Expanding the Paradigm for Cardiovascular Palliative Care.

Cardiovascular disease (CVD) is the leading cause of death worldwide. Despite medical advances, patients with CVD experience high morbidity and mortality rates, affecting their quality of life and death. Among CVD conditions, palliative care has been studied mostly in patients with heart failure, where palliative care interventions have been associated with improvements in patient-centered outcomes, including quality of life, end-of-life care, and health care use. Although palliative care is now incorporated into the American Heart Association/American College of Cardiology/Heart Failure Society of America guidelines for heart failure, the role of palliative care for non-heart failure CVD remains uncertain. Across all causes of CVD, palliative care can play an important role in all domains of CVD care from initial diagnosis to terminal care. In addition to general cardiovascular palliative care practices applicable to all areas, disease-specific palliative care needs may warrant individualized palliative care models. In this review, we discuss the role of cardiovascular palliative care for ischemic heart disease, valvular disease, arrhythmias, peripheral artery disease, and adult congenital heart disease. Although there are multiple barriers to cardiovascular palliative care, we recommend a framework for studying and developing cardiovascular palliative care models to improve patient-centered goal-concordant care for this underserved patient population.

Personal Actions to Create a Culture of Inclusion: Navigating Difficult Conversations With Medical Colleagues.

Microaggressions between members of a team occur often in medicine, even despite good intentions. Such situations call for difficult conversations that restore inclusivity, diversity, and a healthy work culture. These conversations are often hard because of the unique background, experiences, and biases of each person. In medicine, skillful navigation of these interactions is paramount as it influences patient care and the workplace culture. Although much has been published about difficult interactions between providers and patients, significantly less information is available to help navigate provider-to-provider interactions, despite their critical role in improving multidisciplinary patient care teams and organizational environments. This article is intended to serve as a guide for medical professionals who are interested in taking personal responsibility for promoting a safe and inclusive culture by engaging in and modeling difficult conversations with colleagues. The article outlines important considerations to assist with intentional preparation and modulation of responses for all parties involved: conversation initiators, observers of the incident, and conversation receivers. Although these interactions are challenging, together as medical professionals we can approach each other with humility and compassion to achieve our ultimate goal of promoting humanity, not only for our patients but for ourselves and one another.

Relationship Between Confidence, Gender, and Career Choice in Internal Medicine.

BACKGROUND: Understanding factors in internal medicine (IM) resident career choice may reveal important needed interventions for recruitment and diversity in IM primary care and its subspecialties. Self-reported learner confidence is higher in men than in women in certain areas of practicing medicine, but has never been explored as a factor in career choice. OBJECTIVE: The purpose of this study is to elucidate associations between confidence, gender, and career choice. DESIGN: IM residents completed a 31-item survey rating confidence in procedural, clinical, and communication skills on a 9-point Likert scale. Residents also reported anticipated career choice and rated influence of factors. Associations between gender and confidence scale scores, gender and career choice, and confidence and career choice were analyzed using t tests, ANOVA, and multiple linear regression controlled for postgraduate year (PGY), institution, and specialty choice. PARTICIPANTS: 292 IM residents at Northwestern and University of Texas (UT) Southwestern MAIN MEASURES: Resident gender, self-reported confidence, career choice KEY RESULTS: Response rate was 79.6% (n = 292), of them 50.3% women. Overall self-reported confidence increased with training (PGY-1 4.9 (1.1); PGY-2 6.2 (1.0); PGY-3 7.4 (1.0); p < 0.001). Men had higher confidence than women (men 6.6 (1.5); women 6.3 (1.4), p = 0.06), with the greatest difference in procedures. High confidence in men was associated with choice of procedural careers, whereas there was no association between confidence and career in women. CONCLUSIONS: This is the first study demonstrating a gender difference in self-reported confidence and career choice. There is a positive correlation in men: higher self-reported confidence with procedural specialties, lower with general internal medicine. Women's self-reported confidence had no association. Further investigation is needed to elucidate causative factors for differences in self-reported confidence by gender, and whether alterations in level of self-reported confidence produce a downstream effect on career choice.

Effects of gender in resident evaluations and certifying examination pass rates.

