COVID-19

hidden

COVID-19 Stage 2: Embracing Progress, Cautiously.

Mo Al-Khalaf, PhD

In these early days of May 2020, it seems like “change is in the air”. In the northern parts of this planet (myself based in Canada’s capital), winters’ cold, icy grip has thawed, and signs of nature and life are starting to be spotted everywhere. Of course, no mention of the year 2020 is complete without placing the Covid-19 pandemic in its proper context within the topic discussed. I’ve been seeing a lot of articles and discussions online that too easily link the “spring is upon us” and “life is getting back to its normal rhythm” ethos with the recent positive stories about Covid-19 infections. Reports of daily hospital admittance and mortality rates dropping are signs of progress indeed, specifically in nation states that were hit early and hard by the disease at the start of the year, and in the ensuing first few months.

While this is welcome and encouraging news, I can’t shake the feeling that people are either consciously or subconsciously paralleling the arrival of seasonal change, an end of the typical academic school year, and the learned attitudes of past years, onto what this 2020 calendar year will be like, moving forward from this stage. Undoubtedly, overall status of the Covid-19 pandemic is now changing, with factors like spread rate seemingly decreasing (in spots), knowledge about the virus increasing (everywhere), and local and national healthcare systems all working and adjusting to better handle the situation (with some exceptions). This, in addition to coordinated social, governmental and economical efforts, working in concert to prevent a much worse outcome from unfolding, all indicate advancement and positive aspects of where we stand at the moment, in early May of 2020.

                                                      (Image from pixabay.com CC-0)

However, and you knew I was going to bring up the “however” adverb! Equating what normally is the care-free, and bright-sunshine attitude of previous years to where we are this year, at this stage in the pandemic, is simply not appropriate and could be dangerous. There are still many unknowns about how SARS-CoV-2 may change with the seasonal transitions, not just within the northern hemisphere where we are coming out of winter and into spring and warmer weather, but also minding how will the seasonal changes affect the southern hemisphere, where the temperature changes go from warmer to cooler at this time of year. There are also questions remaining about how different cities and nations are implementing the various step-wise stages of coming out of the strict physical distancing parameters, which helped limit the size of the surge of infection. Will certain districts and cities experience a second wave of infectious spread? Will citizens be able and willing to go back into physical distancing status if needed? Those and many other questions are still left unanswered presently, and it’s too difficult to forecast with the limited data we have at this stage, in early May of 2020.

Having said that, I still want to bring back the sense of positive momentum we are presently experiencing. From a bird’s eye view point: We the people of this planet, united, are more informed, have a better handle over, and are able to deal with the Covid-19 crisis today much better than we were a couple of months ago. Together we can and will progress into the desired advantageous state of preparedness and better reaction to SARS-CoV-2 infection, and resulting disease, this is a fact. We just need to continue to investigate, learn, and plan appropriate steps to take, so that we can all safely reduce the dangers that still are posed by the virus, and take note and find ways to reduce the pain and loss that our communities have experienced so far, and moving forward. Only through those careful steps, and planning ahead, would we really feel like “spring is in the air”, and not a minute before then! Be safe, stay healthy, and care for one another.

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

The Importance of Maintaining the Public’s Trust in Science and Medicine

Sasha Prisco, MD, PhD

Often, and especially during the COVID-19 pandemic, there is a plethora of misinformation that is spread. We have all probably seen at least one scientific publication, news article, social media post, or YouTube video that is spreading information that is not accurate. Every day, I am bombarded by conspiracy theories or unfounded scientific claims while skimming through social media. During a time when information is rapidly disseminated through the internet, it is often difficult to extinguish a lie.

Sometimes, misinformation is inadvertently spread by well-meaning individuals who have not had the time or energy to confirm or critically appraise the information shared. “Liking”, “retweeting”, and/or sharing a post from a colleague/friend/relative is facile. We have all probably “retweeted” or shared certain articles and posts that we did not completely critically assess before sharing. Sometimes dissecting truth from fallacy is difficult, especially when information is disseminated widely. Our current technological advances with the internet and social media magnify opinions, good and bad. Occasionally, one may think, if multiple people I know and/or respect are sharing certain information and the number of posts about the false information outnumber those on the truth, then the misinformation must be true.

