Viewing posts from: October 2020

Health Care in the Face of the Climate Crisis

Ahmed, Journals and Presentations / 06.10.20200 comments

Jeff Bezos recently adorned the cover of the magazine The Atlantic. The maga- zine had taken presumptive liberties and carved up the profile of his brain to summarize his “master plans.” A sizable portion of the cortex was assigned to the goal of “colonize outer space.” Other notables included “tax avoidance,” “more Jeff-bots,” and slogans such as “resistance is futile.” The article was a fasci- nating summary by the author of what the world’s richest human being wants for the future of the human race: limitless growth.

What was notably missing from the “master plan” was discussion of the un- intended consequence of boundless, unfettered, and irresponsible humanization: harm to our planet. There was no mention of the mounting evidence that anthro- pogenic influences are polluting the planet at an unsustainable rate or discussion about the far-reaching impact of pollution and climate change on highly inter- twined ecologic systems. Disrupted weather patterns, rising seawaters, altered mi- gration patterns, and extinction of millions of species are just some of the reasons pollution and climate change have been described as the greatest threat to human survival in the 21st century.1

Even more removed from consideration is the unintended impact of health care and all its components on the environment. In line with other major economic sectors, each step in the process of healthcare delivery leaves behind an environ- mental footprint; from use of large quantities of natural resources to generation of tons of waste each year to emission of substantial quantities of greenhouse gases. There are countless ways that the healthcare sector as a whole could be more eco-friendly, less wasteful, and more efficient without compromising innova- tion, growth, or quality of care. Opting to continue with business as usual without considering ways to reduce and optimize health care’s ecologic output threatens the viability of the system as a whole and forgoes an opportunity to impact health care’s contribution to climate change, pollution, and population health.

We, as members of the healthcare system, have several reasons beyond just moral responsibility to improve and address the ecologic footprint related to patient care. First, given the vast use within coupled with the size of the global healthcare sector, targeting systematic methods of decarbonization offers an im- mense opportunity to reduce the ecologic footprint related to healthcare delivery. Global healthcare spending is projected to increase from $7 trillion in 2015 to more than $8 trillion in 2020, and health care accounts for approximately 4% of global greenhouse emissions. In the United States, for example, health care–related greenhouse emissions represent 10% of national emissions, an increase of 30% over the last decade.

The Intergovernmental Panel on Climate Change launched the Healthcare Climate Challenge as a global initiative pledging to engage healthcare institutions in reducing their carbon footprint, preparing for the impact of climate change on public health, and being advocates in their communities for healthier people on a healthier planet. In the United States, 7 leading health systems together embarked on the Healthier Hospital Initiative to engage the health sector to address the environmental impact of deliver- ing care. For providers, actionable items include establishing a sustainability task force that conducts an au- dit of current clinical practice with the goal to mitigate waste, increase efficiency, and apply evidence-based resource utilization. There is a near emergent need not only to halt the escalating trends in consumption and carbon output, but also to define a vision for hospital systems that are carbon neutral, toxin free, water balanced, and striving for zero-waste.

Second, there is a direct relationship between pollution and a sicker human race; controlling health care– related pollution is a way to improve the health of our patients. Environmental pollution is a global public health emergency and the most common cause of non- communicable environmental disease and premature death worldwide.4 The commitment to our patients is tightly interconnected with a commitment to the health of our planet. Pollution comes in many forms, and healthcare systems make large contributions to air, water, and chemical pollution. Hospitals are intensive users of fossil fuels, and hospitals in the United States consume nearly 3 times more than the most efficient hospitals in northern Europe.
In addition, the U.S. healthcare sector leads the world in chemical consumption, using more than twice that of other sectors. Air pollution is directly associated with cardiovascular diseases such as hypertension, increased serum lipids, accelerated atherosclerosis, increased incidence of arrhythmia, acute stroke, and myocardial infarction.5 Chemical pollution is linked to increased risk of multiple cancers. As health- care providers, our pledge to do no harm obligates our understanding that pollution and climate change are directly affecting the health of our patients.

