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The Roundtable Panel: a daily open discussion of issues in the news and beyond. Today's panelists are WAMC's Alan Chartock, investigative journalist Rosemary Armao, former Associate Editor of the Times Union Mike Spain, and investment banker on Wall Street Mark Wittman.

Clement is in conversation with political editor at News24, Qaanitah Hunter, Associate Editor at Daily Maverick Marianne Merton, former mineral resource minister Dr Ngoako Ramathlodi, former Chairperson of the Parliament's Eskom Inquiry Zukiswa Rantho and Democratic Alliance Chief Whip Natasha Mazzone, zooming into what the state capture report says about the president, the ANC and parliamentary oversight See omnystudio.com/listener for privacy information.

Associate Editor at Daily Maverick Brooks Spector discusses the Russia-Ukraine conflict, including Russia's use of a missile that killed at least a dozen people at a busy shopping mall in the city of Krememnchek. See omnystudio.com/listener for privacy information.

“My White Coat Doesn't Fit” by Narjust Florez (Duma): a medical oncologist shares her story about exclusion, depression and finding her way in oncology as a Latina in medicine and oncology.   TRANSCRIPT Narrator: My White Coat Doesn't Fit, by Narjust Duma, MD (10.1200/JCO.21.02601) There I was, crying once again all the way from the hospital's parking lot to my apartment, into the shower, and while trying to fall asleep. This had become the norm during my internal medicine residency. For years, I tried hard every day to be someone else in order to fit in. It started with off-hand comments like “Look at her red shoes,” “You are so colorful,” and “You are so Latina.” These later escalated to being interrupted during presentations with comments about my accent, being told that my medical school training in my home country was inferior to my US colleagues, and being assigned all Spanish-speaking patients because “They are your people.” Some of those comments and interactions were unintentionally harmful but led to feelings of isolation, and over time, I began to feel like an outsider. I came to the United States with the dream of becoming a physician investigator, leaving behind family, friends, and everything I knew. Over time, I felt pigeonholed into a constricting stereotype due to my ethnicity and accent. Back home, I was one of many, but in this new setting, I was one of a few, and in many instances, I was the only Latina in the room. I was raised by divorced physician parents in Venezuela; my childhood years were often spent in the clinic waiting for my mother to see that one last patient or outside the operating room waiting for my father to take me home. The hospital felt like my second home, growing up snacking on Graham crackers and drinking the infamous hospital's 1% orange juice. “She was raised in a hospital,” my mother used to say. Sadly, that feeling of being at home in the hospital changed during medical training as I felt isolated and like I did not belong, making me question my dream and the decision to come to the United States. I remember calling my family and crying as I asked “Why did I leave?” “Why didn't you stop me from coming here?” and seeking permission to return home. I felt like I was disappointing them as I was no longer the vivid, confident young woman who left her home country to pursue a bright future. I remember one colleague, Valerie (pseudonym), from Connecticut. Valerie attended medical school in the United States, did not have an accent, and was familiar with the American health care system. She understood how the senior resident-intern relationship functioned, a hierarchy that continually confused me. Over the following weeks, I took a closer look at how my colleagues and other hospital staff interacted with Valerie. I noticed that people did not comment about her clothing or personality. She was “normal” and fit in. I remember my senior resident asking me, “Narjust, why can't you be more like Valerie?” Ashamed, I mumbled that I would try and then ran to the bathroom to cry alone. That interaction was a turning point for me; I got the message. I needed to change; I needed to stop being who I was to be accepted. As the years passed, I kept key pieces of my personality hidden, hoping I could earn the respect of my colleagues. I refrained from sharing my personal stories as they were different from those around me. I grew up in a developing country with a struggling economy and an even more challenging political situation. It was clear that we simply did not share similar experiences. When I sought help from my senior residents and attending physicians, my feelings were often minimized or invalidated. I was told that “residency is tough” and that I should “man up.” A few even suggested that I mold my personality to fit the box of what a resident physician was supposed to be. I slowly realized that my clothing changed from reds and pinks to greys and blacks because it was “more professional”; my outward appearance faded, as did my once bright sense of humor and affability. All these issues led to depression and an overwhelming sense of not belonging. A few months later, I was on antidepressants, but the crying in the shower continued. Rotation by rotation, I looked for a specialty that would help me feel like I belonged, and I found that in oncology. My mentor embraced my research ideas; my ethnic background or accent did not matter; we had the same goal, improving the care of our patients with cancer. I got to travel to national and international conferences, presented my research findings, and received a few awards along the way. From the outside, it looked like I was thriving; my mentor often called me a “Rising Star,” but in reality, I was still deeply depressed and trying to fit in every day. My career successes led me to believe that not being myself was the right thing to do. I felt isolated; I was trying to be someone I was not. A year later, I matched at my top choice oncology fellowship program; the program had the balance I was looking for between clinical care and research. This meant that I needed to move to the Midwest, further away from family, and to an area of the country with less racial and ethnic diversity. After 2 years on antidepressants and the 10 extra pounds that came with it, my white coat did not fit. My white coat felt like a costume that I would put on every day to fulfill the dream of being a doctor. I would often wake up in the middle of the night exhausted and depressed. I had all the responsibilities of a hematology/ oncology trainee and the additional full-time job of trying to fit in every day; I was using all my energy trying to be someone I was not. Regardless of my fears, I felt in my element when talking to patients and interacting with my cofellows. Despite having a different skin color and accent, I felt accepted by my patients with cancer. I remember when one of my patients requested to see me while in the emergency room because “Dr Duma just gets me.” She had been evaluated by the head of the department and attending physicians, but for her, I washer doctor. Tears of happiness accompanied my bus ride to see her; at that moment, I knew I was an oncologist, and oncology was the place I belonged. The next day, I realized that it was time to be myself: Narjust from Venezuela, a Latina oncologist who was her true self. I searched the bottom of my closet for the last piece of colorful clothing I had saved, a yellow dress. I put on that brightly colored dress for the first time in 5 years and finally felt comfortable being my authentic self; the yellow dress represented freedom and embraced the culture and colors I grew up seeing in my hometown. I finally understood that I brought something special to the table: my unique understanding of the challenges faced by Latinx patients and trainees, my advocacy skills, and my persistence to endure the academic grindstone. Psychotherapy was also an essential part of my recovery; I learned that happiness lived within me as a whole person—hiding my accent, cultural background, and past experiences was also hiding the light and joy inside me. Along the way, I found colleagues who faced the same challenges and validated that my experiences resulted from an environment that excludes the difference and values homogeneity. This route to self-discovery helped me find my calling to support others in situations similar to mine.3 I learned how to incorporate and celebrate my ethnicity in the world of academic oncology by teaching others the power of cultural humility, diversity, equity, and inclusion. Together with newfound friends and colleagues, I cofounded the #LatinasinMedicine Twitter community for those who face similar burdens during their training and careers. The #LatinasinMedicine community was created to share our stories, embrace our culture, and amplify other Latinas in medicine—to create connections that alleviate the sense of isolation that many of us have experienced and serve as role models to the next generation of Latinas in medicine. To help drive systemic change, I founded the Duma Laboratory, a research group that focuses on cancer health disparities and discrimination in medical education. Through research, the Duma Laboratory has shown that my experiences are not unique but rather an everyday reality for many international medical graduates and other under-represented groups in medicine. The Duma Laboratory has become a safe environment for many trainees; we seek to change how mentorship works for under-represented groups in oncology, with the hope that the isolation I felt during my training is not something that future physicians will ever have to endure. After years of depression and self-discovery, my white coat now fits. However, this is not your regular white coat; it has touches of color to embrace my heritage and the ancestors who paved the way for me to be here today. The face of medicine and oncology is changing around the world; young women of color are standing up to demonstrate the strength of our experiences and fuel the change that medical education needs. For all minority medical students, residents, fellows, and junior faculty, we belong in medicine even during those moments when our identity is tested. Through my journey, I learned that we can and must challenge the status quo. I hope to inspire others to join me in this path of advocating for diversity, equity, and inclusion because the time for change is now. I was finally free the moment I realized I could not be anyone else but myself, a proud Latina in medicine and oncology. Dr. Lidia Schapira: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, which offers a range of educational and scientific content and enriching insight into the world of cancer care. You can find all of the shows including this one at podcast.asco.org. I'm your host, Lidia Shapira, Associate Editor for Art of Oncology and Professor of Medicine at Stanford. And with me today is Dr. Narjust Duma, Associate Director of the Cancer Care Equity Program and Medical Thoracic Oncologist at Dana Farber and an Assistant Professor at Harvard Medical School. We'll be discussing her Art of Oncology article, ‘My White Coat Doesn't Fit.' Our guest has a consulting or advisory role with AstraZeneca, Pfizer, NeoGenomics Laboratories, Janssen, Bristol Myers Squibb, Medarax, Merck, and Mirati. Our guest has also participated in a speaker's bureau for MJH Life Sciences. Narjust, welcome to our podcast. Dr. Narjust Duma: Thank you for the invitation and for letting us share our story. Dr. Lidia Schapira: It's lovely to have you. So, let's start with a bit of background. Your essay has so many powerful themes, the story of an immigrant in the US, the story of resilience, the story of aggression and bullying as a recipient of such during training, of overcoming this and finding not only meaning, but really being an advocate for a more inclusive and fair culture in the workplace. So, let's untangle all of these and start with your family. I was interested in reading that you're named after your two grandmothers, Narcisa and Justa. And this is how your parents, both physicians, Colombian and Dominican, gave you your name, and then you were raised in Venezuela. So, tell us a little bit about your family and the values that were passed on in your family. Dr. Narjust Duma: Thank you for asking. Having my two grandmothers names is something that my mother put a lot of effort into. She was a surgery resident with very limited time to decide to do that. And I don't have a middle name, which is quite unique in Latin America, most people in Latin America have one or two middle names. So, my mother did that to assure that I will use her piece of art, which is my first name. But little does she know that my grandmothers were going to be such an important part of my life, not only because they're in my name, but also because I am who I am thanks to them. So, the first part of my name, Narcisa was my grandma who raised me and she gave me the superpower of reading and disconnecting. So, I'm able to read no matter where I am and how loud it can be and disconnect with the world. So, it is often that my assistants need to knock on my door two or three times so, I don't like being scared because I'm able to travel away. That was also very unique because you will find me in the basketball games from high school or other activities with a book because I was able to block that noise. But it also makes very uncomfortable situations for my friends that find it embarrassing that I will pull a book in the basketball game. And as I grow, thanks to the influence of my grandmothers, I always have these, how can I say, mixed situation, in which they were very old school grandmothers with old school habits and values, and how I'm able to modify that. My grandma told me that you can be a feminist, but you still take care of your house. You can still, you know, cook. And that taught me that you don't have to pick a side, there is no one stereotype for one or another. Because as my mother being a single mother and a surgeon, my parents divorced early on, told me, ‘Yes, I can be the doctor but I can also be the person that has more than a career that's able to have hobbies.' I love cooking, and when I'm stressed, I cook. So, I had a grant deadline a few weeks ago and I cooked so much that there was food for days. So, having the names of my grandmothers is very important because I have their values, but I have modified them to the current times. Dr. Lidia Schapira: Let me ask a little bit about reading. I often ask the guests of this podcast who have written and therefore I know enjoy reading and writing, what their favorite books are or what is currently on their night table. But I'm going to ask you a second question and that is what languages do you read in? Dr. Narjust Duma: I prefer to read in Spanish. I found that books in Spanish, even if it's a book that originated in English, have these romantic characteristics. And I often tell my editors, ‘Just take into account that I think in Spanish, and write in English'. Because I grew up with Gabrielle Garcia Marquez, and when he describes a street, that's a page of the little things that he describes. So, that's how I write and that's how I read in a very romantic, elaborate way. The aspects of realistic imagism, which is my favorite genre in literature, and there are so many Latin American and South American writers that I don't think that I am going to run out. And when I run out, I reread the same books. I have read all of Gabrielle Garcia Marquez's books twice, and Borges, too. It's the type of stories that allows you to submerge yourself and you imagine yourself wearing those Victorian dresses in the heat of a Colombian street, as you try to understand if, you know, Love in the Time of Cholera, if they were more in love with being in love or what it was happening in the story. And that just gives me happiness on a Sunday morning. Dr. Lidia Schapira: That's beautiful. I must confess that reading Borges is not easy. So, I totally admire the fact that you have managed to read all of his work. And I think that you're absolutely right, that magical realism is a genre that is incredibly fresh, and perhaps for the work that we do in oncology, it's a wonderful antidote in a way to some of the realities, the very harsh realities that we deal with on a daily basis. So, let me ask you a little bit about growing up in Venezuela in the 80s, 90s, early aughts. That must have been difficult. Tell us a little bit about that, and your choice of attending medical school. Dr. Narjust Duma: So, growing up in Venezuela, with a Colombian mother, it was quite a unique perspective because she was very attached to her Colombian roots. So, a lot of the things that happened in the house were very Colombian, but I was in Venezuela. So, it was a unique characteristic of being from a country but your family is not from there. So, my parents are not from Venezuela, my grandparents either, and I'm Venezuelan because I was born and raised there. So, that brought a unique perspective, right? The music that I played in my house was Colombian music, not Venezuelan music. So, my family migrated from Colombia to Venezuela due to the challenges in the early 80s with violence and the Medellin, due to the drug cartels. So, we moved to Venezuela for a better future. And growing up in the first years, Venezuela was in a very good position. Oil was at the highest prices. Economically, the country was doing well. I remember, in my early years, the dollar and the bolivar had the same price. But then little by little I saw how my country deteriorated, and it was very heartbreaking. From a place where the shells were full of food to a place now when there is no food, and you go to the supermarket, and many of them are close. And now you're only limited to buying certain things. And you used to use your federal ID that has an electronic tracking on how much you can buy because of socialism. So, you're only allowed to buy two kilograms of rice per month, for example, you're only allowed to buy this number of plantains. So, every time I go home, because Venezuela is always going to be my home, it doesn't matter where I am., I see how my country has lost pieces by pieces, which is quite very hard because I had a very good childhood. I had a unique childhood because I was raised in hospitals. But I had a childhood in which I will play with my friends across the street. We were not worried about being kidnapped. We were not worried about being robbed. That's one thing that children in Venezuela cannot do right now. Children of doctors – there's a higher risk of being kidnapped as a kid right now if your father is a doctor or your mother. So, my childhood wasn't like that. When I teach my students or talk to my mentees, I'm often selling my country, and saying that's not what it used to be. That's not where I grew up. But every year I saw how it no longer is where I grew up. That place doesn't exist, and sometimes, Lidia, I feel like my imagination may have to fill it out with more good things. But I think it was a good childhood. It's just that nobody in Venezuela is experiencing what I experienced as a kid. Dr. Lidia Schapira: So, both parents were doctors and you chose to study medicine, was this just right out of high school? Dr. Narjust Duma: Even before high school, I found myself very connected to patients. So, since I turned 15, my father would give his secretary a month of vacation because that's the month that we fill in. So, I was the secretary for a month every summer since I was 15 until I was 20. That early exposure allowed me to like get to know these patients and they know I was the daughter, but I was also the secretary. So, I really cherished that. Growing up in my household, we're a house of service. So, our love language is acts of service. That's how pretty much my grandmas and my parents were. So, in order to be a physician, that's the ultimate act of service. I have wanted to be a doctor since I was 11. I think my mother face horrible gender harassment and sexual harassment as a female in the surgery in the early 80s, that she tried to push me away from medicine. Early on, when I was 11, or 12, being an oil engineer in Venezuela was the career that everybody should have, right? Like, people were going to the Emirates and moving to different parts of the world and were doing wonderful. So, my mother, based on her experience in the 80s, was pushing me away from it. She's like, ‘You can do other things.' My father always stayed in the back and said, ‘You can do what you want.' This is how our parents' experiences affect our future. If I wouldn't be this stubborn, I would probably be an oil engineer today, and I wouldn't be talking to you. Dr. Lidia Schapira: So, you went to medical school, and then after you graduated, what did you decide to do? Because when I look at what we know about the history there is I think you graduated in '09, and then the story that you write about sort of begins in '16 when you come to New Jersey to do training in the US, but what happened between '09 and '16? Dr. Narjust Duma: I started residency in 2013. '16 was my fellowship. So, going to medical school was one of the hardest decisions I made because right in 2003 and 2004 was a coup in Venezuela where part of the opposition took over the country for three days, and then the President of the time came back and the country really significantly destabilized after that coup. Most schools were closed. Entire private industries were closed for a month. And I think for some people, it's hard to understand what happened. Everything closed for a month, McDonald's was closed for a month. There was no Coke because a Coke company was not producing. Everything was closed. The country was just paralyzed. So, my mother and I, and my family, my