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ECPR: What is it? And what do we know in 2020?

Despite advances in the resuscitation field, cardiac arrest, especially cardiac arrest in the setting of cardiogenic shock, continues to carry significant morbidity and mortality. This topic continues to challenge healthcare providers on ways to improve outcomes in patients with refractory cardiac arrest. Extra-Corporeal Membrane Oxygenation (ECMO) is a type of mechanical circulatory support device utilized for various conditions, including cardiogenic shock and multi-organ failure. I heard about ECPR recently, so I wanted to share what is out there, and potentially motivate colleagues and professionals to share their thoughts on this important topic.

What is ECPR?

ECPR (Extra-corporeal Cardio-Pulmonary Resuscitation) is the implementation of ECMO in selected patients with cardiac arrest, and may be considered when conventional CPR efforts fail in a setting with expeditious implementation and support.by skilled providers When/where does ECMO cannulation occur in these patients?

Patients with cardiac arrest and ongoing CPR are transported to the hospital while ongoing resuscitation efforts are being taken. ECMO potentially provides the circulatory and respiratory support these sick patients need until reversible conditions are addressed. ECMO cannulation usually occurs at the healthcare center, where skilled personnel and healthcare providers have expertise in ECMO. Figure 1 shows a simple illustration veno-arterial VA-ECMO utilized in ECPR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

Figure 1: Simple schematic illustration of veno-arterial VA-ECMO utilized in EPCR.

What is the scientific evidence for the use of ECPR?

Unfortunately, there are no randomized controlled trials (RCTs) on the use of ECPR in cardiac arrest patients at this time. The evidence supporting ECPR comes from observational studies in the past two decades, in patients with out-of-hospital cardiac arrest, and studies looking at ECPR in in-hospital cardiac arrest. Many, but not all, of the observational studies showed overall favorable neurological outcomes in those who receive ECPR compared to conventional CPR. It is important to note, however, that these studies had variable inclusion criteria, and potential risk for confounding bias, making their validity and generalizability questionable.

Are there any AHA guidelines supporting the use of ECPR?

AHA 2019 Guidelines Updates:

Recommendations—Updated 2019

  • There is insufficient evidence to recommend the routine use of ECPR for patients with cardiac arrest.
  • ECPR may be considered for selected patients as rescue therapy when conventional CPR efforts are failing in settings in which it can be expeditiously implemented and supported by skilled providers (Class 2b; Level of Evidence C-LD).

Why is this important?

Some studies in the past 2 decades have shown that ECPR might be associated with favorable neurological outcomes compared to conventional CPR. It is known that neurological outcomes in cardiac arrest patients have a significant effect on morbidity and mortality. As such, although these are observational studies with limited evidence, they shed light on a potential therapy that could lead to better outcomes in this very sick population. Future studies, including RCTs, are much needed to assess the outcomes of ECPR and identify patients who would benefit the most from this potential therapy.

I would like to say special thank you to my friend and colleague, Dr Khaldia Khaled, for her help on this blog.

Reference

Panchal et al: 2019 American Heart Association Focused Update on Advanced Cardiovascular Life Support: Use of Advanced Airways, Vasopressors, and Extracorporeal Cardiopulmonary Resuscitation During Cardiac Arrest: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2019;140:e881–e894. DOI: 10.1161/CIR.0000000000000732.

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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Resolutions for 2020: Optimizing my Ikigai and the pursuit of happiness

While reflecting on an extraordinarily busy yet rewarding career year of 2019, I thought of my resolutions for 2020. I’m exceptionally bad at keeping new year resolutions, so I only made one: to be happy.

The concept of Ikigai

Happiness can mean different things to different people, and each of us, particularly medical professionals, is on a personal journey. There is a cool Japanese concept that encompasses multiple spheres of happiness, called Ikigai. Meaning “a reason for being”, it is well-depicted at the intersection of a quintessential Venn diagram that is really doing the rounds on the internet.

The concept of Ikigai

Image: Find your Ikigai. BODETREE, ADAPTED FROM FRANCESC MIRALLES

 

Fundamentally, it encompasses aligning one’s personal and career goals by combining the things one loves, is good at, what the world needs and what one is/could be paid for.1 Applied to physicians, it’s essentially the pinnacle of work-life balance.

