Welcome to the Clinician Researcher podcast, where academic clinicians learn the skills
to build their own research program, whether or not they have a mentor.
As clinicians, we spend a decade or more as trainees learning to take care of patients.
When we finally start our careers, we want to build research programs, but then we find
that our years of clinical training did not adequately prepare us to lead our research
program.
Through no fault of our own, we struggle to find mentors, and when we can't, we quit.
However, clinicians hold the keys to the greatest research breakthroughs.
For this reason, the Clinician Researcher podcast exists to give academic clinicians
the tools to build their own research program, whether or not they have a mentor.
Now introducing your host, Toyosi Onwuemene.
Welcome to the Clinician Researcher podcast.
I am your host, Toyosi Onwuemene.
I'm excited to be here today because I have a really amazing host on the show, Dr. Jerry
Bloomfield.
Jerry, welcome to the show.
Hey, Toyosi.
Thanks for having me.
So Jerry, you are what I would call an esteemed clinician scientist, and you may not feel
that way.
And I find this to be the trend.
Most people just don't feel like they're distinguished, but they are.
You are.
And I wonder if you would just introduce yourself to our audience with regard to your role as
a clinician scientist and how you came to be here.
Thanks, Toyosi.
You're too kind.
My name is Jerry Bloomfield.
I am an associate professor with tenure in the Department of Medicine in the Division
of Cardiology.
I'm a clinical cardiologist, and I do all the things that academic cardiologists do,
the tripartite mission, clinical research, education.
I also have a role within the Duke Global Health Institute, where I'm the associate
director for research, which ties into what I do as a clinician investigator, which is
predominantly in the global health space.
And global health doesn't always mean international health, but most of my research portfolio
is in low and middle income countries, as well as doing research in impoverished, underresourced
areas of the US, particularly in the US South.
I've been at Duke for, I think, 16 years now, four of those were during my cardiology fellowship.
And yeah, like most clinician investigators, just keep trying to put shots on goal.
Wow.
So I feel like I've already learned something from you, Jerry.
You talk about global health not always being international work.
Could you speak more about that?
Absolutely.
The field of global health has evolved tremendously over the last few decades, mostly in terms
of what our understanding of global health is.
So we no longer really talk in terms of international health.
We don't really talk in terms of tropical medicine.
There's a lot of old connotations aren't really relevant as much.
And even if our initial understanding of global health, that term really became popular
I'd say in the early 2000s, early 2010s, where global health, as I understand it, and as
I involved it in my research, is really a methodology of your research that addresses
the health inequities for populations who are historically been under-resourced or experiencing
worse health outcomes.
On a global scale, that occurs in low and middle income countries.
I mean, that's just, you know, that's sort of at the front door.
However, even within higher income countries or upper middle income countries, as we know,
take the US as an example, there are, you know, gross disparities, gross differences
in certain regions and other ways that we sort of slice and dice society.
So global health to me is really research that addresses vulnerable populations and
doing things to mitigate some of these barriers to better health.
Thank you, Jerry.
I really appreciate you shedding light on that perspective.
And that really does make sense in terms of it's global.
And so if you look at it from the US perspective, you might want to think of it as internationally.
But if we think about the whole world, it really is, it's global from that perspective,
which is cool to think about.
Now, many, many people want to get into global health research and find it to be difficult.
So I'd love you to talk about your journey and how you came to be a researcher in the
global health space and how other people potentially could think about it as they're interested
in it.
My journey is a circuitous one, full of providence and serendipity.
I'll give you the short truncated version.
I knew I wanted to be a cardiologist from back when I was in internal medicine residency.
Because of my background and upbringing, my parents were immigrants to the US in the 1960s.
I always had a global view of the world and global view of health.
But during med school in the late 1990s, early 2000s, there was really no great model of
how one incorporated international health, which was a term at the time, and cardiovascular
disease.
That changed for me when a friend of mine who had graduated residency a few years before
me went to work in Kenya as a missionary doctor.
So early 2000s, and he went to Kenya to treat HIV in a mission hospital.
And after working there for a few years, he said, Jerry, you got to come out and see what
life is like out here and see what we're seeing and how we're practicing medicine.
So this was in 2003.
And I'll tell you, Toyosia, I went out to Kijabi, Kenya, the city I was working at the
time.
This is back before we had smartphones and things like that.
I went with a stack of up to date articles on treating all of the worms and all the infections
and the manifestations of TB, expecting that that's what I would be treating in this small
hospital.