Lastly, a more sustainable, efficient, and carbon- neutral healthcare system is a more economically sound system with positive ripple effects. Analysis of wasteful practices and implementation of strategies to reduce over-testing, over-treatment, and over-prescribing will lead not only to better and less costly care, but also care with a smaller environmental footprint. By lowering levels of health care–related pollution, we have an opportunity to impact climate change and its indirect adverse economic impact. It is estimated that more than 700 global climate-related events resulted in more than $300 billion of economic losses in 2017,5 and in 2015, the cost of lost productivity associated with pollution-related diseases was $53 billion in high- income countries.5

Given the imminent global impact of climate change and pollution, and the healthcare sector’s escalating contribution, our response as healthcare providers is im- perative. We have to foster a conscience and a culture that delivers exceptional health care with the smallest footprint. We must look to create a circular healthcare economy that commits to increased use of renewable energy, prioritizes use of environmentally responsible products, and incentivizes ”reduce, reuse, and recycle” in all aspects of healthcare delivery. Our master plan must require us to do better for our patients and our planet. Through commitment, advocacy, and leadership we must effect change for a healthy human race thriving on a healthy planet.


1. Costello A, Abbas M, Allen A, Ball S, Bell S, Bellamy R, Friel S, Groce N, Johnson A, Kett M, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet. 2009;373:1693–1733. doi: 10.1016/S0140- 6736(09)60935-1

2. Pichler P, Jaccard I, Weisz U, Weisz H. International comparison of health care carbon footprints. Environ Res Lett. 2019;14:064004.

3. Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PLoS One. 2016;11:e0157014. doi: 10.1371/journal.pone.0157014

4. Landrigan PJ, Fuller R, Acosta NJR, Adeyi O, Arnold R, Basu NN, Baldé AB, Bertollini R, Bose-O’Reilly S, Boufford JI, et al. The Lancet Commission on pollution and health. Lancet. 2018;391:462–512. doi: 10.1016/S0140-6736(17)32345-0

5. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Berry H, Bouley T, Boykoff M, Byass P, Cai W, et al. The 2018 report of the Lan- cet Countdown on health and climate change: shaping the health of nations for centuries to come. Lancet. 2018;392:2479–2514. doi: 10.1016/S0140-6736(18)32594-7


2020 View of Women’s Heart Health

Ahmed, Journals and Presentations / 06.10.20200 comments

It’s great to see State street adorned with American Heart Association (AHA) flags to celebrate American Heart Month.  Though for a cardiologist, every month should be heart health month, it does help to intensify the message every February.  

February also celebrates the Go Red for Women campaign, a remarkably successful cause campaign launched in 2003 aiming to raise awareness about cardiovascular diseases (CVD) in women.  I remember when I was first captivated by the emerging story surrounding women and CVD.  It was at the start of the new century and there was no denying the data.  CVD had been the most common cause of mortality in the United States for more than 50 years but it wasn’t till two decades ago that we noted a disturbing trend-one that could no longer be ignored.

Each year, the American Heart Association (AHA) updates heart disease and stroke statistics in the United States.  It is a comprehensive and exhaustive evaluation of the impact of CVD on the US population as a whole.  The document is rich with data on everything from mortality trends to survey results regarding all the known risk factors that drive CVD.   It breaks down data by type of CVD (six different diagnoses make up CVD; coronary heart disease and stroke are the two most prevalent), sex, age and race.  

The figure I remember most vividly was one that compared CVD related mortality in men and women over time.  Starting in 1979, with the help of research improving our understanding of CVD and development of advances in pharmacotherapy and mechanical treatment of coronary heart disease, men derived a drastic and steep decline in mortality.  A trend which was good reason to celebrate. In complete contrast, the mortality trend line among women was climbing, reaching its peak in the year 2000.  And with this, the mortality gap in CVD between men and women was widening and caught us (the medical community) completely off guard.  We would spend the next two decades first deconstructing the possible explanations for this trend and then use the power of science, education and social media among other things to construct the solution.  

The Campaign

The Go Red for Women campaign became the microphone through which we would spend the next two decades disseminating the message about the under recognized risks of CVD in women. In addition to spreading the word about the risk of CVD, the campaign has had immense impact through various other avenues.  Advocacy efforts led to passage of the Heart Disease Education, Analysis, Research, and Treatment (HEART) for Women Act in 2011 mandating that there be adequate representation of women, racial and ethnic minorities in clinical studies, that studies be powered to examine sex specific outcomes and that there be a report on the quality and access of care for women with CVD.   The campaign continues to go red and strong, now existing in over 50 countries and helping to continue to fight for the cause.  

