1000+ folks, in one building for a few days).

So far, I must say I find the #BCVS20 experience to be quite rewarding. It is different, and the limited and reformatted ways of networking and engagement takes a little bit of time to get used to. But overall, I believe there is great potential to make this format, or better yet, a hybrid format where both online and in-real-life parallel options available, a very appealing and appropriate next step in the evolution of how these types of meetings can be conducted. The ability to cater to a worldwide audience, and the convenience provided to allow attendees to participate and learn from field experts without the difficulty of planning a trip, is without a doubt an advantage to students and early career professionals, who do frequently face difficulties in attending such meetings.

One thing I note: Unlike past conference going experiences, I definitely need to put in the 30-minute daily jog before or after the day’s sessions… because there is no need to run from room to room to catch talks that you’re interested in… it’s all just a mouse click or head turn to a second screen away!

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

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On Blood and Bridges: Remembering Congressman John Lewis

I was recently reading a Time magazine article, which included previously unreported coverage of Congressman John Lewis, the Civil Rights icon, who succumbed to cancer last week. When asked why he continued to tell his story, he responded:

          …it affects me — and sometimes it brings me to tears. But I think it’s important to tell it. Maybe it will help educate or inspire other people so they too can do something, they too can make a contribution.

As history tells us, Congressman Lewis, then a 25-year-old leader of the Student Nonviolent Coordinating Committee (SNCC) and coordinator of “Freedom Rides,” helped lead a march for voting rights from Selma, Alabama towards the state capital of Montgomery over the Edmund Pettus Bridge. The protestors were met with force by the state and local police. Mr. Lewis’ skull was fractured by the strike of a club. His was just one of numerous injuries endured by protestors. This fateful day—“Bloody Sunday”—March 7, 1965, is commemorated annually. People at home watched in shock and dismay as the protestors were brutalized. The ferocity of the images pricked the consciousness of the nation and resulted in many joining the cause. Their humanity wouldn’t allow them to sit passively and watch other humans decimated.

          I gave a little blood on that bridge

Fast forward 55 years…

On March, 13, 2020, the US declared a state of emergency in response the COVID-19 pandemic. US citizens across the country were advised to shelter-in-place to slow the spread of the novel coronavirus that had invaded our shores. Away from typical distractions of work, traffic, and the hustle of everyday life that usually occupies our minds, many sat fixated on the television as we watched cases and mortality increase. Amidst this vacuum, we were confronted by shocking visuals: a video of a police officer kneeling on the neck of an unarmed black man for 8 minutes and 46 seconds. In the context of social distancing, Americans were challenged to face themselves. The reality of racial inequities in the US, previously shielded by a cognitive dissonance (e.g., “we don’t know what happened before the video”), was now proximal and palpable. We had nowhere to go. We had to sit with it. As in the 1960s, we were outraged by the inhumanity – as we should be.

As a Black woman, it’s difficult to think of a time when I wasn’t completely aware of race relations in this country. Seeing others enlightened and even corroborating the stories of injustice in the US that I have known to be true as early as middle school was encouraging. However, I’d like to challenge our comfort a bit further. The same racism that cracked the skull of a peaceful protestor and kneeled on the neck of an unarmed man is the racism that ignores a black mother’s request for medical attention, dismisses the reports of pain of a black patient with a clearly broken bone, or assumes that black bodies die sooner as a matter of biology. Racism is both the lifeblood and the heartbeat of racial disparities in health and healthcare.

Racism built the communities in which we live, the public schools we are able to attend, and the types of businesses in our neighborhoods that provide basic necessities, such as food. It built our Capitol building and the home of our nation’s chief executive. It even built our most premier educational institutions and their medical and research empires. Racism lives in our silence as much as (if not more than) it lives in violence. It quietly sits within the foundations of our institutions and leaches its contaminants into our social spaces in a way that is both proliferative and reinforcing.

So, where do we go from here? Congressman Lewis once recounted a story of hearing Dr. Martin Luther King, Jr. speak. He spoke of:

          …the “spirit of history” inviting him to take his place.