Occasionally, misinformation about science or medicine is shared by members of our own scientific and/or medical communities, which can sometimes be more damaging to our profession. For example, more assumed credibility may be given to a scientist or healthcare provider, even if his/her expertise is not in the area that is commented on. Conspiracy theorists may continually reference these “experts” to support their arguments. Sometimes, refuting incorrect information requires massive efforts but may never eliminate the long-lasting negative effects of the misinformation. For example, Andrew Wakefield’s infamous, now retracted scientific article that was published in The Lancet and falsely claimed an association between the measles, mumps, and rubella vaccine with autism is unfortunately still being referenced to support arguments against vaccinations even though multiple studies have overwhelmingly refuted the claims made in the retracted article.

With less malicious intent, some misinformation may be spread by the media or others in reference to research articles. Certain conclusions of research papers are sometimes not justified by the data presented due to inadequate sample size, biases, issues with the experimental design, etc. During a pandemic, since rapid dissemination of scientific and medical information is needed, there is frequently a tradeoff with the scientific rigor and reproducibility of the results. Since access to papers in preprint servers are available to the public, the media and public figures may tout certain research findings as truth when they have not been vetted by the peer-review process. A fellow AHA early career blogger, Dr. Allison Webel (@allisonwebelPhD), recently wrote an outstanding blog discussing the importance of the peer-review process (https://earlycareervoice.professional.heart.org/in-defense-of-peer-review/). Of note, even peer-reviewed articles are not free from research misconduct and incorrect conclusions. There are many articles retracted from high impact journals. Before the development of the internet and social media, critiques and feedback of research findings were typically only discussed at scientific meetings or at other selective venues (e.g., local conferences/presentations, journals typically not viewed by lay people, etc.). Now, these debates occur in the public arena with beneficial and negative aspects and frequently with nonexperts. These public debates may dilute the truth when unfounded comments are perpetuated.

What should we do about the spread of misinformation? Propaganda and false information are always going to be spread but we should try to mitigate their breadth and potential damage. On an individual level, researchers should thoroughly assess their results and determine whether their data are valid and whether the claims they make in publications are justified by the data before presenting the findings to the public. Limit overreaching conclusions. Scrutiny of results by authors and the research community is essential to the scientific process. Developments and advances in science often occur when findings are reproduced either within a specific lab/group or by other labs/groups and this is especially important to realize during a time when a deluge of single-center, small sample size papers are published about the COVID-19 pandemic. Dr. Elizabeth Knight (@TheKnightNurse), another fellow AHA early career blogger, recently calls to attention the scientific lessons learned from the current pandemic (https://earlycareervoice.professional.heart.org/evidence-whats-good-whats-good-enough-whats-dangerous-lessons-for-now-and-later/).

How do we influence other people’s opinions? Internal changes are often easier to make than changing other people’s opinions. However, we are all likely an influential source of information within our own social circles and networks. We may feel more comfortable directly communicating with people we know to correct misinformation. Altering the opinions of people who we do not personally know is more challenging. At minimum, as researchers and healthcare providers, we should not intentionally try to deceive the public. Flagrant dishonesty from researchers and/or healthcare providers may erode the public’s trust in our profession, possibly to a greater extent than a nonexpert’s comments. We all make mistakes and honest misunderstandings and misinterpretations can affect all of us. However, deliberately lying and abusing the influence of one’s position as a scientist or healthcare professional is more offensive. I do not know how best to address colleagues who blatantly mislead the public. If an individual we personally know is deceiving others, we can directly communicate with him/her about the impact of the misinformation. Depending on the extent of the damage created by an individual in our professional community who is propagating false information, should we review his/her ability to maintain as a member of our profession?

What are your thoughts on how we can preserve the public’s trust in science and medicine?