father, took into account that we didn't know when medical school would resume in Venezuela. We didn't know if the schools would ever open again. I decided to apply for a scholarship and I left Venezuela at the age of 17 to go to the Dominican Republic for medical school. Very early on, I noticed that I was going to be a foreigner wherever I go because I left home. And since then, I think I became very resilient because I was 17 and I needed to move forward. So, that is what happened in 2004. I left everything I knew. I left for the Dominican. I do have family in the Dominican, but it was very hard because even if you speak the same language, the cultures are very different. And then I went to medical school in the Dominican and when I was in the Dominican Republic, I realized I really wanted to do science and be an advocate and focus on vulnerable populations with cancer. So, then I made the decision to come to the United States, I did a year of a research fellowship at Fred Hutchinson, and then I went to residency in 2013. Dr. Lidia Schapira: I see. And that's when you went to New Jersey, far away from home. And as you tell the story, the experience was awful, in part because of the unkindness and aggression, not only microaggression but outright bullying that you experienced. In reading the essay, my impression was that the bullying was mostly on two accounts. One was gender. The other was the fact that you were different. In this particular case, it was the ethnicity as a Latin or Hispanic woman. Tell us a little bit about that so we can understand that. Dr. Narjust Duma: I think what happened is that perfect example of intersectionality because we are now the result of one experience, we're the result of multiple identities. So many woman have faced gender inequalities in medicine, but when you are from a marginalized group, those inequalities multiply. I have an accent and clearly a different skin color. I grew up in a family in which you were encouraged to be your true self. My grandmothers and my mother said, ‘You never want to be the quiet woman in the corner because the quiet woman never generates change.' That's what they said, and I bet there are some who do. But that intersection of my identities was very challenging because I was seen as inferior just for being a woman and then you multiply being one of the few Latinas you are seen like you are less just because you are - it doesn't matter how many degrees or papers or grants you had done and all, I was the most productive research resident in my residency for two years in a row - but I would still be judged by my identity and not what I have produced, or what I do on my patients' experiences, which were great – the feedback from my patients. It's just because I was the different one. Dr. Lidia Schapira: When I hear your story about your origins, it seems to me that you came from a very capable loving family, and they basically told you to go conquer the world, and you did. And then you arrive and you're a productive successful resident, and yet, you are marginalized, as you say. People are really aggressive. Now that you've had some years that have passed, if you think back, what advice would you give that young Narjust? Dr. Narjust Duma: My number one advice, would be that, I will tell myself is that I belong, in many instances, I feel like I didn't belong. It makes me question all the decisions to that day because when you're doing a presentation, and I still remember like today, and you're interrupted by someone, just for them to make a comment about your accent, it really brings everything down to your core, like, 'Is my presentation not accurate? Is the information not all right? And why am I here? Why did I left everything I love to be treated like this?' Dr. Lidia Schapira: Of course. So, from New Jersey, you write in your essay that you really discover your passion for cancer research, and you land in a fellowship with a mentor who is encouraging, and things begin to change for you. Can you tell us a little bit about that phase of your training in your life where you slowly begin to find your voice in the state, that also where you crash, where you find yourself so vulnerable that things really fall apart? Dr. Narjust Duma: So, when I was a resident, I didn't know exactly - I was interested in oncology, but I wasn't sure if it was for me. So, Dr. Martin Gutierrez at Rutgers in Hackensack is the person who I cold emailed and said, ‘I'm interested in studying gastric cancer in Hispanic patients because I think that patients in the clinic are so young.' He, without knowing me or having any idea, he trusted me. We still meet. He still follows up with me. He encouraged me. I think him being a Latino made the experience better, too, because I didn't have to explain my experience to him. I didn't have to explain that. He understood because he went through the same things. And he's like, ‘I got you. Let's follow what you want to do.' He embraced who I was, and how I put who I was into my research. And thanks to Dr. Gutierrez, I'm at the Mayo Clinic as an international medical grad. So, finding a place in which my ideas were embraced was very important to allow me to stay in medicine because, Lidia, I can tell you several times, I decided to leave. I was very committed to finding something else to do or just being a researcher and leaving clinical medicine behind. So, when I went to Mayo, I still followed with that mentor, but I already knew what I wanted to do. I wanted to do cancer health disparities. I wanted to do inclusion and diversity. And that allowed me to develop the career I have now and is having that pathway because I, with my strong personality and everything else, faced this discrimination, and I can imagine for other trainees that may still be facing that or will face that in the future. So, I use the negative aspects to find my calling and do many things I have done after that. Dr. Lidia Schapira: Speaks to your strengths and your determination. Let's talk a little bit about the people who may also feel different but whose differences may not be so apparent. How do you now as an emerging leader, and as a mentor, make sure that you create an inclusive and safe environment for your younger colleagues and your mentees? Dr. Narjust Duma: One of the things that resulted was the founding of the Duma Lab, which is a research group that focuses on cancer, health disparities, social justice as a general, and inclusion in medical education. So, one of the things that I practice every day is cultural humility. I continue to read and remember the principles. I have them as the background on my computer at work. The number one principle in lifelong learning is that we learn from everyone and that we don't know everything and other people's cultures, and subculture, we learn their culture is rich. So, in every meeting, I remind the team of the principles of cultural humility when somebody is joining the lab. I have one-on-one meetings, and I provide information and videos about cultural humility because the lab has been created as an environment that's safe. We have a WhatsApp group that is now kind of famous - it's called The Daily Serotonin. The majority of the members of the lab are part of marginalized groups, not only by gender but race, religion, sexual and gender orientation. So, we created this group to share good and bads, and we provide support. So, a few weeks ago, a patient made reference to one of their lab member's body, the patient was being examined and that was quite inappropriate. The member debriefed with the group and we all provided insights on how she had responded, and how she should respond in the future. That's not only learning from the person that brought the scenario but anybody else feels empowered to stop those microaggressions and stop those inappropriate behaviors that woman particularly face during clinical care. So, cultural humility, and having this WhatsApp group that provides a place where, first, I remind everybody that's confidential, and a place in which anything is shared has been very successful to create inclusivity in the group. Dr. Lidia Schapira: You have such energy and I'm amazed by all of the things that you can do and how you have used social connection as a way of bringing people up. So, can you give our listeners perhaps some tips for how you view creating a flatter culture, one with fewer hierarchies that makes it safer for learners and for those who are practicing oncology? What are three quick things that all of us can do in our work starting this afternoon? Dr. Narjust Duma: The concept is that we all can be allies. And being an ally doesn't take a lot of time or money because people think that being an ally is a full-time job, it is not. So, the first one tip will be to bring people with you. Your success is not only yours. It's a success of your mentees. It's a success of your colleagues. So, don't see your success as my badge on my shoulder. It's the badge that goes on everyone. So, bring people in, leave the door open, not only bring them but leave the door open because when you do it helps the next generation. Two, little things make a difference. I'm going to give you three phrases that I use all the time. When you think somebody has been marginalized in a meeting, bring them up, it takes no time. For example, 'Chenoa, what do you think we can do next?' You're bringing that person to the table. Two, you can advocate for other women and minorities when they're easily interrupted in a meeting. This takes no time. ‘I'm sorry you interrupted Dr. Duma. Dr. Duma?' So, that helps. The third thing is very important. You can connect people. So, one of the things is that I don't have every skill, so I advocate for my mentees and I serve as a connector. I have a mentee that is into bioinformatics. Lidia, that's above my head. I don't understand any of that. So, I was able to connect that person to people that do bioinformatics. And follow up. My last thing is to follow up with your people because they need you. Dr. Lidia Schapira: Well, I'm very glad that you're not an oil engineer in the Emirates. I'm sure your family is incredibly proud. I hope that you're happy where you are. We started a little bit about where you started, I'd like to end with your idea of where you imagine yourself 10 years from now? Dr. Narjust Duma: That is a question I don't have an answer prepared for. I guess my career development plans I think I want to be in a place where I look back and I can see that the careers of my mentees being successful. And I think that we measure my success based not on myself, I would measure my success in 10 years based on where my mentees are. And medical education is a more inclusive place. That will be the two things I want to see in 10 years. In the personal aspect, I don't know if we have art, don't know if we have those grants as long as my mentees are in a better place. Dr. Lidia Schapira: It has been such a pleasure to have this conversation. Thank you so much, Narjust. Dr. Narjust Duma: Thank you. Dr. Lidia Schapira: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. If you enjoyed what you heard today, don't forget to give us a rating or review on Apple podcasts or wherever you listen. While you're there, be sure to subscribe so you never miss an episode of JCO's Cancer Stories: The Art of Oncology podcast. This is just one of many of ASCO's podcasts. You can find all of the shows at podcast.asco.org. The purpose of this podcast is to educate and inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Narrator: My White Coat Doesn't Fit, by Narjust Duma, MD (10.1200/JCO.21.02601) There I was, crying once again all the way from the hospital's parking lot to my apartment, into the shower, and while trying to fall asleep. This had become the norm during my internal medicine residency. For years, I tried hard every day to be someone else in order to fit in. It started with off-hand comments like “Look at her red shoes,” “You are so colorful,” and “You are so Latina.” These later escalated to being interrupted during presentations with comments about my accent, being told that my medical school training in my home country was inferior to my US colleagues, and being assigned all Spanish-speaking patients because “They are your people.” Some of those comments and interactions were unintentionally harmful but led to feelings of isolation, and over time, I began to feel like an outsider. I came to the United States with the dream of becoming a physician investigator, leaving behind family, friends, and everything I knew. Over time, I felt pigeonholed into a constricting stereotype due to my ethnicity and accent. Back home, I was one of many, but in this new setting, I was one of a few, and in many instances, I was the only Latina in the room. I was raised by divorced physician parents in Venezuela; my childhood years were often spent in the clinic waiting for my mother to see that one last patient or outside the operating room waiting for my father to take me home. The hospital felt like my second home, growing up snacking on Graham crackers and drinking the infamous hospital's 1% orange juice. “She was raised in a hospital,” my mother used to say. Sadly, that feeling of being at home in the hospital changed during medical training as I felt isolated and like I did not belong, making me question my dream and the decision to come to the United States. I remember calling my family and crying as I asked “Why did I leave?” “Why didn't you stop me from coming here?” and seeking permission to return home. I felt like I was disappointing them as I was no longer the vivid, confident young woman who left her home country to pursue a bright future. I remember one colleague, Valerie (pseudonym), from Connecticut. Valerie attended medical school in the United States, did not have an accent, and was familiar with the American health care system. She understood how the senior resident-intern relationship functioned, a hierarchy that continually confused me. Over the following weeks, I took a closer look at how my colleagues and other hospital staff interacted with Valerie. I noticed that people did not comment about her clothing or personality. She was “normal” and fit in. I remember my senior resident asking me, “Narjust, why can't you be more like Valerie?” Ashamed, I mumbled that I would try and then ran to the bathroom to cry alone. That interaction was a turning point for me; I got the message. I needed to change; I needed to stop being who I was to be accepted. As the years passed, I kept key pieces of my personality hidden, hoping I could earn the respect of my colleagues. I refrained from sharing my personal stories as they were different from those around me. I grew up in a developing  country with a struggling economy and an even more challenging political situation. It was clear that we simply did not share similar experiences. When I sought help from my senior residents and attending physicians, my feelings were often minimized or invalidated. I was told that “residency is tough” and that I should “man up.” A few even suggested that I mold my personality to fit the box of what a resident physician was supposed to be. I slowly realized that my clothing changed from reds and pinks to greys and blacks because it was “more professional”; my outward appearance faded, as did my once bright sense of humor and affability. All these issues led to depression and an overwhelming sense of not belonging. A few months later, I was on antidepressants, but the crying in the shower continued. Rotation by rotation, I looked for a specialty that would help me feel like I belonged, and I found that in oncology. My mentor embraced my research ideas; my ethnic background or accent did not matter; we had the same goal, improving the care of our patients with cancer. I got to travel to national and international conferences, presented my research findings, and received a few awards along the way. From the outside, it looked like I was thriving; my mentor often called me a “Rising Star,” but in reality, I was still deeply depressed and trying to fit in every day. My career successes led me to believe that not being myself was the right thing to do. I felt isolated; I was trying to be someone I was not. A year later, I matched at my top choice oncology fellowship program; the program had the balance I was looking for between clinical care and research. This meant that I needed to move to the Midwest, further away from family, and to an area of the country with less racial and ethnic diversity. After 2 years on antidepressants and the 10 extra pounds that came with it, my white coat did not fit. My white coat felt like a costume that I would put on every day to fulfill the dream of being a doctor. I would often wake up in the middle of the night exhausted and depressed. I had all the responsibilities of a hematology/ oncology trainee and the additional full-time job of trying to fit in every day; I was using all my energy trying to be someone I was not. Regardless of my fears, I felt in my element when talking to patients and interacting with my cofellows. Despite having a different skin color and accent, I felt accepted by my patients with cancer. I remember when one of my patients requested to see me while in the emergency room because “Dr Duma just gets me.” She had been evaluated by the head of the department and attending physicians, but for her, I washer doctor. Tears of happiness accompanied my bus ride to see her; at that moment, I knew I was an oncologist, and oncology was the place I belonged. The next day, I realized that it was time to be myself: Narjust from Venezuela, a Latina oncologist who was her true self. I searched the bottom of my closet for the last piece of colorful clothing I had saved, a yellow dress. I put on that brightly colored dress for the first time in 5 years and finally felt comfortable being my authentic self; the yellow dress represented freedom and embraced the culture and colors I grew up seeing in my hometown. I finally understood that I brought something special to the table: my unique understanding of the challenges faced by Latinx patients and trainees, my advocacy skills, and my persistence to endure the academic grindstone. Psychotherapy was also an essential part of my recovery; I learned that happiness lived within me as a whole person—hiding my accent, cultural background, and past experiences was also hiding the light and joy inside me. Along the way, I found colleagues who faced the same challenges and validated that my experiences resulted from an environment that excludes the difference and values homogeneity. This route to self-discovery helped me find my calling to support others in situations similar to mine.3 I learned how to incorporate and celebrate my ethnicity in the world of academic oncology by teaching others the power of cultural humility, diversity, equity, and inclusion. Together with newfound friends and colleagues, I cofounded the #LatinasinMedicine Twitter community for those who face similar burdens during their training and careers. The #LatinasinMedicine community was created to share our stories, embrace our culture, and amplify other Latinas in medicine—to create connections that alleviate the sense of isolation that many of us have experienced and serve as role models to the next generation of Latinas in medicine. To help drive systemic change, I founded the Duma Laboratory, a research group that focuses on cancer health disparities and discrimination in medical education. Through research, the Duma Laboratory has shown that my experiences are not unique but rather an everyday reality for many international medical graduates and other under-represented groups in medicine. The Duma Laboratory has become a safe environment for many trainees; we seek to change how mentorship works for under-represented groups in oncology, with the hope that the isolation I felt during my training is not something that future physicians will ever have to endure. After years of depression and self-discovery, my white coat now fits. However, this is not your regular white coat; it has touches of color to embrace my heritage and the ancestors who paved the way for me to be here today. The face of medicine and oncology is changing around the world; young women of color are standing up to demonstrate the strength of our experiences and fuel the change that medical education needs. For all minority medical students, residents, fellows, and junior faculty, we belong in medicine even during those moments when our identity is tested. Through my journey, I learned that we can and must challenge the status quo. I hope to inspire others to join me in this path of advocating for diversity, equity, and inclusion because the time for change is now. I was finally free the moment I realized I could not be anyone else but myself, a proud Latina in medicine and oncology. Dr. Lidia Schapira: Welcome to JCO's Cancer Stories: The Art of Oncology, brought to you by the ASCO Podcast Network, which offers a range of educational and scientific content and enriching insight into the world of cancer care. You can find all of the shows including this one at podcast.asco.org. I'm your host, Lidia Shapira, Associate Editor for Art of Oncology and Professor of Medicine at Stanford. And with me today is Dr. Narjust Duma, Associate Director of the Cancer Care Equity Program and Medical Thoracic Oncologist at Dana Farber and an Assistant Professor at Harvard Medical School. We'll be discussing her Art of Oncology article, ‘My White Coat Doesn't Fit.' Our guest has a consulting or advisory role with AstraZeneca, Pfizer, NeoGenomics Laboratories, Janssen, Bristol Myers Squibb, Medarax, Merck, and Mirati. Our guest has also participated in a speaker's bureau for MJH Life Sciences. Narjust, welcome to our podcast. Dr. Narjust Duma: Thank you for the invitation and for