Hannah Gower | Cardiology and Internal Medicine Speciality Registrar, Royal Cornwall Hospitals NHS Trust, UK
Citation: EMJ Cardiol. 2023; DOI/10.33590/emjcardiol/10306448. https://doi.org/10.33590/emjcardiol/10306448.
You were one of three trainees from your National Health Service (NHS) Trust to have received one of the prestigious regional awards for the 2022 Medical Awards for Training Achievements (MAFTA). Could you tell us a bit more about this? Why did you receive the School of Medicine Trainee of the Year?
It is an award that recognises the contributions of southwest training doctors to regional education and training opportunities. It was awarded to me based on nominations for contributions to supporting junior doctors and my other colleagues. There is often not much you can control within the leviathan machine that is the NHS, but we can control how we interact with each other and our patients. As a Cardiology and Medical Registrar, I am in this unique position where I can be the link between our consultant body of two major inpatient specialties with the junior team. I try to focus my attention on supporting my fellow junior doctors and the wider team, both mentoring and educating where I can, to foster a sense of camaraderie and team spirit in the face of many systematic challenges.
I am keen on teaching, and I contribute to our local hospital and medical school teaching programmes, with the hope of making cardiology more accessible. I think cardiology can be a topic that people often fear, especially in the acute setting. I want to reassure trainees and inspire them to see that cardiology is truly fascinating with such a wide scope of focus for all interests.
In 2021, you published a case report entitled ‘A Rare Finding: A Left Atrial Cavernous Haemangioma’. How could this report help inform other clinicians when they encounter similar cases?
Whenever we put forward case reports to be published, it is often to demonstrate a nuanced case where there is often lack of guidance on how to manage the unique scenario, due to the nature of their infrequency. It enables clinicians to consider how the authors manage the situation and consider modelling any future similar scenarios on their approach or alternatively, build upon the strategy and offer an alternative option.
You started as a Clinical Fellow in cardiology for the Royal Devon and Exeter NHS Foundation Trust, UK, and are now a Cardiology Registrar at the Royal Cornwall Hospitals NHS Trust. What do you consider to have been the most significant advances in clinical cardiology and cardiovascular pharmacotherapy during these periods?
As a hopeful future Heart Failure Consultant, the big difference I have seen is the introduction of sodium-glucose co-transporter-2 inhibitors and the impact of the REVIVED-BCIS2 trial. These are two key things that, even in my short junior cardiology career, I have seen change how we practice management of heart failure day-to-day. I will be most interested to see how this impacts our use of devices in heart failure with reduced ejection fraction, especially cardiac resynchronisation therapy. It is an exciting place to know that there are potential major changes in the near future for heart failure management.
What do you consider to be the major unmet needs in cardiovascular medicine? How might these be addressed going forwards?
In the Southwest Peninsula, we do not just have an older population but also a frail, older population. One area that we could benefit from is a direct connection between the care of elderly/frailty services with our cardiology services. We often run parallel models of care next to each other; however, the patient care can be quite binary: they are either with the cardiology team or they are in the care of elderly team. In the future, I would really hope that we can start to merge our services, and maybe even see joint clinics and the inclusion of care of elderly specialities in our multidisciplinary team meetings.
That is where I think the needs are unmet currently, but I am optimistic that they will be addressed, especially in the next coming generations of Cardiology Registrars, who also will be dual trained with a general internal medicine Certificate of Completion of Training alongside their cardiology Certificate of Completion of Training.
As you have mentioned, you have published a case report and are in the process of submitting another. What other interesting cases have you encountered as a Cardiologist? What are the key learnings that you have taken away from these situations and how have you applied them in your daily practice?
I find anything that’ is new, or anything that can change your day-to-day practice, interesting. I read an intriguing recent case report about neurogenic pulmonary oedema in the absence of heart failure, with normal albumin and normal renal function, which I thought was fascinating. It was not something I had ever heard of before, and never had even considered as a potential cause of pulmonary oedema. Therefore, it just widens your differentials when you consider these patients presenting in front of you. That is probably a rare case, as you report the rarest and the most unusual ones.
A great thing about case reports is that they are a great opportunity for junior or new team members to write up cases while being supported by more senior clinicians. The ‘cycle of case report life’ in a way, where now I am mentoring a medical student and foundation doctor with their submissions.
Digital health was a recurring theme across a lot of the content presented at the European Society of Cardiology (ESC), and digital health in cardiology quite a big topic at the moment. How important do you believe digital health interventions are in the prevention of cardiovascular disease? Is something that you are involved with at your NHS Trust?
