Resonance

Spotify | Apple Podcast | Amazon Music | Length: 45:58 minutes | Published: June 20, 2024

In this episode, we sit down with Dr. Mollie Gordon, Assistant Professor in the Department of Psychiatry at Baylor College of Medicine and founder of the nation's first psychiatry fellowship dedicated to treating human trafficking survivors. Dr. Gordon shares insight from her research and advocacy efforts aimed at combating human trafficking, both domestically and internationally. She provides practical guidance on identifying victims of human trafficking as well as next steps for clinicians once a victim is identified.

Transcript

Gianni Calderara:
Hello, and thanks for listening to Resonance podcast, a podcast run by medical and graduate students at Baylor College of Medicine where we interview clinicians, faculty, and researchers about their work in an effort to promote health education and Ingenuity. My name is Gianni Calderara. I am a third-year medical student at Baylor College of Medicine, and I'm going to be the host for this episode.

Today I'm excited to interview Dr. Mollie Gordon. Dr. Mollie Gordon is an assistant professor of psychiatry in the department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. She currently works as the associate director of the inpatient Psychiatry unit at Ben Taub Hospital in Houston, Texas. Much of her work both in and outside of the hospital centers around human trafficking research, service, and advocacy. In 2016 Dr. Gordon founded the Baylor College of Medicine anti-human trafficking program to help treat victims of human trafficking, and she currently serves as the program's medical director. She is also co-founder of the Baylor College of medicine's division of Global mental health.

In this episode, Dr. Gordon will share her experience working with victims of human trafficking as well as how she came to be involved in this work. She will shed light on the current issue of human trafficking both in Houston and across the United States and will provide clinicians with tools and resources to help identify and assist victims of human trafficking.

I was introduced to Dr. Gordon through the Psychiatry clerkship while rotating through the Ben Taub inpatient Psychiatry unit during my second year of medical school. She served as my preceptor for two weeks and often discussed her work within the realm of human trafficking research, treatment and advocacy. Her work serves as a testament to the unseen struggles that many of our patients experience. I hope that through this episode listeners will gain an appreciation for the scope of this issue as well as better understand the steps we can take as a community to advocate for these patients.

And without further ado, let's hear from Dr. Gordon.

Well, Dr. Gordon, thank you so much for being on the show. I got really excited when you agreed to meet with us, and I've been looking forward to learning a little bit more about your work since that time. So thank you so much for being here.

Dr. Gordon:
I'm glad to be here any opportunity to talk about human trafficking to anyone who will listen I will take.

Gianni Calderara:
If you could, would you just start off by telling us a little bit about your background and what brought you to Houston?

Dr. Gordon:
Well, I grew up in Houston, so Houston is home, and I completed medical school and residency at Washington University in St. Louis and then after we had kids and needed a little bit more help raising a family we came home here where all our brothers and sisters and parents are, and it's hard to say no to the best medical center in the world when you have that and family around. So I have been at Ben Taub since 2009, it was my first job out of residency, and I'm not going anywhere. So, it's been an awesome experience; it was a good a good choice.

Gianni Calderara:
And how did you decide on medicine?

Dr. Gordon
Medicine as a field?

Gianni Calderara
Yeah, just has a field or what kind of introduced you to that idea?

Dr. Gordon:
Oh, well lots of things. I like people. I'm a people person. So, I definitely wanted a job where I could be with people and talk to people all day long and not all fields of medicine allow you to be with patients talking to them all day until I got to Psychiatry and I thought oh, this is perfect for me. I could sit here and talk to patients all day long, which is my favorite part about medicine. I liked the Diagnostics and the biology and the science behind medicine, but I think it's really the people that drew me to medicine and their stories. So, Psychiatry was a perfect match.

Gianni Calderara:
So you're currently an associate director of inpatient psychiatry at Ben Taub. I think, you know, for people that are at Baylor or in Houston, we’re pretty familiar with Ben Taub and kind of that patient population, but for our listeners that you know aren't so familiar with Ben Taub, could you kind of just explain a little bit about what your patient population kind of looks like and what working at Ben Taub typically looks like in a given week.

Dr. Gordon:
Sure! We're very busy which is good. We offer a lot of care to patients with acute exacerbations of major mental disorders, and that's what we do on the inpatient unit. We stabilize patients with a huge team. So there's two attending psychiatrists multiple Learners, we have medical students residents and then all sorts of team members that help bring patients back to a well state. So, we have occupational therapists, psychologists, nurses, social workers, case managers chaplains, pharmacist, and then of course our medical and surgical colleagues at Ben Taub who need to step in when patients have concurrent medical and surgical needs.

A lot of our patients are un or underinsured so a lot of them are on the Harris County Gold Card. Sometimes our patients struggle with what is now identified as social determinants of health. So ,access to care barriers, homelessness, sometimes our patients have comorbid substance use disorders or transportation issues or trauma histories, things that make sometimes getting to doctors difficult.

So, I think it's a unique setting for lots of reasons. It's an amazing opportunity to spend a day with patients. Patients are hospitalized and the team is on the unit throughout the day and so to really get to know patients and to see their symptoms and see their symptoms improve is a really unique experience and we're very busy. So typical work week looks like a lot of different things so clinical care, rounds, teaching. We sprinkle some clinical research into that, lectures formal didactics. So, it's a very fun and busy week and patients get better and it's very rewarding for everybody involved I think.

Gianni Calderara:
I know a lot of your work has been dedicated to treating victims of human trafficking and other forms of trauma. Could you tell us just a little bit about how you became interested in that work specifically and kind of your background working with that specific patient population.

Dr. Gordon:
So I actually became very interested in trauma work when I was a medical student. I was a first-year med student during 9/11, some of you guys listening may not have even been born or were in preschool then, and so we lived through the experience of you know, mass disasters. I've always been interested in how the interactions between humans can create disease . So patients are well until something happens to them. And usually it's something inflicted on them by another person. Whether that is terrorism or war or natural disasters or interpersonal violence, it's always been an interest of mine that you can create disease because of interactions between people. So I did a lot of work when I was a medical student with Carol North who I think is now retired, and we did a lot of focus groups of survivors of the 9/11 terrorist attacks and that got me interested in trauma as a construct but more importantly trauma as trauma and resiliency, how do people survive distressing life events and then move forward from them.

Resiliency as a field was sort of just starting then and so it had always been an interest since I was in training, and a lot of the patients that we take care of currently have some form of trauma in their life. You know, I may be dating Myself by telling you this with the original Felitti studies that looked at adverse childhood events, you know didn't come out until the late 90s. I was in college then, so I was just starting medical school. So trauma as a as a comorbidity was just starting as a field. It's been really interesting to watch the understanding of trauma and how it impacts physical and mental health over the last 25 years and be a part of that.

The patients that we take care of have a lot of concurrent traumas and patients with major mental disorders are more likely to be victims of violence and trauma, and so it feels very protective or paternalistic is the term we use as psychiatrists to want to care and work with patients who have been harmed.

We built the human trafficking program because the patient's needed it. It wasn't like I walked into work one day and I thought “what are we doing about trafficking and health systems these days.” The problem came to us as faculty. Back in 2016, we had seen a cohort of patients who were reporting that they had been victims of labor and sex trafficking either as children or as adults, and when we went to the medical literature to look up what we were supposed to do with this, there was a lot of literature in the emergency medicine space and in the health education space, but very little about what we needed to do as psychiatrists and mental health providers to address the primary and secondary prevention of trafficking right. So we built it because the patient's needed it.

We approached the city of Houston. We told them we had an idea about maybe offering a public health model to the city. We received pilot funding to do that. It was successful and then from there, you know from the ashes it developed because there's a need unfortunately. But at least if we're going to educate health professionals on the topic of human trafficking we have a solution which is very empowering as a clinician to have something that you can offer a patient who's been a victim of trafficking.

Gianni Calderara:
Just kind of as a general background and kind of like starting point, could you just go ahead and define what human trafficking is for us?

Dr. Gordon:
Sure. So, we think about trafficking in the clinical space the way policymakers and lawmakers think about trafficking in the International Space. So we think about trafficking in accordance with the United Nations Palermo Protocol or the Trafficking Victims Protection Act which is the United States federal government trafficking laws. And for a person to be trafficked, they have to meet what’s called the AMP model: an act, a means, and a purpose. Those three elements have to be present. So there has to be an act, so the recruiting transferring, transporting, harboring, and receiving of a person doesn't act and that implies movement, like people are recruiting and transferring and harboring people. Like people are moving across the seas or across International lines. Lines are crossed like state lines and that's always that's not always the case. What that act is, is a development of a relationship between a vulnerable person and a perpetrator and that can be family and it can happen in a house. It doesn't have to be a stranger, it often isn't, but it is the development of a an attachment to a vulnerable person and then exploitation of the attachment for financial gain through an element or means of force fraud and coercion.

So A is the act, the recruiting transferring harboring or the development of relationship. M is a means of force, fraud, and coercion and one or all of those elements are often present in that relationship. So somebody may be forced which is a physical element that maybe you know physically assaulted or sexually assaulted or branded something physically happens to them. Fraud is a lie. So they're lied to about what kind of work they're going to be doing whether it's labor work or some sort of work that ends up being sex work and they get frauded or lied to, or they get coerced which is threatened. So they threaten them or someone they love are threatened to retaliate against them. So we call that psychological coercion. And one of those three elements have to be met for the purpose, that's the P in the amp model of Labor or sexual exploitation. So, that's a very long-winded answer, but that’s because a lot of elements have to be present for somebody to traffic someone else. So you have to create a relationship through the means of force fraud or coercion for the purpose of Labor sex.

Gianni Calderara:
I think that's something interesting. You know, I kind of encountered when I was rotating through Ben Taub, this idea of like labor trafficking. I think most people when they think of human trafficking, you know, tend to think more about like sex trafficking, but I know in Texas, you know, labor trafficking is also a very big issue as well.

What are some other examples of how, you know, human trafficking may look differently than you know, kind of what may initially come to mind when we hear that term?

Dr. Gordon:
Yeah, that's a good question.

It's true. Most people think about sex trafficking when they think about human trafficking and they usually think about sex trafficking of minors. I think one of the reasons that is is because when you define trafficking as an act, a means, and a purpose, if you the sexual exploitation of a minor you don't need a force, fraud, and coercion because a minor, whether it's whatever gender, cannot consent to commercial sex acts. So they cannot exchange sex for something of value like food, housing, shelter, clothes, money, drugs, whatever they're exchanging sex for, you don't necessarily need force, fraud, or coercion. So it's a little bit easier to prosecute the sexual exploitation of a minor if the prosecutor doesn't have to prove force, fraud, or coercion. So I think that's why that's one of the reasons sex trafficking gets a lot of attention.

Like any form of exploitation, it's very egregious. But sexualization of minors has always been a taboo subject, and so I think it's always receiving a lot more attention for that reason.

There are lots of different forms of trafficking when it comes to labor trafficking. Things that are pretty common that you would expect in the state of Texas are things like agricultural work or construction work or domestic servitude like home care, but there's also a lot of spaces where trafficking intersects health systems that may not be just in the patient space. So for example, one of our medical students wrote a paper with us about healthcare and supply chains. So are we buying materials in health systems that exploit labor and persons or children worldwide? And what are we doing as health systems to make sure that the products that we use, the pharmaceutical products, the medical products, the papers, the masks aren't contributing to labor exploitation on the global scale. Are we employing people, for example nurses, as part of labor trafficking fraud. There's been a lot of cases in the United States where health workers including nurses have been forced into those positions. So even in our day-to-day work, we probably bump up against labor trafficking. It doesn't have to be in construction sites or in fields.

We also probably underestimate the relationship between intimate violence and trafficking. So we've seen situations where persons are in intimate partner relationships and then are forced to either engage in sex trafficking or sex work or physical work. Let's say whether it's legal or illegal like panhandling, forced panhandling can be a form of trafficking which we don't often think about when we're driving around the city and see people panhandling. Criminality can be a form of trafficking. So you have young boys and Girls who are forced into criminal acts by force fraud and coercion and maybe arrested for criminal endeavors as opposed to identified as being a victim of some form of exploitation. So when we think about trafficking, yes sex trafficking exist. It's a very large problem, but the exploitation of vulnerable populations is really sort of globally what we're talking about when we talk about trafficking.

Gianni Calderara:
Okay. I know it's difficult to like give a specific number about, you know, how many individuals are involved with trafficking and how many victims there are, but could you kind of share any insight as to, you know, how big of a problem this is both in Houston, Texas, the United States, and then also just globally. Like how far does this problem, how large of an issue is this actually?