But in fact, honestly, what I spent most of my time doing that summer of 2003 was treating
hypertension, diabetes, and heart failure in a very remote part of Kenya.
So that started to put some connections in my mind to say, well, here I am with a passion
for cardiovascular disease and CBD risk factor issues.
And here's a place where someone like me could partner with other Kenyan physicians to actually
do something about this burden.
What really sort of made this fit for me, what really sort of sparked a passion for
me for this was the fact that the patients who were having these conditions, they had
no idea what they were.
They didn't have the terminology for them, much less did we have medicines.
And even physicians, they weren't attuned to cardiovascular diseases.
So flash forward many years, I came to Duke for cardiology fellowship.
I applied for some fellowship grants, worked with mentors to apply for larger grants to
start a cardiovascular research program to understand what's causing all of these cardiovascular
diseases in low and middle income countries, specifically in Kenya.
So that's what got me started in it.
Now, what's beneficial for folks who are interested in global health and cardiovascular disease
these days is that we're 20 years on from that.
So everyone or most people are aware of the global burden of disease, the global burden
of cardiovascular disease.
So the fact that 70 to 80% of all cardiovascular disease deaths occur in low and middle income
countries where we've made great strides in decreasing CBD deaths in the US, in many parts
of the world, that curve is actually on the upswing.
So there are a lot of opportunities, both NIH funded, both foundation supported, and
I have a lot of colleagues who use their non-professional time to go abroad to someplace where they
have partners and an opportunity to use their skills.
So I'd say there are a lot of roads into global health these days, and I continue to use the
academic route and the clinician investigator route.
That's really, really amazing.
And thank you for sharing.
What a remarkable story.
I am curious to know, you talk about partners, and I think it is important as we think about
doing this work globally, especially outside of the United States, where there's a concern
that researchers go and they do research in a different country and then they come back
home and the benefit of the research may not accrue to the places in which they've done
the research.
Can you speak to what some of those partnerships look like in terms of bringing the benefit
back to those communities?
You know, you hit the nail on the head, you know, parachute research.
I mean, my goodness, we have so many examples of that, both in the cardiac space and the
HIV care space, just a real travesty.
I think the way you get around that is making sure that you are not bringing a solution,
looking for a problem.
That's really important for people coming from the U.S. specifically who haven't engaged
in global health research.
If often, well, I have this new tool or I have this new app, or if only folks would
do this, then things would change and health would be better.
What's really been instructive for me is really taking the time to listen.
So it took me a few years of working in Kenya to really realize that I had only scratched
the surface of what some of the health system issues were, what some of the issues that
patients and families face, why is it that nurses weren't checking blood pressures in
a particular hospital I was visiting?
Well, that's because the ratio was one to 30.
What do you expect these people to do in the middle of the night and one person gets really
sick?
So I think time is the real factor there and actually getting to know your partners and
listening and sometimes just injecting a little bit of silence into the conversation
and let that silence leave room for your partners to chime in to.
Thank you for sharing that perspective.
I think it is really important to, even if we're not involved in global health research,
to think about how our work serves the people that we are working with in the research endeavors
that we continue and how listening is so important in anything we do really.
I wonder if you can speak to kind of how can, now you got into research in global health,
it sounds like at the level of being a resident.
Let's say you are interested in this from being a med student, what are opportunities
potentially that exist for medical students or how early can people get involved?
Yeah, that's a great question.
And I think there are a lot of opportunities for medical students.
Number one, I would say that a lot of programs and I'm going to focus on the on the resident
level for a second, but I think that is an indicator for medical students for whether
or not there'll be opportunities for you.
A lot of residency programs now offer a global health track or a global health interest.
And that can be anything from six weeks abroad to a whole year abroad plus clinical research
experiences.
So for medical students, if your institution offers a global health residency option, that
probably means that there are trainees and faculty and administrative staff who are thinking
about work abroad.
So that's a place where you could plug yourself into.
There are other programs out there actually from the NIH for medical students.
So there is a Fogarty Global Health Scholars Program.
There's also a Fogarty Fulbright Program.
And they have different eligibility criteria for various stages in training.
But there are those two programs from the NIH plus the residency programs around the
country I think are really great opportunities for students to plug into.
There are also private foundation opportunities and they sort of come and go.
So I don't feel like I have a good grasp on all of them.
But there are also private foundations that will support medical students.
But I would say if your institution has a global health residency or faculty that are
doing global health, that's usually a good place to start.
I like that.
I appreciate what you're saying.