letting us share our story. Dr. Lidia Schapira: It's lovely to have you. So, let's start with a bit of background. Your essay has so many powerful themes, the story of an immigrant in the US, the story of resilience, the story of aggression and bullying as a recipient of such during training, of overcoming this and finding not only meaning, but really being an advocate for a more inclusive and fair culture in the workplace. So, let's untangle all of these and start with your family. I was interested in reading that you're named after your two grandmothers, Narcisa and Justa. And this is how your parents, both physicians, Colombian and Dominican, gave you your name, and then you were raised in Venezuela. So, tell us a little bit about your family and the values that were passed on in your family. Dr. Narjust Duma: Thank you for asking. Having my two grandmothers names is something that my mother put a lot of effort into. She was a surgery resident with very limited time to decide to do that. And I don't have a middle name, which is quite unique in Latin America, most people in Latin America have one or two middle names. So, my mother did that to assure that I will use her piece of art, which is my first name. But little does she know that my grandmothers were going to be such an important part of my life, not only because they're in my name, but also because I am who I am thanks to them. So, the first part of my name, Narcisa was my grandma who raised me and she gave me the superpower of reading and disconnecting. So, I'm able to read no matter where I am and how loud it can be and disconnect with the world. So, it is often that my assistants need to knock on my door two or three times so, I don't like being scared because I'm able to travel away. That was also very unique because you will find me in the basketball games from high school or other activities with a book because I was able to block that noise. But it also makes very uncomfortable situations for my friends that find it embarrassing that I will pull a book in the basketball game. And as I grow, thanks to the influence of my grandmothers, I always have these, how can I say, mixed situation, in which they were very old school grandmothers with old school habits and values, and how I'm able to modify that. My grandma told me that you can be a feminist, but you still take care of your house. You can still, you know, cook. And that taught me that you don't have to pick a side, there is no one stereotype for one or another. Because as my mother being a single mother and a surgeon, my parents divorced early on, told me, ‘Yes, I can be the doctor but I can also be the person that has more than a career that's able to have hobbies.' I love cooking, and when I'm stressed, I cook. So, I had a grant deadline a few weeks ago and I cooked so much that there was food for days. So, having the names of my grandmothers is very important because I have their values, but I have modified them to the current times. Dr. Lidia Schapira: Let me ask a little bit about reading. I often ask the guests of this podcast who have written and therefore I know enjoy reading and writing, what their favorite books are or what is currently on their night table. But I'm going to ask you a second question and that is what languages do you read in? Dr. Narjust Duma: I prefer to read in Spanish. I found that books in Spanish, even if it's a book that originated in English, have these romantic characteristics. And I often tell my editors, ‘Just take into account that I think in Spanish, and write in English'. Because I grew up with Gabrielle Garcia Marquez, and when he describes a street, that's a page of the little things that he describes. So, that's how I write and that's how I read in a very romantic, elaborate way. The aspects of realistic imagism, which is my favorite genre in literature, and there are so many Latin American and South American writers that I don't think that I am going to run out. And when I run out, I reread the same books. I have read all of Gabrielle Garcia Marquez's books twice, and Borges, too. It's the type of stories that allows you to submerge yourself and you imagine yourself wearing those Victorian dresses in the heat of a Colombian street, as you try to understand if, you know, Love in the Time of Cholera, if they were more in love with being in love or what it was happening in the story. And that just gives me happiness on a Sunday morning. Dr. Lidia Schapira: That's beautiful. I must confess that reading Borges is not easy. So, I totally admire the fact that you have managed to read all of his work. And I think that you're absolutely right, that magical realism is a genre that is incredibly fresh, and perhaps for the work that we do in oncology, it's a wonderful antidote in a way to some of the realities, the very harsh realities that we deal with on a daily basis. So, let me ask you a little bit about growing up in Venezuela in the 80s, 90s, early aughts. That must have been difficult. Tell us a little bit about that, and your choice of attending medical school. Dr. Narjust Duma: So, growing up in Venezuela, with a Colombian mother, it was quite a unique perspective because she was very attached to her Colombian roots. So, a lot of the things that happened in the house were very Colombian, but I was in Venezuela. So, it was a unique characteristic of being from a country but your family is not from there. So, my parents are not from Venezuela, my grandparents either, and I'm Venezuelan because I was born and raised there. So, that brought a unique perspective, right? The music that I played in my house was Colombian music, not Venezuelan music. So, my family migrated from Colombia to Venezuela due to the challenges in the early 80s with violence and the Medellin, due to the drug cartels. So, we moved to Venezuela for a better future. And growing up in the first years, Venezuela was in a very good position. Oil was at the highest prices. Economically, the country was doing well. I remember, in my early years, the dollar and the bolivar had the same price. But then little by little I saw how my country deteriorated, and it was very heartbreaking. From a place where the shells were full of food to a place now when there is no food, and you go to the supermarket, and many of them are close. And now you're only limited to buying certain things. And you used to use your federal ID that has an electronic tracking on how much you can buy because of socialism. So, you're only allowed to buy two kilograms of rice per month, for example, you're only allowed to buy this number of plantains. So, every time I go home, because Venezuela is always going to be my home, it doesn't matter where I am., I see how my country has lost pieces by pieces, which is quite very hard because I had a very good childhood. I had a unique childhood because I was raised in hospitals. But I had a childhood in which I will play with my friends across the street. We were not worried about being kidnapped. We were not worried about being robbed. That's one thing that children in Venezuela cannot do right now. Children of doctors – there's a higher risk of being kidnapped as a kid right now if your father is a doctor or your mother. So, my childhood wasn't like that. When I teach my students or talk to my mentees, I'm often selling my country, and saying that's not what it used to be. That's not where I grew up. But every year I saw how it no longer is where I grew up. That place doesn't exist, and sometimes, Lidia, I feel like my imagination may have to fill it out with more good things. But I think it was a good childhood. It's just that nobody in Venezuela is experiencing what I experienced as a kid. Dr. Lidia Schapira: So, both parents were doctors and you chose to study medicine, was this just right out of high school? Dr. Narjust Duma: Even before high school, I found myself very connected to patients. So, since I turned 15, my father would give his secretary a month of vacation because that's the month that we fill in. So, I was the secretary for a month every summer since I was 15 until I was 20. That early exposure allowed me to like get to know these patients and they know I was the daughter, but I was also the secretary. So, I really cherished that. Growing up in my household, we're a house of service. So, our love language is acts of service. That's how pretty much my grandmas and my parents were. So, in order to be a physician, that's the ultimate act of service. I have wanted to be a doctor since I was 11. I think my mother face horrible gender harassment and sexual harassment as a female in the surgery in the early 80s, that she tried to push me away from medicine. Early on, when I was 11, or 12, being an oil engineer in Venezuela was the career that everybody should have, right? Like, people were going to the Emirates and moving to different parts of the world and were doing wonderful. So, my mother, based on her experience in the 80s, was pushing me away from it. She's like, ‘You can do other things.' My father always stayed in the back and said, ‘You can do what you want.' This is how our parents' experiences affect our future. If I wouldn't be this stubborn, I would probably be an oil engineer today, and I wouldn't be talking to you. Dr. Lidia Schapira: So, you went to medical school, and then after you graduated, what did you decide to do? Because when I look at what we know about the history there is I think you graduated in '09, and then the story that you write about sort of begins in '16 when you come to New Jersey to do training in the US, but what happened between '09 and '16? Dr. Narjust Duma: I started residency in 2013. '16 was my fellowship. So, going to medical school was one of the hardest decisions I made because right in 2003 and 2004 was a coup in Venezuela where part of the opposition took over the country for three days, and then the President of the time came back and the country really significantly destabilized after that coup. Most schools were closed. Entire private industries were closed for a month. And I think for some people, it's hard to understand what happened. Everything closed for a month, McDonald's was closed for a month. There was no Coke because a Coke company was not producing. Everything was closed. The country was just paralyzed. So, my mother and I, and my family, my father, took into account that we didn't know when medical school would resume in Venezuela. We didn't know if the schools would ever open again. I decided to apply for a scholarship and I left Venezuela at the age of 17 to go to the Dominican Republic for medical school. Very early on, I noticed that I was going to be a foreigner wherever I go because I left home. And since then, I think I became very resilient because I was 17 and I needed to move forward. So, that is what happened in 2004. I left everything I knew. I left for the Dominican. I do have family in the Dominican, but it was very hard because even if you speak the same language, the cultures are very different. And then I went to medical school in the Dominican and when I was in the Dominican Republic, I realized I really wanted to do science and be an advocate and focus on vulnerable populations with cancer. So, then I made the decision to come to the United States, I did a year of a research fellowship at Fred Hutchinson, and then I went to residency in 2013. Dr. Lidia Schapira: I see. And that's when you went to New Jersey, far away from home. And as you tell the story, the experience was awful, in part because of the unkindness and aggression, not only microaggression but outright bullying that you experienced. In reading the essay, my impression was that the bullying was mostly on two accounts. One was gender. The other was the fact that you were different. In this particular case, it was the ethnicity as a Latin or Hispanic woman. Tell us a little bit about that so we can understand that. Dr. Narjust Duma: I think what happened is that perfect example of intersectionality because we are now the result of one experience, we're the result of multiple identities. So many woman have faced gender inequalities in medicine, but when you are from a marginalized group, those inequalities multiply. I have an accent and clearly a different skin color. I grew up in a family in which you were encouraged to be your true self. My grandmothers and my mother said, ‘You never want to be the quiet woman in the corner because the quiet woman never generates change.' That's what they said, and I bet there are some who do. But that intersection of my identities was very challenging because I was seen as inferior just for being a woman and then you multiply being one of the few Latinas you are seen like you are less just because you are - it doesn't matter how many degrees or papers or grants you had done and all, I was the most productive research resident in my residency for two years in a row - but I would still be judged by my identity and not what I have produced, or what I do on my patients' experiences, which were great – the feedback from my patients. It's just because I was the different one. Dr. Lidia Schapira: When I hear your story about your origins, it seems to me that you came from a very capable loving family, and they basically told you to go conquer the world, and you did. And then you arrive and you're a productive successful resident, and yet, you are marginalized, as you say. People are really aggressive. Now that you've had some years that have passed, if you think back, what advice would you give that young Narjust? Dr. Narjust Duma: My number one advice, would be that, I will tell myself is that I belong, in many instances, I feel like I didn't belong. It makes me question all the decisions to that day because when you're doing a presentation, and I still remember like today, and you're interrupted by someone, just for them to make a comment about your accent, it really brings everything down to your core, like, 'Is my presentation not accurate? Is the information not all right? And why am I here? Why did I left everything I love to be treated like this?' Dr. Lidia Schapira: Of course. So, from New Jersey, you write in your essay that you really discover your passion for cancer research, and you land in a fellowship with a mentor who is encouraging, and things begin to change for you. Can you tell us a little bit about that phase of your training in your life where you slowly begin to find your voice in the state, that also where you crash, where you find yourself so vulnerable that things really fall apart? Dr. Narjust Duma: So, when I was a resident, I didn't know exactly - I was interested in oncology, but I wasn't sure if it was for me. So, Dr. Martin Gutierrez at Rutgers in Hackensack is the person who I cold emailed and said, ‘I'm interested in studying gastric cancer in Hispanic patients because I think that patients in the clinic are so young.' He, without knowing me or having any idea, he trusted me. We still meet. He still follows up with me. He encouraged me. I think him being a Latino made the experience better, too, because I didn't have to explain my experience to him. I didn't have to explain that. He understood because he went through the same things. And he's like, ‘I got you. Let's follow what you want to do.' He embraced who I was, and how I put who I was into my research. And thanks to Dr. Gutierrez, I'm at the Mayo Clinic as an international medical grad. So, finding a place in which my ideas were embraced was very important to allow me to stay in medicine because, Lidia, I can tell you several times, I decided to leave. I was very committed to finding something else to do or just being a researcher and leaving clinical medicine behind. So, when I went to Mayo, I still followed with that mentor, but I already knew what I wanted to do. I wanted to do cancer health disparities. I wanted to do inclusion and diversity. And that allowed me to develop the career I have now and is having that pathway because I, with my strong personality and everything else, faced this discrimination, and I can imagine for other trainees that may still be facing that or will face that in the future. So, I use the negative aspects to find my calling and do many things I have done after that. Dr. Lidia Schapira: Speaks to your strengths and your determination. Let's talk a little bit about the people who may also feel different but whose differences may not be so apparent. How do you now as an emerging leader, and as a mentor, make sure that you create an inclusive and safe environment for your younger colleagues and your mentees? Dr. Narjust Duma: One of the things that resulted was the founding of the Duma Lab, which is a research group that focuses on cancer, health disparities, social justice as a general, and inclusion in medical education. So, one of the things that I practice every day is cultural humility. I continue to read and remember the principles. I have them as the background on my computer at work. The number one principle in lifelong learning is that we learn from everyone and that we don't know everything and other people's cultures, and subculture, we learn their culture is rich. So, in every meeting, I remind the team of the principles of cultural humility when somebody is joining the lab. I have one-on-one meetings, and I provide information and videos about cultural humility because the lab has been created as an environment that's safe. We have a WhatsApp group that is now kind of famous - it's called The Daily Serotonin. The majority of the members of the lab are part of marginalized groups, not only by gender but race, religion, sexual and gender orientation. So, we created this group to share good and bads, and we provide support. So, a few weeks ago, a patient made reference to one of their lab member's body, the patient was being examined and that was quite inappropriate. The member debriefed with the group and we all provided insights on how she had responded, and how she should respond in the future. That's not only learning from the person that brought the scenario but anybody else feels empowered to stop those microaggressions and stop those inappropriate behaviors that woman particularly face during clinical care. So, cultural humility, and having this WhatsApp group that provides a place where, first, I remind everybody that's confidential, and a place in which anything is shared has been very successful to create inclusivity in the group. Dr. Lidia Schapira: You have such energy and I'm amazed by all of the things that you can do and how you have used social connection as a way of bringing people up. So, can you give our listeners perhaps some tips for how you view creating a flatter culture, one with fewer hierarchies that makes it safer for learners and for those who are practicing oncology? What are three quick things that all of us can do in our work starting this afternoon? Dr. Narjust Duma: The concept is that we all can be allies. And being an ally doesn't take a lot of time or money because people think that being an ally is a full-time job, it is not. So, the first one tip will be to bring people with you. Your success is not only yours. It's a success of your mentees. It's a success of your colleagues. So, don't see your success as my badge on my shoulder. It's the badge that goes on everyone. So, bring people in, leave the door open, not only bring them but leave the door open because when you do it helps the next generation. Two, little things make a difference. I'm going to give you three phrases that I use all the time. When you think somebody has been marginalized in a meeting, bring them up, it takes no time. For example, 'Chenoa, what do you think we can do next?' You're bringing that person to the table. Two, you can advocate for other women and minorities when they're easily interrupted in a meeting. This takes no time. ‘I'm sorry you interrupted Dr. Duma. Dr. Duma?' So, that helps. The third thing is very important. You can connect people. So, one of the things is that I don't have every skill, so I advocate for my mentees and I serve as a connector. I have a mentee that is into bioinformatics. Lidia, that's above my head. I don't understand any of that. So, I was able to connect that person to people that do bioinformatics. And follow up. My last thing is to follow up with your people because they need you. Dr. Lidia Schapira: Well, I'm very glad that you're not an oil engineer in the Emirates. I'm sure your family is incredibly proud. I hope that you're happy where you are. We started a little bit about where you started, I'd like to end with your idea of where you imagine yourself 10 years from now? Dr. Narjust Duma: That is a question I don't have an answer prepared for. I guess my career development plans I think I want to be in a place where I look back and I can see that the careers of my mentees being successful. And I think that we measure my success based not on myself, I would measure my success in 10 years based on where my mentees are. And medical education is a more inclusive place. That will be the two things I want to see in 10 years. In the personal aspect, I don't know if we have art, don't know if we have those grants as long as my mentees are in a better place. Dr. Lidia Schapira: It has been such a pleasure to have this conversation. Thank you so much, Narjust. Dr. Narjust Duma: Thank you. Dr. Lidia Schapira: Until next time, thank you for listening to this JCO's Cancer Stories: The Art of Oncology podcast. 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Criminal barristers strike over pay, Cross Question and should the PM reverse cuts to the military? Joining Iain Dale on Cross Question this evening are Labour's leader in the House of Lords Baroness (Angela) Smith, Conservative MP Peter Bone, Leader of the True and Fair Party Gina Miller and Gordon Rayner, Associate Editor for The Daily Telegraph.