Dr. Gordon:
It's a very large problem. It's growing. So when we first started in the work it was in 2017, October 2017, the International Labor Organization at that point estimated that there were 40.2 persons globally who were victims of trafficking, the majority of whom were women and children. So it is a gendered phenomenon, but about a third were men. So there's definitely a gender bend to the space, but I think that that's probably a little bit underreported. There's some reasons why I think there are probably more men being trafficked that we probably just aren't identifying. Since then, we have added a lot of interventions to the anti-trafficking space including public health interventions, community outreach, primary prevention strategies, and the numbers have grown from 40.2 to 50.1. So the September 2022 ILO estimates were that there were 50.1 million persons globally being trafficked. So the numbers are rising despite our services and interventions also rising - we're not keeping up.

Gianni Calderara:
Do you think that maybe due to, like, better detection and you know identification on behalf of researchers?

Dr. Gordon:
Yeah, that's a great question. So it may be that we're identifying trafficked persons better, and that's why those numbers are higher. I think that's a great point. It may be that because we have more resources were more likely to ask than maybe 20 years ago or even seven years ago we were less likely to do so. We know that physician or provider-centric barriers to care. Include not asking because there aren't resources and so maybe because we have more resources now we would be more likely to screen. We also have validated screening tools and health systems, which we didn't previously so that may be another reason why we're identifying more.

In the state of Texas, there are not finite prevalence studies but there are estimations. So if you look at vulnerabilities and data that we know where there's high risks of trafficking and then extrapolate a math model from that, the University of Texas Noel Busch-Armendariz and Dr. Melissa Torres in the center of domestic violence there, built a model that was published that estimated there are over 313,000 trafficked persons in the state of Texas, 79,000 of whom were children and the majority, about 264,000 of whom, were trafficked for labor. So the majority is labor trafficking we think in the state, but youth are still being exploited more than they should.

Gianni Calderara:
As a community of educators and, you know, researchers and clinicians, how would you say we could be better at advocating and providing resources for victims of human trafficking?

Dr. Gordon:
Well, listening to this podcast is one way. So you know education is huge. We just hope that people who we rotate with us or work with us think about labor trafficking and sex trafficking as a differential diagnosis of abuse and neglect and harm. So when we think of abuse we think of like child abuse, sexual abuse, physical abuse, elder abuse, why are we not thinking about trafficking as a form of abuse? So just keep adding it to your differential diagnosis.

No matter what field you're in, this perception that trafficking only causes mental health harm we know is not true. Kathy Zimmerman's work at the London School of hygiene and tropical health and many others have documented very diverse health needs of trafficked persons. So if you're going to be a pediatrician you need to know about trafficking because it affects children - peak ages between 12 and 15. If you are going to be an infectious disease doctor, you need to be aware of trafficking because when there's trafficking there's often communicable diseases. Maybe you'll be a head and neck cancer surgeon and during your training you'll see a stab wound to the neck and are you thinking maybe this was trafficking?

So whatever your field is, you will likely see a patient who has been trafficked. Actually a lot of the early literature which came from emergency medicine, OBGYNs, anesthesiologists. We've contributed to literature and written papers in the plastic surgery field and the psychiatry field. If you're going to be a neurologist and a patient comes in with a brain injury, is trafficking on your differential diagnosis? So just keeping it, you know, on your radar is important. What we would love is for clinicians to screen for trafficking the way they screen for other forms of abuse. That's tricky because we need validated screening tools for that, and the only validated screening tools that exist currently are for sex trafficking and in the emergency room setting. But even if we can screen for sex trafficking and adults and children in the emergency room setting, we will have moved the needle because most trainees and students spend time in emergency rooms. And so to learn how to screen in one setting will help sort of continue those skills down the line

Gianni Calderara:
What are some of the other things that, you know, clinicians could be looking out for, you know, some of the common like stories or things, kind of I guess red flags or things to be looking out for when you're seeing patients in clinic or in the hospital?

Dr. Gordon:
Yeah. That's a great question. I wish there was like one red flag, but one of the things we like to teach our learners is that trafficking occurs when there's this sort of convergence of vulnerabilities for exploitation and so is that at the individual level because a person has a lot of individual risk? Is that at the interpersonal level? Is that at the community level? Is that the policy level? When it comes to individual patients, I think that there's probably an overlap between adverse childhood events, social determinants of health, that likely coincide with risk for exploitation.

I'll give you an example, we’re writing a paper with some with some medical students currently on the intersection of food insecurity and trafficking because we don't think about food as being a push factor for exploitation but we learned this from our patients. Our patients have told us that when they have to feed themselves or dependents that trafficking becomes a high-risk endeavor and a choice they may become vulnerable to because it's a way of getting their immediate needs met even at the risk of violence and exploitation.

Gianni Calderara:
I did see on the United States Bureau of Justice statistics some of the data that they published they showed that over the last decade the number of persons prosecuted in the United States annually for human trafficking has actually increased from just over 700 cases to over 1,600 cases per year. I was wondering if you're aware of any policy changes that could explain this increase or could this just be a result of better detection on behalf of prosecutors and researchers?

Dr. Gordon:
That's a good question. I should point out of that that is still a grossly low number of prosecutions compared to victims. It's really hard, I think, to prosecute someone for trafficking because it takes the proof of force, fraud, and coercion, and if that fails then the prosecutors have a case of maybe prostitution or criminal theft or labor abuse that may not elevate to the to the full-blown severity of trafficking. So you want to make sure that you have a trafficking case and then that you can prove those elements of force, fraud, or coercion.

The other issue is that you need a person who's been trafficked. And so people who are trafficked for labor or sex don't always want to get up and testify against their perpetrator. They may fear retaliation. They may be intimidated. Maybe some of the services they receive are dependent on whether or not they testify, so I think laws that allow for hearsay exemption. So for example, if a sexual assault nurse examiner can testify on behalf of a patient instead of a patient.

There's some work, I think her name is Judith. There is a doctor named I want to say, it's Judith Herman, who wrote a great book about restorative justice.

Here it is. Judith Herman wrote a book called Truth and repair. And talks about whether Justice is restorative. Is it helpful to prosecute your perpetrator when you're a victim of labor or sex trafficking for the individual who's been harmed?

So it's a great read if you're interested in that topic.

So I think that you know, there's more awareness to trafficking. I think that's probably why my instinct is that's probably why there's more prosecution if you have more people being identified and people screening more, then they're more likely even, if it's only a small amount that will come to law enforcement, you know a small amount of more still more. So they may be more likely to have more cases because people are screening. There's a lot more community outreach, you know, I've heard stories about you know NGOs and nonprofits in the city going out and doing community educational trainings and person's self-identifying in the audience listening to the lecture and thinking “oh this has happened to me.” And they may not even know that they had been trafficked. So I think education and outreach are definitely valuable and that may contribute to why those numbers are about higher.

Gianni Calderara:
Yeah, I think that's a good point. Obviously better education amongst clinicians and healthcare workers, but also better education among the general population where a lot of individuals may not even be aware that they're being trafficked or that there are programs that could better help them.

We talked a little bit about some of the models in other countries and some of the policy changes that have occurred over the years kind of before we started recording, but are there any specific countries or models that are really handling this issue well, or that we could learn from?

Dr. Gordon:
There's some countries that are doing interesting things. When we think about what countries are doing, there's actually report that's been out since 2001. So for about the last 23 years or so. The “tip” report from the office of trafficking in persons that looks at countries across the globe and then rank them into tiers: Tier 1 2 and 3, and you want to be in Tier 1 because that means you're doing a good job identifying and responding to trafficking and it's less ideal to be in higher tiers because that means you are not doing enough to stop trafficking. There is a model called the Nordic model which comes from the commercial sex work space that seeks to prosecute the buyers of people, whether it's for labor or sex but in the situation is for sex, and it's a demand-reduction model, meaning they think they can arrest their way out of the demand for trafficking which is utopian concept. It's more like whack-a-mole. You know when you arrest one buyer, then that leaves the opportunity for another buyer to take their place in reality.

But Texas has done some really interesting things. So in 2022, there was a bill that passed that criminalized the buying of minors for sex as a felony in the state. And so we're one of the first states to try to criminalize buyers in that manner. And so there's some other really interesting things that Texas has done, actually wrote a paper about it. It's called the Texas model about some of the work that we're doing down here in Texas, which we are flattered by. They say if they write about you, hopefully it’s a good thing. Hopefully they're writing about you for good reasons and not bad reasons. So they're writing about the Texas model.

There's a Texas Bill 2059 that requires healthcare professionals, if they need a license to practice healthcare in whatever field they're in, to get an hour of training in human trafficking. Which is great because the more healthcare providers that get the training, the more likely healthcare providers are to identify trafficking. We know that trafficked persons see healthcare providers during the time they're being trafficked, so somewhere between 65 and 88% of trafficked persons see a healthcare provider during the time they're being exploited for labor or sex.

So if we can train healthcare providers, then maybe we can move the needle. So there are some policies that hopefully will have longstanding impact and good outcomes.

Gianni Calderara:
So let's say a clinician or other healthcare worker is in the hospital or in the clinic, and they start to suspect that a patient may be a victim of human trafficking.

What are some of the steps that that individual can take to advocate for that patient and help them? What are some of the things that they can do?

Dr. Gordon:
Well, the first thing that they can and should do is get their training in human trafficking. I'm gonna send a plug for that. Baylor now has our training online on the Baylor CME and Innovation website. The Center for Innovation has a one hour training available to Baylor faculty and staff on human trafficking. So shout out to Baylor for offering that. So if they suspect that a patient is being trafficked, then they can do lots of different things.

The first thing they should do is let someone on the team know. So share that information with social work, and whether it's a nurse or student or a doctor who's identified, and then the social work team can, or anyone from the team, can call us directly. We have a cell phone that we carry, like a Batman phone, and it's 713-397-1785.

You can put that in your phone, and if you ever come across someone who's been trafficked, you can text it, you can call it, you can email me, you can message our team, recognize HT at bcm.edu. That stands for Recognize Human Trafficking, and that goes to myself and the program director. So if you're in a situation where you're being trafficked, you can reach out to someone in real time, and someone from the team will get back to you. If you need us immediately, call or text us, and we'll call you in real time.

And we've answered phone calls from all across the city, from all different hospitals throughout the day, not only Ben Taub or the Harris Health System. And so it's an early model, and maybe there'll be a better way to do that locally.

There is a National Human Trafficking Hotline.

So the Polaris Project has a Human Trafficking Hotline. It's 1-888-3737-888. So if you're in one of your community clinics, and you don't have your cell phone with you, and you can't call or text me or my team, then you can call 1-888-3737-888.
You can only call that number if the patient consents to allowing you to do that. So keep in mind privacy laws. So if they're an adult and they tell you no, don't call that number and disclose any information.

You can always call that number if you have questions. I'm in Houston. What would I do if I suspected, you know? And they'll ping you back to us.

But it's just good to know what hotline numbers are to call, our cell phone and program number. And then we come up with a plan in real time. So hierarchy of needs.

Is the patient safe and have basic needs like food and shelter? Is the patient medically and psychiatrically stable? Is the patient ready to go into treatment?

Gianni Calderara:
And what are some effective ways or just strategies when you're initially approaching a patient with this discussion or trying to get more information about whether or not they've been trafficked or if they recognize that they've been trafficked, how do you even kind of initiate that conversation with them?

Dr. Gordon:
Yeah, that's a great question. There's a lot of shame and guilt wrapped into survivors of trafficking or people who are currently being trafficked. Patients will tell us that, you know, things like I should have known, it's my fault if I'd known better or if I didn't make that choice.

So I have no one to blame but myself. They don't think to put the onus on the perpetrator of the violence or the trafficking. So we first talk about privacy because of that shame, patients are sometimes hesitant to disclose that they've been trafficked because they don't want other people to know.

So we talk about privacy laws that protect the patient. If they're a vulnerable person like a child or a vulnerable adult that doesn't have capacity, then we are mandatory reporters. So we do have to tell law enforcement.

And that can be difficult if you have a minor who is a teenager, for example, who has shame and also fears disclosure. It's important to tell them that our job as healthcare providers is to provide health services. And we won't, if it's an adult who has capacity, we won't call law enforcement unless they want us to.

And that the reason we're asking isn't to shame or humiliate or to be nosy, but it's because patients may be eligible for services that they may not know about, whether it's housing services, mental health services, victim services, and that part of our duty as healthcare workers is to connect them to those services. And that's why we're asking.

Gianni Calderara:
And I know we talked a little bit about just the anti-human trafficking program you started here at Baylor, but could you just tell us a little bit more about the program and kind of what all it involves and kind of just like how it functions and that sort of thing?