Though it may mean protesting, it may also be interpreted as taking an active role in addressing health disparities in our respective places. If you’re reading this, your place is probably in healthcare, research, policy, or in the community; if not, it could also be finance, criminal justice, human resources, or administration. Regardless of your position, everyone can and MUST make a contribution if we desire to see the best of what our society could be. As during shelter in place, if we can steady ourselves long enough, we will hear the echoes of humans in despair beckoning our individual and collective humanity to act. Together, we have to “slow the spread” of racism—a pandemic1 that stretches as far back as our nation’s earliest years.

Let’s honor Congressman Lewis. This is our bridge. Let’s be human.

 

References

  1. Williams DR and Cooper LA. COVID-19 and Health Equity—A New Kind of “Herd Immunity” JAMA. 2020;323(24): 2478-2480.

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

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Housing and Health Equity in Cardiovascular Disease

So far, 2020 has been a year of public health crises. By early spring, it was apparent that people living in socio-economically disadvantaged areas were being hit hardest by Covid-19 [1]. In these same areas, people across the United States took to the streets protesting the murder of George Floyd, an unarmed Black man – in police custody [2]. In the words of James Baldwin, “It demands great spiritual resilience not to hate the hater whose foot is on your neck, and an even greater miracle of perception and charity not to teach your child to hate.”, and we as a country are still looking for this resilience [3]. Among the many consequences of this year’s events, these tragedies have really prompted a long, hard look at our healthcare system. One recently published article that was particularly heartening to read was the American Heart Association’s Council on Epidemiology and Prevention and Council on Quality of Care and Outcomes Research Scientific Statement on “Importance of Housing and Cardiovascular Health and Well-Being”. It outlines how housing stability, quality, affordability, and neighborhood environment are linked to cardiovascular disease. The statement doesn’t shy away from evidence of how increased psychosocial stress in the Black community and other social determinants of health are associated with cardiovascular health disparities.

The world has changed profoundly over the past year and while we continue to strive to show charity to others in our everyday encounters, I look forward to reading more research that will help inform how we as a community can better address health inequity.

References:

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

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COVID-19: Looking for a silver lining

It’s July 2020, and the COVID-19 pandemic shows no signs of ending. A friend recently asked me if I ‘d ever imagined such a scenario when I decided to do medicine. The answer is no. None of us, not even our mentors had trained for a pandemic of this magnitude. Still, while this is still far from a “when life gives you lemons make lemonade” scenario, looking for those elusive positives in this global catastrophe is just one way to remain optimistic in the face of such unprecedented adversity.

So unprecedented, in fact, that as our hospital committees initially met to formulate new standards of operation, I found that as fellows in training (FIT) and (very) early-career physicians, my colleagues and I had much to contribute in terms of protocols and guidelines, even in guidance documents of national societies. With the need for rapid update of data and protocols in an extremely volatile situation, a FIT and early career COVID response team was formulated, to submit recommendations on a variety of aspects ranging from infection control, requirements for personal protective equipment (PPE), zonal divisions of hospital, allocations of responsibility and treatment protocols of infected staff, based on international guidance. It was something I had never done before, and taught me the important aspects of healthcare administration, outside of clinical work, and a renewed appreciation for what those in management do (It’s not easy to keep everyone happy!)

These testing times were also an opportunity to lead with empathy, help cultivate an essence of team spirit, and collective resilience as a team. When we had an initial outbreak of cases among our healthcare workers in April, I learnt what real leadership is – the importance of being transparent, even in the face of chaos. I learnt what it means to be present and to lead with empathy, to “be there” for junior colleagues and nurses. In the sea of misinformation, I also learnt to speak up for what was right, with authorities, rectify misconceptions especially relating to evidence-based treatment and push for the changes that were needed. Even now, everybody is still apprehensive. In more ways than one, the pandemic offered an opportunity for a much-needed change of culture within work environments, and more open discourse between peers and colleagues, a positive change that we hope will last beyond these difficult times.