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

A new and evolving health struggle for Heart failure patients: COVID-19

Michel Ibrahim, MD

It’s safe to say we are not living in normal times.  This is Heart Failure (HF) in the time of the coronavirus disease-2019 (COVID-19). Patients with COVID-19 and preexisting cardiovascular disease (CVD) are at an increased risk of severe disease and death. Moreover, infection has also been associated with cardiac injury such as acute myocardial infarction (AMI), myocarditis, and stress-induced cardiomyopathy leading to subsequent cardiogenic shock (CS) requiring advanced heart failure therapies. There is a bidirectional relationship between viral upper respiratory traction infection(URI) and worsening HF with an increase in hospital re-admission rate as previously noted with influenza. Patients with HF are especially susceptible to influenza-related complications, including acute decompensated HF and secondary pneumonia. Furthermore, HF is associated with greater in-hospital mortality and adverse clinical outcomes. With around 1 million confirmed COVID-19 cases and counting in the US, one would expect an increase in heart failure admissions. Over the past several weeks as the number of COVID-19 admissions increase, the number of patients admitted with heart failure admissions have been at their lowest, which raises the following question: Where are all the HF patients?

We can speculate that people are terrified at home so they are not showing up to the emergency departments. Patients could be slowly accumulating fluids and getting into a decompensated state. On the other hand, being less active, they could also have been experiencing less symptoms. First it was influenza season now overlapping with a COVID-19 pandemic. It would be expected to see an increased number of HF admissions.  It is suggested that we might be experiencing the calm before the storm when it comes to HF decompensation requiring hospitalization. The alternative is that social distancing is the remedy that we have long been waiting for to help decrease heart failure exacerbation and hospital re-admissions rates.

On one bright note, during a telehealth cardiology visit follow up with a long-term patient with chronic systolic heart failure known to have been admitted several times during the past year secondary to medication non-adherence, who admits that he has been feeling great. He takes all his medications religiously now, including his diuretics. He states that the fact that he stays home, he doesn’t have to worry about going to the bathroom to urinate so often when he gets out of the house, therefore he doesn’t miss any of his diuretic doses. He is also compliant with diet as he doesn’t eat out as often as he is used to. He admits that he stopped going out to fast food places. This is one very small sample. On the other hand, on another telehealth visit, there is a patient with newly diagnosed Non-Ischemic Cardiomyopathy and HF with reduced ejection fraction, who is been followed for up-titration of guideline directed medical therapy. It was a challenge to safely increase the dose of his medications without vital signs and avoiding to have the patient physically get to a laboratory to get blood work done. As of now, no major changes were made in the patient current management. Of note, patient did ask about holding angiotensin-converting enzyme (ACE) inhibitors because of what he heard from another source. Once more, no changes were made to the medical regimen and it was explained that it has been recommended based on different society guidelines and expert consensus report, to continue with ACE inhibitors1.

COVID-19 times are dynamic and medical information is constantly being updated. This is an ongoing discussion as the clinical data comes in. As the pandemic evolves and more telehealth visit under our belts, we will continue to find out more. Although as our health care system is currently fighting the COVID-19; we must brace ourselves for the aftermath whether our patients are dying at home, or slowly decompensating. Only time will tell.  As we are flattening to curve with social distancing, our patients with chronic conditions like HF are waiting at home with so much uncertainties surrounding their current and future medical care. “When life gives you lemon, make lemonade”.

The following suggestions can be useful when taking care of heart failure patients during these unprecedented times. (Figure 1) With COVID-19, we should let our HF patients know although social distancing is essential, they are a higher risk population for a complicated course if infected. It is important to inform them on when to seek medical care, whether it’s to contact a health care provider, call emergency medical services, or go to the emergency department. Although, prevention remains the best medicine. They should take the extra step in precautions and follow the latest recommendations from their local department of public health as we should always remind them of what those recommendations consist of via our telehealth visits.  From a cardiologist stand point, it is important to remain available whether it is via email, pager and/or more frequent telehealth visit if possible.  If they don’t have a scale and/or automatic blood pressure machines, it should be suggested to obtain them along with a thermometer from their local pharmacies. With a phone camera, it is feasible to assess Jugular Venous Distention, pitting edema. In addition, with weight trends, blood pressure and heart rate, clinical decisions could be made.  If available, assessment of data via CardioMEMS can also be very helpful in making medical decisions. Desperate times call for desperate measures.  This is too shall pass. If this is the calm before the storm for our heart failure patients, we should be ready when it hits remembering the sun always shines after a storm.