The Differences

Over the last two decades, we have uncovered many striking differences in CVD which are specific to women.   First, it didn’t take a deep dive to realize that part of the explanation for the worrisome mortality trends was related to perception.  Women did not perceive themselves at risk for CVD and furthermore, providers did not think women were at risk for CVD, in particular heart disease.  Women who were at risk were unaware and even when they had more pressing symptoms, they were more likely to present late in the course of what often was a heart attack. 

Second, there was concern that women did not have classic symptoms of what is infamously known as the ‘Hollywood heart attack’ (man clutching his chest and falling to the ground).  Thanks to detailed study on sex differences in symptoms, we now know that women are more likely to have atypical symptoms, but the vast majority actually do have typical symptoms at the time of their heart attack.  Women had to be reminded to pay attention to symptoms which were not usual for them and were occurring with exertion or stress. 

Third, we have discovered that not only are women at risk for what we have considered a traditional heart attack where there is visible narrowing of the heart arteries, but they are also having heart attacks with open arteries.  Women can have chest pain symptoms with testing suggesting impaired blood flow to the heart muscle without narrowing of the main heart arteries.  These two entities,  myocardial infarction with open arteries and microvascular angina are almost always seen in women and have led to the hypothesis that there are sex differences in how atherosclerosis effects blood vessels with women being more likely to have diffuse disease of the major heart arteries and being more likely to have problems with the small microvessels.  This becomes important when considering treatment options as medical therapy plays a larger role in treating these entities.  

In addition, we have uncovered two fascinating diagnoses which are not new but have been under recognized.  Both are almost exclusively seen in women. First, the Broken Heart Syndrome (also known as Takastubo syndrome) has been described now in thousands of cases and is a heart attack which is usually triggered by an emotional event.  The usual presentation is a woman presenting with classic signs and symptoms of a heart attack after witnessing something emotional and or tragic.  The heart arteries have no blockages but the heart muscle appears to be stunned. Most patients are treated supportively and make a full recovery.  The other is known as Spontaneous Coronary Artery Dissection or SCAD.  SCAD occurs in younger women and presents like a heart attack.  When the heart arteries are evaluated, there appears to be a spontaneous tear one of the heart arteries.  Though the exact cause of SCAD is not confirmed, we have learned through large patient registries that conservative treatment over mechanical treatment is preferred and safest.  

Finally, as the treatment armamentarium expanded for women presenting with heart attacks, we started to notice sex specific risks of treatments.  For example, women undergoing invasive treatments such as heart catheterizations and stent placement were noted to have increased risk of procedural bleeding and with it were having worse outcomes. This sex specific risk is thought to multifactorial with some of the explanation is related to anatomical differences in arteries and some related to differences in the effects of blood thinners and their metabolism.  In an attempt to mitigate the bleeding risk, current practice as evolved away from using drugs which are associated with increased bleeding and most importantly, we have transitioned to using the smaller, safer radial artery as the default site for procedural access.  This has had enormous impact on bleeding complications and has preferentially improved outcomes among women given their predisposition.  

These are just a few of the many lessons we have uncovered trying to navigate our way to answers about women and CVD in the 21st century.  As I re-examine the mortality curve, just as the problem had drawn our attention in 2000, the progress is loud and clear in 2016.  It has been remarkable to take a 20/20 hindsight view in the year 2020 of where we were and where we have come in 2 decades.  The colossal team effort speaks to the power of science, community, advocacy and universal commitment to ensure that we study and treat all at risk for CVD, especially women and minorities.  Though much more work is needed and continues, there is no denying where the heart is on the matter of women and CVD.   


PCI and the Planet

Ahmed, Journals and Presentations / 06.10.20200 comments

The arteries had been recanalized, the Swan- Ganz catheter was in place to help guide clinical decisions, a temporary venous pacer was faithfully generating 80 impulses a minute, and the hemodynamic support device was unloading the sickened muscle. The patient had shown up on the verge of death and now was leaving the cath lab critically ill, but stable. The teamwork was remarkable despite the 4am hour and as I took my lead apron off to document the last three hours of effort, I looked around to see what was left behind… blood, sweat and bins full of trash and plastic containers.