It's that if people are already doing this work, it's a sign that there is a way to support
the work.
And so perhaps it might be more challenging to go to an institution where no one is doing
work in global health research.
It might be harder, not impossible probably, to get started.
But just thinking about what opportunities already exist and kind of going with the momentum
of that as well.
And you know, Toyos, I mean, that actually relates to advice that I give cardiology fellow
applicants sort of at a different stage in the game where you want to go if you're interested
in global health as part of your career, you really want to be at a place where you won't
be the only one.
And I remember when I was applying for fellowship way back when being told things like, well,
we've never done this before, but we'd be happy to support you and we'll open doors
for you and we'll support this or we'll support that.
It was very much appreciated.
But if you step back, you realize that that's really a program or support around you.
What you really want is a program that's supporting the idea, supporting the theme, supporting
global health generally.
So I would urge folks at any stage in their training to aim for a place where there are
other people engaged in global health and that there is a well-oiled machine, that there
is a, continue using analogies, that there is a steam engine that is moving in a good
direction that you can join on to, but you're not having to lay down the tracks.
That's what we did a couple of decades ago.
No, that's awesome.
What I hear you speak about is really the power and the importance of community.
And you, as much as a lot of maybe our earlier training felt like a solo endeavor, it was
never really solo, it becomes more important as you're moving from the medical student
to resident to fellow and to faculty transition to really be part of a community that's engaged
because then you're able to gather a lot more resources and your chances of being successful
are much higher.
Absolutely.
Now, one thing that comes to mind is that many people who are interested in global health
research are interested for a reason.
Or you talk about having your parents who are immigrants and there are many trainees
or early faculty who say, well, I have roots in a certain country or I have connections
to a certain country.
How do you recommend they address that where perhaps there is global health research ongoing
at their institution, but not necessarily targeted to the country of interest?
Yeah, I've learned a lot about that.
I have a lot of conversations with folks who have that exact same story or that interest.
And what I've learned from those colleagues is often your childhood experiences in a particular
country are very different from your country as your experience as a physician.
And so oftentimes people say, I grew up in X, I'd love to go back and do something on
the medical side, but don't really have a great sense of what the healthcare system
is currently and how the healthcare system works and who the right partners are.
So those are all places that I encourage people to start to understand, well, what is the
condition you're interested in?
What is the approach?
Who are the partners?
And I think if one thing that that's really where it starts there, who are the partners?
And if you're having to find and develop partners, that's great.
That clearly takes more time.
But I would really start with partners and partner as you said, Toyosi, partners in the
true sense of partnership, not just, I know the CEO of this particular hospital, so we
can do these great things, but actually speak with people, do some focus group work, have
some, you know, get on Zoom or a chat or coffee or something and say, well, what is it that
me, as whatever type of professional, what can I bring to the table?
What can I do to help this environment?
So I think that the partnership is one.
And that's a great rationale for again, if an institution has ongoing partnerships, they
have a relationship with somewhere already, that that's a great place to start because
a lot of those formative questions have already been answered.
And I guess the last thing I'll say, this might be for folks who are, you know, maybe
earlier on in their careers is regardless of the site that you're engaged in, the methodology
for global health research is what's most important.
And once you have that methodology, once you have that experience, you can transport that
to a country of your choosing.
But if you can't do that yet, I would say irrespective of where you work, it's really
the experience, the methodology, the hard knocks of learning, you know, partnership
and sustainability.
And once you sort of get and start to get that under your belt, you can transport that
anywhere.
I love it.
I hear you saying in that don't be so fixated on one country that you miss what the goal
of starting is all about is and the importance of having a moving train that you can jump
on so that you can learn all the methodology that's necessary.
And so as much as you may have a goal of a certain country, you really want to think
about where is where are the resources already and already available?
And how can I get my feet wet, so to speak, and then ultimately, as a more senior person,
be able to look specifically at different countries?
Is that fair to say?
I think so.
And I think the other side of that coin is as if you're someone from another country
or have roots in a country that you want to go back and work in and partner with and serve,
oftentimes you have the ears that someone not familiar with the country would never
have.
And so whatever the connections are, often those connections with leaders, those folks
in influential ministries, public health officials, professional societies, those connections,
that is really the connective tissue between global health research and implementation.
So I think in academic medical centers, we're great on the research side.
But oftentimes, take someone who knows the country intimately to say, well, how do we
move these findings into practice?
And so I think that is a strength that a lot of people who have international roots bring
to the table to bridge that practice gap, knowing folks who can actually take these
things to people.