BACKGROUND: Though the proportion of female Internal Medicine (IM) residents and faculty has increased, there is minimal large scale modern data comparing resident performance by gender. This study sought to examine the effects of resident and faculty gender on resident evaluations. METHODS: Retrospective observational study over 5 years in a single IM program. IM certifying examination pass rates were obtained from the American Board of IM. RESULTS: Four hundred eighty-eight residents (195 women, 293 men), evaluated by 430 attending physicians (163 women, 270 men) were included. Twelve thousand six hundred eighty-one evaluations between 2007 and 2012 were analyzed. Female residents scored higher in two domains (Medical Interviewing, and Interpersonal and Communication Skills) (p < 0.01 for each), with no significant difference between genders for the other domains (Medical Knowledge, Overall Patient Care, Physical Examination, Procedural Skills, Professionalism, Practice Based Learning and Improvement, System Based Practices and Overall score). There were no differences in scoring between female and male attending physicians. There were no differences in certifying examination scores between women and men among graduating residents. National pass rates for women were not statistically different to pass rates for men from 1987 to 2015. CONCLUSIONS: Data from one large academic medical center demonstrate higher ratings for female residents on performance domains reflecting bedside care and interpersonal skills, with similar scores for medical knowledge and remaining domains. No significant difference was seen locally in certifying examination scores, nor in recent national pass rates, an objective measure of medical knowledge. Despite imbalanced female representation in areas of medicine, our data suggest that gender-based disparities in Internal Medicine resident medical knowledge and physician competency are no longer present.

Increasing Knowledge about Implantable Cardioverter Defibrillators at the End of Life, an Effective Approach for Hospice Workers to Improve Patient Care.

BACKGROUND: Implantable cardioverter defibrillators (ICDs) decrease mortality in high-risk patients but can also cause distressing shocks near death. Patients who lack knowledge about their ICDs are more likely to have an active device at the end of life. Many hospice workers lack sufficient knowledge to educate patients about ICDs. MEASURES: An ICD educational video created for use in a diverse, underserved patient population was shown to hospice workers from two large community hospices and attendees of a regional conference. A validated 10 question survey was given to participants before and after the video. OUTCOMES: Significant improvement in ICD knowledge scores was seen in all participants (W = 3119.5, P < 0.0001). While doctors and nurses showed higher pretest knowledge, post-test knowledge scores equalized across all participants. CONCLUSIONS/LESSONS LEARNED: An ICD patient educational video designed for a diverse, underserved patient population effectively improved ICD knowledge to a uniform excellent level for a broad range of hospice workers.

Simulation-Based Education in US Undergraduate Medical Education: A Descriptive Study.

PURPOSE: Simulation-based education (SBE) provides experiential learning, improvement in quality of care, and reduction in errors. In 2011, the Association of American Medical Colleges described adoption of SBE in 68.0% of medical schools and 25.0% of teaching hospitals. We sought to examine current trends of SBE integration in American undergraduate medical education since previous publications. METHODS: From 2016 to 2019, University of Texas Southwestern Medical Center postgraduate year 1 residents were invited to participate in a survey assessing medical school simulation experience with 26 clinical tasks from three categories: procedural, communication, and other. Deidentified results were analyzed to assess demographics including sex, specialty, residency program type, allopathic versus osteopathic medical school, and medical school region. RESULTS: Nine hundred sixty-seven of 1047 (92.3%) responses were obtained, representing 139 US medical schools, 91% from allopathic training. Of procedural tasks, most simulated was suturing (n = 848, 89.6%) and least simulated was thoracentesis (n = 737, 80.9%). Of communication tasks, most simulated was taking a history (n = 475, 51.1% reporting simulation >30) and least simulated (never or ≤1) were obtaining a consent (n = 669, 73.2%) and disclosing a medical error (n = 666, 72.4%). Of other tasks, most simulated was chest compressions (n = 898, 96.0%) and least simulated was operating a defibrillator (n = 206, 22.1%). Results were similar regardless of procedural or nonprocedural program. There was no significant difference in SBE exposure between allopathic and osteopathic students ( P = 0.89). Two participants (0.002%) reported no simulation exposure. CONCLUSIONS: Our study is the first to describe a high prevalence of SBE adoption in medical schools nationwide since the Association of American Medical Colleges' 2011 publication, with overall equal exposure for students regardless of residency type and allopathic or osteopathic medical school. Despite widespread adoption of simulation, opportunities remain to expand SBE use to teach critically important communication skills.

Electrocardiographic patterns of proximal left anterior descending artery occlusion in ST-elevation myocardial infarction may be modified by 3-vessel coronary artery disease.