Dr. Gordon:
Sure. So it started because the HIV field was doing a really good job in developing linkage systems between healthcare systems or linkage services between healthcare systems and community partners. So for example, if you were HIV positive and you came into a hospital, there would be a social worker that you call, that social worker, make sure all of your needs are being met, medical, surgical, housing, mental health needs are being met in the hospital and then connect you to services in the community. And then those services in the community also often have partners, including case managers or social workers.
And so that was a bi-directional relationship. If someone in the community needed health services for HIV, they would come to the hospital. Someone was identified as HIV and needed services in the community, they would then connect to these out.
They're called linkage workers. And I thought, well, that works for HIV patients because HIV patients sometimes have an interdisciplinary team that helps to take care of them the way our patients with trafficking do. So I said, well, we need a linkage worker.

So that was the idea, is to place a linkage worker, a social worker in the hospital. And then we, in our pilot programs, linked that social worker to case managers at the city level through Salvation Army. And then that way it would allow our patients to get their basic needs, like housing met and follow-up care.

And then patients who are identified in the community could get health services through us. They had a direct connection to the health system. But we also felt like the patients needed a lot of time and work in the psychological space.

So we developed a postdoctoral fellowship for human trafficking. So those are PhDs or PsyDs who have completed their training and then do a postdoctoral year with us in clinical care and research in human trafficking. And then the rest of the team is essentially just us, those of us who work at Harris Health and see these patients day to day.

Some weeks we identify a couple of patients a week, which over the years has added up. We've screened over 700 patients. We've probably treated over 500 patients.

So one patient here or there every other week over a long period of time adds up. And it gives us a tremendous amount of data too. It allows us to understand what vulnerabilities patients have, what medical comorbidities patients have so that we can help to serve them.

So who is the team? The team is myself, Dr. Coverdale, who's a psychiatrist at Harris Health, Dr. Fong Nguyen, who's the chief of psychology. Dr. Coverdale and I as psychiatrists work on the medical director and executive director side, respectively, and Dr. Nguyen as the chief of psychology and program director supervises the fellow. And then we all work together with the social worker.

So it's just us, but it's funny, we are busy.

Gianni Calderara:
Is this something that a lot of institutions have or I guess you were surprised that Baylor didn't have or I guess how unique is this to Baylor?

Dr. Gordon:
It's pretty unique. We're the only academic medical center with a postdoctoral fellowship for human trafficking and mental health.

It would be great if everyone had one. And we had, I mean, I guess not great because then that means there'd be a lot of trafficked people who need healthcare, but we would love to have, if not a dedicated social worker or at least a touch point, like a person in each hospital system in the United States who is a champion for anti-trafficking work, whether it's a nurse, a social worker, a physician, a psychiatrist. The American Hospital Association, the AHA, has a group called Have Hospitals Against Violence that's working to try to distribute plans like this across hospitals in the United States to get awareness of violence and sort of champions of anti-violence work at each hospital in the United States.

Gianni Calderara:
And one of the things that I noticed while rotating at Bent Hob and hearing stories from patients and talking to you about this issue was just how sort of emotionally draining a lot of this work can be. I wanted to get your take just on how you've been able to stay grounded over the years and what sort of things that you do to make sure that you're taking care of yourself.

Gianni Calderara:
Yeah, so some of this work, like actually a lot of things in medicine, whether it's surgery, pediatrics, can be distressing.
And so I think some of the ways of coping with those stressors and not having what we call vicarious trauma, which is the word where providers start to have trauma symptoms, intrusive thoughts, flashbacks, nightmares, shifts in worldview, changes in mood that's being impacted by the distress of your daily work is to be very intentional about working when you're working and not working when you're not working and separating work from other activities. Not to try to work all the time. Just turn your phone and your email off at a certain hour every day.

Have time with your friends and family in the evenings, on the weekends. Find something that helps alleviate stress, whether it's exercise. I'm not an athlete.

I'm sure that's a surprise to you. But I went back to art school a few years ago. And so that's been tremendously helpful to have time every week where I get to paint.

So that has been really more helpful than I thought it would be. And so I think self-awareness is key, recognizing that one of the ways of preventing burnout is to recognize when your work is taking an emotional and physical toll on your health. And then doing something about, more importantly, developing an action plan to do something about it.

I always say that with that resiliency built up, then you'll be able to work longer. Even if you have to take a little bit of time out of every day or every week. To slow down.

Yeah, for self-care. Then you'll be able to be doing the work for longer periods of time. And we hope to be able to be doing this work for a long time.

Gianni Calderara:
I did want to mention, while I was researching for this episode, I did come across an article that was written about you several years ago that sort of detailed your lifelong passion for reading. And I was hoping to end the episode, you could just give us either a book recommendation or another piece of literature for someone who may want to learn more about human trafficking.

Dr. Gordon:
Yeah, so actually the book I'm currently reading and the book I read last week, both actually happen to be related to trafficking.

I wonder if that's why people referred both books to me. The first actually won a Pulitzer. It was Demon Copperhead by Barbara Kings Oliver.

And I don't want to ruin the book for you, but it's about the fentanyl crisis in the Appalachian community and how it came to be. And one of the characters is a young boy who is labor trafficked. He's a vulnerable youth.

He is in the foster system. And it talks about how a child's social circumstances makes them very vulnerable to be exploited so easily and unprotected. So I think that is a beautiful and well-written book.

And then I'm reading a book that's a little bit more sad. I guess it's relative, right? It's called A Little Life by Hanya Hanagihara. I think it was a Man Booker Prize winner or finalist in 2015.

So I'm only getting around to it now. And it is a very beautifully, a very beautiful book about how children without trusted adults can be, which as we know is a protective factor against kids getting exploited, that children who don't have a trusted adult can be harmed and the physical and mental health harm that that has on a person. What resiliency looks like and what the value of a trusted adult brings to the table when you talk about recovery.

So both are excellent books. So I recommend them both.

Gianni Calderara
Okay, and then what about a book that has nothing to do with trafficking?

Dr. Gordon:
Oh, maybe something less distressing.

If you don't wanna work in the anti-trafficking space then go home and read about trafficking all day. So I'm also reading Jhumpa Lahiri's short stories. She was in town recently with the University of Houston imprint program.
And so she just came out with her first book in Italian. She's one of my favorite authors. She wrote the namesake and has won a Pulitzer when she was in her twenties.

And it is her first book written in Italian and it's called Rome Stories. It's a book about ordinary things. And it's just, she's a beautiful writer.

So if you're looking for just some good reading but you only have maybe a little bit of time to commit to a story instead of a whole novel, you can sort of eat, you know, read each story in chunks. So I recommend that book.

Gianni Calderara:
Sounds good.

Dr. Gordon:
Five stars for sure.

Gianni Calderara:
All right, well, I think that's all the questions that I had. Dr. Gordon, thank you so much for taking the time to come and talk to us and kind of share about your work. Really appreciate you being here.

Dr. Gordon:
Thank you for having me and for all the listeners out there.

Spotify | Apple Podcast | Amazon Music | Length: 51:35 | Published: June. 14, 2024

In this episode, Dr. Charu Agrawal shares her experience working as a palliative care physician and her journey through medicine. She discusses the challenges and rewards of palliative medicine while highlighting the importance of holistic end-of-life care.

Transcript

Race Schaeffer:
Howdy, my name is Race. I'm a first-year medical student at Baylor College of Medicine. And today I'm going to be interviewing Dr. Agrawal. Dr. Agrawal is an assistant professor at Baylor College of Medicine. She's a palliative medicine physician in the hematology oncology department at the Dan L. Duncan Comprehensive Cancer Center. Instead of telling you how she ended up at Baylor, something she'll talk about herself in this episode, I wanted to talk about my experience following her around for a day in her clinic. I’ve worked in hospice before, so I sort of thought I know what to expect conversations on futility, overwhelming patient suffering, families in denial, difficult and generally not so fun conversations. In short, I was expecting palliative medicine to center around death and dying. I could not have been more wrong. Of course, there were difficult conversations. But more than that, I remember Dr. Agrawal making her patients laugh, her patients making us laugh, and figuring out a way to manage a patient's pain well enough so that she and her husband could set sail on a cruise together the next week. I was in such disbelief that I even asked her if that day was some sort of outrageous outlier. Dr. Agrawal admitted that there were certainly highs and lows in her work, but this was a pretty typical day. This experience is one of the many reasons I'm excited to interview her today. But before that, a little background on palliative medicine and hospice. Palliative medicine is defined by the AAMC as a subspecialty seeking to reduce the burden of serious illness by supporting the best quality of life throughout the course of a disease and by managing factors that contribute to the suffering of the patient and the patient's family. For much of medicine’s history, all we were capable of really was palliative medicine. The Egyptians and Sumerians were known to use the bark of the willow tree to treat fever and pain. Medieval medicine involved ointments and salves made of worm wood and crop leek were boiled and brass kettles, things more closely resembling Harry Potter potions classes than what we'd call medicine today. Nonetheless, many of these medicines work to relieve the pain and suffering of their patients, even though they may not have treated the underlying disease. The active compound in those willow trees that the Egyptians and Sumerians used was salicin, which was metabolized into salicylic acid, and that turns out to be the main component in aspirin. Then came Pasteur’s germ theory and Lister’s antiseptic, which paved the path for the rest of the medical revolution, and what we would closer closely recognize as medicine today. Surgery boomed, antibiotics were born, vaccines were administered. But then around the 60s and 70s, people began to wonder if our pursuit of curative medicine had perhaps lost sight of the value of palliative medicine. So, the Hospice and Palliative Care movement was reignited. By 1980 hospice care was covered by Medicare. By the 90s it was designated as it sounds specialty, and by 2000, it was gaining widespread recognition in the US, and then in 2010, a paper out of the New England Journal of Medicine clearly demonstrated that hospice and palliative care was more than an existential service for patients at the end of life. This paper showed that not only does palliative care integrated with oncological care improved patient's quality of life, but that it also increases length of life and decreased cost of care. One of my favorite quotes about palliative and hospice medicine is by Dr. Atul Gawande, when he said “if this were a drug, this would be a multibillion-dollar blockbuster, and the FDA would put it on ultra expedited approval. But instead, it was just having these conversations.” 

And with that, I'd like to welcome Dr. Agrawal. How are you Dr. Agrawal, thank you so much for joining us. I'd like to start off with the classic introductory questions. How'd you end up here today? From hometown to college, to medical school to Baylor, and how did you choose palliative medicine?

Dr. Agrawal:
Oh man, how did I end up here? Well, to be honest, I had no idea I was going to be a physician, let alone a palliative care physician. I used to want to be a cashier as a kid, as I really loved math. I was raised in Sugar Land, Texas, not too far from here, brought up in a big fat Indian family who immigrated in the early 80s. All eventually creating their own businesses. I had the one family who did not actively wish for their kids to go into medicine. But I loved math and science, so medicine seemed like the thing to pursue. I went to college at Wash U where everyone was pre-med. And despite the whole look to your right, look to your left, only one of you will finish pre-med. And I was between two very smart Asian guys. Somehow I came out still pre-med. Afterwards I wanted to spend a year in India working at a women's shelter, but tensions got heated between India and Pakistan for, like, the umpteenth time. And my parents were like, no, we don't feel comfortable with you going. And this was like the middle of senior year. So, I had to scrap my plans and try to figure out something else. Given that I was I wasn't really completely sold on medicine. And my parents were telling me, “Are you really sure you want to waste your good years in medical school?” I did a year in Philadelphia, where I took medical school classes to see if this was really what I was interested in. And that's where this path started making sense. I went to Texas A&M for medical school, where not only did I meet the love of my life, but I also felt like I had a system rooting for my success. And I thrived. And my love for medicine and patient care grew. I followed my husband to Georgetown University for internal medicine residency, thinking I wanted to be an oncologist. Then my first month came along and I was in the medical ICU. And I fell in love with that field as well. So fast forward to second year of residency. I had a mid-residency life crisis not knowing what I wanted to do: oncology versus critical care. And I realized what they have in common, very sick patients who need not only medical life prolonging interventions, but also a hand to hold, more conversations, and more of a focus on their quality of life. I realized I really loved being in the room talking to patients, when other people were stepping away. I did a palliative care rotation. And I believe it only took about two hours for me to be like yep, these are my kind of people. And I really love this work. I will never forget tweaking someone's medications, seeing them the next day. And they had tears of happiness, saying they couldn't remember the last time they slept through the night without pain waking them up. I was like, Man, this feels awesome. I want to feel like this every day. Prior to that I had never felt that, you know, that kind of warm and fuzzy feeling when I got somebody's blood pressure down. Their symptoms is what I really cared about and brought me so much joy and wanted me, you know, made me want to come to work every day. I then went on to complete my hospice and palliative medicine fellowship at MD Anderson Cancer Center. And I eventually made my way to Baylor, or somehow I got very lucky. And I got the opportunity to create a palliative care clinic and inpatient service dedicated to the care of patients with cancer. We're embedded within the medical oncology clinic where I get to see patients alongside their oncologist to provide really good, coordinated care. It's just the best job ever.