Figure 1. Heart Failure Care Suggestions During COVID-19

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

 

 
hidden

COVID-19: The Road to Recovery

Barinder Hansra, MD

The disruption COVID-19 has caused globally is nothing short of mind-blowing and extremely fatiguing. On a daily basis, new information is released about economic declines, healthcare burdens, and the ever-changing social distancing norms. Across the US, there are varying degrees of social distancing, shelter-in-place recommendations, and acceptance from the community on steps going forwards. We have recently seen protests to open the country and at times horrific images from the community we are trying to protect. No matter where you may stand on these issues, we can agree the road to recovery from this pandemic for America will be long and challenging. The work going forward will require continued teamwork to keep Americans healthy. Here are a few of my thoughts, in no particular order, that we should keep in mind.

  • Pediatric population: the recent decline in outpatient availability has reduced primary care milestones. Many children are delayed in getting their vaccinations as a result of COVID-19. Plans of efficiently having children receive their vaccinations will be instrumental, especially those who will be of school age.
  • Elective procedures: during this pandemic, in efforts to reduce potential exposure various procedures have been postponed. All across medicine, we have delayed elective cardiac catheterizations, ablations, numerous surgeries, and even radiological imaging. Some institutions have started to plan to have extended operating room hours or even full surgical days on the weekend. All divisions will have to consider the same to be able to catch up with the outpatient procedures. Of course, a tremendous amount of resources will need to be dedicated to this endeavor which adds another layer of complexity.
  • Future clinic visits: something we will have to keep in mind is if we will have clinic days where we only see COVID-19 positive patients. Keeping patients in the waiting rooms safe from potential sources of infection will be of utmost importance. Many epidemiologists believe there will be a second surge but it’s hard to predict it’s impact. Of course, the challenge in America is the lack of universal testing therefore there can be patients who have COVID-19 but were never identified.
  • Health Care Reform: the COVID-19 pandemic in America has highlighted the pitfalls of our health care system. A big share of Americans are uninsured and we as citizens carry more medical debt than our counterparts from other developed nations. And one of the single biggest problems, which is largely American, is cost. In my short career, I frequently meet patients who do not seek medical care due to the costs associated with routine care. I’ve had patients fight with me to use their own medications because the same medications in the hospital setting are exponentially more expensive. The downfalls of the American health system, which already placed us behind our peers on many medical outcomes, have been exposed in this outbreak. I don’t know what the right course is moving forward but I hope to be a part of it.

We are continuing to fight the COVID-19 pandemic with all of our strength and energy, but we have a long road ahead of us. If we continue to work together, collaborate, and utilize our resources efficiently, we will continue to be successful.

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

Conferences in the Time of COVID

Christa Trexler, PhD

As with pretty much everything else, conference season is going to look a lot different from last year due to COVID-19. Conferences have already switched gears to go completely virtual to meet this challenge but still give scientists the opportunity to share their work with the world. Initially, I was a little bummed about the need to switch meetings to a virtual format — but I then realized that there are also some really great advantages to this situation.

As a new mother, I had already resigned myself that I wouldn’t really be able to participate much in conferences this year, but now that has completely changed. I’m actually going to attend three meetings, including the AHA BCVS conference in July, which I am really excited about. While it would be great to see everyone in person and I know that it won’t completely be the same without the social interactions many of us look forward to, the virtual format provides science opportunities to many that otherwise would have missed out. It’s important in this strange time to celebrate the positives. To get more insight on how to make the best of a virtual meeting, check out fellow blogger Shayan Mohammadmoradi’s latest piece — it’s filled with great tips!

