professional role – The Early Career Voice

My Professional Journey

July 21, 2020July 21, 2020 Sherry-Ann Brown, MD, PhD

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.”

On teaching Professionalism

February 26, 2020February 27, 2020 Adham Karim, MD

Professionalism is a multi-faceted concept that carries different meanings to different people; it ranges from a physician’s bedside manner and acknowledging mistakes, to how one interacts with their peers and if they show up on time. Not only that, but this all-encompassing term is cited as a core competency by the American Association of Medical Colleges. It is also a part of the American Medical Association’s code of ethics and explicitly mentioned in the syllabi of most medical schools and training programs across the U.S. Despite the broad acceptance of professionalism as a key character component of a well-rounded clinician, there is a significant difficulty experienced in trying to teach this to trainees. This may seem a little long-winded, but this is a subject that really resonated with me, and with JAMA instituting a professionalism section a few years ago, there have been more and more pieces published on the topic; I’m happy to see that this is gaining more traction. Everybody will tell you that administrative burdens and needing to deal with insurance providers for prior auths and the like definitely contribute to burnout, but having unprofessional colleagues can be just as burdensome and unsafe for patients!

I recently came across an excellent piece in the New England Journal of Medicine titled “Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework” wherein Dr. Wasserman, Redinger, and Gibb attempted to tackle the difficult yet important concept of professionalism in medical training. The article made a strong case for treating lapses in professionalism as if they were medical errors of varying severity, and they included an infographic, as well as gave several examples to go with this framework. In my opinion, professionalism is one of those behaviors that is nearly impossible to teach in a classroom and is often developed through a mix of modeling behaviors from more senior physicians, as well as a little bit of one’s own personality/temperament mixed in.

There was an example cited by the authors that centers around a medical student who has begun a collaboration with a mentor on some database analysis. The mentor states this is an IRB-exempt study and urges the student to begin analysis immediately, but the student’s research office instructs her not to download the data until getting an official exemption was issued by the IRB. The mentor pressures the student into downloading it anyways, and the student gets reprimanded for this. Wasserman et al suggest this is a lapse in professionalism at the lowest level – “no-fault suboptimality” resulting from the student’s faulty understanding that the supervisor (mentor) is right. They focus on teaching the student “strategies for diplomatically addressing her mentor” and acknowledge it is a difficult situation. What they don’t do, however, is acknowledge the context of this lapse of professionalism; they make no mention of addressing the mentor’s behavior or holding them accountable.

By all means, I agree that the student’s incorrect logic needs to be addressed. But, by not addressing the lapse in the professionalism of the mentor, I think the authors missed an opportunity to strengthen the analogy of professionalism and medical errors. In the “Just Culture” movement, physicians were just as accountable as nurses, who were as accountable as medical students for speaking up against unsafe practices. In this scenario, I would argue that the mentor is more liable, and should be held even more accountable than the medical student. As the authors have already made clear, trainees are still developing their understanding of professionalism, but this mentor is arguably an individual who has completed their training and should have a stronger grasp of professionalism than a mere medical student.

I concede that their article was aimed moreso at addressing lapses in professionalism of trainees, but this circles back to my personal view of how professionalism is developed. As others have stated, ensuring an individual trainee’s “competence in the area of professionalism requires the concerted efforts of many.” However, what about non-trainees? You could assume that a hospital board or professional society will self-govern to ensure professional behaviors, but with a term that is so loosely defined, and with financial incentives on the line, how much would someone be able to move the needle? I think most of us can remember at least one time (or many), when a senior physician tore into a helpless colleague, or became frustrated and lost their temper. How often do you think these individuals get a time-out or get part of their wages withheld as a punishment?

This brings me to my point: if the system is flawed, how does putting additional pressure on trainees fix that? The “do as I say, not as I do” approach has never been tested in a randomized trial, but conventional teaching theory (and common sense) will tell you that this is not effective. I myself am a trainee still (you’re reading the Fellows In Training blog, duh), so I certainly do not have all the answers.

From my time spent in developing medical school curricula, and sitting on academic disciplinary committees, I’ve come away with a few insights that I think might help. When the issue is a systems issue – such as “well everyone in my class skips grand rounds, I thought it was ok” the individual who got caught usually got caught due to chance, and reprimanding them would be unfair. Wasserman et al mentioned that the system needs to be changed, but didn’t talk about how. I’m gonna piggyback on that, because systems changes are difficult, and can be nuanced depending on the problem.

I think that lapses in professionalism should be addressed, but a better approach would be one that relies on positive feedback rather than only mentioning professionalism when it is missing. For example, in my medical school, and most training programs, at the middle and end points of a rotation, mentors would take the medical students for some formative “feedback”. Sometimes they were going off a form issued by the medical school, other times they would go off what they felt should be emphasized. If throughout a trainee’s career, different levels of professional behavior are emphasized by instructors, this could go a long way.

One example of this would be that mentors are instructed to focus on the aspect of timeliness and respectfulness with first-year students, making sure to comment on these in each student’s feedback; but when they give feedback to third years, they emphasize other aspects of professionalism, such as truthfulness, admitting to mistakes, knowledge gaps, etc.