Race Schaeffer:
And so was the deal that you follow your husband to Georgetown and then he followed you to Baylor

Dr. Agrawal:
Oh, you know it. I have a big fan family in Houston. And I knew once we got there, we wouldn't be going anywhere else. So that was the agreement. I followed him for residency. He followed me for fellowship, but I didn't tell him what my plans were all along. Now he's stuck here now he loves it.

Race Schaeffer:
And so, I gave the AAMCs definition of hospice and palliative medicine. But I was wondering if you could give us Dr. Agrawal’s official or unofficial definition of what you do.

Dr. Agrawal:
So, I practice in palliative care I am boarded in both Hospice and Palliative medicine. But day to day I practice in palliative medicine. Palliative care is a specialty focused on quality of life for patients with serious illnesses. We help support patients through the course of their illness, get a better understanding of what they value in their healthcare so we can advocate for them. We help set appropriate expectations. And we also try to help their primary caregivers as the patient aren't going through this disease alone, but rather with their whole village. Hospice, on the other hand, is provided when the patient has an illness where their physician says I wouldn't be surprised if this patient passes away within six months, and no further disease modifying treatments are being pursued. So, they focus on allowing nature to take its course while providing comfort and minimizing suffering. This is usually like a multidisciplinary team who comes to the patient's home to provide that kind of care. So, there are different things, hospice you could kind of consider it like the tail end of palliative care, but palliative care itself is a broader scope and can be integrated at any point in the disease a trajectory. A typical week for me is split about half and half between inpatient service and clinic. And you know I like I said before I get to work alongside are awesome oncologist and providing coordinated care to our patients. And in the hospital, oftentimes, we're dealing with acute symptom crises, cancer related complications, and sometimes even having very difficult conversations about this huge life change that they've gone through, and what lies ahead. While in the clinic, we're able to sit with a patient, discuss what everything means, what their hopes are, what's stopping them from being able to live their lives the way they want, and what we can do about it. I really do think here at Baylor, we've got this unique service where we get to follow our patients, from the clinic to the hospital and back. And we really provide excellent continuity of care.

Race Schaeffer:
And so, in medical school, we're taught about the ubiquity of uncertainty and the necessity for good physician to be able to navigate it. What does uncertainty in your specialty look like? And how have you learned to navigate it?

Dr. Agrawal:
My specialty is fraught with uncertainty. It's very humbling. And I think it keeps us grounded as physicians. The way I navigate it, is by simply acknowledging it. It's oftentimes the elephant in the room, and it's okay even as physicians to say, I don't know. I too often tell my patients that I'm not God, I don't pretend to be God, and I have no crystal ball. All I can do is present evidence-based medicine, but they're a person, they're not a statistic. I will share those statistics if they want to know that. But other than that, I can't see into the future. Even when asked to give a prognosis. I say minutes to hours, hours to days, days to weeks, weeks to months, etc. I often say, I worry that they may not survive the night or I wouldn't be surprised. But I will never say things in certain terms. Because again, I can't see into the future. Some of my patients joke with me saying, Yeah, I know you're a physician, you're never going to say anything with certain terms. And I say, Yeah, that's true. We don't know, we have no idea. And we're constantly surprised by people both for the better and for the worse.

Race Schaeffer:
You talked a little bit about how you manage it. And I was wondering how you think your patients manage it? Like you gave us an example of humor. But what sort of coping styles have you seen in your patients?

Dr. Agrawal:
Yeah. So, you know, they say, when it comes to coping, the way you cope with something is the way you've coped with things all your life. And so, every person is different. And their life experiences really dictate that. So usually, with patients, one of our mottos that we talk about is taking things one day at a time. And it's something that we say very often, and they repeat that back to because for a lot of them, that's how they feel like they are taking things: one day at a time. I have some patients who say, hey, if I'm awake, and I'm alive, and you know, I'm doing okay, for the most part, it's going to be a great day. And so, it really is one day at a time, given that kind of uncertainty. We, you know, we try to provide the tools that they need to cope in a healthy way. But coping is extremely complex. One thing I wish all of our patients had access to, which we're actually actively working on, is having access to a psychologist, because I do think every one of our patients could benefit from that. And I'm really happy to say in a few months, we're going to have our own psychologist who is able to see, you know, any of our patients who have those needs. But they can only do so much, I can't change family dynamics, I can't change the experiences they've had about losing another loved one to cancer and the way that they deal with it, but I can try to just be there for them. Let them feel like they have a safe space where they can talk about things. I do think, you know, it's a really humbling position to be in where people can do, people can share how vulnerable they feel. And some of their deepest darkest fears that they don't talk to other people about. They don't talk to their own family about for fear of how they may take it. And so, I do think we are very lucky that we get to have this kind of sacred relationship with our patients. And it's important to take that seriously and do whatever you can to support them.

Race Schaeffer:
And I might be biased because I'm such a fan of palliative care, but it's really evident that relationship. You know, people call medicine, a science and an art. And whenever you talk about that sacred relationship and having those that No Man's Land conversation with these patients, that becomes really clear.

Dr. Agrawal:
Yeah, so actually, you know, when I was in residency, especially my intern year, there were times where with certain physicians, I felt like we had one conversation outside the patient's room and then we would go in and say something somewhat different where we didn't talk about our concerns and when I was like, come on, you can do it type of thing. And I would be like, but we just talked out there about how the chances of response are so low and there's just this disconnect. And the patients are looking to us to give them the best treatments possible. But oftentimes to also be, you know, transparent and honest about things. Why would we ever recommend something we didn't think would or could potentially help. And yet, very often, we do that, because we don't know what else to do. And so, I think that this kind of relationship we have with patients is something not to take lightly. And really, it's so important, I always tell all my patients, I can't speak for other people. But for me, you will always get honesty and transparency as much as you want. Because everyone, you know, they take information differently.

Race Schaeffer:
One of my favorite scenes from a movie called Interstellar, have you seen it? With Matthew McConaughey? Yeah, you know, the robot. It's like SARS, or VARs, or something,
I don't remember the robot's name, But it has an honesty setting. And throughout the movie, it changes from like, you know, whenever I think he reduces the honesty setting, because he gets tired of the robot, like saying all this really dark stuff. And I think he also has a humor setting or something like that. And so, I feel like being in your position, you modulate your settings.

Dr. Agrawal:
Oh, absolutely. Absolutely. Like, there are times where when I'm working with a resident, I'll be like, Look, they understand the severity of their disease, every time I see them, I don't have to sit there and be like, you know, you have a stage four cancer. And this is what this means. You don't need to beat them over the head with what is going on. Most of your patients have a very clear understanding. And once you've established that they do understand things, you move on, you talk about what makes you know, what helps them have a good day and what their everyday is like, and you don't have to keep beating them over the head with it. You talk about where you went on date night recently, you have restaurant recommendations. I had a patient who loves telling me about the massages she would get around town and fun Korean spas. We talk about those things.

Race Schaeffer:
That sort of leads into another question that I have about the language surrounding your specialty? How do you understand and deal with language like, “he's a fighter”, “don't give up on me”, “we'll do everything it takes”, “we'll beat this.”

Dr. Agrawal:
I think I hear this in some capacity, probably almost every day. But here's the thing, my patients are super tough. They give it their all, and we don't give up on them. I remind our patients, and especially their family members, because usually the language is coming from the family members, that this is a disease happening to them. There is something that's in their control, compliance with treatments and appointments, relating to us their symptoms, staying active on nutrition to a certain degree, you know, not smoking, but then there's a lot that's not in their control: the way the cancer responds to the treatment, for example, it's not in their control, it's not really even in our control. As a medical team, we use our expertise to give them the best treatments for that patient balancing between efficacy and quality of life. And then after that time will tell. We’ll always be there for the patient, walk with them, provide with them, you know, provide them the best care possible, and remind them that the cancer does not define who they are. If the cancer does not respond the way we hope, the patient hasn't failed, they've not given up. But rather the treatments have failed them. We're also limited by the treatments we know of and clinical trials that that are available to us. If we run out of cancer modifying treatment options, or if the risks outweigh the benefits. It's because we haven't come as far as we would like in medicine. So, I tell people, there's no doubt that they're extremely strong. No one thinks that they're giving up. And we're absolutely you know, going to do everything we can to help get through this. But we are also limited. And not everything's in our control. And not everything is in our poor patient’s control. So, reminding them that this person is not cancer, but that cancer is happening to them. I think that can be really helpful for trying to kind of separate the two. But I never refute them when they say those things. Because I think I would feel the same way if I were them.

Race Schaeffer:
How's it been dealing with that? We talked about patients but how's it dealing with family members? How does that experience vary?

Dr. Agrawal:
So, I really do think especially when dealing with a disease like cancer your support system can make or break your experience. I feel so horrible for the for the patient to have no family or friends here. Whether that's they've emigrated from another country, or you know, they've lost touch with people, or we've had patients who have lost all of the closest people around to them to other illnesses, and oftentimes to cancers. It is so difficult to go through this journey, whether it's your calendar, being full of appointments, simple things like transportation, feeling so weak feeling so terrible, you feel like you can't drive, getting sedated on medications, how much gas costs, and you're already hemorrhaging money by having to meet all your deductibles, and co pays, and in all of our patients pretty much meet their deductibles in January. Having cancer is a very expensive disease, you can't work very commonly, people aren't able to work as they go through diseases, and trying to keep your insurance during that time can be really difficult. I mean, all of these things, and you have nobody to help you with these things to make you a meal, when it's really hard for you to go to the grocery store, get the food, make something, you know, stand for that long and do these things. I mean, it's, it's so difficult. Family or friends can be extremely helpful, whatever your support system really. I truly mean it, when I say they can make or break your experience, they can provide you so much support in terms of all of these other things that we mentioned, that can be in your control, making it to your appointments, staying on top of your nutrition, motivating you to get out of bed, and walk around, things like that. Now, of course, family has its pros and cons. We've had it where, you know, a family member said, oh, don't take any chemo, that stuff is going to kill you. And then a person with “x” condition has declined significantly. When that could have been avoided by, you know, by other types of treatments, or the person at church who tells you to take the worm medication as they know this person whose cancer was cured by this, and they convince you not to do those things. We've also had family members who are convinced that doctors have a silver bullet for cancer, but we just refuse to give it because we'll be out of business. And I've actually probably just this year alone had this conversation at least three or four times with different people about how if we had the cure to cancer, and we were just sitting on it, wouldn't we at least give it to our family and friends that people that we love and doesn't really make sense that we would keep it from people? I try to remind them that, you know, going into medicine is a very difficult thing. You don't just do it on a whim. The vast majority of people in medicine are in it for the right reasons. They want to help people. So, if we had something that could actually cure cancer, why wouldn't we be acting on it? You know, and unfortunately, misinformation spreads very quickly, especially through things like social media. And there are so many people who will comment on “do this, do that, do this, do that.” And I do try to I try to help be that person who's like, okay, tell me all the things that you're hearing? Let's go through things one by one. I try not to refute it right from the beginning. But we talk about what's the evidence behind what they're saying. Is it going to drain all your money? How can this be an adjunct to treatment. And so very commonly, we end up talking about, you know, herbal supplements, we are recently we've been talking about marijuana a lot, other drugs, vitamins, etc. And so, I try to make sure that the family feels that they're being heard, because they're always coming from a good place where they're like, they want to help. But sometimes you have to balance that with, you know, the actual science part behind it.

Race Schaeffer:
So, I'm glad you brought up that I ignorantly haven't really given a lot of thought of, and it deserves an entire conversation of its own is the employer base structure of health insurance, and how so many people who are getting treatment for cancer lose their jobs. And so that means so many of them are going to lose their insurance.

