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From Race-Based Medicine to Fighting Structural Racism

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

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

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

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

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

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

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

How?

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

 

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

 

References:

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

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

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

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

 

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

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On Blood and Bridges: Remembering Congressman John Lewis

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

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

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

          I gave a little blood on that bridge

Fast forward 55 years…

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

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

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

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

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

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

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

 

References

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

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

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My Professional Journey

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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A Graduating Fellows Guide to Pediatric Cardiology Resources

July is an important month for medical education— whether it’s graduating from med school and starting intern year, finally becoming a senior or starting fellowship.  With fellowship ending for me, and starting for many, I started to compile a list of resources for pediatric cardiology to share.

Many of these resources were passed down to me by seniors or mentors, but also many were found on twitter (read more about how you can use this to your advantage in my previous blog). Some emerged recently during COVID-19 in an effort to bring pediatric cardiology together virtually and bridge education gaps for webinars, lectures and more.

For online resources, I recommend creating a folder on your browser and saving sources for easy access later. Another helpful thing for me was saving the links to Moss & Adams, Mayo Clinic Board Review, & Lai echo e-books in this folder so that you can access them anytime and not have to carry the books around(you can find the codes in the front cover of the book).

Below are websites for great lectures, webinars and reading, clinical resources, apps, podcasts, important organizations and ways to find job postings. Enjoy and please share!

Websites for Lectures, Reading and Resources:
Heart UniversityEducational video on pediatric and adult congenital heart disease (ACHD) includes pathology lectures by Dr. Robert Anderson. They also host great webinars on various topics with leaders in the field.
SPCTPD PC-NES (Pediatric Cardiology National Education Series), a lecture series that was started to provide education to fellows during the pandemic— you can access all the previous lectures that were given on various topics with lecturers from around the country, this is planned to continue in the fall.
SCMR– Cardiac MRI case based webinars.
ACHA– ACHD association with webinars on various topics.
Dr. Robert Pass EP lectures; Excellent weekly EP conferences(Mondays 7am EST) with the Mount Sinai pediatric cardiology fellows, past conferences are on this YouTube page and the link to join live is sent via pediheartnet(see below), you can also find Dr. Pass on his podcast(below) and on twitter!
Multimedia Manual of Cardio-thoracic Surgery Surgical videos and descriptions geared towards surgeons but helpful to explain and see common CHD procedures).
Cardiology Notes– Summaries of various chapters from Moss & Adams, Lai Echo, as well as other pediatric cardiology tests and resources.
Parameterz website for Z scores to use for echo, easy to use on desktop or phone
Virtual TEE (Toronto) – TEE simulator.

Podcasts:
Pediheart– Peds Cardiology Podcast hosted by Dr. Robert Pass (above) – review of recent literature and topics usually with a great guest, tune in each week (released Friday) and learn to appreciate Opera too.
CardionerdsMostly geared toward adult cardiology with some overlap to Peds.
PCICS– Cardiac ICU topics and discussion with various leaders in the field.

Apps: (links are to the apple store, but they should be available through google play too!)
EP tools lite– Various EP calculators including WPW pathway localization tool.
Heartpedia Great resource for education for patients, medical students and residents with easy to use interactive diagrams of common CHD and repairs.
Pacemaker Using the patient’s chest XR, snap a picture of the pacemaker and this will tell you who the maker is (Medtronic, St. Jude, etc.)
Practice Update– Follow topics (i.e. Cardiology) and receive virtual “stacks” of the latest literature on that topic with quick reviews and links to full text.
Dimity– Use this app to make patient phone calls from your phone so your number shows up as the hospital line and not your number or unknown. Very helpful for home call!

Conferences/Organizations: all conferences through 2020 are now virtual allowing you to access more content. Remember as a fellow your membership and registration is usually discounted or free, take advantage while you can!
ACC Annually in March.
ASE Annually in the summer (virtual August 8-10) and only $75 for fellows).
PICS-AICS Cath focused conference annually in September.
AHAAnnually in November.
PCICS Annually in December for those interested in cardiac ICU. Bonus fact- they are also hosting virtual meetings on experience and research related to COVID-19 and pediatric cardiac care.
PAC3, PC4 & NPC-QICCollaborative organizations to improve outcomes in congenital heart disease, along with these are great organizations for quality improvement and outcomes research and hold an annual conference along with webinars.
CHOP pediatric cardiology update  Annual dedicated pediatric cardiology conference in February.

