Oby: This is our final compilation episode. And the next episode in February will be the beginning of the new content on the podcast. Enjoy these recaps of some of our favorite conversations from last year.

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From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center, and by NCATS, the National Center for Advancing Translational Sciences.

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First up, our interview with Dr. Alicia Whittington, Assistant Director of Engagement and Health Equity Research at the Football Players Health Study, and board member at the Augustus A White Institute for Health Care Equity. She joined us in May of 2022 to talk about her family history and experience and how that led to her work in equity research.

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It is such a pleasure to be able to talk to you and hear about your journey to research. So I know a bit about you, and your family background, and education, and feel like it would be great for our listeners to hear before we jump into what keeps you interested in research. So can you just start by telling us a bit about your family history and background?

Alicia Whittington: Sure. Thank you so much. It's so wonderful to be here with you today to talk about my journey. And I appreciate that opportunity. So I am number seven of eight children. And I grew up in Saint Louis, Missouri, in an area that produced several elite athletes.

Now, the interesting thing is that my parents always had this plan to have a large family. And I used to always ask questions like, where did this come from? And it stemmed from their upbringing. So the both of them grew up in rural Mississippi. And what I always found really interesting about them is that they grew up 113 miles apart and did not know each other when they were children.

But their families went through the same devastating crisis in 1946 when their fathers died. And so my mom was an infant when her dad died. And my father was about 10 years old when his father died. And he ended up becoming the man of the house.

My grandmothers were left with large families. So my dad is one of 11. And my mom was the youngest of 13. And so with their fathers dying prematurely-- and I have to mention that they died as a result of lack of access to adequate health care in Mississippi because of their race. And the families struggled after they died.

And with that, you see a multi-generational effect. And so I'm a first-generation college graduate. And when I think about just what my family's been through, I always tell everyone that. yes, I'm a scientist, I'm a musician, but at the core of who I am, I am a storyteller.

And the reason for that is because when I was a little kid, I would sit around the more seasoned members of the family because they would tell all of these stories about our family history. Even as a little girl, I was struck by just all of the hardship that they went through, and also the resilience that they have and had. Because I'm able to now do all of these amazing things when they didn't have that opportunity, but yet they remained positive. And they just knew that future generations would be able to do all the things.

And so I knew as a child that this thing that I didn't know was called health equity, health disparities, but I thought about it all throughout my education. And I knew that it would be a part of my journey, a significant part of my journey.

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Oby: Next up is Dr. Anyane-Yeboa, a gastroenterologist at Massachusetts General Hospital and an instructor of Medicine at Harvard Medical School. She talks to us about how she went from being interested in policy, to pediatric cancer, to adult medicine, and then finally GI.

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You are a gastroenterologist at Massachusetts General Hospital and an instructor of Medicine at Harvard Medical School. Would you be able to walk us through your career path?

Adjoa Anyane-yeboa: Sure, absolutely. So it's been a long road, but I am currently practicing gastroenterology. So that's really everything in your GI tract, so esophagus, stomach, small intestine, large intestine. And so I decided I wanted to go into medicine probably late in high school. I initially thought I wanted to do policy, but I recognized that it wasn't enough people. And I wanted more human interactions.

And so I kind of went pre-med full force at that point. I did my medical school actually in Cincinnati. I initially wanted to be a pediatrician, actually a Peds cancer doctor. And then I eventually realized that sick kids with cancer, especially cancers that return, and metastatic cancers, and dealing with those kind of conversations, and going to kids' funerals was not something that I could do regularly.

So eventually, I ended up going into adult medicine and then GI. And so I chose GI because it was really what was just the most fun for me. And so it was the thing that I would-- in my residency, I would do my GI rotation, and come home and do more reading, and was excited to do presentations, and to talk about it. And it felt like fun going to work. So I was like, wait a minute, I think this is it for me. So that's how I ended up in GI.

But after my GI fellowship, I also did what was called the Commonwealth Fund Fellowship in Minority Health Policy. So it was like a full circle, coming back to policy. And that was a program geared towards training individuals who are passionate about caring for historically marginalized populations, and really advancing care delivery, and working towards equity.

Oby: You said you went back, you kept reading about GI. You were-- it interested you. That's an interesting topic to get really fascinated about.

Adjoa Anyane-yeboa: Yeah.

Oby: Is there anything else that comes up in there, that you're like, yes, that's really what drew me towards GI?