Dr. Agrawal:
Yeah, actually, just this morning, I was seeing someone in the hospital who had just started concurrent chemo and radiation and when you start radiation, you need to continue all your treatments. And it's for her at six weeks of radiation. And she was going to be starting her chemotherapy this week. And she comes to check in and she gets told your insurance plan was terminated. This is how much chemo is going to cost out of pocket. Doesn't mean we don't even know how much radiation is going to cost but that's going to be what for another five and a half weeks of treatment. And it had to do with the fact that when she got diagnosed she had to stop working and then she went on her husband's plan, and then her husband had to leave that job in order for it to be something a little bit more flexible such that he could be there for his wife. So now she doesn't have health insurance, she's already started three treatments of radiation. You can't go a long period without just having to kind of discard those three treatments. And also, time is of the essence at the moment, she has a potentially curable disease. But now because of this, I don't know what's going to happen. So, I'm frantically calling her oncologist. We're trying to figure out a plan. We've got social work on the phone; we're trying to figure out can she apply for Medicaid? Can we go through Harris County, and the thing is, all of these things take time. And I don't know what's going to happen to the cancer in the meantime. And on top of that, we started her on treatment, we started her on, you know, we started her on radiation. And it was like all for naught. I feel terrible for her. It's a horrible system. It really is. And unfortunately, those have a lower socioeconomic status are absolutely hit harder. Luckily, in Harris County, we have an awesome system. But we get so many patients from Montgomery County, Fort Bend County, all these other places that don't have these kinds of resources for those patients.

Race Schaeffer:
That's one thing I didn't know about Harris County before coming here was how good of a job it does have taken care of its own. But that doesn't mean that people aren't left falling through the cracks here.

Dr. Agrawal:
Yeah, absolutely.

Race Schaeffer:
I'm going to pivot a little bit. And I was wondering how in a world that values curative treatment so much, how do you help manage expectations of treatment with the reality of mortality, and that not all treatment can be curative?

Dr. Agrawal:
So that's a really good question. It's, it's really tough. Now, because I work alongside our oncologist, I get to cheat a little bit by having someone else normally tell them before I do, our oncologists are really, they're incredible for many different reasons. Aside from being truly experts in their field, I love that they set expectations from the beginning, they sit down, they have a long, you know, chat with patients as to what does this mean. And compared to other oncology groups I've worked with in the past, they are much more, they're much more than just kind of forthright about, hey, this is what the goal of treatment is, if it's curable or incurable. And I've heard the language that they use, and I do think that they try to use layman language and make it such that the patient and the family understand things. So, I mean, I really try my best to kind of talk to them about, hey, this is what we know of this disease as of 2023, medicines constantly evolving, but we don't have cures for everything. You know, for example, from what we know of stage four, pancreatic cancer at this point in time, we don't have a cure. So, we talk about how I wish we had a cure. But we don't, at this point in time, if that ever changes, you'll be the first to know. But we have treatments that we can provide with the hope of living longer, and with a good quality of life. And so again, I think it's really important to be upfront about the expectations of treatments, but in a compassionate way. You don't just say, hey, this is terminal, you're never going to be cured, you're going to die. Nobody, you should never talk to a patient that way. But you reassure them that you're going to do everything you can to help them. But that may evolve what that means may evolve over time. But at this point in time, we don't have something that we can say, hey, this is going to cure this. But we do have other treatments that we that will hopefully give you a longer life. But without sacrificing your quality of life.

Race Schaeffer:
I wanted to know what the what your favorite part of your job is? And then what your least favorite part of your job is?

Dr. Agrawal:
Oh, my. The best part? That's a very easy question. My patients, they're just the best. I mean, you got to you got a little taste of them the other day. My patients are the absolute best. Whether it's, you know, busting a pancreas piñata with the patient, or, you know, talking about Korean massages, I mean, they're just, they're the best. They have the best outlook on life. It's all about the it's all about the small things. And when you sit there and you talk to them, you're like, Man, my problems are so tiny. I need to stop whining like I've got it really good. And getting to just talk to them about what they value is so refreshing. It's really incredible. The hardest part is seeing them suffer and seeing their family suffer. And feeling like you can only do so much. Of course, losing them as always very hard to, I've had so many patients become such a regular part of my life, and I'm talking to them monthly, sometimes even weekly for years, that when they're gone, it hurts so much, it does feel like some does feel empty. Seeing their family, especially their little kids left behind to grieve this amazing person is just the worst. Seeing the kind of devastation that's left behind. What I hope, though, is, we can help prepare them as much as you can possibly be prepared for something like this. And that we can get them the resources they need to try to cope in a healthy way. But it's always so hard.

Race Schaeffer:
I know you mentioned the initiative y'all are doing with getting a psychologist on your team? Do you consider talking to the family and preparing them by having conversations with them part of your job.

Dr. Agrawal:
I do think it's a part of my job.

You know, I'm a big proponent of painting a picture. And we talk about best case scenario, worst case scenario and thinking about those different things. In general, in medicine, we do a very good job of hoping and praying for the best, but we do a terrible job of preparing for the rest. And so that's what we really try to talk to patients about is this is what I hope and pray happens that this cancer is going to respond beautifully, that we're going to see this. Your pain is going to be less, you're going to feel more like yourself, you're going to get to go on that trip to Paris, etc. But let's also talk about what if we don't get what we want, whether that's now or further down the line. Talk to me about what's important to you. It's important that you have those conversations with your family about what if we don't get what we want such that they've heard it from you. Because oftentimes, complications happen, and then you can't make your own decisions, returning to family. And if they've never heard it from you. That's a really hard thing to try to have to come up with all these decisions on your own. And I tell them, I hope you never, you know, I hope your family never has to use that information. But if they do, they've heard it from you. And my husband and I–he's pulling critical care–do this. And so, we see unexpected things happen all the time to also young people with little kids like us. So, we've had multiple conversations about

Um, you know, what if this horrible thing happens, you know, I want you to remarry. This is what I'd want to happen to the kids, you know, at what point are you okay with a trach and peg and all these other things. And we're both bawling. We're sitting in our cars just crying. But at the same time, I hope he never has to use us that information, but he's heard it from me. Then you move on, right? We had that conversation. We don't talk about that every day. We rarely ever talk about it. But then we focus on the living, and we focus on the here and now and how we can just try to enjoy things, you know, to the best of our capacity.

Race Schaeffer:
Yeah, advanced directives, is a pretty serious issue for public health right now. I think most Americans die without an Advanced Directive, which is absolutely crazy. It takes such a short period of time to complete them.

Dr. Agrawal:
I think I give this spiel to every single patient and probably every trainee as well that I'm like, have you done your medical power of attorney? Do you know your parents would be your medical power of attorney right now? Is that who you would want?

It's very important to do them. And there's some basic ones, or selfishly, as a physician, I care a lot about a medical power of attorney such that I'm always talking to the right person. But that's a really simple thing to do. And I tell people, it's just like car insurance, you hope you never have to use it, but you get it just in case. Same thing with advanced directives. You hope you never have to use them. But you got it just in case. Have you completed your advanced directives?

Race Schaeffer:
I have. 

Dr. Agrawal:
Okay, good.

Race Schaeffer:
Yeah, super simple one. That's super simple.

Dr. Agrawal:
Okay.

Race Schaeffer:
Yeah, going back to your favorite part of your job, I remember, at the end of the day, I asked you, if that was some sort of outlier of the day, because I was so impressed by the people that I had met, like about one patient. I know exactly how she had me rolling. I was about to fall off my chair, this patient was so funny. And then this super sweet patient that
we talked about, you talked about making it possible so that she and her husband could go on the cruise from Galveston, and they were so sweet. I was so impressed.

Dr. Agrawal:
I'm telling you, my patients are just the best actually. With that patient, we bond over our love for Trader Joe's and Costco. And we talk about the seasonal items. I mean, it's just who can do this in their job, it's really the best. And one thing I commonly hear is that they appreciate that they feel human in our clinic, they don't feel like a disease process or lungs or kidneys or whatnot. They feel like we're treating them like humans, which is what we are constantly reminding them of is you are human, you are not this cancer.
But yeah, my patients are really the best. Yeah.

Race Schaeffer:
So, this is this next question is a bit of background and then the question comes at the end. So, one study in the New England Journal of Medicine took two groups of patients treated or being treated for metastatic non-small cell lung cancer and scheduled only one group for palliative care visits. In this study, palliative care resulted in a significant reduction to be on chemo in the last two weeks and three months of life, more time spent at home, less time spent in the hospital, a decrease in the likelihood of dying in the hospital, less suffering, lower rates of anxiety and depression, lower costs and a 25% longer survival. Considering these metrics, why do you think palliative care is still underutilized? And how do you think we can go about bridging the gap between people who would benefit from palliative measures, and those not receiving it?

Dr. Agrawal: 
I wish all of those things could be on a billboard. And like put in front of every medical institution. I think that while we've come really far, there's still a lot of misunderstanding about what palliative care is.
You know, it's often confused with end-of-life care or hospice, even by many physicians. I mean, oftentimes when I tell people what my job is, you know, the response is home and must be so sad. And it's, you obviously don't understand what palliative care is.

But people just equate it to end of life care. And so, I really think it comes down to kind of education, I'm really happy to see so many medical schools and residencies exposing trainees to palliative care, because this will influence what they know of the field and therefore utilize them. So, when I joined Baylor, I will say our oncology group is you know, on the younger side, but all of them have had exposure to palliative care in their training at some point, so they actually understand what we do, and therefore they utilize us in that capacity. They're not like, oh, this patient is actively dying. Now I need you. They're like, hey, this person is symptomatic, or this person has a [gastric tumor] I can't cure, and they're really suffering in their quality of life, I do think that their prognosis is years. And I'm like, yes, we should. Absolutely, that's absolutely appropriate for us to see that patient.

But it's also often misunderstood by medical institutions, again, as end of life care. It's a vital service for our patients with serious illnesses and requires, you know, investment by medical institutions. Given the fact that we don't do procedures, and instead, we spend just a lot of time with patients, we don't generate a lot of revenue. insurance doesn't really reimburse well for time spent with patients. They reimburse well for things you do to the patient. And so, it does make it harder for institutions to prioritize it. They also because they think of us as end-of-life care, they tend to utilize them really only in the hospital, when it's equally important, if not more important, that we're also in the clinics,
helping people even when they're not in a crisis,as we generate more data showing the value of palliative care, I really hope it becomes more available to patients.

Race Schaeffer:
Now, we just need to rely on the insurance companies to change their reimbursements.

Dr. Agrawal:
Right. And that’s not going to happen. That's not going to happen.

Race Schaeffer:
Have you seen a change? You talk about your team? But have you seen a change in your career on the perception and utilization of palliative care?

Dr. Agrawal:
Yeah, I really have. You know, I mean, I went into medical school, not knowing what palliative care was, I think maybe I even went into residency not really understanding what palliative care was. Not that I came from a big medical family, but still like, you know, highly educated. And I didn't know. And so, in residency when I actually got some exposure to it, and then really, of course, immerse myself in it in fellowship, I had a much better appreciation for the scope of the field. And so, in my first job, right out of fellowship, I was working at Memorial Hermann in the heights. It was pure inpatient. And there were very few, very few physicians who actually, you know, consulted us early. And for the most part, it was ICU physicians, or, you know, sometimes even dispo, like, this person has been here for three months, we don't know what else to do, let's consult palliative care.

And then I came here, and it was like, great, you're here, I just got this, you know, new consult, and this person has a new diagnosis of pancreatic cancer, I think it'd be great to get you involved right now. And it was a world of difference. It was, it was so, so nice to see that. Even in the hospital now, it's pretty rare for me to get consulted to you know, more than a few days into the person being here. It's usually in the ER, they're calling being like, “Hey, I think they would benefit from seeing you at some point.”It's really, it's really nice to see that change. Again, we still have a long way to go because a lot of people still think what we do is end of life care. But I'll say especially in the oncology world, given awesome data, like what you just presented, there is more of a focus on integrating palliative care early.

Race Schaeffer:
And how do you think we can change the conversation around end-of-life care so that it's not, um… so, doesn't get the reputation of end-of-life care?

Dr. Agrawal:
So that's a hard one, because I do think even a lot of people, when they hear the word hospice, even they think, oh, this is a place you go to die. It's not a particular place, you're not going there to die. It's oftentimes dying patients are referred to hospice. And so, you could call it in a sense, a self-fulfilling prophecy, but it's not where you go, somebody hangs a morphine drip, which is what a lot of people still think it is. There's a lot of mistrust there. But during my fellowship, I actually got to work with hospice companies and go to people's houses and see what they provide. And it was really eye opening. And thanks for that experience. I get to talk to patients more about what they do, where it's a whole team of people, nurses, social worker, chaplain aides, and then there's usually a team physician, and they go and check in on you and check in on your whole family. How are you feeling? How's it going? What do you need to help care for your loved one? Do you need a hospital bed? Do you need oxygen, do you need medications? Everything comes delivered to them such that families aren't having to run around town. They can turn aides out to help with bathing, things like that to take away some of the stress of providing round the clock care that that is put on families and they're also there to provide counseling. So that's my favorite part is actually the grief counseling that they provide all hospices after the person has passed away provides free grief counseling for at least a year to a family. We can't ever get that with anything else. I mean, even when people pass away in the hospital, I mean, it just feels like that's it, there's no closure. You know, I had my uncle passed away in the hospital from COVID. And his family is out of the country couldn't come here. And so I was at his bedside, when we, when we kind of withdrew the artificial life support and allowed him to pass naturally. And when I left, it was a very weird feeling. I was like, Wait, that's it. But that's it, I'm just going to now leave and get into my car and drive home. This can't just be it. There was zero closure, there was nobody calling in to check in aside for my family. But there wasn't there was there was nobody looking out for me, other than my family.