Job Postings: below are links to sites that may be helpful as you are looking for jobs, don’t hesitate to reach out to people, have your mentors reach out or cast a wide net, you may find opportunities that aren’t posted.
Pediheartnet- A list server with job postings; this also facilitates discussion between cardiologists around the world, this is the server that the weekly EP conferences (above) will be sent out on and other great opportunities- a must join!
Other sites for job postings-
Congenital Cardiology Today
CareerMD Pediatric Cardiology Job Bulletin
NEJM Career Center ACC Career & AHA Career Centerrefine your search by specialty and receive emails with new postings.

Happy July, and don’t forget to be kind and welcoming to someone new in the hospital, you were there once too!

“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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Knowledge Advances Incrementally

Learning and advancing one’s personal and professional goals is a dynamic and active process. We never truly “finish” learning anything. We get better and better at tasks the more we practice them. We increase the accuracy of our data the more analysis on bigger and more relevant sets of samples we collect and measure. The scientific method is built on accepting the facts as they get unveiled, fully realizing that optimization and accuracy comes gradually with more work done and more information gathering.

One of the present global issues that I want to address here is the erroneous practice of some individuals that point out shifts in recommendations and gradual changes in the understanding of a scientific/medical phenomenon, and using these shifts and changes in the information shared as basis for doubt and denial for the whole process. Certainly when it comes to complex and novel discoveries/puzzles to solve, there will be a period of optimization and incremental advancement in understanding. These could lead to changes in conclusions from where things were first reported, to where they are now, and to where they will be in the future as more and more science is uncovered and facts are checked and replicated.

The act of refuting what we presently know and understand of a novel discovery or challenge to tackle, simply because the present understanding doesn’t match exactly what was previously reported and shared, is simply an act of refusing to accept that human beings are, by nature, dynamic learners. We gain more as we try, experience, and process information. Humans are not the kind of species that begin and end their lives with the same genetically programmed set of actions and behaviors inherited from the previous generation and are carried down to their progeny. Each one of us knows more now than we knew when we were younger. Experience matters. Time to perform more measurements and analysis brings us closer to accuracy and understanding. In other words, we get wiser as a whole, the more we experience and accumulate data.

Individuals that insist on focusing on the divergence of information coming from science and medicine, that’s separated by a non-trivial amount of time, are trying to sow doubt and nullify the value gained by executing the scientific method to its fullest potential. Accuracy, and a full understanding of anything complex, requires optimization, replication and diverse set of experts working separately and together, to incrementally achieve the most precise understanding of a challenge or novel discovery.

Our society benefits from scientifically assessed and understood information. Evidence-based decision making is far superior to other forms of societal choices, made by and for the public. And as mentioned here, the precision and accuracy of scientific information gathering advances the more time is allowed for investigation and understanding. We should celebrate and embrace changes accumulated with more data analysis and scientific rigor applied to test the facts uncovered along the way.

It is a self-correcting and enhancing mechanism, built into the scientific method and research process that we implement as scientists and healthcare researchers and providers. Sure this means that some data and knowledge will shift with time, but this should be seen as progress, and we should not let mis-informers and pseudoscience spreading behavior and individuals hijack the system of self-correction and improvement built into our method.

And as a last point to make: Scientists, medical researchers, and everyone involved in healthcare, research and academia should find ways to communicate and/or amplify voices of communicators that are on the front-lines of providing evidence-based information to the public. The best use of the scientific process is when the product of this process is shared with everyone.

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

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Residency and Fellowship Interviews During COVID-19

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Transcatheter Interventions of the “Forgotten Valve”

We have witnessed tremendous advances in the transcatheter therapies for various cardiac conditions in the past couple of decades! The “forgotten valve” usually refers to the tricuspid valve, due to the fact that most of the research in the literature is on the left-sided heart valves. In the past two decades, although there has been progressive interest in implementing transcatheter techniques to treat tricuspid valve pathologies, we are still in the early stages of this development.  So, I decided to write briefly about some of these transcatheter techniques, which will continue to improve in the future; as we get more experience with these tools and continue to implement the advances in related technologies.

Tricuspid Valve Interventions

There are two main types of transcatheter interventions of the tricuspid valve: repair and replacement.

  • Tricuspid Valve Repair

Tricuspid valve repair can involve the tricuspid annulus and/or leaflet coaptation. Leaflet coaptation is performed using the off-label use of MitraClip (Abbott) in the tricuspid valve (also known as TriClip), mainly because of the device availability and operator familiarity [1]. There are other repair systems to repair the tricuspid leaflet coaptation, including Forma (Figure 1) and Pascal systems from Edwards Lifesciences.  The Forma repair system consists of a spacer that occupies the regurgitant orifice and thus decrease regurgitation. The Pascal repair system consists of two paddles, clasps and a spacer, thus overcoming some of the limitations of Forma repair system regarding anchoring and dislodgement [1]. Other repair interventions involving the annulus are usually performed using sutures or an annuloplasty ring (Figure 2) [1].