Joining Iain Dale on Cross Question this evening are Labour's leader in the House of Lords Baroness (Angela) Smith, Conservative MP Peter Bone, Leader of the True and Fair Party Gina Miller and Gordon Rayner, Associate Editor for The Daily Telegraph.

------------------Support the channel------------ Patreon: https://www.patreon.com/thedissenter PayPal: paypal.me/thedissenter PayPal Subscription 1 Dollar: https://tinyurl.com/yb3acuuy PayPal Subscription 3 Dollars: https://tinyurl.com/ybn6bg9l PayPal Subscription 5 Dollars: https://tinyurl.com/ycmr9gpz PayPal Subscription 10 Dollars: https://tinyurl.com/y9r3fc9m PayPal Subscription 20 Dollars: https://tinyurl.com/y95uvkao This show is sponsored by Enlites, Learning & Development done differently. Check the website here: http://enlites.com/ Dr. Mathias Clasen is associate professor in literature and media at Aarhus University. He is the Director of the Recreational Fear Lab, and Associate Editor of Evolutionary Studies in Imaginative Culture. He studies horror fiction, and is the author of Why Horror Seduces, and A Very Nervous Person's Guide to Horror Movies. In this episode, we talk about horror from an evolutionary perspective. We discuss horror from an evolutionary perspective, and the sociocultural factors behind it. We talk about the traits of monsters, and the different types of horror. We talk about slasher movies, and apocalyptic stories. We get into human universals in horror, what makes for popular monsters, and what makes some films “so-bad-they're-good”. We discuss the relationship between personality traits and art appreciation. We discuss a study on the relationship between being morbidly curious and more psychologically resilient during the COVID-19 pandemic. Finally, we talk about what an evolutionary approach adds to the picture in literary studies. -- A HUGE THANK YOU TO MY PATRONS/SUPPORTERS: KARIN LIETZCKE, ANN BLANCHETTE, PER HELGE LARSEN, LAU GUERREIRO, JERRY MULLER, HANS FREDRIK SUNDE, BERNARDO SEIXAS, HERBERT GINTIS, RUTGER VOS, RICARDO VLADIMIRO, CRAIG HEALY, OLAF ALEX, PHILIP KURIAN, JONATHAN VISSER, JAKOB KLINKBY, ADAM KESSEL, MATTHEW WHITINGBIRD, ARNAUD WOLFF, TIM HOLLOSY, HENRIK AHLENIUS, JOHN CONNORS, PAULINA BARREN, FILIP FORS CONNOLLY, DAN DEMETRIOU, ROBERT WINDHAGER, RUI INACIO, ARTHUR KOH, ZOOP, MARCO NEVES, COLIN HOLBROOK, SUSAN PINKER, PABLO SANTURBANO, SIMON COLUMBUS, PHIL KAVANAGH, JORGE ESPINHA, CORY CLARK, MARK BLYTH, ROBERTO INGUANZO, MIKKEL STORMYR, ERIC NEURMANN, SAMUEL ANDREEFF, FRANCIS FORDE, TIAGO NUNES, BERNARD HUGUENEY, ALEXANDER DANNBAUER, FERGAL CUSSEN, YEVHEN BODRENKO, HAL HERZOG, NUNO MACHADO, DON ROSS, JONATHAN LEIBRANT, JOÃO LINHARES, OZLEM BULUT, NATHAN NGUYEN, STANTON T, SAMUEL CORREA, ERIK HAINES, MARK SMITH, J.W., JOÃO EIRA, TOM HUMMEL, SARDUS FRANCE, DAVID SLOAN WILSON, YACILA DEZA-ARAUJO, IDAN SOLON, ROMAIN ROCH, DMITRY GRIGORYEV, TOM ROTH, DIEGO LONDOÑO CORREA, YANICK PUNTER, ADANER USMANI, CHARLOTTE BLEASE, NICOLE BARBARO, ADAM HUNT, PAWEL OSTASZEWSKI, AL ORTIZ, NELLEKE BAK, KATHRINE AND PATRICK TOBIN, GUY MADISON, GARY G HELLMANN, SAIMA AFZAL, ADRIAN JAEGGI, NICK GOLDEN, PAULO TOLENTINO, JOÃO BARBOSA, JULIAN PRICE, EDWARD HALL, HEDIN BRØNNER, DOUGLAS P. FRY, FRANCA BORTOLOTTI, GABRIEL PONS CORTÈS, URSULA LITZCKE, DENISE COOK, SCOTT, ZACHARY FISH, TIM DUFFY, TRADERINNYC, AND MAX BEILBY! A SPECIAL THANKS TO MY PRODUCERS, YZAR WEHBE, JIM FRANK, ŁUKASZ STAFINIAK, IAN GILLIGAN, LUIS CAYETANO, TOM VANEGDOM, CURTIS DIXON, BENEDIKT MUELLER, VEGA GIDEY, THOMAS TRUMBLE, AND NUNO ELDER! AND TO MY EXECUTIVE PRODUCERS, MICHAL RUSIECKI, ROSEY, JAMES PRATT, MATTHEW LAVENDER, SERGIU CODREANU, AND BOGDAN KANIVETS!