In addition to conferences going virtual, seminars at universities and professional organizations have done the same thing. Once it was apparent that COVID-19 was changing the face of the world, The International Society for Heart Research quickly organized a virtual seminar series that has been keeping researchers from all over the world updated on the latest science. Check out the schedule here to attend any meeting you want via zoom from your home!

If you are planning a meeting, going completely virtual may seem like a daunting task, but since so many have started to work out the kinks to the online format, it’s becoming easier to find resources to help you make the event a success. Additionally, before COVID-19 took hold, many scientists were already pushing the community to move to a virtual system to combat climate change, so this switch may have been inevitable. Online meetings can be just as enriching as the in-person events that we are used to — we just have to keep an open mind.

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

Evidence: What’s good, What’s good enough, What’s dangerous? Lessons for now and later.

Elizabeth Knight, PhD, DNP

COVID-19 has created a complex environment for health research. In an evidence vacuum with a clinical imperative to act, we have few choices. They include relying on analogues (such as SARS or MERS), trying treatments based on theoretical biological plausibility, relying on anecdotal evidence and case reports, and rushing evidence from small studies that may have significant limitations into print. There is a need for answers that are definitive but also rapid: a condition that science as we currently practice it can’t satisfy. Additionally, peer review relies on content-area experts, which are hard to find for a rapidly evolving area when potential experts are also stretched thin with clinical and research roles. The result is that evidence may look different from what we are accustomed to.

Some healthcare practitioners and scientists have reacted with alarm when low-quality studies have been published by normally meticulous journals. Are we abandoning the RCT, they ask? Is appropriate statistical analysis no longer required? Does the name of a prestige journal no longer guarantee rigor? Is low-quality evidence worse than no evidence at all? Is it wise to publish clinical observations in a newspaper rather than a medical journal? Who is responsible when a public (or public official) not equipped to recognize the limits of early evidence spreads misinformation? Are resulting adverse events or medication shortages partially the responsibility of the publication? The researcher?

These are debates worth having, and there will be compelling arguments on both sides. No matter your stance, though, there will be an impact on the future of science.

Lessons include:

  • Critically reading studies and understanding their strengths and limitations remains a valuable skill. Just because something is in print doesn’t mean it should be in practice. Scientific education in all disciplines needs to continue to focus on this skill.
  • Perhaps the standard glacial pace of evidence dissemination can, in fact, improve. Faced with undeniable urgency, the mechanisms of publication are adapting. Turnaround time measured in days or weeks rather than months or years is possible.
  • Lots of content related to COVID-19 from academic and lay publications alike is open-access— because it is seen as for the public good. Perhaps that perception can broaden, and alternative payment structures will make science more accessible.
  • The translation of basic science to clinical application (bench to bedside) can move rapidly when needed. As my fellow blogger Sasha Prisco has noted, there are currently administrative barriers that hinder this work, and their long-term necessity may need to be reevaluated.
  • Real-time information sharing and collaboration occurs through multiple channels beyond academic journals, including social media sites.

Have you considered the potential impact of this pandemic on the future of scientific publication and knowledge dissemination? Has it changed your ideas about publishing, research, evidence-based practice?

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

In defense of peer review

Allison Webel, PhD

The generation of knowledge, through rigorous, established systematic methods has informed much of our progress in the past few centuries. Science guides all aspects of healthcare today including how we develop the new medications, therapeutic procedures, and non-pharmacological interventions that have improved the quality and duration of human life. Many of the crucial gates in the scientific journey- funding, ethical approval, and dissemination- are guarded by the process of peer review; a process that is increasing under attack in our current hyper-reactive, digital, media cycle.

Peer review is the critical appraisal of a scientific work by those who have requisite knowledge to evaluate one or more aspects of the work. It is a panel of experts in the related field who understand the importance and novelty of the questions under consideration and the rigor and trustworthiness of the methods proposed or employed to answer that question.