Figure 1: Forma repair system (Edwards Lifesciences), which is a transcatheter approach to improve the leaflet coaptation of native tricuspid valve by occupying the regurgitant orifice area [2].

Figure 2: Cardioband (Edwards Lifesciences) is a transcatheter annuloplasty ring for the tricuspid valve [3].

  • Tricuspid Valve Replacement

The first transcatheter tricuspid valve replacement was performed by Kefer et al in 2014 using the balloon-expandable SAPIEN valve (Edwards Lifesciences). There are 6-7 types of dedicated transcatheter tricuspid valves that have been developed in the recent years; these include NaviGate (NaviGate Cardiac Structures, Lake Forest, California), Edwards Evoque, Medtronic Intrepid, Lux (Chinese designed and manufactured self-expanding prosthesis made from bovine pericardial tissue mounted on a nitinol stent frame), and Tricares (TRiCares GmbH, München, Germany) valve is a self-expanding prosthesis made from bovine pericardial tissue mounted on a nitinol stent frame. Figure 3 illustrates a NaviGate valve, which is the first tricuspid prosthetic valve implanted in humans in the United States, which was performed by Navia et al in November 2016 [1].  It is an example of a self-expanding dedicated tricuspid valve with 3 pericardial leaflets.

Figure 3: NaviGate valve, which is currently available for transcatheter tricuspid valve replacement [4].

  • Caval Stenting

In addition, stenting of the inferior and/or superior vena cava has also been performed to mitigate the effects of tricuspid regurgitation on the central venous system. It is another option for those patients with tricuspid regurgitation, but there are concerns that this procedure might ultimately promote significant hemodynamic deterioration, with ventricularization of the right atrium and increased load on the right ventricle. Ongoing studies are being conducted to assess these effects and the outcomes of this procedure [1].

Do transcatheter interventions of the tricuspid valve affect mortality?

So far, the current evidence we have is from observational studies suggesting improved mortality in patients treated with tricuspid repair/replacement compared to medical therapy [1]. Overall, these transcatheter interventions have shown significant improvement in patient’s symptoms and New York Heart Association (NYHA) functional class, despite only moderate reduction in tricuspid regurgitation severity [1]. There are multiple ongoing trials assessing the impact of these therapies on outcomes.  The TRILUMINATE trial is one example, which is comparing outcomes of tricuspid clipping to medical treatment in patients with functional tricuspid regurgitation.

In conclusion, there are several transcatheter therapies that have been developed for treatment of tricuspid valvular pathologies, most commonly for functional tricuspid regurgitation, in the past few years. Although most of these techniques are still in their early stages, the initial results of the observational data are promising. I look forward to seeing the advances in these therapies in the near future, as we continue to build our experience as operators and familiarize ourselves with these new advanced tools.

References

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

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Pandemics Juxtaposed

Many of you are wondering about what I as a leader in various ways am thinking about the racial pandemic, juxtaposed with the coronavirus pandemic.

In the coronavirus pandemic, I had been starting my emails with something like, “I hope you have been able to stay well during these unprecedented times”.

This morning, I started to write an email to a group of people.

At first, I typed, “I hope you are well”.

Then I deleted that and started over.

And then wrote, “I hope you are sorting through these multiply tumultuous times.”

I deleted that too and skipped that intro altogether, and instead decided to share it with you all.

Let me tell you why. You should already be able to figure this out, but let me walk you through it.

Here it is.

Plainly and simply.

I hope you are NOT well.

I hope you are not OK with seeing what is going on in the world around you. I hope you are not OK with the global ignorance we have as people. I hope you’re not OK with the complacency with which we live our lives.

I hope you are NOT well.

I hope that your heart has been breaking inside due to centuries and decades of injustice.

I hope your well-being has been ruffled knowing that all are NOT well.

That all is NOT well.

We all agreed that as a society the goal is to be well.

However, the goal we should desire is for all to be well.

We cannot be true to ourselves until we honestly recognize that all are not well until the futures of our black men, women, boys, girls, and babies in this country and around the world are well.

Until then, how can you be well?

Together, in community, how can we be well?

We can be well when we start to admit that we are not.

We can be well when we commit to open dialogue and truthful conversation about race.

We can be well when we recognize our ineptitude as a society at understanding and addressing what ails us.