Sure, sure.
So I'm hearing that methodology is important, but relationships are important as well.
And this leveraging the strengths of those relationships to move research forward is
important as well.
Yeah, absolutely.
All right, Jerry, one of the things I am hearing, it almost sounds as if this has been really
easy.
It's been a walk in the park.
Let's talk about some of the challenges, especially the biggest challenges along the journey.
Oh, boy.
I hope I haven't presented this as easy.
It's certainly fun, but it has not been easy.
You know, I'll speak honestly.
Global health, especially in cardiology, it's still a relatively small field.
I think the 10 or a dozen of us who are really engaged in this, we all know each other and
have similar stories of trying to get our careers off the ground.
One of the big challenges actually was, and I think this challenge actually is sort of
irrespective of field, you know, because I think a lot of us as we get older, we develop
a niche, something that we're really passionate about and that distinguishes us.
And in my case, that niche of global cardiovascular health was a niche that initially was thought
as too niche, was thought as not relevant, not significant, the career pathway was undefined.
And as you know, as a mentor, if you have a mentee whose career pathway you can't line
up the building block to see where this leads to success, that's going to give you some
anxiety.
You might caution them to do other things.
And that's what I experienced in my trajectory and in my career development was that struggle
to say like, this is something I am passionate about.
This is something I have a little bit of experience with, but I need the mentorship and the institutional
support to actually take me to the next level.
And that was a challenge.
And those things are critical, as you know.
And so it took time and it took external validation to speak in terms that my mentors would understand
that this was a valid field.
And that's the coin of the realm, the academic currency were publications and grants.
And so getting a few of those out early and getting some few successes early made it easier
for mentors to say, okay, well, maybe there's actually something here.
I appreciate what you said.
And you're right.
It applies to so much more than just global health research.
It's the sense that when you have an idea of really burning passion and people don't
see the way forward, having that external validation is helpful in having grants and
publications is important as well.
One of the things I found, and perhaps this is just in hematology, but sometimes, especially
at the fellow stage, trainees don't tend to understand how important it is to get funding
because it's never free, but it seems like being able to do research in residency is
free.
It's like if you get grants or you don't get grants, you still get to do your work.
I wonder if you want to speak to why it's important for those early funding opportunities
and those early awards and how young faculty or young trainees might want to think about
it.
Yeah, it's critical, so critical.
So there's the funding in and of itself, which allows you to do things that you're passionate
about.
I think that external validation piece is also critical because as your name gets talked
about higher and higher up the chains, people speak in terms that they understand and they
digest.
So whether it's getting good scores on grants or getting fellowship grants or even foundation
grants, the amount is really irrelevant.
It's really just showing that there is some external validation that there's potentially
a future here.
And I would say something I didn't appreciate at the time when I was a fellow in training,
but another really important reason to start to write grants early in your career, if you
see yourself being in an academic career, is that you need the practice.
And you only get better writing grants as with anything else in life with practice.
And I've really benefited from some of the institutional resources for some friendly
peer review and various things that I know exist at many institutions to make sure that
your grant writing is superb.
So use the practice because you need it.
Maybe you'll realize later on that you need it, but you certainly do need it.
Absolutely.
And when the risk, when it seems less risky, it's probably most important to practice because
if you fall, it's still okay.
But you're right, because it's kind of like I think about it in terms of when you start
your first year of fellowship at a new institution and you don't even know where the bathrooms
are, how can you do a good consult?
You just don't even know where you're going.
And so I think it's the same way with writing grants where the more you write it, the more
all those things fall away, you really focus on the science that you're presenting.
That's right.
Yeah.
Okay.
All right.
So I wonder for someone who maybe they finished fellowship and they didn't have those opportunities
that you talked about, and now they are junior faculty really now trying to move their career
forward.
Is it ever too late to get involved in global health research?
And if not, how do you recommend people like that move forward?
Yeah, great, great, great question.
So no, I don't think it's too late.
Not at all.
I think we, and I'll just be philosophical for just for a second.
I think that is one of the benefits of the academy.
One of the things that we benefit from is the ability to change our minds, our ability
to have time, to have a little bit of mental space to say, what is it that I'm passionate
about?
And honestly, it's a blessing that not every career offers where you can say, how am I
going to derive joy and passion and satisfaction from what I do?
So that's an opportunity that we have.
And I think if someone is feeling that global health should be more central in their career,
you should go for it.
Now there's no such thing as a free lunch.