Peer review takes time. Time to find agreeable reviewers with the right expertise, time to review and think about the science, and time to determine how to weigh those critiques against the community’s need for information. From the early days of the novel coronavirus pandemic, this balance of time needed for peer review and unquenchable public thirst for rigorous information has been dominating the conversations at leading medical and scientific journals around the world. To better understand how these decisions are made and what we as clinicians, scientists, and health care consumers need to consider when reading and sharing emerging science, I spoke with Dr. Joseph Hill, the Editor in Chief of Circulation one of 12 AHA Journals.

Even though peer review is an established practice, it is important to start by questioning why we should even do it. Unquestionably, the value of thoughtful peer review is that it enhances the quality of the science. “We [the AHA journals)\] handle approximately 20,000 manuscripts a year and with extraordinarily rare exceptions, the paper always gets better with peer review”.

Having now published many of my own scientific manuscripts, I know the pain of peer review well. “They” missed that detail on line 176. “They” clearly lack the expertise to evaluate my work. “They” kept this manuscript for 8 months before sending their disposition! However, I also know that some of the best revisions to my papers have come from generous peer reviewers. Reviewers who volunteered to spend their time reading my papers and think deeply about my findings in the context of larger literature. While painful, the constant assessment and evaluation of our science is critical to improving the quality and impact of our work.

Prior to the coronavirus outbreak, up to 10 experts, including peer reviewers, statisticians, and editors, would review a manuscript for Circulation. But the need for up-to-date information about the epidemiology, pathophysiology, and treatment of COVID-19 challenged Circulation’s editorial team to move fast. While recognizing that it’s “hard to do good science in a war zone”, the quality of published science cannot be compromised in times of crisis. Dr. Hill continues, “We are walking a fine line between trying to get the information out as quickly as possible but we recognize that [in clinical science] we could make it worse and could do harm. So we have to maintain our high standards but function at a high velocity.”

High velocity seems an understatement. After an initial call for high-quality COVID-19 related papers, the editorial team has done over 300 fast track reviews, contributed to a curated coronavirus and cardiovascular disease collection, and conducted 17 interviews with experts working on the front line around the world. All in the past month. This work is exhausting but done with great energy by a team inspired to advance “cardiovascular science for the good of humanity, especially during these times of urgent challenge, anxiety, and forthright resolve.”

Peer review is the best process we have for evaluating science; but peer review is done by peers- busy, human, distractible peers- who will make mistakes. This is why many reputable journals require an editorial screen and at least two peer reviews before it can make a decision on a manuscript. Scientific volunteers do this work. Which brings us to what you, as an early career professional can do. Peer review relies on us—all of us—to sign up to review, accept the invitation to review, and spend the time carefully doing the review. You may wonder if you have the expertise to peer review for Circulation or another AHA Journal; you likely do and you should. Dr. Hill remarked that “some of the best reviews I’ve seen are from early-career scientists”.  If you are interested in helping to contribute to peer review and the sharing of good cardiovascular science, considering signing up to be a journal reviewer in your AHA Science Volunteer Form or emailing Dr. Hill your interest in reviewing for Circulation.

 

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

Physicians Shouldn’t Be Heard Only During a Pandemic

Adham Karim, MD

I know that COVID-19 has dominated the headlines for quite some time, and I’m sorry in advance, but yeah, this is another COVID-19 article. I’m not an infectious disease expert, and I’m not here to talk about the possible health benefits of black seed oil, vitamin C, or Alex Jones’s anti-covid toothpaste.

The anti-vaxxer movement and the virulent spread of e-cigarettes helped highlight what happens when physicians and scientists are silent on social media – pseudoscience and flat out bad advice rise to fill the void. Of course both of these movements have swung in the other direction as more knowledgeable voices found prominence, but that’s not without many unfortunate cases of measles and vape induced lung injury first causing people to second guess the misinformation.

With our current situation, there are a LOT of learning points. Chief amongst them is what happens when doctors stay out of (or get involved in) public policy. The national stockpiles were woefully understocked. The pandemic response team was dismantled (in 2018). The CDC lost huge amounts of funding. The list goes on and on. On the other hand, having an experienced physician in the room where decisions are made has had a significantly positive impact. Of course, like vaccines, statins, and social distancing, it’s difficult to quantify the impact of something when all you’re left with is the absence of a bad outcome.