While much is being discussed about physician wellness and work-life balance in recent times, for fellows in training and early career physicians, achieving a good work-life balance can be formidably challenging. In a formative and critical stage in your career, you want to maximize on all opportunities to learn and demonstrate competence. Given that conventional wisdom in medicine has always assumed that working harder and taking on more responsibilities is what makes one a better physician, you find yourself in a precarious position, and unable to say no, perhaps to avoid being considered “irresponsible” or “disinterested”, among others.

Thus “having it all” is way easier said than done. Thinking long and hard about this resolution, I went back to the concept of Ikigai. Seemingly, in order to discover your Ikigai, you must first find what you’re most passionate about, then find the medium through which you can express that passion.2

As cardiologists, or in fact medical professionals in general, I’d like to think that we’re already halfway there, having discovered our passion for the work we do. This got me thinking that a great part of my sense of happiness and fulfillment, my ikigai, could actually be achieved simply by getting better, more competent and efficient at my job, thus paving the way (and time) for doing the other things I also wanted to do.

While cardiology can be one of the most rewarding and emotionally fulfilling careers, it does come with significant sacrifices. In my sometimes unrealistic attempts to maintain a social life and achieve the so-called “work-life balance”, I recall doing exam revisions with my study buddy until midnight, forcibly satisfying a respectable quota of daily reading and “rewarding“ myself with a game of Settlers of Catan with my non-doctor friends late into the night, only to have to be present at rounds by eight the next morning. Especially during my initial years of training, in a pursuit to achieve work-life balance, I struggled trying to exclusively “slot out” time periods for work and leisure. As a result, my laptop became a mandatory accessory, finding a place at hangouts, parties and even vacations, where I’d squeeze in that little bit of work if I found the time.

P-squared: Matching passion with purpose

So, how do you effectively ensure time for other things in life, without compromising on expectations and quality at work? I found myself picking up handy tips from Morton T. Hansen’s fabulous book Great at Work: The hidden habits of top performers.3 One aspect that really resonated with me was the concept of P-squared, i.e. matching passion with a strong sense of purpose. He writes about how passion at work is not merely taking pleasure in the work itself, but can come from success, social interactions, learning and competence. In short, pursuing activities that are personally meaningful.

Working smarter over working harder

One way of ensuring one’s focus on meaningful activities is to prioritize and decide what work you will pour your heart and soul into.3 Naturally, each task is not guaranteed to trigger your interest to the maximum. While the “chores” that are one’s professional responsibility absolutely need to be done (and prioritized), it’s important to pick and prioritize ancillary projects, thus ensuring one’s full focus and ultimately better seeing it to fruition. Given professional hierarchy in medicine, it can sometimes be difficult to say no early on in one’s career. A piece of brilliant advice I’ve been given in such scenarios is: If it’s part of a project you happen to land but which can (and should) be done by someone else, delegate it smartly and oversee the work. The advantages are multiple: you facilitate an opportunity for someone else to gain that experience, you gain the experience of overseeing a job and most importantly, it reduces an unnecessary load on you, allowing you to make the time for the projects that matter.

Also, focusing on doing fewer things but doing them better, means that you have more time left over, which you can spend on your private life, effecting towards some degree of work-life balance.3

Share the load

A roster has a purpose and it’s important to share the load. Accepted that we all have our unique personal challenges, some more than others, I found myself chronically covering another person’s roster, stressing out and compromising on my own private time that I could very well have spent with family and friends. While mutual cooperation within a working unit is vital to good work-life balance, particularly in medicine, it should certainly not be at the expense of one’s happiness.

Take breaks

Doctor Hansen also writes about the importance of keeping one’s passion in check, and not allowing it to consume you.3 Grossly translated, it means making the time for one’s private life, be it travel, working out, reading or playing a sport. Thanks to a wonderfully supportive spouse, I might have gotten away with amalgamating work and life on most occasions, but I appreciate the necessity of making an effort to keep work passions in check, and actively make some quality time for family and friends.

“Work on how you work, not on protecting your life from work” – Morten T Hansen

All things said, I’m extremely grateful for being able to do something that I absolutely love, would hope I’m good at (!), get paid for and certainly what the world needs, neatly satisfying the central convergence of the multiple dimensions ikigai. One’s ikigai.is a deeply personal journey, and not one a mentor can spell out for you. However, actively making an effort to being efficient at work, being less stressed out and more balanced would certainly make one better at life too, translating to happier social and private lives. Achieving an Utopian level of work-life balance may not be possible, but finding happiness and fulfillment in what you do certainly is, and it’s a resolution I’m going to make an effort to keep this year. A happy new year to you all!

