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Navya Krishna

IR pd. 2/English 11 AP

Dr. Elyse Foster, Professor Emeritus of Clinical Medicine at the University of California, San
Francisco in the Department of Medicine in the Division of Cardiology
University of California San Francisco
December 12, 2018

EF: Hello?
NK: Hello, Dr. Foster?
EF: Yes, hi.
NK: Hi.
EF: How are you?
NK: I’m good, thanks. How are you?
EF: Ok. Ok. So, you...and how do you say your name, Naveeya?
NK: Navya.
EF: Navya. Navya. And where do you go to school?
NK: River Hill High School in Clarksville, Maryland.
EF: Oh, ok. I saw you had a Massachusetts phone number, and I thought you live in
Massachusetts.
NK: ​laughs​ I used to live there.
EF: Uh huh, ok. And what year are you in?
NK: I’m a junior.
EF: Uh huh, ok. And are you interested in medicine as a career?
NK: Yes, I am.
EF: Uh huh, ok. So, what is the program that you’re in, and what is the idea for your project?
NK: Well, I’m in the Independent Research program at my school, and so I find articles and
other sources, and using that information and a research question that I come up with, I write a
research paper.
EF: Uh huh, ok. And do you have a year to do this? How long...over what period of time…
NK: So, I will hopefully have it done by around May, and the paper is metacritical, so I won’t be
doing a lot of my own research, but I will be looking at a lot of other people’s research. So, yeah.
That’s…
EF: Well, that sounds very interesting. So, do you actually do a meta analysis, or do you just do a
summary of the results?
NK: I actually do an analysis.
EF: Oh, great. So, at this point what is your sort of working hypothesis? Do you have a specific
hypothesis, or are you just sort of like an exploratory at this point?
NK: Well, currently I want to look at decreasing mortality from cardiovascular disease in
pregnant and postpartum young women.
EF: Ok.
NK: And so that’s why this Toolkit that I found that you worked on...it was very closely aligned
with my topic, and I found it very interesting.
EF: Great! Great, yeah, that’s...that was something that came out of a California Quality Review
Process for maternal mortality, which has gotten quite a bit of press lately. Including, I think, the
New York Times. There was an article recently and in a number of other major
papers...newspapers. And the lead of that project, who you probably should look up, and you
might even want to interview him, is Elliott Main, and he’s an obstetrician in San Francisco.
NK: Oh, ok.
EF: At Setter(?) Health, and it might be, because he’s the lead of the project, it might be
interesting for you to interview him in terms of the conception of the project, and…
NK: Ok.
EF: Did you read about the project itself or did you just look at the Toolkit?
NK: I mostly...I’ve been mostly looking at the Toolkit, but I’m also really interested in the
project, because I was actually wondering if maybe it could be expanded to other parts of the
country.
EF: I think North Carolina has done something similar, and I don’t know what other states have
done similar projects. But I’m pretty sure North Carolina has done one in the past ten years.
NK: That’s really interesting.
EF: So...let me just see if I can...here it is, ok. So the whole project that I worked on is California
maternity care...is the entire project, so that’s where you found the Toolkit on cardiovascular
care. And...if you look at...but you can learn more about you know the whole on the CMQCC
website.
NK: Right.
EF: You can learn more about...and, you know, there actually has been a significant decline in
mortality in California.
NK: Wow.
EF: With...following the project. Whereas before the project it had been consistently rising, and
it’s rising in the United States as a whole. So if you look at the CMQCC website, you can kind of
get that information.
NK: Ok, thanks. I’ll look into that.
EF: And then I may have...let me see if I have that...paper somewhere...from North Carolina. So
how are you using, what are you using, are you using PubMed or what are you using for how to
get your articles and your sources.
NK: I’ve been using a lot of Google Scholar, and some databases that I have access to.
EF: Ok, so were there questions you wanted to ask me or something?
NK: Yeah, I was wondering what got you interested in this project?
EF: Well, you know I’m a cardiologist, and throughout my career, I’ve become more and more
involved in care of pregnant women’s cardiovascular disease, and that is because predominantly
because of my interest in congenital heart disease, and so I take care of adults who have grown
up with congenital heart disease, and were diagnosed, most of them, in childhood. And then, they
were either treated with surgery or were treated with some kind of intervention, it could