For those who believe in science, it is impossible to deny the innumerable ways humanization is contributing to the destruction of the planet. The culmination of years of irresponsible consumption has paved the way for climate change and with it, weather-related disaster after disaster. Unprecedented flooding, entire towns reduced to ashes by raging fires, droughts bad enough to cripple economies, and rampant destruction of the oceans are some of the reasons climate change has been described as the greatest threat to the human civilization in the 21st century. Generations are up in arms about all that needs to be done and that isn’t being done. From afar, the cause-and-effect link between bottomless utilization of non-renewable resources, uncontrolled CO2 production, and climate change is clear (to most). But how we as a human race, country, state, community, family, and individual can affect the overdue change is anything but clear.

Like other major economic sectors, the global healthcare industry is massive and makes an un- healthy contribution to all that ails the planet. It consumes large quantities of natural resources, spews significant amounts of greenhouse gases into the atmosphere, and generates hundreds of tons of waste each year. Hospital systems are big structures that not only have a large physical footprint, but an ecologic one to match. Every step of healthcare delivery within the walls of hospitals consumes resources and for too long, we have not stopped to think about what it leaves behind. And more importantly, why should we as healthcare providers concern ourselves with the unintended ecologic footprint created as we take care of our patients?

For one, given the large size of the healthcare system (U.S. and globally), a sustainability effort can be very impactful. We as interventional cardiologists like high- yield results and in this case, even small corrections will come with big gains. Second, prioritizing ways to make the system and process more efficient and less wasteful will yield cost savings. Financial incentives to be greener are plentiful, including reducing waste (spending less), increased energy savings, and minimizing productivity losses due to a healthier work force. And though the larger-scale corrections such as regenerative architectural design (buildings that are resource generators rather than consumers) will take time and cost up front, there is no denying the long-term benefits of lower/non-polluting practices and the resulting impact on economic growth. Third, it should be clear that the health of the human race is intricately related and dependent on a healthy planet. If our priority is our patients, then we have to factor in the health of the planet. Pollution-related illness represents 25% of diseases worldwide and even small steps in the direction of lowering emissions will improve the health quality of the population as a whole.

There are many in healthcare who are concerned, and many more who have not made the connection between healthcare and its contribution to climate change and why it needs us to lead the charge for change. It can be easily assumed that what we do as providers serves a means to an end. Patients are the priority, and all else is a necessary and required part of the process. But there are countless ways we can improve our footprint while we best treat our patients. To that end, for those of us who are part of teams working in cath labs, our efforts have to begin where we work (Table 1).

Starting a sustainability assessment in the cath lab should focus on reducing (minimalist cath procedure), re-using (replacing single-use prod- ucts with instruments that can be sterilized), and recycling. An assessment along the entire utilization chain can help identify ways to limit landfill waste, increase recyclables, and reduce use of unnecessary products. Educating everyone in the lab and hospital system about the existing recycling chain, examin- ing materials that are non-essential, and replacing essential materials with sterilizable options to limit inclusion of single-use products are a few ways to have immediate impact.

We, as part of a cath lab team, go above and beyond to treat, rescue, and save each individual patient. What we need now is commitment to equally consider planet care as we give patient care. Similar to applying the best evidence to guide our clinical practice, we are at a point where we also have to consider delivering the best care with the smallest footprint. It must start where we work and with the expectation that our systems of care as a whole will prioritize the health of our planet, permitting us to continue to take the best possible care of our patients.

Table 1. Ten Steps for a ‘Greener’ Cath Lab and Minimalist Cath Procedure.