BACKGROUND: The electrocardiographic (ECG) pattern of ST-segment deviation in myocardial infarction is integral to the proper assessment of the location, extent, and functional significance of the infarct but may be modified by the underlying coronary artery anatomy. METHODS: We describe the ECG findings in 2 cases of proximal left anterior descending (LAD) artery occlusion in ST-elevation myocardial infarction (STEMI) associated with 3-vessel coronary artery disease. RESULTS: Both patients had atypical ECG patterns of ST-segment elevation in leads V(2), I, and aVL and ST-segment depression with positive T waves suggestive of extensive subendocardial ischemia in leads II, III, aVF, and V(3) through V(6); acute proximal LAD occlusion and concomitant 3-vessel coronary artery disease were observed angiographically. CONCLUSION: Electrocardiographic changes in proximal LAD STEMI may be modified by the presence of significant atherosclerotic disease elsewhere in the coronary vasculature. Recognition of this ECG pattern may aid the clinician in the rapid identification of high-risk STEMI.

ICD Knowledge and Attitudes at End of Life in a Diverse and Vulnerable Patient Population.

BACKGROUND: Studies thus far lacking diversity show many patients with implantable cardioverter defibrillators (ICDs) have poor understanding of ICD functioning, preventing informed decision-making near end of life (EOL). OBJECTIVE: To describe knowledge, perceptions, and preferences regarding ICDs among patients nearing EOL in a diverse, safety-net hospital population. METHODS: A cross sectional phone survey of patients with ICDs nearing EOL from a safety-net hospital was performed. The survey assessed knowledge, perceptions, and preferences regarding their ICD. RESULTS: Nearly half (46%) of patients falsely believed turning off shocking function would stop the heart, 69% were unaware that disabling ICDs does not require surgery, and 88% said no doctor had ever discussed the option of deactivation of shocking therapy with them. CONCLUSION: Challenges in health care delivery in a safety-net hospital patient population may result in patients being poorly equipped to align ICD settings with goals of care when nearing EOL.

Professional Preferences and Perceptions of Cardiology Among Internal Medicine Residents: Temporal Trends Over the Past Decade.

Importance: Internal medicine residents' professional development preferences were discordant with their perceptions of cardiology in a survey circulated a decade ago; no contemporary data exist. This information is important for effective recruitment and retention of a highly talented and diverse future cardiology workforce. Objective: To identify residents' professional development preferences and cardiology perceptions, in relation to specialty choice, and compare the findings with those from a decade prior. Design, Setting, and Participants: The original survey from the 2010 study was updated and sent to US internal medicine programs. Respondents (ie, internal medicine residents) rated 38 professional development preferences and 20 cardiology perceptions. Data were collected in 2020 and compared with survey results from the prior 2010 study. Multivariable models were created for specialty choice using scaled independent variables dichotomized using the top 2 options; categorical variables were recoded into binary variables for analysis. Main Outcomes and Measures: Multivariable models were used to determine the association of demographic characterisitcs and survey responses with prospective career choice. Responses were examined by total group, by gender, by self-reported consideration of entering cardiology as a profession, and by comparison with a decade prior both as a group and by gender. Results: A total of 840 residents (mean [SD] age, 29.24 [2.82] years; 49.8% male; 55.4% White) completed the survey. The survey incorporated a 5-point Likert scale of 1 (not important) to 5 (extremely important) for some of the questions, with additional questions on demographic characteristics. The most important professional development preferences by descending Likert score were as follows: positive role models (4.56), stimulating career (3.81), and family friendly (3.78). The cardiology perception statements with the highest agreement were as follows: interferes with family life during training (3.93) and having met positive role models or having positive views of cardiovascular disease as a topic (3.85). Multivariable analysis yielded a 22-element model predicting cardiology as career choice. Compared with the 2010 survey, the findings of this survey indicated increased importance of work-life balance components for both male and female residents, with a greater change in male residents. Contemporary residents were more likely than their predecessors to agree with negative perceptions of cardiology. Conclusions and Relevance: This survey study found that both male and female residents place a high value on support for optimal work-life balance; these preferences have intensified over the past decade and factor into career choice. Negative perceptions of cardiology persist and, in some aspects, are worsening. Improving the culture of cardiology may make this specialty a more attractive career choice for all.

Perceptions on Diversity in Cardiology: A Survey of Cardiology Fellowship Training Program Directors.