sometimes be catheter-based, in other words they had a cardiac catheterization. Do you know
what that is?
NK: Sort of, can you explain?
EF: So, when someone has a heart attack, and they will, so this is not the only reason but the
most common reason we do this is when someone has a heart attack, or has what’s called an
angina, because one of the arteries to their heart is blocked, they thread catheters through the
veins and arteries in the groin or the arm up to the heart, and then they thread very very tiny
tubes, or catheters, down into the vessels themselves, and open them up with a stent and a
balloon. Have you ever heard of that?
NK: Yes, I have.
EF: So, that sounds familiar to you, ok.
NK: Yes.
EF: So, in patients with congenital heart disease, the problem is generally not the coronary
arteries, but it’s some problem in the structure of the heart.
NK: Ok.
EF: There may be communications between the upper chamber of the heart, those are called the
atria, and that’s called an atrial septal defect, or there may be a communication between the
lower chambers of the heart, which are ventricles, the pumping chambers, that’s called a
ventricular septal defect. And, so um...have you ever shadowed in a hospital or anything? Have
you ever been able to do that?
NK: I’ve shadowed a family doctor.
EF: Oh, great!
NK: Yeah, and I got to see patients, but it was more of learning about the environment of a
practice. And, I’ve also done an online course, actually, through the University of Sydney,
Australia.
EF: Wow, what were you doing over there?
NK: I actually did it on a website, so this summer, it was sort of like a course, but it wasn’t for
any credit, and I learned a lot about the heart, and about myocardial infarction, so…
EF: Uh huh, oh good. So, anyway, that’s how I got involved with this because I was mainly
interested in congenital heart disease, so I started being consulted to take care of women who had
congenital heart disease during pregnancy. And, then I wrote a couple of review articles about
that, and then when this...what happened was they hadn’t really included a cardiologist in their
initial panel for a case review on the CMQCC, and then when they realized that there were some
cardiovascular complications, they asked me to join.
NK: Oh, wow!
EF: So, that was how it happened. So, and then you know the work was very interesting and you
know we really did a lot of deep delving into the causes of death of this population of patients,
and that resulted in a manuscript that I don’t know if you…did you see that one? There was an
article, I’ll try to look for it, did you find the article based on the CMQCC?
NK: I did not. Which publication?
EF: This is, the first author I think is...let’s see...ok, so if you look, there are two articles, one is
in Jama Cardiology, and one is in the American Journal of Obstetrics and Gynecology.
NK: Ok.
EF: The one in the American Journal of Obstetrics and Gynecology, the lead author is Dr.
Hameed, and the other one is Dr. Hayward. So those are two articles. One’s focus is on
congenital heart disease, and the other one is on all cardiovascular deaths.
NK: Thank you. So, how responsive were physicians to this project?
EF: You mean the Toolkit project?
NK: Yes.
EF: I can’t really say. I mean, it actually wound up being published somewhat recently, I don’t
know how to measure that. I don’t know if it can really be measured.
NK: Ok.
EF: That’s something I don’t know.
NK: Ok. What were some challenges that you faced while working on this project about the
Toolkit?
EF: That’s a very good question. So I think the biggest challenge was, first of all, to know who
the target is, because it’s variability as someone who’s target is patients. So that was, you know,
one focus. And then the other was to target physicians. So you want to now target some
obstetricians, who will be taking care of the patients during pregnancy, and also midwives are
very important to target. You also want to...family physicians. Some family physicians do
obstetrics. So, you need to target them, and you want to target family physicians and other family
care providers, because if they see a woman of childbearing age, you want to alert them so they
can pay attention before the women gets pregnant. So, defining an audience is important. And
then the second thing was to make it to develop something that was complete but not overly
complex because you want something that can speak to physicians clearly fairly quickly, and not
get mired in details. But, to alert physicians and care providers when they need to refer on, and
make sure the patient gets seen by a cardiologist, or someone with an expertise. So, I think those
were the primary challenges to building something. The other thing is that one of the problems is
when a woman is pregnant, typically, they feel short of breath, and they have a heart murmur