 

References

  1. Garcia H, Miralles F. Ikigai: The Japanese Secret to a long and happy life. New York: Penguin Books; 2016.
  2. Myers C. How To Find Your Ikigai And Transform Your Outlook On Life And Business. Feb 23, 2018. https://www.forbes.com/sites/chrismyers/2018/02/23/how-to-find-your-ikigai-and-transform-your-outlook-on-life-and-business/#6e99332a2ed4
  3. Hansen MT. Great at Work: The Hidden Habits of Top Performers. New York: Simon and Schuster paperbacks; 2018.

 

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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How My Heart Failure/Transplant Fellowship Changed Me

When I started my Advanced Heart Failure/Transplant fellowship, my program director told me this year would change my life. I thought, “Yeah okay, whatever.” Boy, did that year change my life. The way I looked at the world changed entirely. Transplant is one of the most incredible medical therapies available to patients with end-stage heart, kidney, and liver disease, amongst others. Because of the generosity of the donor and the donor’s family, someone else is given a second chance at life. I always tell my heart transplant patients that they should now be celebrating 2 birthdays every year- to commemorate the gift of life given to them a second time over.

When I say that year changed my life, it truly did, and that change is lasting. When we’re on heart donor call and we’re evaluating hearts for suitability for our recipients, they’re usually younger hearts and cause of death is almost always unexpected. The stories are tragic- suicides, car accidents, freak accidents, and unintended drug overdoses, amongst other causes of death. As I sit in my pajamas (donor heart evaluations happen in the middle of the night a lot) on my laptop making sure I look through all personal and medical details available to me, I can’t help but create an image in my mind of who this donor is, what they may have looked like, where they worked, how much pain they must have been in if their death was intentional, and most gut-wrenching is all the people they left behind. Death is never easy, but when the donors are young, when the deaths are intentional, when the deaths are completely unexpected, it makes me realize how grateful we should be for this life we are living.

That year completely changed how I look at the world. No longer was I going to “sweat the small stuff” whether they were work related or personal. Every donor call reminds me that we sometimes spend so much time, energy, and emotions on things that, in the grand scheme of life, are truly insignificant. I became a happier and more content person. This year taught me that human connections are the most important thing in this world. My family, the friends I consider family, my friends at work, my patients, and all the people I cross paths with that have an impact on my life.

And on the other side of death, after I have pictured this life lost and the family and friends they’ve left behind, I get to tell one of our patients with end-stage heart failure that a heart “has become available” to them and now their life is going to change. I can’t imagine how they feel but I’ve heard all kinds of the emotions on the other end of that phone- tears, shock, anxious smiles that can be heard through the phone, and more tears. My patients tell me it’s a very emotional experience from the time they’re listing. Some have said it feels weird to be “waiting for someone to die” so that they can live. Some have noted guilt. Some of my patients have developed relationships with their donor’s families and I can only imagine how surreal that must feel.

What I do know is that I couldn’t imagine myself doing anything else and that being a Transplant Cardiologist has truly changed my life. I am grateful to the patients who have allowed me to play a small role in their journey and forever grateful to the donors and their families for this incredible gift of life.

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A New Year and A New Perspective on Mentorship!

At every stage of personal growth and development, mentors play a key role in providing advice and support to propel their mentees forward. The act of mentorship is a core element of social interactions and societal advancement. A line like “it takes a village to raise a child” is basically talking about mentorship. Same for the commonly used line in academic and medical circles – “See one. Do one. Teach one.” Graduate and postgraduate students and fellows are required to have assigned mentors to guide them through their final stages of education, and early stages of a professional career.

The level of success a person achieves can be accurately traced to the level of mentorship afforded to them. Mentorship, more so than just academic education, provides a broad spectrum of opportunities for learning and growth. Great mentors are able to provide advancement in what is classically referred to as “soft skills”. These are skills like: communication, leadership, time management, “tricks of the trade”, and other avenues of growth normally left out of school curriculums. This makes finding a highly qualified and experienced mentor an extremely valuable endeavor. Of course these skills are not limited to the medical and academic fields; mentorship is valuable in all aspects of personal and professional growth.

Here is where I introduce the main message I’d like to pass along in this piece. We (correctly) seek and value mentorship from experienced, highly qualified, and revered individuals, to assist us in advancing our knowledge and skills within our chosen fields. However by focusing on finding one type of mentor, we may be setting ourselves up for lost opportunities, learning and advancements of equally beneficial value, from individuals that don’t fit the classic idea of a mentor. By this I mean, when was the last time you looked for a mentor that was junior to you?

