We are thrilled to speak with Dr. Basmah Safdar, past president of AWAEM from 2016-17 and Associate Professor at Yale University. She is an expert in sex and gender-specific research with a focus on cardiovascular health in emergency care. We talk about her journey in medicine, and how involvement in AWAEM advanced both her research career and our understanding of sex and gender in clinical emergency medicine.
Lin: Tell me a little bit about where you are in your career right now and how it was that you got there.
Safdar: So, I am an associate professor at Yale. I think I define myself as mid-career at this point. I had a slightly different start. I grew up in Pakistan and went to medical school there. I started medical school when I was 16, so kind of had a very different journey. But the school I went to was one of the most competitive in the region, it prepared me well for clinical medicine and research. So when I came to Yale, I chose to pick a research career here and I’ve been here all this time. The only time I’ve left is to finish my master’s degree at Harvard a few years ago. When I graduated and became faculty here, I was interested in cardiovascular area, and I became, I was given the position of Director of Chest Pain Center. So, just like you, when I started something, then I said, “why not collect data”? So we created a data base for the chest pain center, and over the years became a massive data base, but one of the things I learned from the data base when looking at it, frequently, were just some clinical observations that chest pain was more common in women, it was unexplained, right around that time, the NIH was looking at different physiology and progression of atherosclerosis in women.
Safdar: I became very interested in microvascular diseases as well as subendocardial disease, which is more common in women. My research in the last what, 10-15 years has kind of honed in on that. So, I initially did some physiological studies, I got extra training through both the master’s, but also through a vascular lab to do physiological work in the chest center patients and that gave a signal that microvascular dysfunction was indeed much more common in my emergency department patients. That people hadn’t looked at before, so we created a phenotype in conjunction with cardiology, using cardiac PET CT to diagnose it in ED patients. And that has kind of morphed into more of a multi-system look because as I’ve spent a lot of time with these patients, I’ve realized these are actually very complex patients, microvascular disease of one organ doesn’t necessarily mean they don’t have it of other organs.
Lin: That’s so interesting. So, what you are saying it sounds like is that, both women and women who present to the emergency department have more microvascular disease.
Safdar: Correct, so a specific cohort that I did look into was patients with chest pain and patients with recurring chest pain. And we find that especially for those who have recurring chest pains, it’s much higher, up to 40% of those patients have microvascular dysfunction. Chest pain, or ischemia from microvascular dysfunction was just not detected by our standard testing tools.
Lin: How does that impact how we should be treating women with chest pain in the emergency department?
Safdar: I think it has implications that they should at least be recognized. That it’s not supratentorial. These patients may have ischemia, which is under recognized with our traditional testing including conventional troponin, and including regular stress testing and even regular angiography. And these patients require more sophisticated testing, so if they are patients that keep coming back, and they have features of microvascular ischemia, then they should be referred to providers who specifically look at microvascular dysfunction. Because they just require additional testing. I think this is all going to change as the high sensitivity troponin enters our market, because it was just approved last year. My suspicion is the high sensitivity troponin will pick up some of these patients.
Lin: Fascinating. I’m going to switch tracks a little bit, and ask how you got involved in AWAEM?
Safdar: I think I got involved in right from the start. I remember attending that first meeting and then just thought it was something interesting and just stayed a part of it. And then I had more of a role in the AWAEM leadership when I became involved with the research, the research committee. I had continued this work of looking at the sex and gender differences in recurring chest pain. Through that I got introduced the whole world of, I guess it started with recurring chest pains from patients who were coming to emergency department and then became, was introduced to this world of that disease which may be actually be different between men and women.
Safdar: I became very interested in how that impacts all the other diseases we took care of. So, it became, almost like a new science of sex and gender medicine. And so I, and then there was another person at Brown, Alyson McGregor, who had been interested in that about the same time, so we had put in a didactic, and I think in 2008, for at ASM, got accepted. But it was like the last didactic of the last day, and it was not attended. We became perturbed by that, that there is a whole side of sex and gender medicine and there’s no recognition in emergency medicine, so we wrote a letter to the editor in chief, and he happen to be somebody in my department, so they didn’t accept it, and when I talked to him he said, “what’s the data”?