While we educate ourselves on everything that isn’t cardiology, most formal training especially in terms of procedures, is still on hold as we respond to the pandemic. Locally, we have somewhat adapted to a virtual learning platform for residents. However, practising in South Asia, exposure to cutting edge technology and insights from international leaders in the field has generally been limited to the ability to be able to travel for in-person meetings overseas. Despite the chaos, the learning must not stop — while restrictions to international travel may have blocked the networking opportunities of in-person meetings, in a strange paradox, the online interactions might just have brought the world closer.

Just this week, I attended webinars from 2 different continents, without having to apply for any educational leave. Moreover, most of these virtual meetings and webinars are free of cost, and especially for fellows, the opportunity to participate and interact with world-class faculty. (Disclaimer: They are by no means a substitute for the real deal, but I’m trying hard to count the positives here!).

Like so many others I know, 2020 was supposed to be “my year” too. But tough luck. It’s not easy having to endure the stress of colleagues and family falling sick, and having to battle on, knowing fully well that it might very well be you, next. It’s important to embrace the situation and cultivate positive vibes, engage in self-care and your own wellness, however limited the options may be. By not being able to travel to see family, or even out of town for a break, it has been overwhelming to say the very least, but I can safely say that I’ve probably helped more people in the last few months, than I have on all my years as a doctor. That would probably be the biggest silver lining of them all—the opportunity to serve so many people. But in uncertain times like these, we’re all apprehensive. We don’t know when this will end. It’s a marathon, not a sprint, and we need to find the silver lining in this new normal, for the sake of our own sanity. At the same time, it’s also imperative that we consolidate the positive effects of the pandemic, the growth it has led to, and incorporate them into our practice as physicians and people.

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

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CardioPulmonary Resuscitation (CPR) in the Time of COVID-19

As we continue to see the increasing number of coronavirus disease 2019 (COVID-19) cases and amid the second peak of this pandemic in the United States (US), everyone from physicians to the general public should know how to approach and perform basic life support (BLS) with certain precautions and modifications of routine BLS protocols for patients with suspected or confirmed COVID-19 status. Importantly, rescuers should always balance the immediate needs of patients with their own safety. Several recently published articles have demonstrated that many patients with COVID-19 can present with cardiac arrest or experience cardiac arrest while hospitalized. In this post, I am going to share a few points on recommended modifications in order to ensure a safe yet effective CPR protocol for our patients.

  • Reduce Provider Exposure to COVID-19

Resuscitations carry added risks to rescuers and healthcare workers for many reasons. CPR involves performing numerous aerosol-generating procedures, including chest compressions, positive-pressure ventilation, and establishment of an advanced airway [1]. It is important to keep in mind that these viral particles can remain suspended in the air with a half-life of around 1 hour per some reports and can be inhaled by those nearby [1]. In addition, resuscitation efforts require numerous providers to work in close proximity to each other and to the patient; thus, the advised social distancing protocols may not be applicable.

Strategies

  • Before entering the scene, all rescuers should don personal protective equipment (PPE) to guard against both airborne and droplet particles.
  • Limit personnel on the scene to only those essential for patient care.
  • In settings with protocols in place and expertise in their use, consider replacing manual chest compressions with mechanical CPR devices to reduce the number of rescuers whenever it is available and in patients who meet the manufacturer’s height and weight criteria.
  • It is important to clearly communicate the COVID-19 status to anyone arriving to the scene and when transferring patients to another setting.

 

  • Prioritize Oxygenation and Ventilation Strategies with Lower Aerosolization Risk
Strategies
  • Attach a high-efficiency particulate air (HEPA) filter securely [Figure 1], if available, to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths.
  • After healthcare providers assess the rhythm and defibrillate any ventricular arrhythmias, patients in cardiac arrest should be intubated with a cuffed tube at the earliest feasible opportunity. Connect the endotracheal tube to a ventilator with a HEPA filter when available.
  • Minimize the likelihood of failed intubation attempts by doing the following:
    • Assign the provider/approach with the best chance of first-pass success, and
    • Pause chest compressions while intubating with minimal disruption.
  • Video laryngoscopy may reduce exposure to aerosolized particles and should be considered.
  • Once on a closed circuit, minimize disconnections in order to reduce aerosolization.
  • Barriers can be used to minimize spread of the particles during aerosol-generating procedures (Figure 2).