And I feel like that's just wrong. That's just wrong. That's the end of someone's life, there should be something more than that. And Hospice provides that whether you're on their service for one minute, or you've been on their service for three years. They're there to help provide that kind of counseling.

Race Schaeffer:
So now, one of my last questions, it's another long one. One of my favorite books is Being Mortal by Atul Gawande. And in this book, he reckons with the question of how we can live a good life up to the very end. Dr. Gawande is a big fan of checklists. So, one of the topics of the book is a checklist for any physician to put in their pocket to help them have these conversations about end-of-life care. At the top of the list is “what does a good day look like for you? And what would you not be willing to sacrifice in the course of your treatment?” I was wondering if you wouldn't mind putting on the patient's hat and answering these questions yourself.

Dr. Agrawal:
You know, there's a reason why I feel a lot more comfortable on the physician side, rather than the patient side. So, what does a good day look like? Well, honestly, the answer to this has changed depending on what stage of life I'm in, and that it'll keep changing. Currently, a good day looks like hanging out with my husband and two kids, maybe dancing around the house, you know, ideally enjoying some good food together. But that's pretty much about it, I wouldn't be willing to sacrifice large chunks of time away from my family, or my disease stopping my children from living their lives. You know, I really think I would want to do whatever I can to watch my kids go through milestones. I never thought I would be the type of person who would even consider trach peg, all of that type of stuff. But I think with having little kids, and I want to see their milestones so badly, that I think I would think a lot more about these things than I would have before having kids. It's definitely changed my outlook on that. But I would also never want their lives to stop. I wouldn't want to do anything that would, you know, prevent them from being all that they can be. Because of what I was going through. I'm okay with shopping my husband's life, but, but not my kids’ lives.

Race Schaeffer:
That's awesome. Thank you for sharing. So as a final question, I wanted to ask you for a recommendation. So, what's a good book, movie or any form of media that you've consumed recently, and have enjoyed?

Dr. Agrawal:
Why do we actually do things outside of work? No just kidding. I think I tend to gravitate towards very light and airy media, given the gravity of the work that I do. I really, honestly rarely watch anything that's like serious or very sad. I'm all about the rom coms and I think it's a nice escape from the realities of my work every day. But I did on a vacation recently read lessons in chemistry by Bonnie Garmus. Highly recommend that book, especially if you are a female in medicine, but that one's a really great book.

Race Schaeffer:
Right on I was recently recommended scrubs

Dr. Agrawal:
Oh scrubs is so good. Oh, scrubs is amazing. I've seen scrubs, like multiple times. It's probably the closest medicine show to actually how medicine is. But that's I think that's a really great show because it shows people working hard but also coping in the ways that they know which includes a lot of humor and appletinis. And, yeah, and the and the bromances that you develop with your colleagues because you're in it together. You're going through a really hard thing together. So that's a great show. Definitely recommend that one.

Race Schaeffer:
Every physician who's recommended that or or even watched part of it. They're always the one thing they always say is that it's the most accurate.

Dr. Agrawal:
Oh, yeah, no doubt about that. I think my parents recently had been watching a, like New Amsterdam or something like that. And they were like, is this what it's like? And I was like, I haven't even seen it. But I can tell you this is not what my job is like.

Dr. Agrawal:
And actually, it was my ethics facilitator, Dr. Hoppenot, whose gynecologist oncologist.

Dr. Agrawal:
I love. I love Dr. Hoppenot. Oh, yeah.

Race Schaeffer:
And we were talking about end-of-life care and what it means to extubate somebody, and somebody was talking about.., somebody was saying, or kind of being flippant about the idea of extubating somebody and removing that life support. And she was like, actually, that's, you know, every patient that I have had to do that sort of, I've had that sort of interaction with, like, they stay with you. And she brought up one of the episodes, or I think throughout the episode, the people who died on their ward, follow them around. I've only finished season one. So, I haven't actually seen that episode.

Dr. Agrawal:
But no, it's true. And I think that, you know, unfortunately, as you go through more and more years of medicine, you feel bad that you can't necessarily remember every single person. But there are many people who just stay with you. So, you know, I had my first year of residency. Christmas Eve night, I was working in the ICU. And I had a really horrible scenario where as a young guy, who pretty much had signs of brain herniation, and was on all forms of life support and, and it was a holiday, and there's no attending in house and I had to have kind of a goals of care conversations before I knew I wanted to do palliative care, and to have a kind of a goals of care conversation 3am Christmas morning, and I had to call his parents and, and we had to have that really hard conversation. And actually, it was his father who brought up to me how kind of crazy the whole end of life is, especially in the hospital where he said, so what we just turn off the machines, get our parking ticket validated and leave, as if our son never existed. And of course, I started bawling.

And that was also a good lesson, you know, to try to hold in your tears as much as you can while talking to family and allow them to cry and be there for them. But that was my Christmas morning. And I just thought about this family and how this is how they're going to remember Christmas, every year. Every year on Christmas, we do Christmas big in our house, and I pour one out for him. And it's been, you know, almost 10 years now. And I will never forget that. And I have many patients who are like that. I have one oncologist for all of his patients, whenever they pass, he puts it on his calendar for one year from now. So, he remembers to call that family on their one-year death anniversary to check in on them. I mean, we all have different ways that we kind of cope with it. But yeah, we're human. You can't just let these things just kind of slide off your back. And that's a good thing. The fact that you know, these people stay with you means you care. And Dr. Hoppenot is amazing. And so, I'm not surprised that those things matter. And we, I mean, she's seen me cry, I've seen her cry, we feel things about our patients.

Race Schaeffer:
So, lessons in chemistry for the book and Scrubs for the TV show.

Dr. Agrawal:
I highly recommend scrubs for the TV show. I think it's actually number one on Amazon right now for its genre.

Race Schaeffer:
Well, Dr. Agrawal, that's all I have for you today. Thank you so much for coming.

Dr. Agrawal:
Thank you guys so much for having me.

iTunes | Amazon | Spotify | Length: 52 | Published: June 7, 2024

In this episode, Dr. Kjersti Aagaard discusses her journey into microbiome research and specifically into placental microbiome research.

In this episode, we talk to Dr. Nathan Lindquist, assistant professor in the Department of Otolaryngology – Head and Neck Surgery, about cochlear implants and his perspective on advancing the field of caring for patients with hearing loss. We discuss his journey to otolaryngology and neurotology, learn about cochlear implants, and look forward to the future work necessary to improve cochlear implant outcomes and increase access to hearing loss treatments.

Transcript

Gianni:
Hello and you're listening to BCM’s resonance podcast. We’re a Baylor College of Medicine podcast, run by students within the medical school and graduate program here at Baylor College of Medicine, where we interview clinicians, faculty, and researchers about their work. My name is Gianni, and I’m a third-year medical student here at Baylor College of Medicine joined today by Aaron.

Aaron:
I'm Aaron Nguyen. I'm one of the co-hosts and the writer for this episode as well.

Gianni:
And Aaron is going to be leading us through a discussion today about cochlear implants with Dr. Lindquist, one of the new faculties within the otolaryngology department here at Baylor College of Medicine.

Aaron:
Yeah, so Dr. Lindquist is an assistant professor, otolaryngologist, and neuro-otologist at Baylor College of Medicine in the Department of Otolaryngology —Head and Neck Surgery. He has a particular interest in both adult and pediatric hearing loss, hearing rehab surgery, implantable devices, including cochlear implants, and lateral skull base tumors. He earned his medical degree at St. Louis University and went on to complete his residency in otolaryngology here at Baylor College of Medicine, and then following residency, he completed a two year clinical and research fellowship in otology, neurotology, and lateral skull base surgery as the Michael E Glasscock III fellow of the otology group at Vanderbilt University. He recently came back to Baylor and joined as a faculty member just last year, and we're really excited to hear his perspective today. Today's episode is focused mostly on cochlear implants, what they are, who could benefit from them, and then also talking about certain themes in expanding access to cochlear implants and other hearing aids and then also improved outcomes for patients with hearing loss.

Aaron:
And so I'm here with Dr. Lindquist, thank you for coming in Dr. Lindquist, how you doing?

Dr. Lindquist:
Doing well, thank you for having me.

Aaron:
And so ,we've already did a little intro about you. But I always like to ask our guests a little bit about their background. And so ,can you tell me a little bit about your journey to medicine? Like, how did you decide that you wanted to be a doctor? Take us back, maybe a couple years.

Dr. Lindquist
Yeah, sure. So I, my father was a family medicine doctor, he did sports medicine. And he actually worked at the health center in the town that I grew up in the student health center at the university. So I remember going with him on weekends and stuff like that, and getting exposed, and then try to try my best to explore other avenues as well, including business and chemistry. But, you know, in college, I ended up gravitating back towards deciding that I wanted to be a little bit more involved with people directly and kind of, you know, how that front facing work to help people improve their health.

Aaron:
And so your dad was a family medicine doctor? What was that kind of conversation about like, coming from a family and medicine and choosing a specialty? Was that ever a consideration to be a family medicine doctor? Did you feel like you had to choose because of your dad? Or did you just feel free to explore whatever.

Dr. Lindquist:
No, he was always, you know, really involved with procedures. And he liked to imagine growing up, I did a lot of things with my hands and really enjoyed that side of things. So I always knew that I wanted to do something, either surgical or procedural. And, you know, he really said, kind of go for the gamut of experiences. And, you know, actually kind of just, it was very freeing. And so I just picked what I liked, I originally wanted to do plastic surgery, actually, because I really like the hand and restoring people's ability to function. And then on my plastic surgery rotations, I had exposure to the head neck region with a lot of cranial facial things. And then, you know, saw all that otolaryngology or ENT, the ear, nose, and throat specialty, deals with and that kind of got me involved with the delicate structures, the integral structures of the neck. And then from there, residency and seeing a lot of the even smaller, more delicate and more intricate structures of the ear, and all the quality of life things and the ability that you have to impact a really important thing, which is the sense of hearing. So that was a really big. And that was a long ways in a short amount of time to talk about that. But that was kind of my trajectory. I will say.

Aaron:
Let's take a step back, and say so your dad was also specialized in sports medicine. It sounds like, did you also play sports growing up? Was that something that you're interested in?

Dr. Lindquist
Yeah, I kind of I played I played everything. I really enjoyed playing water polo and swimming. That was kind of what I did.

Gianni:
Nice, I also played water polo.

Dr. Lindquist:
Yes so, I swam because I needed to stay in shape for water polo. I played water polo in college. And then the 8AM classes got earlier in earlier because our practice was late at night when we could get pool time and I ended up you know, falling asleep in the back of the physics class and realized that I probably needed to focus on you know, the things that I knew I was going to be doing long term. We ended up playing a lot of basketball and stuff like that in college actually had a couple of concussions. So I had to take some time off for that. But you know, it's not I'm actually retired from contact sports. And it's probably a better thing for me long term in my family.

Aaron:
Is water polo really contact heavy?

Gianni:
It can be.

Dr. Lindquist:
Yeah, it's not like, it's not like collision, but it's a lot of like contact. And you know, they do nail checks on the side of the bed, or the side of the pool before you end up getting into so you don't scratch people.

Aaron:
I guess all avoid water polo altogether. It sounds interesting to get that history of concussions and having that sports background. I think a lot of a lot of doctors, especially surgeons have some sports backgrounds as well. And so, it's really interesting to hear that. And so going a little further. So you said in college, you majored in chemistry, is that right? That's correct. Yeah. And then you just had to come to medical school and you went to St. Louis University? And can you tell me a little bit about like, what kind of exposures did you get in medical school that made you think about like a neck surgery, the anatomy of that, what really captivated you in that moment?