  1. Evaluate current sustainability plan at the hospital and identify a sustainability team in charge of hospital-wide initiatives to reduce, reuse, and recycle.
  2. Build a Cath Lab Green Team (cath lab manager, cath lab staff, fellows).
  3. Learn about existing pathways of waste removal from the cath lab. Quantify (by weight) how much is currently going to landfill and recycling (if in place), in order to establish a baseline.
  4. Establish a plan to recycle in the cath lab. This includes identifying what the hospital program recycles. All qualifying rigid plastic and paper packaging materials should be kept clean and disposed at the time of being removed from sterile packaging and placed in the appropriate bin.
  5. Inquire about recycling take-back programs through manufacturing companies.
  6. Educate all cath lab staff, providers, and trainees about the steps to recycling and about what can and cannot be recycled.
  7. Ask waste management to assist with providing appropriate type and numbers of recycling bins for the cath lab.
  8. Review contents of existing cath packs and attempt to make ‘lean cath packs’.
  9. Replace single-use metal or plastic items (scalpels, plastic clips, clamps, forceps) with materials/instruments that can be re-sterilized.
  10. Plan to weigh weekly recyclable and landfill output over the next month and compare to baseline. Conduct an audit to ensure proper chain of waste management from the cath lab.

Tennis and Interventional Cardiology

Ahmed, Journals and Presentations / 06.10.20200 comments

The great game of tennis has origins that date back to 1,000 BC when French monks played ceremonial “je de paume,” or game of the

hand. Initial tennis balls were wooden, and the first wooden racket used was laced with sheep gut. It was not until the invention of rubber and the bouncier ten- nis ball in the mid-1800s that tennis saw its popularity soar. Many versions of the game have evolved to become what is now 1 of the most popular sports in the world. Young and old, rich and poor, amateur and professionals share the simple act of hitting a ball over a net on a rectangular court.

At first glance, there may not be too many obvious similarities between tennis and interventional cardi- ology. But, a closer look draws them together. First, both are graced with pioneers who propelled the sport and the field to affect the lives of so many on a global scale. Tennis legends, such as Althea Gibson, Fred Perry, Margaret Court, Billie Jean King, Virginia Wade, Arthur Ashe, and many others defied norms with courage and perseverance and proved to be champions for the sport. Similarly, the amazing field of interventional cardiology would not exist if not for giant innovators, such as Werner Forssmann, Claude Bernard, Dickinson Richards, F. Mason Sones, Charles Dotter, and Andreas Gruentzig, to name a few. Just like tennis champions, their commitment and love for the field drove their success.

Tennis and interventional cardiology also connect when one considers the training and technique involved, be it on a tennis court or in a laboratory full of x-ray equipment. Both are physically demanding, relying more on technique than brute force. Hitting the flawless single-handed topspin backhand requires countless hours of practice to perfect the mechanics of a complicated stroke. Similarly, many hours are spent during fellowship and beyond to safely obtain vascular access, master wiring a tortuous vessel, or navigate delivery of a percutaneous aortic valve. There are many dots that need to be connected precisely to accomplish the goal each time. Those who do it well have the best outcomes, be it a victory on the scoreboard or a successfully treated patient. In addition to parallelism in technical aspects, both tennis and interventional cardiology require mental focus and acumen that has to be sustained to achieve the desired goals of winning the match and treating the patient safely. Many times, the world’s best players falter to players of lesser caliber because of mental mistakes. Even the masters of interventional cardiology are at risk for complications borne of poor decision-making. The need to have your head in the game is of paramount importance when considering the use of either the racket or the catheter.

Another commonality is the misperception that tennis and interventional cardiology are solo pur- suits. Though there is a single person in charge on the court and in the laboratory, to excel, one needs an outstanding team. In the catheterization laboratory, the team includes nurses, techs, and trainees. On the court, it is the team of personal trainers, coaches, and family members that helps support the player.

Perhaps what brings the 2 closest together is the unpredictable human element. In tennis, it is the opponent across the net, and in the catheterization laboratory, it is the patient lying on the table under a sterile drape. There is an inherent unpredictability in what may be required to be successful on any given day, and the “game plan” needs to be individualized each time. During a match, there needs to be constant awareness of the opponent. A few points often decide a challenging match, and those who play well under pressure usually win on the court. Similarly, when treating a complex, high-risk patient, calmness and focus in a life and death circumstance is an essential trait. Often times, it is millimeters that matter, and just like playing the big points in a match, there is minimal room for error.