Figure 1: A high-efficiency particulate air (HEPA) filter (arrow) is securely attached to any manual or mechanical ventilation device to lower the risk of aerosolization before giving breaths [2].

Figure 2: Example of barriers potentially used to minimize the spread of the particles during aerosol-generating procedures [2].

  •  Consider the Appropriateness of Starting and Continuing Resuscitation

Like any cardiac arrest, it is important to know when resuscitation efforts are likely to be futile. Although the outcomes for cardiac arrest in COVID-19 are still unknown, the mortality for critically ill patients with COVID-19 is high, especially with increasing age and comorbidities, particularly cardiovascular disease. As such, it is critical to consider all these factors in determining the appropriateness of initial and continued resuscitation efforts, to weigh the likelihood of success against the risk to rescuers.

Strategies
  • Address goals of care with patients, or their proxies, in anticipation of the potential need for increased levels of care.
  • Healthcare systems and Emergency Medical Services (EMS) agencies should institute policies to guide frontline providers in determining the appropriateness of starting and terminating CPR for patients with COVID-19 on the scene, early in the process. The risk stratification and potential policies should be communicated to patients (or proxy) during discussions of goals of care.

In conclusion, there have been modifications to the routine CPR protocols in patients with suspected or confirmed COVID-19. With the increasing number of COVID-19 cases, it is very important, for us as physicians and for the general public as well, to review recommended modifications to BLS protocols and apply them where possible, in a step to win the battle against this virus during these unprecedented times!!

References

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

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Residency and Fellowship Interviews During COVID-19

As early-career physicians started residency and many physicians began fellowship training this month, it’s hard to think that recruitment for next year’s residency and fellowship classes is beginning soon. The COVID-19 pandemic has disrupted many of our usual routines and processes. Similarly, this year’s residency and fellowship interviews are going to be different than previous year’s interviews. The Association of American Medical Colleges (AAMC) has now recommended that all interviews for medical school, residency, and fellowship be conducted virtually this year.

There are many potential benefits of virtual interviews, including but not limited to:

  • Lowering the financial burden of traveling and housing during interviews.
  • Not having to spend time traveling and potentially being able to interview at more programs without physical distance complicating scheduling. For example, one can interview at a West Coast program one day and interview at an East Coast program the same or following day.
  • Missing fewer days of work/school/rotations for interviews.
  • Not having to frequently pack and unpack and worry that you forgot to pack something important.
  • Not having to tour a campus during the winter months (especially in heels) or drive in the snow.
  • Sleeping in your own bed before an interview.

For those of you who will be interviewing virtually for residency and fellowship programs this year, I have gathered some advice from my Cardiology fellowship program director (@rhythmkeys) and program coordinators (@UmnCardsfellow). Of course, also ask your mentors and other colleagues for advice. Remember that this is a new experience for both you and the programs so there may be some road bumps and steep learning curves.

  • Be open-minded. Fight the urge to stay at the same training institution because of unfamiliarity with a new city and/or program.
  • Spend time researching the programs and cities that you are interested in. Many programs (including ours) will have virtual tours/videos of our facilities and city. Take advantage of the publicly available information about a program/city (i.e. Google Maps is a great way to explore a campus/city in the comfort of your own home).
  • Ask more questions about a program and environment than you usually would if you were interviewing in person in order to get a feel for the culture/environment of a program since this may be more difficult to determine when interviewing virtually.
  • Try to consider the interview as “normal” as possible. Be professional. Be prepared. Login into your computer and the virtual meeting early in case you encounter technical difficulties.
  • Do not worry too much about technical difficulties. Virtual interviews are also new for the programs. Most programs will have contingency plans in place if there are technical difficulties.
  • Here is some great advice on how to master the art of virtual interviews from fellow AHA early career blogger, Dr. Barinder “Ricky” Hansra (@RickyHansra).
  • Reach out to current or past trainees at a specific program. Most of us are happy to talk about our experience in the program. If any of you are interested in the Internal Medicine or Cardiology fellowship program at the University of Minnesota, please feel free to contact me! Interviewees at our program will be able to still meet with current fellows during their interview days and I assume that this will be a part of interviews at most programs.