We all are kind of aware of how this type of mentorship can be, like how I’m happy to continuously coach my dad on how to advance his usage of smart phone technology, and how my younger relative is mentoring me on how to be a better skater and hockey player! This same kind of mentorship dynamic can also translate in a professional/academic setting. In our present fast-paced advancing world, many novel ideas and tools develop, and typically the earliest adopters are not individuals that have established some previously learned and used idea/tool (i.e. the ones with the lived-in world “experience”). Most of the time, early adopters are typically young, enthusiastic, quick learners!

This group has shown time and again, when it comes to the newest forms of knowledge and skills, they’re ahead of the archetypal mentor. Seeking and accepting younger mentors, in addition to classic mentors, allows the mentee to gain knowledge and skills in a wide range of topics and fields, as opposed to only seeking top-down knowledge. There is great value in learning from experienced individuals, but there is also value gained by seeking the expertise of younger enthusiastic early adopters of novelty, regardless of what field one is pursing mentorship in.

mentor

(Image collage sourced from pixabay.com)

 

Considering this is the time in the calendar where everyone is reflecting on the accomplishments of the past, and making plans and resolutions for the coming year, I thought I would suggest an additional resolution to add to your list this time around. In an effort to maximize personal and professional growth, why not make a resolution centered on mentorship? I’ll even create a fun plot device J What if the resolution could be formulated as follows: This year I will seek (or continue to benefit from) one mentor that is “double” my age/experience AND one mentor that is “half” my age/experience (let’s call it the Double & a Half Mentorship rule!). *All values are approximate.

I’ll use myself for an example: as an early career scientist, a mentor “double” my age is already in place (that’s my boss, Chief Science Officer of the Institute I work in, and Senior Principal Investigator on the research group I’m part of; who truthfully has way more energy than I can achieve, proving that age is not a good measure for vitality!). A mentor “half” my age would be a summer/undergraduate student or temporary employee in our research group (again, the age part of the rule is approximate); someone that will teach me a skill in the lab or on a computer, that will promote my professional goal of learning and conducting high caliber research in cardiovascular disease areas.

This year I aim to continue finding ways to learn and gain skills from both an experienced mentor, and a young enthusiastic mentor, to advance my personal and professional development. I hope you maximize your mentorship opportunities as well. Happy New Year!

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Have You Picked Your Mentor’s Brain Lately?

It’s funny how people meet – some are coordinated efforts at work or meetings while others are random. I met one of my mentors – Dr. Jane Freedman – in the outpatient echo lab. We had never met prior to my fellowship but I recognized her name from the echo reports of my patients. After introducing myself to Jane, I fired all sorts of questions her way – mostly about restaurants in Boston we both enjoy, things we do in our free time, how to get involved in the AHA, and how best to read echocardiograms. This sparked not only a great friendship but an even better mentorship.

Jane has become my work-life-balance mentor, advising me on how to be an effective chief fellow, developing my own leadership style, types of jobs to pursue, and balancing personal life with the intense time commitment of medicine. I soon realized in order for me to be a good mentee, I had to support my mentor when I could. This included, attending her talk at the AHA not out of a feeling of obligation but out of a genuine desire to support my mentor. Over time, our mentor-mentee relationship has taken on more academic facets – largely, honing in the on the type of job I would want in the future. Jane has pushed me to clarify the type of job I want to pursue and more importantly, what are the reasons for wanting it.

mentorOver the course of my training, I realized that not all of my colleagues have mentors to turn to for these critical career conversations. It made wonder how mentors can help fellows in training, and more importantly, what are the key elements to a successful mentor-mentee relationship. To understand what made our mentor-mentee relationship successful, I asked Jane at a recent dinner at one of the many great restaurants we wanted to try.

In her experience, a successful mentor-mentee relationship comes down to be receptive as a mentor and mentee. You have to have the self-awareness of the relationship to provide support for those seeking it.  In addition, the relationship has to be symbiotic. The mentor has to give advice to the mentee based on the level he or she is at. For example, the chair of cardiology may not be a good mentor to a first-year fellow if he or she is not able to give the appropriate support needed for the fellow at that specific stage of training. Conversely, the mentee needs to work hard towards the goals and expectations he or she has set for this to be a successful relationship. This made me think: how do we go about even choosing the ‘right’ mentor??