Safdar: We ended up doing a study, looking at the status of sex and gender medicine in emergency medicine and we found as expected that it’s not very high. We were interested in then using that data, to both create awareness and then create a research agenda for our field and that’s where AWAEM came in, because if you look at AWAEM’s mission statement, the third mission is actually looking at sex and gender differences and so we are light years ahead of other organizations by including it as part of its agenda. When I became involved with the AWAEM research committee, we wanted to do a consensus conference on sex and gender. But around that same time, Marna Greenberg, was also looking at this, so we partnered along with Allison and Esther Choo, and we formed the core group that put in application for the Consensus Conference on sex and gender medicine. That got approved and we used the AWAEM forum to recruit, to make awareness, we put a series of didactics, a series of lectures, manuscripts, both to inform and then to study. In 2014 that culminated in the Consensus Conference. And the proceedings that came out of it.
Lin: That’s incredible.
Safdar: So that’s how it started and then as I became more involved in AWAEM through that committee experience and as a Chair experience I realize how what an amazing group of women these are. It was just, it’s just so different. They are just so passionate and so energetic and they don’t just talk but they actually do. I became interested to be involved, run for the President. So that I had the opportunity of working with them.
Lin: Tell me a little bit more specifically about how the involvement in AWAEM has affected your career directly. It sounds like some collaborations and leadership opportunities.
Safdar: I think certainly the collaboration and leadership opportunities. Certainly it actually advanced my research itself. Not just through identifying people that I can work with but also actual scholarship. It actually just made the trajectory much more steep in the material that came out of it. And informing the collaborations of people that I wanted to work with. For example through this Consensus Conference, I got connected with other people in the cardiovascular area who are working in this. And including some leaders in the field that I was able to work very intimately with. And became part of that group.
Safdar: But also, I think it allowed me to, certainly as I transitioned into the leadership roles in, it allowed me to really formulate a second interest and a second career goal for myself, which was really realizing that systems-based interventions have a much bigger impact. And so I became very interested in how just restructuring and creating systems to allow people to grow, for example, for professional development, can actually have huge impact. And that has now become my second big interest. And I think it’s kind of growing together. It gave me the forum to do that and also made me realize how rewarding it was.
Lin: That’s great. And when you talk about systems change are you talking and thinking again about sex and gender in emergency medicine? Or in other ways?
Safdar: Yeah. The first glimpse of that was the Consensus Conference that allowed the sex and gender for patient care. And how having the Consensus Conference had this ripple effect that is still ongoing. It translated into an interest group. It translated into this whole collaborative group of research and didactics and international and national collaborations.
Safdar: But then the second piece was professional development and faculty development. How creating opportunities and creating systems and resources for people can allow them to advance through the career. And this is not just mentorship, also through AWAEM we created these online modules. We created these didactics. Scholarship. We collected data to identify where women in emergency medicine are. And we used that data to actually inform some of the processes that were put in place including the pre-conference workshop and the focus of each workshop.
Safdar: A lot of resources that you create that affects not just one person, one institution, but the whole academic female emergency physicians as a group. And it was interesting. As President I had reached out to other societies and other specialties to see what else is out there. To see if we can incorporate some of the things that people who, specialties that have been around for much longer have already put in place. And what I realized was there were some things we learned and we incorporated. Such as having a forum to collect data all the time. But then what I realized was we are, in many ways some of the resources that we put together and continue to put together every year is much more than other societies are putting in. It’s very gratifying to see that in some ways we were light-years ahead for a new specialty.
Lin: Yeah. That’s definitely a theme that I’ve heard as well. What would you say is the biggest system change that needs to occur in order to achieve greater gender equity in our field?
Safdar: It’s an important question that I don’t have the full answer to. Because we actually collecting data on that right now. We do have an SAEM equity workforce that was created as a follow-up to the paper that we published as part of AWAEM. In which we showed that there were basic inequities. And through this taskforce we actually interviewing Chairs and Vice-Chairs to figure out what are the barriers at different institutions and what are the perceived solutions? And I think we’re still learning. I don’t have all the answers but I’m hoping that we will have answers in the next year or so.
Safdar: I personally think that it actually has to be a two-prong approach. I think we need to put resources to train the faculty, right? To make sure that when opportunities come that they are ready. And that’s exactly the kind of stuff that AWAEM does, which is for professional development for early and mid-career faculty. To create that pipeline.
Safdar: But I think the second approach, and it has to be at an institutional level as well. There needs to be systems that have to be policies put in place. Not just policies but a cadre of resources. We are actually learning through these interviews that there’s such heterogeneity in what is available at institutions that we can even put a list of ten or five things that everybody can easily adopt. I think simple solutions like that can make a big difference.
Safdar: There has to be effort made by institutions to make sure that there are opportunities that are put in place when people are ready. And then we also have to create the workforce that they are ready to embrace those opportunities when the right time comes.