Many theories have been put forth as to why professionalism can be such a difficult concept to teach and practice, but I think a critical shortcoming we have to acknowledge is the disconnect between the two worlds that trainees must straddle: the world in which we teach professionalism, and the world in which they practice.

References:

Responding to Unprofessional Behavior by Trainees – A “Just Culture” Framework. Wasserman et al, NEJM 2020. https://www.nejm.org/doi/full/10.1056/NEJMms1912591
Undergraduate Medical Education and the Foundation of Physician Professionalism Kirch et al JAMA 2015. https://jamanetwork.com/journals/jama/article-abstract/2290648
Professionalism, Self-regulation, and MotivationHow Did Health Care Get This So Wrong? Madara et al JAMA 2015. https://jamanetwork.com/journals/jama/article-abstract/2290650
Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction A Systematic Review and Meta-analysis Panagioti et al JAMA 2018. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2698144

The Clinician-Scientist-Educator: Why The “Jack of All Trades” is Viable and Valuable

February 11, 2019March 28, 2019 Elizabeth Knight, PhD, DNP

I am a nurse practitioner, nurse scientist, and nurse educator. That means I’m typically teaching nurse practitioner students two days a week, seeing patients in family practice two days a week, and working on a clinical research project one day a week. (At least, this is the “official” breakdown. Sometimes, in the real world, these things bleed into each other, and into the rest of my life!). I am frequently asked, with some measure of incredulity, why I completed both a DNP (clinical doctorate) and PhD (research doctorate). Was I trying to delay graduation as long as possible? Am I just indecisive? There may be some truth buried in those quips, but I think there are compelling reasons to marry clinical practice, research, and teaching.

The physician-scientist is the most well-established professional role that marries science and practice (see recent popular press mentions here and here). Other clinical fields including nursing, psychology, dentistry, and physical therapy also have dual practice/research roles. Often, teaching is additionally part of an academic position, making the role even more diverse. So what’s behind the role of clinician-scientist? Why do we need these jacks-of-all trades?

I asked clinician-scientist colleagues on Twitter what the rewards are for them. Several described feelings including seeing patients is a reminder of the ultimate reason for clinical research, and seeing the ways that research findings impact patients is motivation for further discovery. One mentioned that participating in research combats the tendency to feel like a “cog in the machine” of medicine. Another noted that it keeps the day-to-day exciting to be in practice, as lab work can sometimes be lonely. And then, there’s the exposure to new ideas and methods that comes from following multiple paths.

(Thanks to @andyYchang and @AnberithaT for the feedback!)

Elizabeth teaches health professions students at the Mobile Health Program’s clinic on wheels, where she practices as a family nurse practitioner

I agree, colleagues! In addition to these personal reasons, there are philosophical reasons to take this path. One reason that speaks to me is the nature of the relationship between science and practice. The gulf between research findings and practice change is wide — some is because the research community doesn’t always do a good job disseminating findings, some is appropriate caution on the part of clinicians, and some is inertia. But part of the problem is upstream — a lot of clinical research was not designed with translation in mind, so the findings don’t seem readily applicable or there are logistical barriers to implementation. Clinician-scientists can address these problems by designing clinically relevant studies and publishing papers that speak directly to clinician’s concerns. They may also enhance research translation by serving as hubs of disseminated learning in the clinical context. (see evidence on clinician-scientists as knowledge hubs here). This brings us to the role of educator: people with research and practice expertise are excellent educators, both in clinical and academic contexts. The deep understanding that comes with immersion in both clinical and research contexts is a powerful tool for teaching. Encouraging current students to appreciate the tools of both disciplines will pay dividends in the shared future of science and healthcare.

My colleagues and I identified many reasons to pursue the clinician-scientist-educator role. Why then isn’t this the default position with everyone following this path? There are challenges. Training as a researcher and clinician takes time, and it may require intense focus in areas that are not always well aligned. The “publish or perish” mantra of academic careers is taxing to those who may dedicate a significant amount of time to clinical practice and teaching. The expected pace of productivity for a tenure-track job can seem unattainable. Likewise, the time and focus required to prepare for and lead a large research project may be out of reach for someone with an active clinical practice. While some may find it energizing to switch contexts frequently, it can be taxing for others. It can be an uphill battle, depending on your work environment, to meet the expectations of multiple roles.

On a personal note, I have faced many of these challenges myself, but I’ve found great support in places like the AHA Early Career community. While my path isn’t typical of those in my profession, I’ve been able to seek out the resources I need to succeed. While taking an unusual path isn’t always easy, it’s also deeply rewarding to be one of the only ones who does what you do.

Would you consider a career as a clinician-scientist-educator? If you’re one or the other, do you collaborate with people who have different roles and expertise?

Elizabeth with a team of early-career clinicians and scientists and mentor David Goff at the AHA 10-day seminar on the Epidemiology and Prevention of Cardiovascular Disease in Tahoe City, CA.