Jane highlighted that everyone needs more than one mentor. For example, an academic mentor to help me pursue research opportunities, a clinical mentor who helps cultivate knowledge in my area of interest, and even a work-life mentor that I can turn to when this demanding job seems undoable. Every mentor offers something unique to the relationship and more importantly, not one mentor will be able to give you everything you need. Jane stressed that she never stopped at one mentor but sought those that will help her become successful in all aspects of her life and career.

Jane explained that while she was training she reflected on what would improve her work-life balance. There were only so many things she could accomplish in a day and had to recognize where she needed help. For example, with the various apps to help improve efficacy, I could order groceries to be delivered to our home. The time saved at the grocery story can be spent with my significant other or at the gym. Something Jane stressed – which I took to heart – was to never feel guilty for not being able to do it all. People who go into health care are incredibly driven but we all have our limits. It’s important to recognize these limits to prevent burnout, enjoy our work, and continue to work on achieving a balanced life.

A piece of advice Jane gave me is to make sure I pick a career path that will make me happy, not the one I think I should take. With the extensive amount of board certifications in cardiology, fellows feel pressured to take them even if they do not want to. Again, this comes back to a point Jane highlighted earlier – we need self-awareness to be successful.

As dinner started to wind down, I was able to reflect on how I was performing as a mentee and what steps I can take in the future to make our relationship more successful. Checking in with my mentors always brings about new found motivation and energy to continue to strive for success.

 

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What do Immunology and Impostor Syndrome Have In Common?

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

Sir Peter Brian Medawar

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

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

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

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

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

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

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

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

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

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

 

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

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Support Your Colleagues in 2020: The Year of the Nurse

The World Health Organization (WHO) has designated 2020 The International Year of the Nurse and Midwife (coinciding with and honoring the 200th anniversary of Florence Nightingale’s birth.) “International Year of the Nurse and Midwife”

The WHO stresses that “strengthening nursing and midwifery – and ensuring that nurses and midwives are enabled to work to their full potential – is one of the most important things we can do to achieve universal health coverage and improve health globally.”  If you work in health care in a clinical, community, education, or research setting, you almost certainly work with nurses. In the U.S. alone, there are over 3 million registered nurses (via Bureau of Labor Statistics).

Do you know what roles nurses serve in in your community, and what their scopes of practice are? In many areas, nurses are not permitted to practice to the full scope of their education and training (which may include bachelors, masters, and/or doctoral degrees) due to both legal and institutional restrictions. This means we’re leaving much needed, highly skilled work on the table. Why, and how can we fix this?

The December 2019 issue of the Lancet includes an editorial about the value and potential of nursing. The authors note that “…for all its importance, nursing remains underappreciated. Perhaps the biggest barrier that continues to stifle the profession concerns gender and stereotypes. Most nurses are women, and nursing is still viewed by many as women’s work and as a soft science, rather than as the highly skilled profession it really is.” Though most readers likely feel they do not value women less than men, the institutions we work within demonstrably do. What are the gender and educational preparation of the president of the university, the CEO of the health system, the PI of the big grant? How many full professors in your department are women? What salaries do nurses make, what salaries do women make, and how do they stack up against others in an organization? If your organization is typical, you might be surprised at the disparities. AHA pledged to have no all-male panels (#nomanels!) at Scientific Sessions this past November— is that true of other events you’ve attended?

Understandably, some nurses have met the WHO’s announcement with skepticism. We’ve heard calls for recognizing and honoring nurses before, without much substantive change following. Can this time be different? I believe we can work to address the undervaluing of nursing as a profession and women as professionals, which is hindering improvement in global health. Institutions can support nursing— and I don’t mean with a pizza party during nurses’ week (although I do love pizza, so please don’t stop doing this). I mean with safe staffing, respect, leadership roles and adequate compensation. With decision-making power. With professional autonomy. This is easier said than done.

Providing this support means developing a better understanding of the breadth and depth of nursing expertise. As early career professionals, we are poised to set priorities for the coming decades of healthcare, research, and education. When it comes supporting nurses and nursing, ask yourself if you are truly walking the walk, and look for ways to do more.

Here are some ways to increase your awareness of the actual and potential impact of nursing:

  • Read the Journal of Cardiovascular Nursing or other nursing research journals. Learn what kinds of research nurses are doing and how it might impact your work.
  • Invite nurses to present at grand rounds. Their clinical expertise is often vast.
  • Invite nurses to be part of your research team— not only as staff to do your data collection, but as co-investigators. Doctorally-prepared nurses work as researchers, teachers, and advanced practice clinicians, and they are likely to have invaluable insights into aspects of science and health that others may not have.
  • Look at your citations when you write: are you including diversity, including professional role, gender, race, and nationality?
  • For nurses and those interested in nursing, have you affiliated with the Council on Cardiovascular and Stroke Nursing? Get involved, fill out a science volunteer form (committee assignments are made in April), and get in touch with the leadership.
  • Consider joining other professional organizations and getting involved with political causes— scope of practice and reimbursement issues are often hashed out by legislators, and voices supporting nursing are sorely needed. This includes from physicians!