Adjoa Anyane-yeboa: It's funny, because when you're a resident, people-- and you're trying to figure out what you want to do, people say to think about and look at the people who are in those careers. Could you see yourself working with them? And so I considered cardiology. I considered adult hematology, oncology, and GI.

And the people with the GI personalities, I just felt like I clicked with them the most. They were making jokes. I mean, if you're dealing with poop and patients farting, like you can't be so serious, right? And so I felt like those were the people that I jived with the best.

And also, what I liked about it is that it's a mix of procedures, a mix of inpatient, and mix of outpatient. And I'm somebody who can get bored really easily. So no day is like the last. For instance, tomorrow I might have clinic, and the next day I might be doing procedures, and the next day I might be in the hospital. So it's kind of a nice mix that always keeps you on your toes.

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Oby: In September of last year, Dr. Paul Le Floch talked to us about the potential of using his technology to place implantable devices on the soft tissue of the brain.

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One of the examples you said was someone-- maybe in the future, someone who has paralysis may be able to work a robot, or a computer, or a phone by using their thoughts. Can you draw the connection between--

Paul Le Floch: Yeah.

Oby: Thank you.

Paul Le Floch: Essentially, to do that we need an implant that can record or stimulate neurons electrically. The reason it's not working very well right now is because the tissue tends to reject the implants, and you have these strong scar tissues that form around your implant. Or sometimes the implant is moving within the brain. And that limits our ability to have an implant that lasts for many years, and have an implant that you can scale up to measure more neurons or stimulate more neurons at the same time. So most implants don't last very long because of that.

So what we do is we fill that which materials that are almost as soft as the brain tissues we can use to make the implants, the part that goes inside the brain. And that's solved those two problems that I just mentioned, about the temporal and the number of neurons scalability.

And this implant is connected to a chip that can be placed at the level of your skull. So this one is outside of the brain, but it's still connected to the device. And this does all the electrical functions that allow to transmit the signal to the outside world, or signal from the outside world to the brain. So this is one part of the system.

And if you think in particular of the example of paralysis, you have two other pieces in this system that needs to be developed and that we'll work on in the future. One is the software that analyzes the data that you get from the brain. And that sends a command to this third part, that is the effector.

So the effector is what you described. It's the computer, the robots, or whatever that is, human made and electrically controlled. Or not even human made. You could use your brain to stimulate your hand. Who knows.

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Speaker 1: We'd like to take a moment to tell you about one of our upcoming online courses. Fundamentals of Comparative Effectiveness Research, Data Sources, and Methods, running March 22nd to June 21, is designed as an introduction to Comparative Effectiveness Research, or CER.

In this course, participants discover the purpose of CER and the variety of data sources and analytic methods that are used in CER studies. This course is open to both those in and outside of Harvard. To learn more, visit the link in the episode description. Registration ends on March 17. Thank you and enjoy the rest of today's episode.

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Oby: Last year we had the great fortune of collaborating with the Mind Project at Harvard University and offering a series on mental health among medical trainees, graduate and postgraduate students. We were joined by Drs. Ward and Castanho to begin this important conversation, which we plan to carry on this year.

[music playing] OBY: Content warning: during this episode we discuss a persons experiences with depression, anxiety, and briefly mention suicide. We acknowledge this contact may be difficult for listeners and encourage you to care for your safety and well-being if you choose to listen to this episode.

So now I want to talk about these groups that we're talking about, medical trainees, graduate, and postgraduate students, and some of the factors that are prevalent in these learning environments in particular that can be damaging to mental health. And I feel I may take it one step further, because I heard both of you talking about this a little bit. But what are some ways that these factors you identify can be more critically looked at, assessed, changed to help in this area?

Isabel Castanho: So that last part of your question is the most difficult part. Because the easiest is to identify what are the triggers and then to identify how we solve them. That's definitely the most difficult part. Just to name some of the factors that may contribute to graduate students and postgraduate researchers' overall worsening mental health. In academic environment, there is a high expectation on high productivity.

We hear things on the publishing side, it's publish or perish. And you're expected to publish in high-impact journals, which are constantly seeking for novelty. And then there's pressure to get funding, which is now more and more limiting for the number of people that are trying to get funding. It's an overall competitive environment.

And there's a big culture of overworking in order to be able to respond to this competitive environment. So that includes overload, long hours. It can lead to burnout as Dr. Ward mentioned. And then something that is unfortunately quite common, way more than it should be, is abusive and toxic environment.

So there's a lot of pressure on all sides. And that this often leads to toxic environments with bad mentorship or mentors asking for more than they should be asking for. Then on top of that, there is the uncertainty and lack of job security from students, postdocs.