Lin: How do you think these experiences have translated into greater gender equity in your own workplace?
Safdar: I would say maybe in a couple of ways. I have been fortunate that I’m under one of the few institutions that has a female leadership. We already have some things that are given. As one of the things that I brought back from AWAEM was just a peer support group. Because one of the things I’ve really enjoyed about AWAEM is you go there, you share experiences and you realize that many of the hurdles and achievements that you have are common themes and you can learn from each other. That peer support I really value at AWAEM.
Safdar: And in our department, what we started doing was luncheons. For women of different stages. Just an open luncheon that the department pays for. That we have, it started as monthly and then we moved to do it every other month. We have one item that we bring up that we usually a talk about imposter syndrome or promotion guidelines for our institution and things like that. But then we just chat and we just connect. I thought that was something that AWAEM helped us create here.
Safdar: The second was just being involved with recognizing important women in the department. Just how AWAEM recognizes and has created this cadre of awards to recognize women in our specialty. We thought it was important to at least recognize your peers who may qualify for those awards. Making a focused effort on putting them up was a more recent change in our department. We were just not doing it in general before.
Lin: How would you say that gender has affected your own career development?
Safdar: I think through life I’ve chosen things that are not necessarily clear-cut. So choosing, you know, emergency medicine for where I came from, choosing research in an area which is that is not very clear-cut. Where the resources are not aligned because it’s not clear-cut, I’ve learned to navigate and figure out nuanced ways of dealing with things. I think women in general and women physicians, and particularly academic women physicians, face that every day. Like where things are not very clear-cut, they have to create their own opportunities. In that way, I think gender plays a very clear role because you just have to figure things out. And talking to other women who have kind of created their own path in the same way, which are not very clear-cut, and which there is no clear system of mentorship and sponsorship the way it’s … At least you see in the literature how people talk about it. I feel like it’s different and I’ve had to create my own path.
Lin: What career accomplishment would you say that you’re most proud of?
Safdar: I think, and I don’t know if it is an accomplishment yet, but I think putting this microvascular dysfunction on the map for emergency medicine, is something that I’m most proud of. It just came out. It required many years to even put it into a paper, and I feel like that was a goal, and I think I have to continue to work on that. So it’s not a perfect goal there yet, but it’s an intermediate step which I’m very proud of.
Safdar: I think what I had the most fun with was actually the AWAEM presidency. It was a very diverse and amazing group of women that I just enjoyed so much. I learned and grew so much in that experience.
Lin: What piece of advice might you give a younger version of yourself or an AWAEM member at an earlier stage of her career?
Safdar: I would say don’t wait for your mentor to reach out to you. And especially when I look back, even though I had mentors, and some very good mentors, I was kind of sitting there expecting that they will pick me out from step one to step two. And it took me about five years to realize that you actually have to create your own agenda and you have to bring it and you have to kind of push it forward. And when I made that switch, it actually helped me the most. That’s what I would tell anyone who’s starting. Really, that when you have a mentor, if you have identified a mentor, or people you are going to work with, then you need to reach out constantly and keep the new moving forward.
Lin: Great advice. Please name three other AWAEM members we should interview, maybe one around your career stage, one slightly more junior or one slightly more senior, or just three outstanding women.
Safdar: Libby Nestor, who’s at Brown, I don’t know her too well, but the reason she came to mind is because I’ve just been impressed how she advocates and how she has put other people within her department, other women in the department, up for different awards and different promotions. Somebody who’s around my stage is Marna Greenberg. I had the opportunity of working with Marna, you know, through the Consensus Conference, but then, since then, that part of the second gender medicine interest group. And I just find her one of those few gems who’s truly invested in students, residents, people who she oversees. Like she just goes out of her way in cultivating them and genuinely cares about their growth and is a stickler for details, making sure that she makes all the resources available for them and continues to hound other people to make sure that they give her students the attention they deserve. And then somebody who is junior is somebody in my department, Rachel Liu. She was president of the Ultrasound group before, but she’s still relatively junior. You know, I think she’s just in the transition of the early to mid now. But she’s just fantastic. And what I appreciate about her is that she thinks outside the box constantly and has really advanced the field of ultrasound in emergency medicine.
Lin: Anything else about AWAEM or about yourself I haven’t asked that you’d like to share?
Safdar: What encourages me is how there is a turnover. It’s not just led by the three or four people who originally started it. There’s a succession plan which has helped create, you know, bring in constant people, new energy and new passion, which is what makes AWAEM so rich.
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