What will you do to support nursing this year?

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

Has the image of nursing changed since these historical photos were taken? (Photos via Unsplash.com)

 

 

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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What Are Your Thoughts on Work-Life Balance/Imbalance in Science and Medicine?

My blog post this month is meant to be a starting point for discussion. There are a plethora of articles and blog posts on work-life balance/imbalance in medicine and science (and many other professions). Some articles and blog posts even discuss that it is not possible to have work-life balance in medicine/science/academia1-3. As the winter holiday season comes to an end and a new year and decade starts, I find myself reassessing my personal and professional goals and resolutions for this upcoming year and decade. On my list is “continuing to work on work-life balance.” My blog is meant to stimulate discussion and solicit advice from those of you in science and medicine on potential tips to improve work-life balance. Figuring out how to balance the personal and professional aspects of our lives throughout a long and arduous career can be a formidable process.

Some people have voiced concerns about the recommendations often told to trainees and early career physicians/scientists to maintain work-life balance and wellness in order to prevent burnout: get adequate sleep, eat well, exercise, meditate, pet dogs, wake up earlier to plan your day, travel, read nonmedical/nonscience books, continue your hobbies, find good mentors, and spend time with family and friends all while providing good clinical care and/or doing good research. How are there enough hours in a day to do all of this?

An article in The Atlantic published last year entitled “Give Up on Work-Life Balance”4 discusses a recommendation from Brad Stulberg, author of The Passion Paradox, of not thinking of work-life balance as dividing hours within a day for personal and work activities. Alternatively, consider balance in terms of “seasons.” For example, one “season” could be a few years where the majority of the time is focused on one’s training/career and another “season”, possibly during a time when one has young children, where focus is on spending time with family. One of my mentors who has young children says that when he goes home, he prioritizes spending time with family and tries not to do any work until he and his wife go to bed. Some people have noted that they dislike the term work-life balance since it implies that there is a scale where one side is competing against the other. Instead, “integrating” work and personal lives is encouraged. Unfortunately, careers in science and/or medicine do not always allow for easy integration of work and personal lives, but system changes can occur to allow for better integration of work and personal life. For example, I applaud the efforts of one of my co-AHA early career bloggers, Dr. Nosheen Reza (@noshreza), in assisting with establishing a culture and creating tangible changes to support breastfeeding cardiology fellows5. Another AHA early career blogger, Dr. Renee Bullock-Palmer (@RBP0612) wrote a blog post last year discussing tips for integrating motherhood and a career as a female cardiologist (https://earlycareervoice.professional.heart.org/balancing-versus-integration-of-motherhood-and-your-career-as-a-female-cardiologist/).

Many established researchers and clinicians have recently told me that they regret not spending more time with their families. This same sentiment has been echoed by many clinicians/researchers on Twitter over the holiday season. While it is not always possible to spend every holiday with loved ones, especially while in training, allotting some protected time to spend with loved ones is important for maintaining wellness.

Establishing work-life balance is a constant evolving process dependent on the stage of our careers and personal lives and is a very individualized process. As mentioned before, I hope that we can have a further discussion on work-life balance and that you will share some tips on ways to improve work-life balance. I wish all of you a happy, healthy, and productive new year!

 

  1. Lazzari, Elisa. To be a top performer you need to be happy – something academics tend to forget. Naturejobs Blog. 13 Jun 2016. http://blogs.nature.com/naturejobs/2016/06/13/can-scientists-really-have-worklife-balance/.
  2. Powell, K. Young, talented and fed-up: scientists tell their stories. Nature538, 446–449 (2016).
  3. Is Work-Life Balance for Physicians a Unicorn? com. 3 Jan 2018. https://www.kevinmd.com/blog/2018/01/work-life-balance-physicians-unicorn.html
  4. Khazan, Olga. Give Up on Work-Life Balance. The Atlantic. Atlantic Media Company. 30 May 2019. https://www.theatlantic.com/health/archive/2019/05/work-life-balance/590662/.
  5. Kay J, Reza N and Silvestry FE. Establishing and Expecting a Culture of Support for Breastfeeding Cardiology Fellows. JACC: Case Reports. 2019;1:680-683.