What’s not difficult, is to learn from what happened with this outbreak. We’ve seen a rapid shift towards telemedicine adoption, and a lag in the deployment of testing kits. We’ve also seen that rapid adoption of a potential wonder drug treatment (hello Hydroxychloroquine) might actually result in MORE deaths, and make it difficult for people with lupus and rheumatoid arthritis to get refills on their HCQ prescriptions. Society as a whole has come to realize.

As a trainee, I’ve read heart wrenching stories about people in my position forced to work with inadequate PPE, and ultimately succumbing to this virus. I agree that medicine is a field that demands sacrifice, but I disagree that someone who signed up for this job should accept improper protection at the risk of their own life. In my own program, residents have come down with the coronavirus despite adequate PPE; so I can only imagine how those with less equipment must feel like. Having spent time on the Covid unit myself, I got a taste of what my friends in New York and Chicago were dealing with on a larger scale, and an every day basis for the past several weeks. Of course, I’m fortunate enough to work in a state that was not in the top 3 hit by coronavirus, and whose leadership includes a pro-active governor and an experienced physician.

We need to be more vocal on the policy level – and while it may not be as sexy as deploying a stent into a thrombosed LAD or as intellectually titillating as making a breakthrough in the science of atherosclerosis, it is arguably just as necessary. We don’t need to be running for office, but it certainly wouldn’t hurt to write to one’s Congress representative (https://www.house.gov/representatives/find-your-representative), and sign with your name and job title. Let them know how many people’s lives you impact, and tell them to provide you with aid. I’m not just talking about masks and gowns. I’m talking about hazard pay and disability benefits. If I suffer complications related to coronavirus, I most likely got it because of my job, not because I went to the grocery store one time last week. I want to know my family won’t get sacked with a huge bill because of that. As a physician, I’m fortunate enough to expect an increase in pay when I finish training, but I work alongside many other healthcare providers who are not so fortunate – they shouldn’t have to worry about financial calamity just for doing their job and helping their fellow countrymen.

Several iterations of coronavirus relief aid have been put out by Congress, and trillions of dollars have been disbursed. I’m glad to know that Shake Shack was able to secure 10 million dollars to pay its employees, but I’d like to know what has been done for the residents in NY who died from complications relating to Covid. What’s more is that we are now starting to see the consequences of the Covid scare – the dramatic down tick in strokes, STEMI activations and other acute illnesses doesn’t mean America suddenly got healthier – it means that a lot of these people were staying home, and our hospitals will need to be prepared to deal with the sequelae of these conditions as people start to come out of the woodwork.

In a climate where the aid given to businesses and Wallstreet far outweighs that given to the front line providers, I can only say that we physicians are not blameless. Ultimately, these are just the frustrated ramblings of another trainee who has seen so many of his colleagues impacted negatively one way or another, all while the public is more concerned with being able to mow their lawn than the wellbeing of those on the front line. As Dr. Fauci (who, by the way, might be getting nominated to be Vanity Fair’s Sexiest Man Alive) once said: “you just have a job to do. Even when somebody’s acting ridiculous, you can’t chide them for it. You’ve got to deal with them. Because if you don’t deal with them, then you’re out of the picture.”

Sources

https://www.ama-assn.org/delivering-care/public-health/residency-pandemic-how-covid-19-affecting-trainees

http://www.onlinejacc.org/content/early/2020/04/07/j.jacc.2020.04.011

https://www.medscape.com/viewarticle/928337

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

 
hidden

COVID-19 Pandemic: 5 lessons about the way we (should) debate in medicine

Amr Barakat, MD

In my previous blog, I shared five lessons about the way we practice medicine, which I believe were highlighted by the unprecedented circumstances of the COVID-19 pandemic. I would like to share five more COVID-19-inspired reflections, but this time it’s about the way we, as physicians, debate our medical opinions and the thought processes through which we form these opinions to begin with. While these thoughts came as a result of following scientific debates on social media, I believe they apply to all sorts of debates in other contexts as well:

  1. Opinions are not principles.  Principles are ethical codes we live by and cherish for our whole life. Opinions, on the other hand, are impressions and ideas that we make as we go, based on information that is available to us (with some emotional influences as well). That being said, while it might take a major life event for someone to change their principles; opinions can, and should, change quite often. There is nothing wrong about changing one’s opinion based on new information or on changing circumstances. In fact, this only reflects a healthy and dynamic thought process. Keeping that in mind makes it easy for us to admit when we’re wrong and to accept that others are allowed to change their position without being accused of hypocrisy.
  2. Debate is not an aim. With the urge to prove our point and support our convictions, we often forget the real aim of any debate; reaching the truth through exploring alternative interpretations. Social media has opened unprecedented venues for endless debate, and the field of medicine has remarkably caught up to this. Unfortunately, we sometimes forget that proving our point often gets in the way of actually finding the truth.
  3. Absence of evidence is not evidence of absence. As physicians, we adopt a scientific thought process. We always strive to find evidence to support any medical claim. Nonetheless, it is important to remember that just because something is not supported by evidence, it does not necessarily mean that it’s not true. It often only means that “we don’t know”. In the midst of scientific debates, we tend to forget this simple fact and start to proclaim that a certain medical intervention doesn’t work simply because it hasn’t yet been assessed by clinical trials. The more accurate way to address this is to say that we don’t know if it works or not, otherwise, we would be committing the same error we were criticizing in the first place.
  4. Bias is vulnerability. Bias and prejudice are human flaws. And we are all human. We tend to be a lot less rigorous in our scrutiny of the methodology and the validity of the results of an article (scientific or otherwise) when the findings are consistent with our own bias. We tend to drop our most important defense mechanism against gullibility—our ability to think systematically and to critically appraise the evidence. This becomes particularly obvious on social media where we are quick to enthusiastically share (and sometimes praise) studies that support our viewpoints, without properly examining the content. Eliminating this bias requires a conscious effort when assessing data that align with our opinions to be even more careful.
  5. We know very little, so be humble. Every day, nature shows us that no matter how much our medical knowledge increases over time, we still know relatively very little about the world we live in. COVID-19 is just another reminder. It’s true that some of us know more than others, but in the big scheme of things, none of us is in a position to brag or be condescending. So no matter whom or what we’re debating, let’s remember to be humble, be kind, and be respectful.

 

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

Tele-medicine and COVID-19

William Aitken, MD

The coronavirus pandemic has changed the world profoundly over the past few months. Globally, millions of people have contracted COVID-19 and hundreds of thousands have died [1]. Millions more have had their lives up-ended with jobs ending, schools closing, family separations, and varying degrees of quarantine. We face uncertainty daily: Did someone I pass at the grocery store have COVID? How much longer should I stay home? Fortunately, people have been taking precautions to keep themselves and others healthy: washing their hands, covering their mouths, and avoiding unnecessary exposures.

One exposure that I didn’t expect we would be able to avoid here in the US has been visits to the doctor’s office. However, given recent Centers for Medicare & Medicaid Services (CMS) temporary expansions, more people than ever are using tele-health. In March, there was a 50% increase in tele-health visits across the country [2]. This expansion into tele-health has been aided specifically by the recent CMS 1135 waiver that has increased access to and reimbursements for tele-health [3].

That said, I’m left wondering how tele-medicine will affect caring for patients with heart disease and other high-risk groups in the future. Will adherence improve without the hassles of having to drive to the office? Will tele-physical exams be accurate enough to confidently make medication changes? Only time will tell. Certainly something I’ll be looking out for.

[4]

 

References:

  1. https://coronavirus.jhu.edu/
  2. https://www.cnbc.com/2020/04/03/telehealth-visits-could-top-1-billion-in-2020-amid-the-coronavirus-crisis.html
  3. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
  4. Author: Intel Free Press

“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.”