Usually the salaries are lower compared to other jobs. There's additional financial stress. Student loan debt is incredibly common here in the US. This all leads to difficulty to balance with personal, social, and family life, which are so important to keep us balanced.

Often, there is isolation. The academic work can be very lonely, where you're very focused on making the experiments work, writing your papers. And these are just some of the factors that may contribute.

Heather Ward: Yeah, and I would say that in medical training there are certainly factors that are very similar to PhD training, especially if you're doing a lot of research, if you're publishing, if you're in academic medicine. And then there are definitely factors that are different.

Like PhD training, I would say becoming a physician requires a significant amount of training. And so each of the challenges faced by trainees vary or differ at each phase.

So the first phase is medical school. So four years of getting this broad medical education. So some classroom-based topics, like learning biochemistry or attending a gross anatomy lab. And then in your later years of medical school, you're actually in the hospital, working with medical teams. You're learning how to be a doctor. You're interviewing patients. You're coming up with your diagnosis, coming up with a treatment plan.

And like I said, working on teams. And these teams switch every couple of weeks or so. And so you have to learn very quickly how to interact with lots of different people, with lots of different styles, and know that you're being graded the entire time. Those are challenges for medical students. Again, they're long hours, and you're having to study on top of all these demanding clinical rotations.

And then when you become a resident, you have a lot more autonomy. So as a resident, you are a licensed physician, but you have to practice under the supervision of more senior physicians because you're still training. So you have a lot more autonomy, more responsibility. But what residents also very quickly find is that with this increased autonomy and responsibility, you also have a lot more administrative work. And our health care system is just filled with administrative work.

And most prominently for residents, this takes the form of using the electronic medical record. So reviewing patients' histories, writing notes, placing orders. There's just a lot of time spent in the electronic health record. And we know that-- so research has actually shown that increased time using the electronic medical record is associated with increased burnout in residents and attending physicians.

And this makes sense. You went to medical school. You did a residency to treat patients, and to be face to face with people, not to be face to face with a computer all day.

And so your question as to what sorts of interventions could we do, I've actually been involved in work, studying trying to characterize what aspects of the electronic health record are associated with burnout. And one aspect that we found was actually physicians who left their notes open for more than one day, who didn't just see a patient and finish the note that day.

Leaving that note open actually was more associated with burnout. It's almost like having this nagging to-do list. If you can just get this note off your to-do list quickly, you're going to then be able to go home, and maybe spend time with your family, do other things that you enjoy personally, rather than dragging these notes along, leaving them open.

So that's one potential aspect. And then I would say other challenges to medical training are interacting with this gargantuan health care system that we have in the United States. Sometimes there are systems-level issues that can make you feel like Sisyphus, rolling the stone up this hill, just to have it roll right back down again. So I think that is a major contributor to burnout.

And so it might be a physician having to make sure that the tests that you ordered-- make sure it's actually getting done at the hospital. Making sure the patient's on the schedule. It might be taking care of the same patient over and over because they're getting readmitted because the system has failed them. They haven't done anything wrong. We just don't have the right system to properly care for their illness. And so I think these sorts of experiences for physicians in general can just really grind them down, can really contribute to burnout.

There are also-- Isabel mentioned, there's obviously tremendously long work hours. And I will say that for residents, in recent history, they did institute duty hours restrictions. So residents have to work fewer than 80 hours a week, averaged over four weeks, which is still a tremendous amount of work. And they can work a maximum of 24 hours continuously, with an extra four hours to finish all those notes I was talking about before. So there are restrictions, however there's still tremendously long continuous periods of work, and also just cumulative periods of work in a week.

We know that physicians citing this lack of personal time to spend with their families or do things that they want to do is also a contributor to burnout and to depression. And if you don't have that time to recover from the tremendous stresses that you've been under every day at work, eventually it's going to take its toll.

And then finally, another aspect that I wanted to bring up is that-- that Isabelle also mentioned, is that we know that trainees can be mistreated. And one area of mistreatment that we're actually studying more and more are things called microaggressions, so derogatory comments or behaviors that are most commonly made on the basis of someone else's gender, race, or ethnicity, or their age.

And so one-- common examples of microaggressions, at least in health care, would be being told, oh, you're too young to be a doctor. Or a female doctor being mistaken for a nurse. Or a Black doctor being mistaken for support staff. These happen all the time. And actually a recent study found that 60% of medical students experience microaggressions on a weekly basis.