that’s normal with pregnancy, they can get some swelling in the ankles which could be a sign of
heart failure, but could also be normal for pregnancy. So, you don’t want to be overly alarmist,
because then you’d be sending everyone to a cardiologist, so you have to really sort through
what really is significant and what isn’t.
NK: Ok.
EF: So those are some of the challenges that we faced in trying to make a useful tool. And,
helping people with appropriate triage.
NK: So, was your process for developing this, were there parts of it that are unique to California,
or could it…
EF: No, I think it’s very, I don’t think so.
NK: Ok. Also, so just generally in this field, where do you think the research is going?
EF: You know, I don’t know that there’s a lot of really active research in terms of...other than,
sort of looking at large populations, like if you see that paper that the second paper in Jama
Cardiology, you’ll see that we used a large database of hospitalizations to try to identify the risk
of pregnant in patients with congenital heart disease. But as far as specific interventions, I’m not
aware of any.
NK: Ok. Do you think that the results of this Toolkit will be long term, or do you think that this
is an immediate sort of effect?
EF: Well, I think it can have a long term effect, I mean one of the problems in the United States
is the fragmented health care system. So, many of the people who died didn’t have access to
care, as you’ll see, until very late in their pregnancy. Didn’t have the usual prenatal care. But not
all of them. You know, having access to facilities where the obstetricians are in house rather than
taking calls from home, the number of deliveries that are done is there. Are there cardiologists
and intensive care doctors that can take care of the patients, so a lot of the problems are, you
know systemic problems. There was a recent...there is recent evidence that in Texas, they closed
a lot of the Planned Parenthood clinics, and there was recent data that associated with that, not
only because, aside from the issue of abortion, if you take that aside and don’t consider that,
many women got all of there prenatal care there. They got all of their contraception there. And
so, I think closing these clinics, people weren’t getting prenatal care properly, there weren’t
many places because they didn’t have any other options, and maternal mortality seemed to go up
as these clinics declined in numbers. That might be something that you want look at because so
much of it is related to the availability of care for women.
NK: Right.
EF: The other major issue that I think has impacted maternal mortality, and probably fetal
mortality as well, is drug use. So, many of the women who died because of cardiovascular
disease, it was also complicated by drug use. So, that is I think is...so while the Toolkit can do
some things, ​laughs​, the Toolkit can’t do, you know, everything. So, you know, a lot of the
problems are social problems and societal problems. But I certainly think it can help people who
are in care and whose physicians learn to pay attention to the signs and symptoms of heart
disease in the diagnosis and treatment.
NK: Right. Also, what time during pregnancy do you think is the most critical for women with
congenital heart disease?
EF: So, in terms of when they present with symptoms and signs, and they start to have what we
call decompensation, in other words they start to develop heart failure, that’s usually at the end
of the second trimester. So, in the range of about 28-32 weeks. Beginning in the third trimester.
And the reason for that is due to the physiology of pregnancy, is what happens to your body
during pregnancy. And what happens to your body during pregnancy is that you have to have an
increase in the output of the heart, what we call the cardiac output, and typically that goes up by
50 percent at that point during pregnancy. So the heart’s having to work much much harder, and
that’s when we start to see decompensation, whether it’s congenital heart disease, or a valve
problem, or whether it’s a heart failure problem. When I say heart failure problem that means
that there’s something wrong with the muscle of the heart, it doesn’t squeeze normally.
NK: How common is it for a woman to develop a cardiovascular disease while she’s pregnant?
EF: It’s still pretty rare, I mean I would say it’s certainly less than one percent in the United
States. Much less. But, you know, even though it’s rare, it’s still something that we need to...but
there are other problems that are sort of related to the heart. So, you know patients who develop
high blood pressure during pregnancy, and there’s a spectrum of that could be developed, of
what we call pregnancy-induced hypertension, or high blood pressure, but people can go on and
get a syndrome that’s called preeclampsia. And those conditions could be associated with heart