Whilst I am not aware of anything in Cornwall at the moment, I do believe, particularly as I quite like technology, that digital health has a huge role to play. I would be cautious, though, because traditionally technology can gather a lot of data but not necessarily a lot of information that is valuable, particularly when we want to reassure patients. Sometimes, I can be almost paradoxically unhelpful, particularly in patients with heart rate monitors where you are trying to reassure them that the data collected does not necessarily reflect pathology.
In addition to that, we must have an awareness that technology is expensive. If we are not supplying it on the NHS, we could create a tier system where less fortunate individuals are not able to access the same opportunities as those who can afford it.
Between 2021 and 2022, you published several papers as a member of the RECOVERY Collaborative Group. Could you tell us a bit more about the findings and wider relevance of the group and the research conducted by it?
I was a contributor, like many junior doctors, medical students, and nurses across the NHS. I think that anyone who was working amongst inpatients with COVID-19 had a role in contributing to the RECOVERY trial, but this was mostly when I was based on the COVID-19 wards.
The RECOVERY trial was a widespread national programme with multicentre contributors. It originally stemmed from thinking about the first wave. We had this new condition that no-one knew how to treat. A paper from a group in China was initially published, which was one of a kind. Interestingly, they commented a lot about acute coronary syndrome and the cardiovascular complications. It then evolved, and we began to understand that there were a lot more renal and cardiovascular complications. Though, interestingly, that has evolved further. Now you are seeing a lot of COVID-19 myocarditis and COVID-19-related heart failure.
It was really exciting in many ways because you had this novel condition that no-one knew how to manage, and you felt very much at the forefront. However, that was also quite terrifying because you could not use your previous understanding of viral conditions in this circumstance. It was great to be part of such a wide scale project. Many of us were collaborators and it was a real opportunity to understand research, something that I had never really done before as an undergraduate. Even being a small part of that was a good first step into the world of research.
What advice would you give to medical students and trainees who may be considering a career in cardiology?
Do not feel overwhelmed by the eagerness and success of others. I think cardiology can attract very high flying, very capable, and very articulate type A personalities. For some people who do not identify with that cohort, they might feel that this is not for them. In other centres that could be the culture, but that is why I love the southwest because we have a range of characters and personalities. You can be the surfer who wants to have a good work–life balance and be a Cardiologist and just as easily be a multi-published, leader in your field, head of the British Heart Rhythm Society (BHRS).
We also need to emphasise to students and junior colleagues, as my supervisor often stated to me: “It is a marathon, not a sprint.” It is a craft that takes a considerable length of time to develop and while the annual review of competency progression, exams, and courses are all stepping stones to the next phase, it is also okay to take some time off the training treadmill and broaden your experiences and understanding. I did that when I undertook a clinical fellow in cardiology. At the beginning of that post, I would have never thought that cardiology would be the career for me, and now I cannot think how else I would spend my working time.
When you finished medical school, did you get a choice of which NHS Trusts you were going to, or did you just get posted to Cornwall?
UK graduates apply for foundation programme posts, which is the next stop in medical training following undergraduate degree. They are compared to one another through a central system. Graduates then can rank their desired posts and locations, with those highest ranking having first choice.
I am from Devon, UK, originally, which is just one county east from Cornwall, and I studied in Glasgow, UK. While I absolutely adored Scotland, it is an amazing country and excellent place to learn and train, family is vital to me, so I came back to the southwest to spend more time with them following completion of the foundation programme to take up a Core Medical Trainee post in Exeter, UK.
Where do you see your attention and focus in the coming years?
If given the opportunity, I would very much like to see the management, recruitment, and welfare of junior doctors improved. Just by the very nature of the NHS, it has evolved, grown, and exceeded its capacity, and I feel like it needs a reshape and some reorganisation. We need more nurse, doctor, and physiologist managers who understand the challenges faced on the shop floor. I think that the COVID-19, with the rapid development of remote working, has widened the communication barrier between front-line staff and management. I think that any attempts to narrow that gap of experiences between the various stakeholders in the NHS is key. I am sure there are a number of patients who are also frustrated with the system and feel they are left unheard for the same systematic issues that face staff. I am undertaking a full-time Master’s degree in health care leadership and management at the University of Exeter, UK, later this year, hopefully to further my understanding of NHS management and to equip myself with the skills to take on some of these challenges in the future.
I also feel the same for heart failure. I would love to see a heart failure ward run by specialist heart failure nurses, with a provision of co-care through elderly and cardiologist multidisciplinary teams. In heart failure care, if you are not on a cardiology ward, you do not do as well and you have longer hospital stays. I see that as a perfect opportunity for a really merged multidisciplinary team approach. A combination of those two would be brilliant. However, I am still quite a junior registrar, maybe that is a question to ask me again after several years as a Consultant.