Although the similarities are many, there is some- thing tennis can teach us as medical providers, and that is the art of celebrating our victories. World-class tennis players show their mental fortitude by not allowing mistakes to dictate their game and build on the confidence of each victory. In medicine, we often review and critique our mistakes ad nauseam, but we rarely talk about the many ways we help and treat countless patients each day. It is rare that there is a celebratory recognition of a job well done when a sick patient is treated successfully. It takes a team of committed individuals, including doctors, nurses, and techs, to awake in the middle of the night, to rescue an artery, the pericardium, or a threatened limb: a feat that should be celebrated each time. This may not include a loud scream accompanied by a fist thrust in the air replayed in slow motion or a fall to the knees in gratitude, and there is not a beautiful trophy that will sit on our shelf. But, a verbal acknowledgement of a job well done would go a long way in shifting the focus from our mistakes to our successes.

Tennis complements interventional cardiology, and vice versa. A tough victory on the court can enhance the confidence needed to perform a flawless inter- vention, and similarly, a successful day of intervention can bolster the right attitude on the court.

For those who play, tennis can be the perfect antidote to a tough day in the laboratory. As it may be true for many other pursuits, there is a therapeutic release that accompanies hitting a tennis ball. Perhaps it is the singular focus of swinging the racket to meet the ball at the perfect time in flight and willfully forcing its direction. Perhaps it is focusing on the sound the ball makes as the racket swings through it. Maybe it is simply because of the challenge it represents. Regardless of the reasons, I feel privileged to partake in both, and I also recognize the passion and dedication that both require.


Training Millennials

Ahmed, Journals and Presentations / 05.10.20200 comments

Of all the transitions after starting the multitiered training process in medicine, the fellow to attending evolution has to be one of the most daunting. The onus of responsibility that occurs after graduating fellowship is several orders of magnitude more challenging than even the medical student to intern transition. It seems that almost overnight a graduating fellow permanently loses the comfort of the very protective training umbrella and assumes the role of being in-charge. This change can feel even more weighted when practicing in a procedural field. The trainee suddenly assumes not only the sole responsibility of the patient on the table but also is supposed to know how to guide the nervous hands of a first-year cardiology fellow – hands that are very likely to be those of a millennial in 2019.

Though generational cutoffs are an inexact science, generations are defined by key political, economic and social events. For example, the Pew Research Center defines the millennial generation as those born between 1981 to 1996, followed by the post-millennial generation (1997-present). Most millennials are old enough to remember and understand the lasting geopolitical impact of Sept. 11, 2001, they were the powerful voice of the youth that helped elect Barack Obama as president, and they have grown up in the midst of an economic recession. They require and need constant connectivity, and social media is their sixth sense without which life would be less lived. These among many other factors have shaped the ethos and emotional IQ of the millennial generation, which are noticeably different from previous generations. Better knowing and understanding millennials and their expectations can be a very valuable lesson for those in their early career, as they may find themselves working with or mentoring millennials.

This becomes even more important when we realize that the training culture in medicine is deeply woven around ideas of hierarchy, tradition and assumed respect based on rank. These concepts are in many ways “anti-millennial,” who have been called “Trophy Kids” and referred to as “Generation Me.” Though generalizations are not completely accurate, there are consistent trends which suggest that millennials are self-centered and in some ways more narcissistic than previous generations. They thrive on positive reinforcement and are less likely to accept negative criticism. This can affect how they learn and what they expect as trainees, almost mandating that mentoring skills be adjusted accordingly.

Listening to senior faculty (baby boomers) tell stories of days in the cathlab when attending physicians reigned supreme and any misstep by a trainee could result in ejection from the cathlab, or at the very least a hand slapping, seems juxtaposed from what millennials can and do expect from their training experience in 2019. As a Gen X interventional cardiologist, trained by early Gen Xers who were trained by baby boomers, my cathlab experience lies closer to what senior faculty describe. By no means did I have a hostile training experience, and in some ways, we have been described as having it easy when compared to my mentors. However, as a trainee, I needed to be prepared for whatever was and would be required of me by each of my mentors. I expected myself to make the most of training regardless of the fact that it was hard and challenging at times. It was inconceivable for me to think about complaining or anonymously “writing’ up” my attending over a difference in expectations.