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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Can artificial intelligence save our lives?

The role of artificial intelligence (AI) in our life is advancing rapidly and is making strides in early detection of diseases. The consumer market is composed of wearable health devices that enables continuous ambulatory monitoring of vital signs during daily life (at rest or physical activity), or in a clinical environment with the advantage of minimizing interference with normal human activities1. These devices can record a wide spectrum of vital signs including: heart rate and rhythm, blood pressure, respiratory rate, blood oxygen saturation, blood glucose, skin perspiration, body temperature, in addition to motion evaluation. However, there is a lot of controversy whether these health devices are reliable and secure tools for early detection of arrhythmia in the general population2.

Atrial fibrillation (afib) is the most common arrhythmia currently affecting over 5 million individuals in the US and it’s expected to reach almost 15 million people by 2050. Afib is associated with an increased risk of stroke, heart failure, mortality and represents a growing economic burden3. Afib represents a diagnostic challenge, it is often asymptomatic and is often diagnosed when a stroke occurs. Afib represents also a long term challenge and often involves hospitalization for cardioversion, cardiac ablation, trans-esophageal echo, anti-arrhythmic treatment, and permanent pacemaker placement. However, if afib is detected, the risk of stroke can be reduced by 75% with proper medical management and treatment3.

Physicians need fast and accurate technologies to detect cardiac events and assess the efficacy of treatment. A reliable, convenient and cost-effective tool for non-invasive afib detection is desirable. Several studies assessed the efficacy and feasibility of wearable technologies in detecting arrhythmias. The Cleveland clinic conducted a clinical research where 50 healthy volunteers were enrolled. They tested 5 different wearable heart rate monitors including: (Apple Watch, Garmin Forerunner, TomTom Spark Cardio, and a chest monitor) across different types and intensities of exercises (treadmill, stationary bike and elliptical). The study found that chest strap monitor was the most accurate in tracking the heart rate across different types and intensities of exercises4.

The Apple and Stanford’s apple Heart Study enrolled more than 419,297 Apple Watch and iPhone owners. Among these users 2,161 (roughly 0.5%) received a notification of an irregular pulse. Of those who received the notifications, only about 450 participants scheduled a telemedicine consultation and returned a BioTelemetry ECG monitoring patch. When the Apple Watch notification and ECG patch were compared simultaneously, researchers found 71% positive predictive value and about 84% of the cases were experiencing Afib at the time of the alert. Additionally, in 34% of participants whose initial notification prompted an ECG patch delivery were later diagnosed with Afib. This finding shows that Apple watch detected afib in about one third of the cases which is “good” for a screening tool considering the “intermittent nature of afib and that it may not occur for a whole week” says Dr. Christopher Granger, a professor of medicine at Duke University who participated on the steering committee for the Apple Heart study5.

These studies are observational studies and are not outcome driven. They are not randomized and are not placebo controlled. There are potentials for false negatives, where the Apple watch fails to detect the afib and false positive where it detects arrhythmia that does not exist. Unfortunately, patients who are false negative don’t consult the physician about their symptoms of palpitations and shortness of breath since it provides false security. While patients with false positive are sent unnecessarily to the clinic that could lead to further unnecessarily test and anxiety for the patient.

Is the Apple Watch ready to be used as a default screening tool to monitor the heart rate and rhythm in the general population and by physicians with patients with or at high risk for Afib is still unclear and warrant further studies.  In conclusion, physicians should be cautious when using data from consumer devices to treat and diagnose patients.

 

References:

  1. Cheung, Christopher C., Krahn, Andrew D., Andrade, Jason G. The Emerging Role of Wearable Technologies in Detection of Arrhythmia. Canadian Journal of Cardiology. 2018;34(8):1083-1087. doi:10.1016/j.cjca.2018.05.003
  2. Dias D, Paulo Silva Cunha J. Wearable Health Devices-Vital Sign Monitoring, Systems and Technologies. Sensors (Basel). 2018;18(8):2414. Published 2018 Jul 25. doi:10.3390/s18082414
  3. Chugh, S., Sumeet, Havmoeller, J., Rasmus, Narayanan, F., Kumar, et al. Worldwide Epidemiology of Atrial Fibrillation: A Global Burden of Disease 2010 Study. Circulation. 2014;129(8):837-847. doi:10.1161/CIRCULATIONAHA.113.005119
  4. Wrist-Worn Heart Rate Monitors Less Accurate Than Standard Chest Strap. Medical Design Technology. http://search.proquest.com/docview/1875621494/. Published March 9, 2017.
  5. Turakhia, Mintu P., Desai, Manisha, Hedlin, Haley, et al. Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: The Apple Heart Study. American Heart Journal. 2019;207:66-75. doi:10.1016/j.ahj.2018.09.002