problems. That is more frequent. The other thing is that patients who develop diabetes during
pregnancy, have you heard of that? We call that gestational diabetes.
NK: Yes, I have.
EF: And they can be at greater risk for developing cardiovascular complications. Obesity seems
to be a risk factor, and certainly smoking seems to be a risk factor.
NK: Right, so...I’m trying to think of how to ask this. What are the best treatments so far that are
being used, either through the Toolkit, or that you’ve just seen being used for this.
EF: So, that’s a very general question. So, I think there are several phases. One is, you know,
first of all prevention. So, you know, I think that you can look at a woman who has at least
known or preexisting heart disease, and most of those will either have a heart valve problem or
they’ll have a congenital heart defect. Sometimes people have what’s called a cardiomyopathy.
That’s a problem with the muscle in the heart. So those patients should be seen, you know,
ideally before they conceive so that they can...so that their treatment can be either with
medication or with other means, so that can be taken care of before they become pregnant. So
that’s one...so prevention is very important. And having a very healthy lifestyle, and ideal
weight, and making sure blood pressure’s not elevated, and diabetes does not exist prior to
pregnancy are all very important. So then the second phase is that regular prenatal care, you
know screening for high blood pressure, and other things, is very important. And as the high
blood pressure is diagnosed, there are a number of known, you know, well known therapies for
hypertension during pregnancy. And then finally, you know, if a patient does develop heart
problems during pregnancy, or they become more manifest during pregnancy, then, you know,
they...basically, the treatment is very similar to those who are not pregnant, with the exception
that certain medications that we use are contraindicated during pregnancy. So, we have to use
alternative medications for some patients who are pregnant. Very rarely will we actually need to
do surgery, or cardiac catheterization during pregnancy. Usually, we do that during the second
trimester, if the patient is very sick or at high risk.
NK: Ok, well that’s the extent of my questions, thank you.
EF: So, what do you...so maybe...what do you need in terms of mentorship, and maybe it would
be a good idea for me to talk to your advisor as to what that entails, see if that would be, or your
teacher.
NK: Yeah, I can send you her email and her phone number, and what I would need is, where to
look for sources, and I would send you my research paper as it develops, and I would just need
some feedback on what kind of information to include, and where to take my research.
EF: Uh huh, ok. Yeah, so this would be over the next six months that you would need this?
NK: Yes.
EF: How long a paper is it? In general.
NK: Well, I actually don’t know because our class is very general, so you can do a paper on any
subject, so at the moment, I don’t know, but I’m hoping to get it published, so…
EF: Well, great! Alright, well you know, why don’t you email me her information, and after
talking with her, I’ll decide if it’s something that I definitely can do.
NK: Ok.
EF: Well, tentatively, I would say that I can.
NK: Ok, thank you!
EF: Ok, how near to D.C. are you?
NK: I’m about 45 minutes to an hour.
EF: From Washington? Ok, because there’s a really terrific person there named Anithra John,
and she’s at Washington Hospital Center, at National Children’s hospital, and so she might be
somebody local who you might want to contact as well.
NK: Ok, thank you.
EF: So you can look her up. Ok, well send me your advisor’s information, and then I will get to
talk to her, and go from there.
NK: Ok, thank you. Thank you so much for talking with me.
EF: It was so nice to talk to you. Ok, bye.
NK: Bye.

Reflection

Some takeaways for my research are that I can look at the limited health care coverage as

a reason for rising maternal mortality, and I can also look at implementing the California Toolkit
in other states. Dr. Foster also gave me the names of some people who I can contact for more

information about the topic. I think that the interview went very well, and Dr. Foster said in the

interview that she will most likely be able to be my advisor. For my next interview, I will ask

more specific questions, and I will done more research, so I will have more to ask. Coming up

with questions before the interview was easy for me, because I have a lot that I want to learn

about the topic. Something that was a bit challenging, however, was that Dr. Foster answered

some of my questions in her explanations before I asked them, so I had to come up with some of

the questions during the interview.