This week's episode features an interview with Anna Kijas, Head of Lilly Music Library at Tufts University, and Quinn Dombrowski, Academic Technology Specialist in the Division of Literatures, Cultures, and Languages, and in the Library at Stanford University. The interview was conducted by Leah Hinds, Executive Director of the Charleston Hub and Tom Gilson, Associate Editor of Against the Grain. Anna and Quinn are two of the three co-founders of the SUCHO initiative: Saving Ukrainian Cultural Heritage Online. SUCHO is a group of more than 1,300 cultural heritage professionals – librarians, archivists, researchers, programmers – working together to identify and archive at-risk sites, digital content, and data in Ukrainian cultural heritage institutions while the country is under attack. Join us to hear about the origins of the project, recent updates, and plans moving forward. Links: SUCHO: https://www.sucho.org/ SUCHO Gallery: https://gallery.sucho.org/ Nimble Tents and Bunkers: Safeguarding Digital Cultural Heritage - A presentation by Quinn Dombrowski at the 2022 Fiesole Retreat: https://youtu.be/woOwXva0Yfs In the News: Ukraine - A panel presentation including Quinn Dombrowski at the 2022 Charleston In Between virtual conference: https://youtu.be/_HhbYRqHAqA Social Media: Twitter: Quinn Dombrowski: @quinnanya Anna Kijas: @anna_kijas SUCHO: @sucho_org

Kevin Maguire, Associate Editor, The Daily Mirror

The Russia-Ukraine conflict is causing wide ranging impact across commodity markets and the political landscape, with short and longer-term implications for China. Join Tom Reed, VP of China, Crude and Oil Products, Kevin Foster, Editorial Manager, Asia and Haik Gugarats, Associate Editor and resident expert on US and international energy policy and politics as they discuss and answer key questions including: What the conflict portends for China in economic and political terms Whether the liberal democratic world order is moribund, fractured, and systemically weak to China's advantage - or will it in fact emerge stronger to China's disadvantage What is the impact on China's near-term security environment - how does China view a reinvigorated West and discussion of Taiwan? Does China stand to benefit from Russia refocusing energy exports towards Asia - can China can just wait on the sidelines, mopping up all the Russian oil that no one else will buy How will the west/Russia/China relationship evolve?

The Roundtable Panel: a daily open discussion of issues in the news and beyond. Today's panelists are WAMC's Alan Chartock, Political consultant and lobbyist Libby Post, Albany Law School professor and Director of the Immigration Law Clinic Sarah Rogerson, and former Associate Editor of The Times Union Mike Spain.

This lecture was given on April 5, 2022 at the University of North Carolina, Chapel Hill. For more information on upcoming events, please visit our website at www.thomisticinstitute.org. About the speaker: Dr. Chad Pecknold received his PhD from the University of Cambridge (UK) in 2005 and since 2008 he has been a Professor of Historical & Systematic Theology in the School of Theology at The Catholic University of America in Washington, DC. Pecknold has authored or edited five books, each relating the thought of St. Augustine to modern philosophical and theological reasoning, including, Transforming Postliberal Theology (2005), The Promise of Scriptural Reasoning (2006), Time, Liturgy, and the Politics of Redemption (2008), Christianity and Politics (2010) and the T&T Clark Companion to Augustine and Modern Theology (2014). He teaches in the areas of fundamental theology, Christian anthropology, and political theology. In fundamental theology he brings Augustine's rejection of skepticism and embrace of metaphysical accounts of causality to bear on modern skepticism and metaphysical agnosticism. In Christian anthropology, Pecknold focuses especially on 20th century nature-grace disputes, and the relationship between Augustinian and Thomistic distinctions between natural and supernatural orders. In political theology, Pecknold is principally concerned with close readings of Augustine's masterwork, The City of God, as a fundamental and transcendent vision that inspires, and has the power to critique and correct, the dynamics of Western civilization. Professor Pecknold is also a frequent contributor to debates in the public square. He writes weekly columns as the U.S. Contributing Editor to The Catholic Herald, one of the oldest Catholic magazines in the world, and also writes regularly for other publications, such as First Things, Wall Street Journal, the New York Post, and National Review on a range of timely topics related to the importance and impact of Church teaching on social and political questions. Professor Pecknold is frequently sought after for his opinion on current events, and has been quoted in hundreds of news outlets around the world such as The New York Times, The Wall Street Journal and The Washington Post. He has appeared as an invited guest on radio and television shows from NPR's “All Things Considered” to EWTN News Nightly offering his clear analysis and expert opinion on the Catholic Church, the papacy, and the relationship between the Church and politics in American culture. Pecknold serves on the Editorial Board of The Catholic University of America Press, and also co-edits with Fr. Thomas Joseph White, O.P., their celebrated Sacra Doctrina series. He serves as an Associate Editor for the English Edition of the international Thomistic journal of theology, Nova et Vetera. He serves as Chairman of the Academy of Catholic Theology, and has the honor of serving as a Fellow of the Institute for Human Ecology at Catholic University. Dr Pecknold is currently writing a book on a Catholic understanding of Augustine's City of God.

Host Luisa Lyons chats with composer, producer, and lawyer Jay Kuo all about the Broadway musical Allegiance. Topics include how Sunday in the Park with George inspired the filming of Allegiance, the amazing happenstance of meeting George Takei and how Jay came to write George's story, why producers should get behind filming their shows, and more! *Editor's Note* We had some difficulties with the audio, but we hope the quality of the content will make this episode a worthwhile listen!Learn more about Allegiance and find where you can stream it at Filmed Live Musicals. Watch clips from the 2021 Japanese-language Horipro Stage production. Jay Kuo is the CEO of The Social Edge, a digital publishing and social media company based in New York City. Jay is head of "Team Takei," managing engagement with Star Trek legend George Takei's 23 million Facebook, Instagram and Twitter followers. Jay is also the composer, lyricist and co-librettist for the Broadway musical Allegiance as well as the librettist on the Broadway-bound Indigo, the first musical to feature and star a teenage girl on the autism spectrum. Jay is also a two-time Tony-winning co-producer for the hit musical Hadestown and the critically-acclaimed, epic play The Inheritance.Apart from his Broadway and social media work, Jay is a published author, an avid political blogger, and a partner in Gaingels LLC, the nation's largest private investment syndicate. While he worked as an attorney, Jay was an appellate litigator admitted to practice before the Ninth Circuit and U.S. Supreme Court.Jay has served on the boards of the Northern California ACLU and the Bay Area Lawyers Individual Freedom, and he argued the first Ninth Circuit challenge to the military's “Don't Ask, Don't Tell” policy. Jay currently serves on the national board of the Human Rights Campaign, the nation's oldest and largest civil rights organization serving the LGBTQ+ community.Jay holds an A.B. in Political Science from Stanford University and a law degree from U.C. Berkeley where he served as student body president, Associate Editor of the California Law Review, and co-founder and Managing Editor of the Asian Law Journal."Follow Jay on Facebook and Twitter. Filmed Live Musicals is the most comprehensive online searchable database for musicals that have been filmed live on stage. Visit www.filmedlivemusicals.com to learn more. Follow us on Facebook and Twitter. You can also support the site at Patreon. Patrons get early access to content, bonus content in the weekly newsletter, and exclusive access to the streaming calendar, no matter how much you pledge. Become a Patron today! Filmed Live Musicals is created by Luisa Lyons. Luisa is an Australian actor, writer, and musician. She holds a Masters in Music Theatre from London's Royal Central School of Speech and Drama and now lives, works, and plays in New York. Learn more at www.luisalyons.com or follow on Twitter, Support the show

Michael speaks to Jamie Walker, Associate Editor the Australian newspaper, about disgruntled Queensland MPs and high-level public servants describing Annastacia Palaszczuk as the part-time Premier – more interested in treading the red carpet than knuckling down to the grind of governing. “Annastacia Palaszczuk's premiership in Queensland has entered a dangerous twilight zone. Her grip on the levers of power, never strong, has slipped to the point that the seven-year-old Labor government is drifting. The coming weeks will dictate whether the situation is retrievable”, writes Mr Walker. See omnystudio.com/listener for privacy information.