As I transition through my years as faculty (now close to entering mid-career), I find myself struggling with the following: How do I meet the expectations of a generation different from mine and bridge the proverbial generational gap? How do I best teach, train and mentor them without lowering my expectations? How do I let them know what is expected without causing them to disengage?

A recent article in the Journal of the American Medical Association discussed myths, truths and best practices to help with mentoring millennials. Traits such as impatience, entitlement, laziness, narcissism and neediness – which have been used to describe millennials – in reality may represent efficiency, motivation, balanced, empowerment and engagement. As an example, “millennials generally desire frequent interaction, are quick to multitask and relish the ability to connect rapidly across the globe. These connections are often brief and need not occur within a backdrop of lengthy face-to-face connections. As a result, millennials differ in skills critical to building professional relationships and may be perceived as impatient and needy, rather than efficient and engaged.” Understanding this shift in perspective may allow us to shift our own perspective about the generation.

It may be time to make a concerted effort towards developing a better understanding of the “millennial approach,” especially since they are about to represent more than half of the work force. Applying the same hard-nosed expectations to Gen Me is not only ineffective but also may be disadvantageous to an entire generation of physicians and the medicine they practice.


Do No Harm, To Patients Or The Planet

Ahmed, Journals and Presentations / 05.10.20200 comments

It is a virtual certainty that humans have played and continue to play a vital role in global climate change. We have now reached a point where climate change is considered the greatest threat to human health and survival in the 21st century (1). Continuing with business as usual and taking a head in the sand approach jeopardizes the health of the human race across the globe and more importantly, places the planet at perilous risk.

My constant need for environmental stewardship has become a good source of humorous fodder for those subjected to my militant requests to reduce wastefulness and consumption in my workspace, a hospital. I find myself relentlessly searching for ways to reduce my carbon footprint and though this is easier to accomplish at home, it is a daunting task at work.

Health care systems such as hospitals are important sources of environmental pollution and contribute significantly to greenhouse emissions, generation of chemical waste and consumption of natural resources and products. The United States spends a fifth of its GDP on health care related costs- an estimate three trillion dollars in 2013. With this comes the sobering fact that US health care related greenhouse gas emissions have increased by more than 30 percent over the past decade and represent 10 percent of national emissions. Even more sobering is that if U.S. health-related emissions were ranked globally, it would rank 13th in the world, more than all of the United Kingdom.

Hospitals are large, energy-consuming buildings that are always open and utilize an extraordinary amount of resources in the form of fuel and electricity. They also drive the use of products such as pharmaceutical and medical devices that use significant resources for production. Every step of health care delivery has an environmental impact including both the upstream and downstream delivery of services, through utilization of natural resources and through generation of millions of tons of waste each year. Wasteful and inefficient practices within a hospital system are rapidly contributing to adverse climate change and climate change at its current trajectory will have far-reaching effects on the health of the global population. It is no wonder that improving hospital practices can have enormous impact on the rapidly enlarging health care related carbon footprint.

There is growing interest in estimating the health care sectors direct impact on environmental pollution and indirect impact of the pollution on public health. In a study evaluating trends in health care sector emissions and its potential harmful effects on public health in the United States, the authors concluded that the health care sector was responsible for 10 percent of national air pollution emissions with hospital systems providing the largest contribution. In addition, the indirect adverse impact on public health from environmental pollution related to healthcare systems was similar to annual death rates related to preventable medical errors.

For all of us in the health care system, our primary calling is to prevent and treat disease. What we are failing to recognize is that we as providers and those who deliver health care are inadvertently contributing to a public health crisis. Fortunately, there are initiatives that are raising awareness and are a call to action to prioritize decarbonization of health care systematically. At the Paris Climate Accord in 2015, in partnership with Health care without Harm and Global Green and Healthy Hospitals, the global community put forth the Health Care Climate Challenge. This as an opportunity for hospital systems to pledge to mitigate and curtail their current environmental impact, be prepared for the impact of climate change on public health and lead the way in educating their communities to be responsible and better informed citizens.