Dr. Lindquist:
Yeah so I think that for a lot of medical students thinking about otolaryngology, the cases that you're involved with are a lot of the big surgical cases oncologic stuff, head neck surgery, but you get a pretty varied approach. So you know, you're scrubbing into the cases that are the big free flap reconstruction, where you're taking, you know, basically a distant piece of tissue and sewing it into the vessels of the neck to help reconstruct after and helping with quality life in that aspect, where, you're trying to restore the ability of people to swallow or to breathe or talk and so, a lot of those surgeries are really morbid. But then on that you also see the other parts, there's not just the communication side, that's the voice that otolaryngology offers, but the hearing, there's the smell and sensation, taste, all those things. So there's a lot of the senses that are involved, obviously. And then, we can talk about, kind of why the ear specifically, but I felt that cochlear implants, which is part of the discussion today, was one of the single coolest things that, you know, you could imagine in terms of probably the most successful neuroprosthesis of all time, that we actually can restore one of those senses. So the things that you're doing, for head, neck, people trying to get them to swallow safely or breathe safely, you're restoring the ability of someone to hear, which I think is really amazing.

Aaron:
I think that's one thing that is really cool about ENT, I've heard it described to me as it's a specialty really dedicated to the art of communication, because of senses that are involved in the ear, nose, and throat. And it's really cool to hear you talking about hearing in particular, because I think that's something that can be taken a little bit more for granted. It's not something like vision, where it's very, very obvious, like you can't see, but it's something that's very important as well. And so, you mentioned earlier that you didn't want to get into a little bit about why you wanted to be a nerd neurotology. But could you describe a little bit, the circumstances of what that decision was like for you as well? Like, why the ears in particular

Dr. Lindquist:
So again, kind of echoing what you're talking about, restoring quality of life, helping communication, I think that we are in a period of time, where, at least in terms of the advances that are going on with a lot of the field that I'm in is, we're learning more and more about, cochlear implants have been around for decades, but we're starting to learn, and we're starting to expand kind of what they're used for. And so, seeing just the ability in, seeing the children that were implanted, many, many years ago, and having them come into the clinic and have basically, normal speech and intelligibility is incredible. And so, we’re finally at the point where, there's been decades enough for those children to be grown up and to be integrated into the speaking world. And so, there's very formative encounters that I had as part of my work, shadowing as a medical student, and then working as a resident, that that helped form that and I wanted to be part of the service of that, and also looking at how can we make things better? How can we expand access to people in terms of getting what they need? And there's a whole bunch of things that I could talk about, hearing aids are another thing. We're learning a lot about with some studies coming out in the past year, that there are a lot of consequences other than hearing loss for people with difficulty understanding and with damage or hearing loss in the inner ear. Things like depression, things like social isolation, we know the association with dementia, and now we're starting to see that maybe there's more of a causative effect to that. So, losing hearing or not treating hearing actually can exacerbate or accelerate the development of those kinds of things. And now we're looking at well, does treating that problem, help curtail some of those other issues? And that's something that I think is going to be hopefully very influential here in the coming decades as we move towards treating those conditions like a little bit more preventative like you would weight loss and preventing cardiovascular, metabolic disease. Can we help stave off some of those things by, maybe making hearing aids a little bit more accessible? Because those are really, really expensive. A lot of your insurance plans don't cover those.

Aaron:
Yeah, that's really interesting here, I think I've read a study that said that, it was like, within three years, having access to hearing aids or cochlear implants helped stave off like 50%, of dementia in older patients. And so, it's something that is becoming more of a conversation, especially as we see that hearing loss is connected to a lot of these other conditions, I think it's something that's going to come into view a lot more. And so yes, we're already kind of talking about the main focus of this episode, which is cochlear implants. And so, and then also for other like hearing aids and other kinds of like aural rehabilitation, so could you for a lesson for our listeners who might not be as familiar with cochlear implants, or the treatment options for hearing loss, can you just describe a little bit about what they are and who might benefit from that?

Dr. Lindquist:
Yeah, for sure, I will say, this, the treatment algorithm for someone who comes in with hearing loss, is part of what I really enjoy about otolaryngology, too, is that you're doing a lot of the medical care for them. And then, if the medical treatment doesn't help, the you're also the person that would, be able to do the surgery for him, which is nice, because another specialty, sometimes you have to refer to, neurology and neurosurgery or, cardiology and cardiothoracic surgery. But in our case, we get a great longitudinal type of care for the patient. So someone who comes in to my clinic with hearing loss, they come in, they generally get an audiogram, we go through the history and physical, if there's a type of hearing loss that they have that is treatable with a hearing aid, then that's usually a really good option. There's other things like bone conduction devices, which is talking about the different types of hearing loss, there's really the nerve type of hearing loss, which is inner ear type of hearing loss, associated usually with getting older, or genetic, or hereditary factors, noise exposure, stuff like that. And that's kind of the run of the mill thing that people think about when they think about hearing loss, especially as people get older, that's usually the type of hearing loss that's improved with hearing aids. The other type is the conductive hearing loss, which is problems with the eardrum or earwax, or the bones in the ear, fluid in the ear. And that's usually more what you know, maybe kids have with ear infections and stuff like that. And those can also be helped with hearing aids, too, it's just a matter of whether those hearing aids are powerful enough to kind of overcome that degree of loss, and making sure that there's not a problem kind of lying deeper in the ear that might cause worsening issues or infections, things like that down the line. And so that's kind of my main assessment. And we usually start with hearing aids, as are something that, generally are accessible, yes, they're expensive. There's other things that you can do to different types of hearing aids, different powers, and then also bone conduction devices for people that they have the good inner ear type of hearing loss, but the signal is just not able to get through the ear canal, through the eardrum, all that kind of stuff in the ear, and there's surgical and medical options for that. But then when you start talking about cochlear implants, those are mainly for folks that have damage to the inner ear that hearing aids can't really rehabilitate. And a lot of that is kind of the clarity of speech. So with a hearing aid, you can turn it up. And if it's a volume problem, then that's going to help. If it's a clarity problem, you know, you're basically taking garbled noise or, a signal that's unclear and turning up louder, that's not going to be helpful, that actually may be hurtful or harmful. And so, the cochlear implant bypasses kind of those damaged parts of the ears to directly stimulate the nerves that send the signal to the brain, the auditory nerve. And by doing that it's a different type of hearing, it's not the acoustic type of hearing that we're born with, or that we are using right now, it's more of an electronic or electric type of hearing, that really takes a while for the brain to kind of adjust to and there's a bunch of different electrodes on the, on the implant that are in the inner ear at different frequencies. And over time, the brain learns how to use those for something that's functional, for recognizing speech. And certainly, the implants that are around today are our best use for speech rehabilitation, rather than music or anything like that. But that's kind of the end stage of hearing loss, , people that we used to tell, hey, you got to learn how to read lips or sign language. Now we have an option for people that have developed speech and language, but have then lost it over time.

Aaron:
So, can you just tell us in more simple terms, what does the process look like of implanting a cochlear implant, and how does it work?

Dr. Lindquist:
Yeah, so the nuts and bolts of the day of surgery and then kind of the immediate care afterwards is that it's usually an outpatient procedure, takes a couple hours. And basically what we're doing is we're taking an internal device and placing it under the skin behind the ear, and then putting a tiny little electrode into the inner ear, the cochlea, through a tiny little window, and then, basically, having the patient recover, and then turning the device on with an external processor about two or three weeks later. And that's really when the first sound perception happens when that sound from the microphone is transmitted into an electrical signal and then transmitted through the skin, to the receiver stimulator, and then down to the cochlea and the auditory nerve. And so, that's the pathway there, that you have an external device and an internal device. But most of the time, like I said, it's a pretty, pretty safe procedure. And it's usually outpatient, unless there's other factors that would, you know, necessitate people staying in hospital for other reasons. But I think certainly you have to think about, you know, the comorbidities that come along with hearing are also some of those that are more serious medical conditions. But we do do this surgery routinely, for people in the 70s 80s 90s. Certainly, we have the right amount of trepidation as you get older and age, but, if someone looks like they're going to get benefit from it, and they're interested and motivated, then, that's the age where you want to give people all the tools that are available.

Aaron:
So it sounds like, so you see a patient, a patient is referred to you into your clinic. Your first assessment is, is there a difference between conductive versus sensorineural, which is conductive would be like the outer ear and transducing that sound?

Dr. Lindquist:
Exactly.

Aaron:
And then, sensorineural would be perceiving based off of that signal? And so, it sounds like what you're saying is, hearing aids would mostly be for conductive or sensory neural hearing that is a little more mild. And then cochlear implants would be more something more profound. Also, maybe like, integrating into the idea of perception of, are you able to process the information, not just perceive it?

Dr. Lindquist:
Exactly. Yep, and also the clarity of speech. And that's been changing.  You say the mild is what we used to use for hearing aids. Now, we have a hearing aids that we can crank up and, you can get more than that, you can get moderate severe. The same thing is true for cochlear implants, where the first FDA approval of cochlear implants was for patients who had 0% speech recognition of sentences or words. And now, by expanding and liberalizing the criteria, now we're implanting people in the moderate range, that just aren't getting the same benefit, or the perceived necessary benefit from hearing aids because of the pattern of the speech or the clarity problem, like you talked about.

Aaron:
So can you talk a little bit about the criteria for the differentiation between you see a patient who comes in with a hearing loss, what would make them a good candidate for a cochlear implant, rather than that traditional hearing aid?

Dr. Lindquist:
Yeah, so a lot of that is building relationship over time, assessing the etiology, or the cause of the hearing loss. So a lot of times, we'll do that with an audiogram with a physical exam, a history, genetic factors, and then imaging typically, and I think that a lot of times, we'll do imaging, as part of the cochlear implant evaluation process, but it's really also to help work up the cause of the hearing loss and make sure there's not another inner ear reason for it, or inflammatory infectious etiology. And then from there, most people come in with some trial of hearing aids where they say, Hey, my, whatever ear is diminishing in quality here, my hearing aids aren't as helpful, they told me, either Hey, can you help me with this with a different hearing aid? Or is there another option for me, and so a lot of times, I'm kind of the one who's helping explain what that next step would be and figuring out, if they need that further evaluation. There's a process that they go through, and this is a lot of, it's actually counseling. So there's a cochlear implant evaluation where people go through a battery of tests, but it's also kind of learning about, alright, what would be the expectations for getting this device, because there's a lot of pros to them, but there's certainly some cons and if people aren't prepared, or at least you haven't prepared them, for what to expect with the surgery, but also, in the months that they're doing a lot of the hard work afterwards, it's not me, I see them for a postop visit. And then, it's kind of like, alright, you just got to use this thing, there's certain things we can do to program it. But a lot of the time ,you're going to be putting in, I'm not living that, you're the one living that, I'm just here to kind of help facilitate it and come up with solutions along the way, if you have problems. But, especially with the expanding criteria, people that used to be really clear cut, and we say, okay, this is definitely going to help you. Now we're going to point of well, it's a nuanced decision. It's an audiologist, who is the hearing doctor, and also an otolaryngologist who's deciding, well, is it worth doing a little bit longer with the hearing aids, and we will tweak some things, there's some things I can do with the programming or a different fit, is that going to help you more? Or is it, hey, we're talking about this next step. Like if we're saying we're out options, what do we go to? And there's some evidence now that, the earlier that we implant people, the better that they do, and that's because of residual ear and function and all that kind of stuff. But preparing them for that the sound will not be the same quality and that the brain and neuroplasticity has to have its the ability to help modulate that signal and help it mesh with kind of what they're used to in terms of hearing. That's the important part, and a lot of that is finding people that could benefit from it, but also making sure that the people that are getting it are actually the right people for it and making sure they're not becoming non users or things like that.

Gianni: 
I think that's something that a lot of people don't recognize, like myself included, just the amount of rehabilitation in the process of getting used to the implant. What does that process generally look like? And what are some of the challenges that a lot of those patients have? And about how long would you say it typically takes somebody to kind of get used to using it and feeling comfortable with it?