Did Thabo Mbeki set the table for state capture? Mark Gevisser's prize-winning Thabo Mbeki: A Dream Deferred has just been published in an updated and revised edition, and Ferial Haffajee tackles him on Mbeki's legacy. Mark Gevisser is one of South Africa's foremost writers. He is the author of five works of non-fiction, including Thabo Mbeki: A Dream Deferred, Lost and Found in Johannesburg and The Pink Line (2020). His journalism has been widely published in South Africa and he frequently writes for the Guardian, The New York Times, Granta, and many other publications. In 2022 a brand new edition of Thabo Mbeki: A Dream Deferred will be released, including a detailed epilogue exploring Mbeki's legacy since he fell from power 15 years ago. Mark has been a Writing Fellow at the University of Pretoria and at the Wits Institute for Social and Economic Research (WISER). Since 2018, he has been a judge on the Gerald Kraak Award for writing on gender, human rights and sexuality in Africa. He lives in Cape Town. Ferial Haffajee is a recipient of the 2014 International Press Freedom Award, Ferial Haffajee is one of South Africa's most trusted and respected journalists. She is known for her clear-cut political analysis and her unwavering dedication to the truth. Haffajee has worked in numerous print and online newsrooms including holding the positions of editor at City Press and the Mail and Guardian before joining Daily Maverick as Associate Editor. Her new book Days of Zondo will be published by Maverick 451 in 2022.

This week on the podcast MPs are struggling to pin universities' problems on the right body - where does responsibility lie when things go wrong? There's also the next phase of our research on belonging with Pearson, a fall (in England) to dramatic new lows for student financial support, and the free speech bill clears the commons. Plus we listen in as George Freeman and Ottoline Leyser appear at the Commons Science and Technology Committee, and hot off the press there's some new graduates outcomes figures out from HESA. With Ben Elger, Chief Executive of the Office of the Independent Adjudicator, Selena Bolingbroke, Director of Sighthound Consultancy, Sunday Blake, Associate Editor at Wonkhe, and presented by Mark Leach, Editor in Chief at Wonkhe.

Grace and Alvina welcome special guest Ruqayyah Daud, Associate Editor at Little, Brown Books for Young Readers. They discuss what is entailed in terms of assisting and how things have changed since Alvina was an assistant. See complete show notes at www.bookfriendsforever.com. Click here to become a Patreon member: https://www.patreon.com/Bookfriendsforever1.

Can banks and investors shift to climate-friendly business in a way that will have a global impact on slashing greenhouse gases? This panel discussion at Davos 2022 goes into the details of this complex but crucial part of the fight against climate catastrophe. Speakers: Mark Carney, UN Special Envoy for Climate Action and Finance Anne Richards, Chief Executive Officer, Fidelity International Makhtar Diop, Managing Director, International Finance Corporation (IFC) Celine Herweijer, Group Chief Sustainability Officer, HSBC David Schwimmer, Chief Executive Officer, London Stock Exchange Group Moderator: Martin Wolf, Associate Editor and Chief Economics Commentator, The Financial Times

Editor's Summary by by Anne Cappola, MD, Associate Editor of JAMA, the Journal of the American Medical Association, for the June 14, 2022 issue.

The Roundtable Panel: a daily open discussion of issues in the news and beyond. Today's panelists are WAMC's Alan Chartock, RPI Adjunct professor and investigative journalist Rosemary Armao, Diplomat in residence at Bard College Frederic Hof, and former Associate Editor of The Times Union, Mike Spain.

Ellie Saklatvala, Global Editor, Argus Metals International is joined by Thomas Kavanagh, Associate Editor, and Will Talbot, Senior Analyst, to discuss the competitive landscape of battery chemicals and introduce the new cathode price assessments from Argus. 

Today we have our first of two episodes featuring Brooke Masters, the Chief Business Commentator and Associate Editor of the Financial Times. (Repeat)

In this episode I speak to Prof Mark Beauchamp. Mark is a Professor at The University of British Colombia. His research primarily focuses on the social psychology of groups within health, exercise, and sport settings and has been published in a variety of journals such as the Annals of Behavioral Medicine, Journal of Sport and Exercise Psychology, and the American Journal of Preventive Medicine. Mark is a Chartered Psychologist, Associate Fellow of the British Psychological Society (BPS), Associate Editor for the 'Scandinavian Journal of Medicine and Science in Sports', and he is on the editorial boards for a number of other journals including 'Sport, Exercise and Performance Psychology'​ (APA), and the 'Journal of Sport and Exercise Psychology'. Mark characterises his work as the psychology of human thriving.  Mark and I discuss a brilliant paper he has written along with Alan Kingstone and Nikos Ntoumanis entitled “Psychology of Athletic Endeavor” which examines the (high quality) evidence that allows athletes to succeed, to thrive and to perform well. You can find the pre-print version of the paper on ResearchGate https://www.researchgate.net/publication/360181284_Psychology_of_athletic_endeavor

In this episode, we are joined by Bruce R. Sutherland, the Associate Editor of Physical Review Fluids, and a Professor in the Departments of Physics and Earth & Atmospheric Sciences at The University of Alberta.  As someone who is deeply interested in environmental concerns, Mr. Sutherland employs “a combination of laboratory experiments, numerical simulations, and mathematical modeling to examine atmosphere-ocean, environmental and industrial fluid flows.” Most recently, he has focused his innovative research methods on the world of microplastics . . . Click play to learn about: Mr. Sutherland's particular microplastic research. How modeling microplastics can tell us more about how they are created. How toxins and microplastics interact with each other.  Offer: This episode is sponsored by Organifi. To receive a 20% Off on your order, use the coupon code GENIUS at checkout. Go to https://www.organifishop.com/pages/genius/ to shop now! What can we do about the mysterious problem of microplastic contamination? Bruce Sutherland is determined to find out.  To learn more about Bruce Sutherland and his work, visit sites.ualberta.ca and www.birs.ca Episode also available on Apple Podcast: http://apple.co/30PvU9C

GUEST OVERVIEW: Alan Tonelson is RealityChek's founder and voice. He's finished more than 30 years of senior positions at leading US think tanks and publications. He's written and lectured on trade, manufacturing, and their interaction with the rest of the economics world, plus national security issues, for the U.S. Business and Industry Council and the Economic Strategy Institute. He's served as Associate Editor of FOREIGN POLICY magazine. He's written The Race to Bottom. His articles and reviews have appeared in Foreign Affairs, Atlantic, Harper's, NYT, WaPo, New Republic, BloombergView, Marketwatch.com, The Hill, FOREIGN POLICY, and many other leading national publications and news sites. He's appeared on CNBC, BloombergTV, CNN, and John Batchelor's show. He's testified before numerous Congressional committees and U.S. government commissions, and lectured in fora ranging from the National Defense Univesity and the State Department's Foreign Service Institute to numerous world affairs councils and labor and business groups in the USA, along with government and academic institutions in the UK, Germany, China, and Japan.

This week on the podcast the 2022 Student Academic Experience Survey is out - has the student experience bounced back post-pandemic? Plus we discover that free speech is alive and well on UK campuses, we think big about microcredentials and there's some interesting new data out on innovation and outreach. With Marian Hilditch, academic registrar at the University of Bradford, Amatey Doku, consultant with Moorhouse, David Kernohan, Associate Editor at Wonkhe and presented by Jim Dickinson, Associate Editor at Wonkhe.

In light of Justice Alito's leaked draft opinion suggesting the court is poised to overturn Roe v. Wade, what are the potential health and legal implications of the Supreme Court decision in Dobbs vs. Jackson Women's Health Organization? What will the health status of US women and of families look like? What is public health already doing to limit the direst consequences? My guests are Dr Herminia Palacio (Guttmacher Institute, NYC), Prof Farzana Kapadia (NYU), Deputy Editor, AJPH, Prof Wendy E. Parmet (Northeastern), Associate Editor, AJPH

What's your earliest memory about money? For me, it's the anxiety I felt as a boy, sitting in my father's apartment, waiting for his unemployment check to hit our mailbox. He suffered at times from anxiety and depression, which wasn't understood very well back then, so steady work was always a challenge for him. I remember buying him lunch at a malt shop once I started working -- not because I was trying to show how grown up, I was, but because we really needed the five dollars.  Those formative experiences drove me to a career that taught me how to take care of my own finances and help other people do the same. After nearly 30 years in financial services, I'm positive that there's a real connection between money memories, good financial habits, and mental health that influences our relationships, our emotions, our careers, and our progress towards a safe and secure retirement. To help me explore these important intersections, I'm thrilled to welcome Dr. Megan McCoy to today's episode. Dr. McCoy is a licensed Marriage and Family Therapist and a Certified Financial Therapist-I. At Kansas State University, she's a Professor of Practice and Director of the Financial Planning Masters Program and key faculty in the Financial Therapy Certificate Program. Dr. McCoy is also an Executive Board member for the Financial Therapy Association and the Associate Editor of the Journal of Financial Therapy. 

Dr. James DiNicolantonio, known as Dr. James DiNic for short, is a cardiovascular research scientist and doctor of pharmacy at Saint Luke's Mid America Heart Institute in Kansas City, Missouri. He's also the author of best-selling books, The Salt Fix and Superfuel and he's contributed extensively to health policy and has even testified in front of the Canadian Senate regarding the harms of added sugars.     Dr. DiNicolantonio also serves as the Associate Editor of Nutrition and British Medical Journal's (BMJ) Open Heart, a journal published in partnership with the British Cardiovascular Society, and he's authored or coauthored roughly 200 publications in the medical literature.  He is also on the editorial advisory boards of several medical journals and he's shared his expertise on The Dr. Oz Show, The Doctors, and international news media outlets.   Dr. James DiNic comes on the show to discuss whether a low-salt diet really improves blood pressure, what else you can do to combat or prevent high blood pressure, what happens when you switch to a low-salt diet, and more.   Dr. James DiNicolantonio also shares his journey and his aha moment, how to supplement with electrolytes, who they're right for, and whether or not commercial sports drinks are really helping replenish electrolytes.   Here's a peek at the topics Dr. DiNic and Chris Irvin, The Ketologist, get into: 00:00 Introduction to the Keto Answers podcast 00:29 Introduction to this episode's guest, Dr. James DiNicolantonio 01:27 A brief overview of the topics discussed in this episode 02:26 Dr. DiNicolantonio's story and how he found himself in this space 03:24 Where Dr. DiNicolantonio's aha moment came from 05:02 What made leading experts think salt was the problem? 07:01 What happens when you switch to a low salt diet to improve your blood pressure? 11:15 Does a lack of key minerals drive insulin resistance? And, if so, what can be done about it? 13:50 What you can do to get your blood pressure down 18:48 If you're taking blood pressure meds, how can you safely switch to a higher salt intake? 22:07 Important heart health markers to look at 25:35 How sodium affects other blood markers 29:35 What's the best way to track sodium levels? 31:35 What's the best way to replenish your sodium levels? 33:42 How to time your salt intake around exercise 40:43 Are mainstream sports drinks a good way to rehydrate and add in electrolytes? 43:00 Using glycine instead of glucose for rehydration 45:18 What is the best type of sodium to use? Should you avoid table salt?   Resources mentioned in this episode: Dr. James DiNicolantonio's website Dr. DiNicolantonio's Instagram, Twitter, Facebook, and YouTube channel Dr. DiNicolantonio's books, The Salt Fix, The Immunity Fix, Superfuel, and The Longevity Solution Vivoo at-home urine test strips Diet Doctor resource Perfect Keto Electrolytes