So it's very common. And you can imagine hearing these comments over, and over, and over, it just wears you down. And another recent study found that lesbian, gay, and bisexual individuals are more likely to experience mistreatment and burnout. And so we can see that particular populations are more susceptible to mistreatment. And, therefore, are also more likely to experience burnout, and depression, and other mental health struggles.

As Isabel said, there are certain-- there are definitely factors in common between PhD training and medical training, but there are also very different challenges faced by medical trainees.

Oby: What is the larger implication for the medical community if these mental health issues are not addressed? This is significant.

Heather Ward: Yeah, the implication is that this system is not sustainable. So we cannot continue to have a health care system where the idealistic individuals who have chosen to dedicate their lives to service and taking care of others are becoming burned out, depressed, and anxious. And even in rare cases, killing themselves. The health of really our physicians and the quality of our medical care is at stake. So the stakes really could not be higher.

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Oby: Finally, we will end our compilation episode with Dr. Elliott Antman, Professor of Medicine at Harvard Medical School, a senior investigator in the TIMI Study, a senior physician in the Cardiovascular Division of Brigham and Women's Hospital, and the faculty director of the Education Program for Harvard Catalyst.

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Can I ask you a little bit about your patients? And generally, I have had the pleasure of going on service with you or seeing you on service, and was just struck by how attentive you are to your patients, and how thoughtful you are in their care, and the teams that you lead as you go in and out of rooms. How do you think about that while you do clinical trials and that being the care of an individual?

Elliott Antman: So this is something that I feel very passionate about. The patient centeredness of what we do is so important. And we've heard this from many, many individuals, but I really feel it's important to live that mission, if you like, when you interact with patients.

So I think of it from several different directions. One is if I was a patient or a patient's family, what would I want to know? And so the questions that I ask from a research perspective are how can we answer questions that might be in the minds of patients or their family members right now? Conducting that research needs to be done in a humane and ethically bounded fashion. And so, again, from a patient perspective, thinking about what's fair when asking a research question? And what's fair to ask of the patient?

Applying the science and really using every bit of understanding of all the physiology we studied and learned is fascinating to me. And trying to convey to the patient not only the fact of what they should do, but why it's important to do that. And that, to me, is a very important aspect of the interaction with a patient. Not just simply telling them what to do, but explaining the rationale for your choice of your recommendation. And that helps a lot, because it really improves the likelihood that the patient will comply with the recommendation.

Oby: I could talk to you all day about your work as a cardiologist, as a physician, as a researcher. And we are going to transition here and talk about your leadership of the postgraduate education program at Harvard Catalyst, which I'm lucky to be a part of. And what led you to this role? What interested you in education in this space?

Elliott Antman: We've been talking about how I was inspired all the way along in my educational development and career development path to pursue my passion, and to ask the questions, and to learn more about how to do research. When I was growing up, if you like, through that process, through that pathway, there were many things that I had to just simply seek out in order to learn more about them. There was no well-defined instructional pathway or supportive educational resource environment.

And I realized that if I had not had the passion to seek those things out on my own, I might not have actually learned what I learned, might have dropped off in terms of my interest level. So I feel a inspiration to actually train the next generation of our biomedical workforce so that they don't have to seek things out as much, but it's there, available as a training pathway for them.

I also feel that we have an obligation to learn how we can do things better in training that next generation of the biomedical research workforce. And, Oby, you and I have had many conversations about how can we improve the way we deliver our educational resources. And this is a work in progress.

We're finding different ways to deliver the information. And I'm sure that different types of learners will find delivery methods that suit their needs that are different from some of their colleagues, who may learn via different method. And you've been very, very attuned to that, and very helpful in identifying things that we should be experimenting with.

And experimenting is an interesting word there. Because very often, people just assume they have the answer to the best way to deliver educational material. And I hope that we can think more about what we call A-B testing. We're going to compare method A versus method B and decide whether A is better than B, or B is better than A, and then for whom. And that's an important aspect of our continued work in our educational program.

Oby: That's a great point, especially about education generally. We all are different types of learners. And I loved how you ended that with which version is best for whom. Because A may be great for one population, and B may be fantastic for a different population.

Elliott Antman: Absolutely, yes.

Oby: So we need all of them. We need both.

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Thank you for joining us over the past three episodes to revisit the past seven years ThinkResearch. We look forward to meeting with more amazing researchers in 2023 and having conversations about mental health, research studies, career paths, and more. Thank you.

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