We can be well when it finally legitimately rings true that all men, women, boys, girls, and babies in the United States are indeed understood, recognized, perceived, and treated as equal.

“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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Virtual #QCOR20 and the future of cardiology academic meetings

Much like many recent academic cardiology meetings, the American Heart Association (AHA)’s Quality of Care & Outcomes Research 2020 (#QCOR20) meeting took place virtually as well, owing to limitations posed by the COVID-19 pandemic. Having attended AHA Scientific Sessions 2019 as an international delegate, this was both my first time attending QCOR as well as my first virtual QCOR. There was a wide range of content encompassing cardiovascular outcomes research, abstract presentations, plenary sessions and also an online interactive early career session via zoom.

So, as I logged into HeartHub (https://www.hearthubs.org/qcor ) for the sessions, in the comfort of my pajamas in a time zone a dozen hours apart, I found that the platform was rather unique, convenient and user-friendly. Talks were pre-recorded in good quality, but what really stood about the #QCOR20 format was the chat function that ran simultaneously with the ongoing talks. Completely flattening all medical hierarchies, this allowed for extensive, insightful and interactive discussions in an informal manner between speakers and attendees, irrespective of where they stood in the totem pole of medicine.  This also served to obviate some of the conventional barriers of Q&A sessions at large meetings, allowing for more questions as well as the active engagement of more junior delegates.

Additionally, Virtual QCOR registration came with on-demand access to recorded lectures as well as other available conference materials including handouts for until three months after sessions, allowing one to catch up on sessions that might have been missed.

This was particularly useful, because, that very weekend SCAI also hosted their annual scientific sessions virtually. In a parallel world, I wouldn’t have dreamed of testing my efficiency with two parallel meetings. But the effort to attending both was significantly less than usual, including financially, involved no flights, commutes or time off work, and conveniently, I could switch between windows to “pop in” to the sessions of my interest at either meeting.

Despite some of these conveniences, I found myself missing the buzz of in-person meetings: the anticipation of results of late-breaking clinical trials, discussions of live cases, interaction and camaraderie of meeting colleagues face to face from the around the world, seeing new technology in the exhibit calls and especially, coming to think of it, the downtime off work and the absolute joy of travel.

Basically, the nerd, the wanderlust, and the human in me didn’t quite agree entirely with this virtual format. But that’s personal. And while we can agree that the science and education will certainly find its way to clinicians, many of the other goals and expectations of such annual academic conferences hinges on in-person meetings. These include small-group practical education, meeting and networking with peers, sharing of experiences, and potential collaborations borne thereof, none of which can be effectively achieved by a virtual meeting. From the perspective of scientific associations, building agendas, policy-making, professional skills development, and interactions with industry are all far better achieved with face-to-face interactions.

With restrictions to air travel, dwindling economies, social distancing measures and the varying commitments of the global medical community facing different phases of the pandemic in their respective countries, there has been much discussion on the future of medical conferences. Given the current climate, delegates (especially international) may re-evaluate priorities, with considerations of finances and if in-person presence was in fact, absolutely necessary.

And as many more international cardiology meetings are successfully converted into virtual events, and many more physicians adapt to this convenient method of education, it begs the question if this indeed will be the default arrangement for the foreseeable future? Further, into the future, academic societies ought to consider the possibility of combining the best of both worlds, so to speak, with a “hybrid” format, offering the in-person meeting as well as the virtual format, thus giving delegates who might prefer it, the option of attending sessions live from the comfort of their homes.

Also, while large global meetings with thousands of delegates might survive the pandemic and transition into hybrid conferences, what of the smaller meetings? Some of these are dedicated to niche specialties for smaller audiences, offering opportunities for hands-on learning and more intimate networking with experts and mentors. Only time will tell if such smaller meetings will indeed prevail.

Virtual meetings may have sufficiently filled the void of medical education and academic discourse that occurred as a result of cancellations of in-person conferences. Part of this void has also been filled by increased interactions between peers on social media platforms, particularly twitter, with renewed importance of the role of social media ambassadors. In more ways than one, virtual meetings may even have brought the world closer, with many of us logging in at the same time from different time zones. But let’s be real: We can dissect a trial on twitter all we like, but it will never be the same as the standing room only attendance at late-breaking clinical trial sessions. Also, let us seriously spare a thought for the principal investigator presenting his/her pioneering research to a computer screen: that is nowhere near the real thing.

The impact of COVID-19 on the course of major professional meetings has been huge. While Science will always find a way to reach us, meetings are so much more than just science. The whole world is adapting to a new normal and it will be interesting to see how this pans out for the medical community.

“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.”