Depending on the experience of the programs and applicants this year, perhaps virtual interviewing for medical school, residency, and fellowships will continue in the future. Interviewing virtually may be more convenient and cost-effective. Best of luck to all of you interviewing for medical school, residency, fellowships, or jobs this year and stay safe!

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

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Diversity, Equity, & Inclusion Are Not Just Buzzwords— Practical Steps for People Who Teach

Those of us who work in science, healthcare, and academia often find ourselves teaching others, whether or not we set out to be educators. Residents teach medical students. Nurses precept new nurses. Graduate students teach undergraduates. And faculty roles for researchers and clinicians also include teaching loads. Yet for many of us, our training did not include any grounding in how to teach. We might not have brought the same theoretical rigor and deep expertise to our teaching that we have to our other roles. Now, as we are teaching in a world of rapid change and increased awareness around structural racism, we must approach equity in our educational practices with intention, but some among us may not feel prepared and we are already overwhelmed. We are already adapting to enormous change related to COVID-19, and the intellectual energy required to reexamine another entire part of your professional life can feel paralyzing. It can feel like an impossible task that there will never be time for.

Despite these barriers, I strongly believe that you can start (or carry on) right now, no matter where you or your institution are in the struggle for antiracism. Here are some immediate suggestions to make your practice as an educator explicitly equity-focused and antiracist, for folks who teach in all kinds of contexts (these topics work for self-education, too):

No matter what format you teach in, there are some basic practices you can adopt to establish a “floor” for equity and inclusion.

  • Can you pronounce the name of everyone in your group? Do you know what they prefer to be called and what pronouns they use? Some teachers inadvertently avoid calling on students because they haven’t bothered to learn these things and don’t want to make a mistake. Don’t be that teacher.
  • How much time does every person (including you) speak? Is anyone taking up more space than they need? Now, the era of video calls, some platforms can actually show you how much time each individual speaks for, and this can be eye-opening. I encourage you to actually measure and observe this at least once. It can be surprising to see how some groups are consistently dominating conversation at the expense of others.
  • Have you adopted principles of Universal Design for Learning in your teaching? If not, now is a good time to start. UDL is a set of principles that improves the experience for all learners by focusing on accessibility and flexibility and assuming diversity.
  • Are you yourself familiar with concepts of antiracism? Have you examined your own privilege, bias, and ignorance? Are you learning?

For those who teach in a classroom or seminar format, Dr. Valerie Lewis has shared some more tips:

  • Include an equity-focused reading with every topic (e.g., if you are teaching about asthma, include an article about disparities related to race and social determinants of health).
  • Message that equity isn’t a specialty; every field should address it as part of ongoing professional practice.
  • Create a dedicated class session for equity, and if possible do two— one at the beginning to frame the ideas for learning, and one towards the end to integrate the content you’ve covered with broader ideas around equity. This can help to lay the groundwork for ongoing reflective professional practice.
  • Audit your syllabus: can you include AT LEAST one scholar of color every week? You might have go-to reading lists that you’ve inherited or developed, but if your list doesn’t measure up, you can change it. Go to PubMed or google scholar. Look at professional societies. Ask colleagues. Crowd-source on twitter. This is a key way to amplify voices— remember that citations are academic currency.
  • Don’t be afraid to make mistakes. Be open with students that you are doing this intentionally and why, and take feedback.

This is not a checklist or an exhaustive resource for inclusivity. But I hope that if you are floundering as you try to figure out how to teach with a focus on equity and inclusion, that you’ve got a good first foothold. Let’s keep the conversation going— I’d love to hear more ideas. Hit me up on twitter @TheKnightNurse and let me know what you are doing.

“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.”