 

 

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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How to Celebrate the Year of the Nurse

Full disclosure. I am nurse. A proud nurse. I am a nurse because the strongest, kindest, and most adventurous women I knew when I was growing up were nurses. And throughout the course of my nursing career, I have been repeatedly reminded that nurses are privileged to experience some of the most distressing times in a person’s life alongside them – and to expertly help them through it.

My love for my chosen profession is one of the reasons I celebrate the World Health Organization declaring 2020 The Year of the Nurse and Midwife. This official recognition of the pivotal role that nurses, around the globe, have in creating healthier lives for all people regardless of their age, sex, or social status. As countries and health care rapidly evolved during the 20th-21st centuries, fewer people died from maternal and child illness and infectious diseases and today cardiovascular disease is one of the biggest killers of adults around the globe. The type of cardiovascular disease varies in different global settings- we see more ischemic heart disease in more developed countries and more hypertensive heart disease and cardiomyopathies in low income countries. Yet, despite the differing types of cardiovascular disease, in every corner of the globe nurses are helping people prevent, manage, and recover from cardiovascular disease.

There are more than 12 million cardiovascular nurses around the globe making them the largest discipline promoting cardiovascular health. Decades of evidence demonstrate that nurses have a critical role in promoting high-quality, cost effective care to improve cardiovascular health. As Leonie Rose Bovino, PhD, APRN, FAHA – Nurse Practitioner at Yale New Haven Hospital Outpatient Cardiology – states “Much of the premature cardiovascular morality is due to modifiable factors and nurses excel at building a rapport and establishing shared decision-making with patients about their health. This allows them to have an integral, immense and important role in decreasing CVD mortality.”

Francis Njoroge and his team at the Cardiac Care Unit at Moi Teaching & Referral Hospital in Eldoret, Kenya.

Francis Njoroge and his team at the Cardiac Care Unit at Moi Teaching & Referral Hospital in Eldoret, Kenya.

Nurses and nurse practitioners use this rapport to manage hypertension and high cholesterol; provide smoking cessation, diabetes and nutrition counselling; facilitate patients completing cardiac rehabilitation; and help manage the distressing symptoms of heart failure. And when nothing more can be done, nurses are there to help patients die with the comfort and dignity they deserve—holding hands, crying with family, and comforting those who don’t know what tomorrow will bring.

Francis Njoroge (pictured left) is the Nursing Officer-in-Charge at the Cardiac Care Unit at the Moi Teaching & Referral Hospital in Eldoret, Kenya. He provides care to patients with rheumatic heart disease, infective endocarditis, and heart failure. He helps them understand how to prevent complications from these conditions, conducts home visits after their discharge, and counsels both patients and their family members about their “ongoing disease process, adherence to medication, dietary habits and lifestyle modification”.  Like Dr. Rose Bovino, Francis’ role as a nurse and a leader is big and diverse, and sometimes complicated by familiar challenges – patients being unable to buy necessary medicines, high acuity patients, not enough time with patients, and too few hospital beds.  But despite these challenges, Francis and Dr. Rose Bovino chose their profession because they wanted a challenging career – one that would allow them to make a difference in people’s daily lives and, themselves, to be changed by the patients and their own stories. Asked what he wants young people to know about nursing, Francis states, “Nursing is a career that helps a person save lives, brings happiness to individuals and their families, and comfort to those in need. Despite being a challenging job, it’s very interesting and makes a difference in people’s lives. I would encourage young people to join us, and join nurses everywhere, in making a difference in their own communities”.

Many of the readers of this blog will be nurses, and many will not. But no matter what your profession is, chances are you know a nurse. So this year, ask the nurses you know about their stories. Why did they choose nursing? Why do they continue to be a nurse? What would make it easier for them to provide the best quality nursing care possible? Listen to them. Let their stories change how you think about your own health, or your work, or your relationships. Let them inspire you to be stronger, kinder, bolder, and seek out adventure in your right. Because when we recognize the pivotal role that nurses have in our community, we recognize the best of all of us. And I hope that recognition lasts long after the Year of Nurse and Midwife concludes.

 

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.