Background The lack of diversity in the cardiovascular physician workforce is thought to be an important driver of racial and sex disparities in cardiac care. Cardiology fellowship program directors play a critical role in shaping the cardiology workforce. Methods and Results To assess program directors' perceptions about diversity and barriers to enhancing diversity, the authors conducted a survey of 513 fellowship program directors or associate directors from 193 unique adult cardiology fellowship training programs. The response rate was 21% of all individuals (110/513) representing 57% of US general adult cardiology training programs (110/193). While 69% of respondents endorsed the belief that diversity is a driver of excellence in health care, only 26% could quote 1 to 2 references to support this statement. Sixty-three percent of respondents agreed that "our program is diverse already so diversity does not need to be increased." Only 6% of respondents listed diversity as a top 3 priority when creating the cardiovascular fellowship rank list. Conclusions These findings suggest that while program directors generally believe that diversity enhances quality, they are less familiar with the literature that supports that contention and they may not share a unified definition of "diversity." This may result in diversity enhancement having a low priority. The authors propose several strategies to engage fellowship training program directors in efforts to diversify cardiology fellowship training programs.

Managing Implantable Cardioverter-Defibrillators at End-of-Life: Practical Challenges and Care Considerations.

Implantable cardioverter-defibrillators (ICDs) monitor for and terminate malignant arrhythmias. Given their potential as a life-saving therapy, an increasing number of people receive an ICD every year, and a growing number are currently living with ICDs. However, cardiopulmonary arrest serves as the final common pathway of natural death, and the appropriate management of an ICD near the end-of-life is crucial to ensure that a patient's death is not marked by further suffering due to ICD shocks. The tenets of palliative care at the end-of-life include addressing any medical intervention that may preclude dying with dignity; thus, management of ICDs during this phase is necessary. Internists are at the forefront of discussions about end-of-life care, and are likely to find discussions about ICD care at the end-of-life particularly challenging. The present review addresses issues pertaining to ICDs near the end of a patient's life and their potential impact on dying patients and their families. A multidisciplinary, patient-centered approach can ensure that patients receive the maximum benefit from ICDs, without any unintended pain or suffering.

PPARgamma agonists and coronary atherosclerosis.

The prevalence of type 2 diabetes mellitus (T2DM) is growing at an alarming rate and reaching epidemic proportions, and cardiovascular disease continues to be one of the leading causes of death in the United States. The key relationship between these two diseases (knowing that T2DM is a strong risk factor for cardiovascular disease) is insulin resistance and the detrimental effect it has on macrovasculature. Thiazolidinediones (TZDs) are peroxisome proliferator-activated receptor gammaagonists that are beneficial in the treatment of T2DM and have the added benefit of modifying lipid profiles. This review discusses the basic science linking insulin resistance to atherosclerosis and describes the major TZD trials in the recent literature. It also addresses the clinical implications of these studies and media scrutiny surrounding the recent controversial report that TZDs may be linked to an increased risk of myocardial infarction.

Increased expression of glutathione reductase in macrophages decreases atherosclerotic lesion formation in low-density lipoprotein receptor-deficient mice.

OBJECTIVE: Thiol oxidative stress leads to macrophage dysfunction and cell injury, and has been implicated in the development of atherosclerotic lesions. We investigated if strengthening the glutathione-dependent antioxidant system in macrophages by overexpressing glutathione reductase (GR) decreases the severity of atherosclerosis. METHODS AND RESULTS: Bone marrow cells infected with retroviral vectors expressing either enhanced green fluorescent protein (EGFP) or an EGFP-fusion protein of cytosolic GR (GR(cyto)-EGFP) or mitochondrial GR (GR(mito)-EGFP) were transplanted into low-density lipoprotein receptor-deficient mice. Five weeks after bone marrow transplantation, animals were challenged with a Western diet for 10 weeks. No differences in either plasma cholesterol and triglyceride levels or peritoneal macrophage content were observed. However, mice reconstituted with either GR(cyto)-EGFP or GR(mito)-EGFP-expressing bone marrow had lesion areas (P<0.009) that were 32% smaller than recipients of EGFP-expressing bone marrow. In cultured macrophages, adenovirus-mediated overexpression of GR(cyto)-EGFP or GR(mito)-EGFP protected cells from mitochondrial hyperpolarization induced by oxidized low-density lipoprotein. CONCLUSION: This study provides direct evidence that the glutathione-dependent antioxidant system in macrophages plays a critical role in atherogenesis, and suggests that thiol oxidative stress-induced mitochondrial dysfunction contributes to macrophage injury in atherosclerotic lesions.