This week, please join author Ratika Parkash and Editorialist Sean D. Pokorney as they discuss the article "Randomized Ablation-Based Rhythm-Control Versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF trial" and the editorial "The Evidence Builds for Catheter Ablation for Atrial Fibrillation and Heart Failure." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the Journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor, from the National Heart Centre and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature discussion, oh, so exciting. We enter the month of June, and it pertains to heart failure and atrial fibrillation. And we are going to learn a little bit more from the RAFT-AF trial, involving randomizing patients to ablation and rhythm control, as opposed to just settling for rate control for patients with AFib. But before we do that, how about we grab a cup of coffee and start with some of the other articles in the issue? Would you like to go first? Dr. Carolyn Lam: I absolutely would. And I will start by asking everyone a question. Could a single high-sensitivity cardiac troponin T level, below the limit of detection of six nanograms per liter, exclude an acute myocardial infarction? Well, you are going to find out because, remember that data for excluding AMI with a single high-sensitivity cardiac troponin level relies largely on the limit of detection, which is really a threshold of five nanograms per liter, which cannot be reported in the United States, per the FDA, because there, only the lowest reportable concentration is allowed, which is the limit of quantitation of six nanograms per liter. Dr. Carolyn Lam: So, today's authors Dr. Sandoval from Mayo Clinic and colleagues, very cleverly sought to determine whether a single high-sensitivity cardiac troponin T level below the limit of quantitation of six nanograms per liter could indeed identify patients at low risk for AMI. Dr. Greg Hundley: Very interesting, Carolyn. So we have the limit of quantitation and then the limit of detection. This is really intriguing. And of course, cardiac troponin T, as cardiologists, we receive a lot of requests for consults on this. So, what did this study find, Carolyn? Dr. Carolyn Lam: A total of over 85,000 patients were first evaluated in the CV data marked biomarker cohort, amongst which 29% had a baseline high-sensitivity cardiac troponin T level below this limit of quantitation of six nanograms per liter. Among 11,962 patients with this baseline high-sensitivity cardiac troponin below six nanogram per liter and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% and a sensitivity of 99.6%. Dr. Carolyn Lam: In an adjudicated cohort, among those with a non-ischemic electrocardiogram, only 0.2% had myocardial infarction or death at 30 days. So in summary, Greg, this is the largest study evaluating a single high-sensitivity cardiac troponin T level below this limit of quantitation of six nanograms per liter to identify patients at low risk for AMI. Dr. Carolyn Lam: And indeed, the present study demonstrates that a single high-sensitivity cardiac troponin level below six nanogram per litter is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction. Dr. Greg Hundley: Oh wow, Carolyn, really informative study. Well, Carolyn, my next study comes from the world of preclinical science. And Carolyn, vascular smooth muscle cell phenotypic switching contributes to cardiovascular diseases. And epigenetic regulation is emerging as a key regulatory mechanism with the methylcytosine dioxygenase Tet2, acting as a master regulator of the smooth muscle cell phenotype. Dr. Greg Hundley: The histone acetyltransferases, HATs p300, and CBP are highly homologous and often considered to be interchangeable. And their roles in smooth muscle cell phenotypic regulation are not known. So Carolyn, these authors led by Dr. Kathleen Martin from Yale University School of Medicine assessed the roles of p300 and CBP in human vascular smooth muscle cells with knockdown in inducible, smooth muscle specific knockout mice, and in samples of human intimal hyperplasia. Dr. Carolyn Lam: Cool, Greg. So what did they find? Dr. Greg Hundley: Right, Carolyn. So, they found that p300 and CBP serve non-redundant and opposing function in vascular smooth muscle cell phenotypic switching and coordinately regulate chromatin modifications through distinct functional interactions with Tet2 or HDACs. And Carolyn, targeting specific histone acetyltransferases therefore may hold therapeutic promise for future cardiovascular disease interventions. Dr. Carolyn Lam: Oh, that's great, Greg. Well, to round it all up, there are some other papers in today's issue. There's a Research Letter from Professor Zhang, entitled “Single Nucleus Transcriptomics: Apical Resection in Newborn Pigs Extends the Time-Window of Cardiomyocyte Proliferation and Myocardial Regeneration.” There's also a Research Letter from Dr. Vaduganathan, entitled “Estimating the Benefits of Combination Medical Therapy in Heart Failure with Mildly Reduced and Preserved Ejection Fraction.” Ah, that's such a cool issue. Now, let's go on to our feature discussion. Shall we, Greg? Dr. Greg Hundley: You bet, and learn a little bit more about rhythm versus rate control in patients with heart failure and atrial fibrillation. Dr. Carolyn Lam: Our feature discussion today is about the long-awaited results of the RAFT-AF trial, and that is the randomized ablation-based rhythm control versus rate control trial in patients with heart failure and atrial fibrillation. Thank you so much, Dr. Ratika Parkash for joining us today as the first and corresponding author from Queen Elizabeth II Health Sciences Center in Canada, as well as Dr. Sean Pokorney, the editorialist from Duke University. Dr. Carolyn Lam: I am so, so excited to be discussing this paper. I really meant it. You know, as a heart failure cardiologist, we've been waiting for these results and trying to understand everything in context. So maybe, Ratika, could you please start off by telling us about the RAFT-AF trial and what you found? Dr. Ratika Parkash: Thank you, Carolyn. I'm happy to be able to talk about this study on behalf of the RAFT-AF investigators and my co-PI, Dr. Anthony Tang. So the trial... First of all, the rationale for the study, I think many of us, as heart failure or heart rhythm specialists, understand that in the past, we've done many trials looking at rate versus rhythm control, the AFFIRM trial being the largest, and then of course, specifically in heart failure patients, the AF-CHF trial, both of which were negative in reducing cardiovascular events and mortality in patients with or without heart failure, in terms of a rate to rhythm control. Dr. Ratika Parkash: One of the issues with those trials is that the form of rhythm control was antiarrhythmic drugs. So we have learned that catheter ablation is superior to antiarrhythmic drugs in maintaining sinus rhythm. And based on that premise, we decided to go forward with the RAFT-AF study. Dr. Carolyn Lam: That's great, Ratika, so thanks. And what were the results? Dr. Ratika Parkash: The main finding, so the primary outcome of the study was mortality and heart failure events. Heart failure events was defined as a heart failure hospitalization or any escalation of heart failure therapy that was done in the outpatient settings, including the use of intravenous Lasix in an emergency department setting. Dr. Ratika Parkash: So the main findings were that ablation-based rhythm control was not statistically significant in reducing mortality and heart failure events over rate control in patients with atrial fibrillation and heart failure. The study included patients both with preserved ejection fraction, as well as reduced eject fraction. And we did stratify based on ejection fraction at the entry point into the trial. The hazard ratio was 0.71 and the 95% confidence interval just crossed unity, ranging from 0.49 to 1.03 with a P value of 0.066. Dr. Carolyn Lam: Oh, ouch. So, thank you. And again, truly, congratulations on a very, very important trial. Sean, I said it before, I'll say it again, really, really loved your editorial. Could you put these findings in the context of... Maybe, start with even the most recent guidelines, the 2022 ACC/AHA/HFSA heart failure guidelines, which I believe gives catheter ablation a class 2A recommendation. Maybe, start from there, and how does this fall in place? Dr. Sean Pokorney: Yeah, no, absolutely. I think, first of all, it's a really important trial and it's great to have this additional data. I do think, as you said, that it's important to understand the context. We now have several recent guidelines that have commented on the role of catheter ablation in patients with heart failure. Dr. Sean Pokorney: You mentioned the most recent heart failure guidelines. We also have additional AFib guidelines and we have the 2019 AHA/ACC/HRS guidelines for atrial fibrillation that give catheter ablation a 2B recommendation in patients who have heart failure, to potentially lower mortality and reduce hospitalization. And it has a 2A indication in the 2020 ESC guidelines. And we're currently undergoing some revisions of the guidelines for atrial fibrillation, and there'll be new guidelines around atrial fibrillation coming out from AHA/ACC/HRS in the coming years. And so that will also be helpful, I think, to incorporate some of this additional data. Sean Pokorney: When you really look at the guidelines and see what's driving the guidelines, there are several trials now that are really driving the guidelines. And so I think, looking back on the data, we have the AATAC trial, which was a trial of 203 patients that looked at ablation versus amiodarone. And we have the CASTLE-AF trial, which had 363 patients in it and was looking at atrial fibrillation in patients with heart failure with reduced ejection fraction and defibrillators. Dr. Sean Pokorney: And when you put that data into context, the AATAC trial did find lower rates of death and hospitalization as a secondary outcome, and CASTLE-AF did identify a reduction in heart failure hospitalizations and death. At the three year follow-up, there was a statistically significant reduction, although the event number was lower than the previously sort of calculated target sample size. Dr. Sean Pokorney: And so in aggregate, these trials do show a modest evidence of benefit for clinical outcomes in this population. And that's where adding more data is really critical. Dr. Carolyn Lam: That's so true. And actually, Ratika, is there any plan for some meta-analysis or sort of adding the data? And if you could, also speak to, the trial was interrupted at some point, so how that may have impacted things as well. Dr. Ratika Parkash: Those are important questions. So, first of all, there is a planned longer term follow-up for the study, to look at whether or not following these patients out beyond our meeting follow-up of 37 months, it will actually produce a different result than what we observed in the current findings. Dr. Ratika Parkash: I think a meta-analysis is obviously going to show benefit for ablation-based rhythm control, based on the data that Sean had just described. One of the things that we'd need to keep in mind is that this trial, the RAFT-AF study really enrolled patients who were suitable for either ablation-based rhythm control or rate control. So it wasn't a study that looked at rhythm control only. Dr. Ratika Parkash: So, the CASTLE-AF trial had essentially two rhythm control arms. The medical therapy arm was, was amiodarone in that trial, versus catheter ablation. So patients could get rhythm control in both. And so, the types of patients that would've gotten into CASTLE-AF were different than the patients in our trial, even when you look at the reduced ejection fraction patients. Dr. Ratika Parkash: Having said that, our curves, when you look at the reduced ejection fraction group in our study does mirror what was observed in CASTLE-AF. So, even if a patient is not deteriorating initially with rate control, it appears that over time they begin to deteriorate. And that's what all of these trials have shown, is that patients do better with ablation-based rhythm control, the best form of sinus rhythm maintenance that we have. Dr. Ratika Parkash: And it takes time for them to deteriorate and it takes time to accrue those events. And this is evident in all trials of atrial fibrillation. You either need a very large sample size, like 15,000 patients, to look at heart failure in a short period of time, or you follow them longer, so that you can accrue those events. Dr. Ratika Parkash: In terms of the stopping of the trial, certainly, had we reached the sample size of 600, which was the intended sample size after recalculation during the study from 1000 down to 600, I believe we would have reached a positive outcome. But again, we hope that our longer term follow-up might shed some light on that. The interruption of the study was based on the DSMC decision and certainly could have affected the power of the study. Dr. Ratika Parkash: We have to remember that the other possibilities are that ablation-based rhythm control is not superior to rate control. And as someone who is pro-ablation, it's difficult to say that, but we see hints of benefit and we have to recognize that. Dr. Ratika Parkash: The other issue is that the secondary endpoints in our trial were all significant, as overall, it doesn't matter which group you looked at, NT-proBNP, six-minute walk test, quality of life, both for heart failure and atrial fibrillation, as well as ejection fraction, were all improved. And for many of the studies that have been done previously, those were the primary endpoints of those studies. Dr. Ratika Parkash: The idea of whether ablation-based rhythm control reduces heart failure per se, is from our study, purely from our study, we can't be a hundred percent certain. There's definitely a hint of clinical benefit there. From all the secondary endpoints, which are the current guidelines, is what they indicate ablation should be done for, is to improve quality of life. Our study was certainly supportive of that. Dr. Carolyn Lam: You know, Sean, I especially appreciated your discussion of these issues, the early stopping of the trial, the secondary endpoints. Could you know, share some of those thoughts? Dr. Sean Pokorney: I think it's really an important topic. I think that, again, as Ratika said, part of why this trial is so important is that many of the previous trials that have been published and many of the data sets have really looked at rhythm control versus rhythm control in this population, even including the analysis from CABANA, which included almost 780 patients from CABANA that had heart failure. And in that population, they did show a reduction in the composite primary endpoint of death, disabling stroke, serious bleeding, or cardiac arrest. And again, CABANA was, as well, a study of rhythm control with ablation versus medical therapy, most patients getting rhythm control in that medical therapy arm. Dr. Sean Pokorney: And so this data really is additive. I think that one of the challenges is always, how do we make sure to get the most information out of a clinical trial once we commit patients to that scientific process? And I think here, at least in retrospect, it's obviously unfortunate that the trial was stopped early. I think that more data would certainly be helpful. Dr. Sean Pokorney: I appreciate the fact that longer term data may help solve that gap and close that gap a little bit. I think that, I guess, it'd be interesting to hear from Ratika a little bit more about the process that was involved with interaction with the DSMC and stopping the trial. Dr. Ratika Parkash: Yeah. Thanks, Sean. That also is a very good question. The DSMC really evaluated the data, evaluated the progress of the trial, back in 2017. It had been six years since we'd started the study. The data they had, in fact, did not show any benefit to ablation-based rhythm control over rate control at the time. So the follow-up period at the time was around two years. Dr. Ratika Parkash: And again, if you look at our Kaplan-Meier curves, you can understand why they would have made that decision at the time, based on 363 patients for the data that was available to them. They had a futility index that they looked at. it was calculated. The cutoff for stopping of the study was 0.8, and it was 0.81. So, there was a 19% chance that the study was going to show any benefit. And based on that, plus the progress of the trial, they made a decision to stop the study. Dr. Sean Pokorney: Yeah. I think it's really important when we look at these decisions, that there was example when we talk about this in the editorial as well with the ISIS-2 trial, where early on in the data, ISIS-2 was a trial looking at aspirin versus placebo. And basically in that trial, when you looked early on at the events that were accumulating, there was really roughly no difference between aspirin and placebo. And ultimately, that trial became positive and was a really critical trial. And if it had been stopped at that point for futility, we wouldn't have had some really critical data. Dr. Sean Pokorney: So, it's always a challenging decision. And obviously, the decisions are trying to be made in the best interest of the patients. Here, it just shows how important this additional follow-up data is for this trial, for RAFT in particular. And ultimately, it'll be interesting to see, as you mentioned, as we add additional long-term follow-up, how that will affect the results. Dr. Ratika Parkash: Absolutely. So, we hope that our additional follow-up is of benefit to clarifying our results. The unfortunate issue, I agree, was the stopping of the study, but we do trust our DSMCs. We have them for a reason and they perform an important function. So, we have to pay attention of course, to how they see things and evaluate the... at the time. Dr. Ratika Parkash: The other thing we should keep in context is that ablation for those, that time period, is not the same as it is today. Our safety has improved. You may have noticed that there were some adverse events in the study with ablation, and we would expect it to actually be lower, but in this day and age, but at the time, contact force wasn't available. Dr. Ratika Parkash: There were some tools and techniques that we now have at our disposal, improved mapping systems and so on, that allow us to do a safer and more efficacious job. But even in the context of that, our sinus rhythm maintenance was almost 80 to 90% for patients that you wouldn't normally expect to have that much sinus rhythm. Dr. Sean Pokorney: Yeah. I think that's a really critical point. You made a lot of really important points there, actually. Obviously, the vision of the field of electrophysiology is shifting, as you mentioned. And with data from EAST-AFNET 4, we're really shifting towards earlier rhythm control, as well as additional ablation trials attest, stop AFib or stop AF. Dr. Sean Pokorney: So again, there have been several studies that have shown the benefits of earlier rhythm control, EAST-AFNET 4, I think, being obviously one of the most relevant, looking at addressing atrial fibrillation of population of patients who've been diagnosed within the last year, and showing that there was a benefit to rhythm control, although the majority of rhythm control in that study was antiarrhythmic medications. Dr. Sean Pokorney: I think in the heart failure population, the challenge with rhythm control is that we're a lot more limited in terms of the medical therapies that are available for these patients. And I think that's where ablation really plays in a more important role, because not only have you shown that it seems to be efficacious in this patient population, with a really high rate of rhythm control, but in a lot of these patients, it's often a safer alternative than antiarrhythmic therapy. Dr. Ratika Parkash: Absolutely. And we've already shown that amiodarone is ineffective in this population, in AF-CHF. So, using that drug does not seem to be, in a population that could go for an ablation, the appropriate approach. Dr. Sean Pokorney: Yeah. And as well, I think that's important. And when you look back at data from SCD-HeFT as well, there were some concerns with safety signals of amiodarone in patients with heart failure as well, from that study, again, likely related to the side effects of the medication itself. Dr. Sean Pokorney: So again, it is a complex patient population in terms of decision-making and management. And I do think, again, we talked a lot about the trial being stopped earlier than we would've ideally liked. I still think that the data that you guys produced is really important and critical and additive. Again, we're consistently seeing these modest treatment effects across multiple studies. And the fact that all the studies are pointing in the same direction is very reassuring. Dr. Ratika Parkash: Yeah. I was just going to comment on some of the points that Sean had raised, with respect to early rhythm control and the concept of atrial substrate, and how advanced atrial substrate with a negative remodeling effect in patients with heart failure or prolonged atrial fibrillation may not necessarily be in our patient's benefits to then try to intervene, and trying to get these patients early would be useful. Dr. Ratika Parkash: So in RAFT-AF, patients did not have to fail an antiarrhythmic drug in order to get into the study. So that, again, critical, very much along the lines of EAST-AFNET and EARLY-AF, which was also published, demonstrating benefit for early intervention. Dr. Carolyn Lam: Wow. Just, thank you so much, both of you. That was such a rich discussion, really, really unpacking very, very important elements of the trial, not just the trial results, but also the implications of what happens with trial conduct and execution and so on. Dr. Carolyn Lam: Again, thank you so much Ratika, for publishing this very important paper in circulation, Sean, for your beautiful editorial that put it all in context, the audience for listening today. From Greg and I, you've been listening to circulation on the run. Thank you for joining us today, and don't forget to tune in again next week. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors or of the American Heart Association. For more, please visit AHAJournals.org.  