We as providers and protectors of our patients and our planet have to acknowledge that it is time for action. We must lead the charge in bringing necessary change to how we think about not only delivering the best care but also one that leads to the smallest footprint. We must urge our institutional leadership to prioritize an assessment of current wasteful and inefficient practices, perform a “green check,” to bolster efforts to promote patient care with the smallest footprint possible and to invest in the long-term promotion of a stronger, smarter and a sustainable health care system.

The Gaia theory is a reminder that we have a symbiotic and synergistic relationship with all our surroundings on this majestic and vast planet we call home. How we respect and treat that which we inhabit will perhaps be the most important determinant of the future of the human race. We cannot expect to live healthy lives on an ailing planet.


1. Nick Watts, Markus Amann, Anthony Costello et al. The 2018 report of the Lancet Countdown on health and climate change: shaping the health of nations for centuries to come. The Lancet 2018. 392 (10163) 2479-2514


Viewing Serena’s Outburst as A Woman in Medicine

Ahmed, Journals and Presentations / 05.10.20200 comments

The tennis fan in me, the woman in me and the career professional in me were all uncomfortable watching the drama unfold at the US Open Women’s Tennis Championship this year. By now, everyone knows the details and most have an opinion. Serena Williams found herself reacting to an umpire who forgot that his job was to maintain the integrity of the match without affecting its outcome. She was also reacting to being deftly outplayed by a dialed-in, eager 20-year-old who had idolized her and she was reacting to the weight and pressure of all that was at stake at that moment. In spite of who she is and what she has accomplished, the moment over-powered the mighty Serena. She caved. She lost her cool. She lost control and least importantly, she lost the match.

Serena argued that a sexist bias was at play and that men have done much worse on the court with far less consequence; that she was profiled and penalized on the grandest of stages because she was a woman, a black woman. Supporters claimed that the umpire “couldn’t handle” being spoken to by a woman in that manner resulting in the harsh penalty. Like me, many have expressed their thoughts. Tasteless cartoons have been drawn; arguments have been made in support of Serena and against her behavior. We have been asked to check the state of our unconscious bias. Would I react differently if Roger Federer had behaved that way? Would I be more likely to stand in support of him than I do of Serena?

As I tried to internally deconstruct my feelings towards this incident, I found myself drawing parallels between my career as an academic interventional cardiologist and some of what Serena might experience on the tennis court. On most days, I find myself across the net from a disease state; one that costs thousands of people their lives every year, one that has an impressive collection of strokes to counter my best efforts. I have to be in my best form, mentally and physically, every moment of every day that I am on my version of a tennis court. What is riding on the line for me is life and death of another human being and if I count each patient treated successfully as a win, I have amassed cabinets full of trophies and victories. Similar to the pressure that Serena felt, I too feel the weight of the outcomes of each of my patients. Like Serena, I desperately want to win each and every time.

I also can relate to the presence of a sex-based bias in my workplace. My ability to get “away” with things that I express under conditions of stress and pressure is not the same as my male colleagues. Trainees are less likely to handle criticism from me than a male version of me. I am more likely to be asked to be “gentler and kinder” than my male colleagues. I know that over my lifetime, my paycheck will be smaller and that I may not be naturally perceived for leadership positions because I am a woman.

I acknowledge that there are many examples of sex-based bias, conscious and unconscious that continue to exist in all aspects of our everyday lives; but I still find myself wishing Serena had chosen to handle her situation differently. Not like Roger would have but like a woman should have. My comparator for Serena is not a male tennis player thrashing his racket and berating the chair umpire. Similarly, I don’t want moments of frustration and anger to be the moments we ask for equality between men and women – that is not the conversation that moves us forward. My expectation of myself and my sport idols, male or female, is that we lead by example — that we stand in the face of pressure and maintain the control amidst the chaos regardless of the outcome. Serena in that moment lost that control and that is what led to the outcomes and spectacle that evening.

The presence or absence of bias and “misogynoir” leading to the umpire’s decisions that night will be argued and discounted all at once. What cannot be lost or forgotten is the need for us as role models, mentors, idols, superstars to behave and express ourselves with the respect and veneration that we expect from others. Not every match is won and not every patient can be saved, despite our best efforts; but our behavior has to show the best of us. In that moment, Serena forgot to apply her greatest strength; her ability as a woman to maintain perspective, control the chaos and silence the doubts like she has done countless times before.