So you're going to have to put in the time and the effort to be successful, especially
if this is a departure from something you've done before.
And you're going to have to show that the credibility, show that stick-to-it-iveness,
that passion.
You're going to have to show that you can do it.
But it's absolutely not too late.
Again, especially at an institution where others are involved in global health, I think
it's an easier on-ramp.
But here's where I also say one thing that is not unique to global health, but it's certainly
characteristic of global health, is this idea of team science and this idea of collaboration.
By very nature of the fact that most of my research occurs in another country, that means
that I have at least one partner, and I actually have many, who are working with me on these,
on these projects.
So multiple PI relationships, two, three, or four multiple PIs relationships, those
are critical.
And if you're starting out in global health research, maybe you're a co-investigator on
a project.
Maybe you're testing the waters as much as your potential collaborators are testing the
waters.
So I don't think it's too late, but I do think there are a lot of different ways to get engaged.
I love it.
I appreciate you saying that.
Because I think in all things, and you said it isn't unique to global health, it's what
do you want to do?
What is it that you are most passionate about?
And how can you work to move it forward?
And really sometimes that's thinking creatively as far as how do you fund it?
Who are the partners already engaged?
How do you connect with them in moving forward?
So thank you.
Thank you for sharing that perspective.
Yeah, great.
Thank you.
So we have come to the end of the show.
And I'm curious to know if there's one thing that I haven't asked about that you feel is
important to share with our audience.
I think the one thing that has been in my mind of late is a conversation I had with
a mentee of mine.
And we were talking about meeting those academic milestones and going on the promotion and
tenure pathway and how we are judged and measured along those ways.
And we had a conversation about success and significance.
And I think my own approach is success, sometimes that's externally defined.
You've gotten this number of publications, these number of grants, you've become full
professor or your dean or this or whatever it is.
So those are externally defined.
Those are all great things.
Those are all good things.
Those are, that's the world we live in.
But I think it's not the same thing as significance.
And I do think that those circles do overlap significantly.
But I was encouraging my mentee, as we do the successful things, as we make our way
through the APT process and we progress, those are all good things.
Just to define for yourself what significance means, define for yourself, what is it that's
going to keep me up late at night or wake me up early in the morning that I'm joyful
about?
What is it that's going to make me have to be away from my family sometimes when I'd
rather be with them?
What's drawing me to do that?
And just remember significance.
I think that's a good anchor.
I appreciate you saying that.
I like that.
Significance.
I think that's what we inherently, innately are shooting for as physicians, especially
who are doing this thing as scientists.
I wonder, and I wonder if maybe there might be a lot of this sometimes with especially
early career folks who don't necessarily understand the metrics for success.
To what extent is it possible to have significance without success?
I think that's very possible.
I'm not sure it's possible in academic medicine, given the way our current environment is set
up, but I think my true north is significance.
And I think if you're doing excellent work, I think if you're doing things that you're
passionate about, the success will follow.
I'm not saying that it's easy and that it's automatic.
I stay up late and I sometimes, unfortunately, work on a weekend, but I think if you aim
for significance and if you're using sound methodology, I think success will follow.
Yeah, I do believe to a great extent there's overlap.
I think also recognizing your environment, because you talked about whether you're doing
that within academic medicine and recognizing your environment and recognizing what those
metrics are, then you're able to align what you're doing with the metrics so that as you
are pushing for significance, you're addressing all the other things as well.
Because you certainly can do that outside of academic medicine, but if you're going
to stay within academic medicine, then it's worth understanding what the currency of the
environment is and trying to work to overlap the two.
I wonder if you want to speak some more to that.
Yeah, no, I think you can't ignore one for the other.
And so again, if we're talking about the way academic medicine is currently, we have an
APT system that's fairly ingrained.
As you know, our institution is starting to think more broadly about types of scholarship
and how we judge scholarship.
Many institutions are.
But I think if promotion, if success in academia is part of what you're aiming for, there are
just certain metrics you have to be cognizant of while you also aim to do significant things
in this world.
Absolutely.
It's being aware and savvy about your environment.
I love it.
Well, Jerry, thank you.
You've shared some amazing insights.
I want to thank you for coming on the show.
It was my pleasure.
Thank you for the invitation.
All right, everyone, you've heard Dr. Bloomfield.
He's given us some really important insights, especially with regard to thinking about global
health research.
If you can think of somebody else who needs to hear about this, please forward this episode.
And we look forward to talking with you again next time on the Clinician Researcher Podcast.
Thank you for listening.
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