JAMA Pediatrics Editors' Summary by Dimitri A. Christakis, MD, MPH, Editor in Chief, and Alison A. Galbraith, MD, MPH, Associate Editor, for the June 6, 2022, issue. Related Content: Associations of Parental Cancer With School Absenteeism, Medical Care Unaffordability, Health Care Use, and Mental Health Among Children Psychosocial Interventions for the Treatment of Functional Abdominal Pain Disorders in Children: A Systematic Review and Meta-analysis

As a serious uptick in gun violence leaves many in the U.S. fearing for their safety, Americans look to lawmakers to take action — leading conversations surrounding gun control, red flag laws, and mental health resources to take center stage in Washington. On top of domestic difficulties, the U.S. also continues facing obstacles overseas — with last Friday marking the 100th day since Russian troops invaded Ukraine. Republican Congressman Lee Zeldin joins the Rundown to explain why he believes reaching bipartisan agreements is crucial in combatting gun violence. He also shares his thoughts on the prolonged war in Ukraine as an Army Reserve Lieutenant Colonel and why he believes Americans are still facing record-breaking inflation. This May, 390,000 new jobs were created while unemployment is at a flat rate of 3.6 percent, according to the Labor Department. While it's a great time for jobseekers who have more say over their pay, inflation continues to be an issue for Americans, taking away their extra income. John Bussey, Associate Editor at the Wall Street Journal and FOX News Contributor joins the Rundown to explain the job growth's impact on the economy, the factors driving the tight labor market, and how COVID, the war in Ukraine, and supply chain disruptions led to the inflation situation at hand.   Plus, commentary by Guy Benson, host of 'The Guy Benson Show.' Learn more about your ad choices. Visit megaphone.fm/adchoices

As a serious uptick in gun violence leaves many in the U.S. fearing for their safety, Americans look to lawmakers to take action — leading conversations surrounding gun control, red flag laws, and mental health resources to take center stage in Washington. On top of domestic difficulties, the U.S. also continues facing obstacles overseas — with last Friday marking the 100th day since Russian troops invaded Ukraine. Republican Congressman Lee Zeldin joins the Rundown to explain why he believes reaching bipartisan agreements is crucial in combatting gun violence. He also shares his thoughts on the prolonged war in Ukraine as an Army Reserve Lieutenant Colonel and why he believes Americans are still facing record-breaking inflation. This May, 390,000 new jobs were created while unemployment is at a flat rate of 3.6 percent, according to the Labor Department. While it's a great time for jobseekers who have more say over their pay, inflation continues to be an issue for Americans, taking away their extra income. John Bussey, Associate Editor at the Wall Street Journal and FOX News Contributor joins the Rundown to explain the job growth's impact on the economy, the factors driving the tight labor market, and how COVID, the war in Ukraine, and supply chain disruptions led to the inflation situation at hand.   Plus, commentary by Guy Benson, host of 'The Guy Benson Show.' Learn more about your ad choices. Visit megaphone.fm/adchoices

For Episode 9: Pat is joined by the mostly co-host Eetu to discuss drafted and 2022 prospects that played in the 2022 World Championships. Click here to read Eetu's piece on the World Championships here: https://dobberprospects.com/2022/06/03/nhl-prospects-and-draft-eligibles-at-the-2022-world-championships/ Thanks for watching/listening. Remember to LIKE and SUBSCRIBE on Youtube. Do not forget to come to the website to view all of your prospect needs: https://dobberprospects.com/ Follow us on Twitter: Pat, Host and Associate Editor, DobberProspects: @FHPQuinn Kyle, Co-Host and Junior Editor, DobberProspects: @kyle_nw Eetu, Occasional Co-Host and Head of Scouting, DobberProspects: @siltaneneetu

In this episode of H2TechTalk, Tyler Campbell, Associate Editor of H2Tech, shares some of the top H2 news from May. From green ethylene production to a planned electrolyzer production facility, this episode will keep you in the loop on the happenings in the global H2 sector.

Lydia Starbuck, Associate Editor for Royal Central, Vincent McAviney, London based journalist

Lydia Starbuck, Jubilee & Associate Editor at Royal Central, shared all the latest details with Ross and Russel on Friday! See omnystudio.com/listener for privacy information.

Hello everyone and welcome to Ultimate Motorcycling's weekly Podcast—Motos and Friends. My name is Arthur Coldwells. We really appreciate you listening to our sponsors' ads—this podcast would not exist without their—and of course your—support.   This week's Podcast is brought to you by Yamaha motorcycles. Filling the gap between the entry-level R3, and the flagship superbike R1, Yamaha's YZF-R7 is a brilliant supersport machine that provides real performance—perfectly balanced with rider comfort. Check it out at YamahaMotorsports.com, or of course you can see it for yourself at your local Yamaha dealer. This Podcast is also brought to you by the new, state-of-the-art Schuberth C5. The modular C5 is a flip up design that blends safety with amazing quietness within its compact, light weight design. Visit Schuberth.com for more information. This week, Editor Don Williams tells us all about the new Indian Pursuit. This high performance full-dresser features Indian's powerful liquid-cooled v-twin engine that spools up quickly and smoothly. If you're a performance rider who likes full-dresser luxury—then you're probably going to want to hear what Don has to say.     In the second segment Associate Editor and Podcast producer Teejay Adams chats to Loren Turnbull. She's one of the moderators at the respected East Coast Female Riders group in Australia—you can find it on Facebook—and has just started her own digital Motorcycle magazine for ladies, called Girl Moto Media. Loren chats with Teejay about her experience riding in Thailand's northwest corner. The famed Mae Hong Son loop is an unbelievably spectacular, ride through mist-covered mountain passes and steamy jungles. Loren and her partner rented a couple of Yamahas and rode the nearly two thousand corners that make up the almost 400-mile long, 4-day ride. From all of us here at Ultimate Motorcycling, we hope you enjoy this episode!

In this episode of the IJGC podcast, Editor-in-Chief Dr. Pedro Ramirez is joined by Dr. Rene Pareja to discuss conservative management of cervical cancer. Dr. Pareja is a gynecologist-oncologist at Astorga Oncology Clinic in Medellín and the National Cancer Institute in Bogotá, Colombia. He is a reviewer for more than 20 specialty journals, an Associate Editor for IJGC, a member of the Editorial Board of Gynecology Oncology, and a member of the board of directors of the International Gynecological Cancer Society (IGCS). Additionally, he is a member of FIGO committee on Women's Cancer. Dr. Pareja is the author of nine book chapters and more than 70 publications in peer-reviewed journals, and at IGCS 2021 he received an award for Community Advancement in Resource-Limited Settings. Highlights: 1. Fertility preserving options have to be offered to all women wishing to preserve their fertility potential, that fulfil the ECOG status, histological, and imaging criteria. 2. It is recommended to have an evaluation by human reproduction specialized teams in order to rule out any potential impairment before the surgery. 3. The relapse rate for vaginal radical trachelectomy, abdominal radical trachelectomy and simple trachelectomy/conization are around 4-5%. 4. The highest live birth rates are seen in patients undergoing conization + lymph node assessment (over 88%). 5. Vaginal radical trachelectomy and minimally invasive radical trachelectomy, with preservation of ascendent branch of uterine artery, are contraindicated in women with tumors > 2 cm, due to the high rate of relapse (over 20%).