Dr. Lindquist:
Yeah, it's a great question. That’s part of what's being actively looked at, in the field in terms of what we want to learn more about. There's a recent study that came out that about 30% of people that get cochlear implants have decisional regret, meaning there's something that they didn't know that they wish they had known. And that's a third of people. So that's pretty impressive. And if you could change that, that would certainly make me feel better about it and also make my patients do better with it. But there's a whole lot of things, when people had bilateral, so both sides profoundly deaf that was, well, let's just pick one ear and go with it. People that have different degrees of hearing loss, people that may even have normal hearing on one side, and then no hearing on the other side, single sided deafness. That's an indication that was approved in 2019. And, we did a study where 15% of those patients are non users, when we look back and figure it, we want to figure out why. Sometimes it's situations, so are people in a busy area where maybe having both ears can help with a lot of the diminishing the noise, the background noise, or helping with localization? Or do they work in an office where they really just need one ear, and that's good enough. And if they have an ear that the, the quality is not good, they're just not going to use it. And we know that those people tend to use their devices less. But there's a whole bunch of things. So there's the pre-surgical part of it, where you're talking about the age, the duration of deafness, how long they've been without usable hearing on that side. A lot of the cognitive things, the top down processing, where, you do need the central auditory processing in the brain to help really with this rehabilitation, neural health, things like that. You have the surgery, where, I’m picking what electrodes going in, there's different types, maybe surgical planning, placement, trying to preserve any residual hearing. And then there's the part afterwards, which is the programming part, which is making sure, hey, all these electrodes are fitting with the different frequencies there that but also data logging, which is a focus of mine, which is how long do we have to use this device, in order for it to work. So it's the analogy I would make is that it's somebody who's going out to the soccer pitch and has all the right equipment and has been fit well with their shoes and all that stuff. But they need to go out there and just kick the ball around. And that's the amount of time that it takes to become a proficient user. And so, that's, we're learning that those people that use them all day, 12-14 hours, they are doing the best at it. And so, there's a lot of things that kind of come into play. That being said, to answer your question a little bit more with timing, it's interesting. There's a, one of the earlier ecologists, their neuro otologist, down in Arkansas actually had one of these devices placed, common knowledge, he wrote some papers about it. And I remember hearing him speak at a meeting where two to three months in, he was not liking it very much. But then he came back with a paper around the four to six month mark, and was like, hey, look, a lot of things changed here. This has really changed my outlook. And just those few extra months of practice and some of the neuroplasticity, the brain adjusting to it. He's like, this is changed my life. So I do think it's a buy in. We usually measure people, you know, at activation at one month afterwards, at three months afterwards, six then 12. And you usually start people, there's some people that do great off the bat, and they love it, but a lot of people, it takes them kind of three, six month mark, and then, there's a question about do people plateau? When do they plateau? And that's something that we're still kind of figuring out where there's the worry that they plateau early, and then after 12 months, they don't get a whole lot more benefit. We may be doing some research to help kind of clarify that. But, I think early use and kind of early investment is really key as with anything, right? If you're most excited to use it, right when you get it, then more power to you. Let's just do it.

Aaron:
That’s really interesting. Good question, Gianni. And one thing I was thinking about is that it is a long process and there is an interest with like the data logging, what is the kind of like an interdisciplinary nature of that care? You talked about audiologists, speech language pathologists, what kind of like other people are part of this team to make sure that patients that do receive cochlear implants are actually utilizing them in the way that they are able to benefit from the most, and then also, making sure that they are able to kind of stave off some of those regrets that you were quoting earlier?

Dr. Lindquist:
Yeah so, on the adult side, we have the cochlear implant audiologist, the cochlear implant surgeon, and then a lot of patients end up doing aural rehabilitation so a lot of kind of learning how to use the implant afterwards with, there's some folks at University of Houston, in different places, different programs for it. The Veterans Affairs has a program that they help people get. On the pediatric side, which I also do ear surgery for the pediatric population of Texas Children's one day a week, we have a big team with a social worker, we have audio verbal therapists who are a particular type of speech language pathologist, and we do evaluations and we do a big team discussion, multidisciplinary care for all these kids to make sure that they are going to be set up for success, they're going to become users, and, they're invested as much as we are. And I think that helps get everybody kind of maximize in terms of their benefit, but it is a big process and a big team. And a lot of it, the work that I do, I'm doing my hard work for a couple hours, and then seeing them in post op. It's the patient and a lot of the therapy that goes on afterwards, that's where the major strides are made. So it's a big effort kind of all around, and the more people you get involved, you know, it can make it a little bit more difficult, difficult for scheduling and stuff like that. But with telemedicine, things like that, certainly, things have been improving. And for kids, we know, it's a very pivotal time to help with their language development, if they're already behind because of their hearing loss.

Gianni:
Do you generally find that like kids have better outcomes, given the increased neuroplasticity that kids have?

Dr. Lindquist:
Yeah so, it's a great question. There's different types of language development, there's pre lingual, and then postlingual. So hearing loss that happens in the pre lingual stage, that's somebody who's maybe more congenital, right. And we know that implanting them earlier helps. The FDA has approved up to nine months or nine months and above, I should say, and we will implant people even below that, if there's a good reason to. And that tends to give people a really, really good outcome, those kids get really good speech intelligibility, they get really good at understanding, they're able to often, if there's not other comorbidities, they're often able to live a life where they walk into my office 15 years later, and I can't tell that they're an implant user, except for then I read the chart, which is pretty incredible. The patients that, maybe we identify a little bit later, have had a delay where they're three, four or five years old, where a lot of that language development should have already happened, they do not do as well, we know that. Adults that didn't really develop language, that's a tough pill to swallow in terms of implant for them may give them some sound awareness, but it's not going to necessarily give them speech recognition. And then the adults who are post lingual and that they have speech and then over time they lose their hearing, for whatever reason, those patients generally do very well as well. So it's a whole spectrum. And, in terms of the sound quality, it's a great question. I feel like the older folks, because they've had hearing so long of the acoustic variety that they'll say the hearing is different. But for the kids that you implant early on, they don't know anything else. So it's, that's normal for them, which is cool in itself.

Aaron:
Yeah, so I think one thing that you're talking about here is like the difference between pediatric patients and adult patients and their process and their ability to access. So I was wondering, what is the screening process like for a pediatric patient who might be a better candidate or might benefit from a cochlear implant versus like an adult, or an older adult who is newly experiencing hearing loss.

Dr. Lindquist:
So, you know, the pediatric side of things where, there's a lot of hospitals screening, which is great. And there's a rule, which is the 1 3 6 rule where you want to identify people, you want to screen them, then you want to identify them, and they want to treat the hearing by six months is the goal. With adults, people often get dragged in by their family members and stuff like that, so they're not always as eager. The people that have a sudden hearing loss and then come in, those people are motivated, but those are the people that I still say, if you have hearing on the other side, there's not a rush to do it because we can do the implant at any point. Some people adjust, it's not something you want to make a rash decision about getting into. But it certainly does affect things in terms of the timing of it. And it's a very interesting question. It's one that we get together, and talk about in our boards about, “hey, is this duration deafness been too long? Yeah, maybe? Well, is still a candidate, I think he was, just got to talk to him about expectations. He's pretty motivated, I think, let's do it.” Things like that. I mean, there's different criteria that are laid out by the FDA. And one thing that if we can get approval for these implants, a lot of times, the doctor knows, what's what with that relationship, as long as they discuss, “hey, it's off label.” Those people are still candidates, and they still do really well, and they still derive benefits. So that's what we do.

Aaron:
That’s really interesting. I kind of like that implant board is kind of like a cancer board or like transplant board. It sounds really very interesting. And so, I think the one thing that might be a concern, so it's one thing to know that somebody is a candidate, but like how about somebody who may not have insurance or might be concerned about maybe the cost? And so one concern I can imagine for potential recipients would be that they, they may be a little concerned about the cost or the upkeep and then also potentially having to get a subsequent cochlear implant later, how would you say that cochlear implant accessibility kind of has changed over time? And what kind of barriers continue to exist with that?

Dr. Lindquist:
Yeah so, it's great question, certainly there's been some recent opening of the candidacy criteria from both the Centers for Medicare and Medicaid, as well as private insurance. And so the big upfront cost is the is the surgery in the device itself. That, hopefully, is a one time cost. And I will say, the internal part is the part that you put in during surgery, and that's the receiver stimulator, which is the part you hopefully never have to remove from the patient's body. Obviously, there's the failure and failure rate of those devices, which is small over time, or medical problems with it, whatnot. But the outside part, which is the processor, is the part that you can switch out, and that's the part of that has all the upgrades and the fancy features and maybe waterproof and may have different sound cancellation stuff, different programming things, different streaming to your phone, or whatever. And so that's the part that is the upgradeable part. With insurance generally, that's covered because, at a certain point, obviously, if you lose it or break it over over and over, there's probably going to be some cost to that. For people that use it, and then five years, maybe the device isn't supported as much by the company, that is a medical necessity. So I write letters for insurance companies and the cochlear implant companies to help replace those all the time. So hopefully, those costs are actually less over time. And I would say it's probably more of the upfront cost. But you know, it's having not had one myself, I don't see those numbers. And that's part of where, as a doctor, you have to think about that stuff for the patient. It's a great thing to be aware of that, yes, these things are expensive. They're, they're 10s of 1000s of dollars.

Aaron:
So if I'm a patient, I have a cochlear implant, how long do you expect me to have that cochlear implant for is something that you know?

Dr. Lindquist:
Yeah, no, it's the implants that we're putting in now, again, I would say that we want them to last the rest of the patient's life. We have devices now that are MRI compatible, we have devices in the past that were not. And so sometimes we end up having to switch them out because of MRI compatibility issues, if they need imaging for any other reason. But as long as there's not a failure, or anything like that, or an adverse medical issue, like an infection, or exposed electrode or extrusion through the skin or anything like that, as long as it's working, and then if it needs to be changed out, there are ways to do that, where generally people get back to where they were, with the prior device, in terms of speech recognition, within three months of doing a revision surgery, if there's no complications or other complicating factors.

Aaron:
I think one thing is, what I heard from you're saying is also that cochlear implants, especially when it gets to the point where you are indicating you've been evaluated seems like it is going to be covered by insurance. Can you tell us a little bit about the discrepancy between like insurance covering that kind of surgery versus covering something like a traditional hearing aid, because I know a number of plans don't cover traditional hearing aids or Medicare doesn't cover it often, especially when you have mild to moderate hearing loss. And so, where do you see that kind of discrepancy between covering that kind of surgery versus covering something that's a little bit more tame, but still is pretty expensive and inaccessible for patients with hearing loss?

Dr. Lindquist:
That is a question I've asked myself before, why are these expensive devices covered, and sometimes, the cheaper devices aren't? It's a good question. So I think a lot of it has to do with, there's a, we have a very strong American cochlear implant Alliance, who I would say, has done a great job in terms of awareness and working in terms of helping make sure that those things get covered. We have a lot of interest. I think that it's a good question, because the hospitals truthfully don't make a ton of money on cochlear implant surgery. But I think that they realize that these people are having a really hard time and it's the only answer. I wish that it would extend to covering more of the hearing aids. And so, I would say that that would be something that I would take it as a preventative treatment, and I do think should be covered as well. But that's a question that I wish I could solve that problem and it's a valid question.

Aaron:
Okay, and then, I guess maybe a little change of pace as well. So Dr. Lindquist is a newer faculty here at Baylor, he did his residency here. And then he did his fellowship at Vanderbilt, and then he's come back, this is first year as an attending. And so just looking forward into your career, into the future, what is something that really excites you about being a new faculty? And what kind of things do you want to evaluate in your career in the future?

Dr. Lindquist:
Yeah, so I think that, obviously, the teaching part of things is really important. For me, I love working with residents and working with the fellow that we have, as part of training future neuro otologists. I think that the environment is awesome. I love my colleagues and coworkers. And that was a big part of it is kind of the mentorship that I that I received in fellowship from where I went, and at Vanderbilt, I saw some of the same traits and the folks here at Baylor. And so that’s been not only as friends, but also as people that have been through before and can kind of help make the direction that I want to take my career, something that's achievable. Obviously, the diverse patient populations here, I have time at the Children's Hospital, at the Veterans Affairs, and then also at the main Baylor group practice. And so treating the whole gamut of different pathologies, also ages is one thing that I really enjoyed. And the fact that I can go to Texas Children's one day a week and see, children there is just like, it's great, being able to do the medical and surgical and all ages, which is really cool. And so that's the other thing that I really enjoyed. My wife's family's from East Texas, and so this is a very nice spot to land, in terms of being close to family, and it's just a place where there's all sorts of people to reach out to and collaborate with, there's Rice, there's University of Houston, there's different hearing and speech schools in the area. It's just a great center for it. So I think we'll be able to do as much as I want to, and won't have time for everything. But I really am interested in looking at a lot of the outcomes for cochlear implants. So one of my things that I'm most proud about is kind of deciding or helping to give an answer for how much people should use their devices afterwards by looking at kind of a more scientific approach to scores and things like that. But I also want to figure out, is there a way to improve accessibility? There's a, obviously, Houston's a very diverse city, you know, there's a lot of people out there that don't have access, for whatever reason. And I think trying to expand, that would be awesome. In the past, they looked in and of all the people in a private practice environment, I think I read that the average primary care doctor has about eight patients in their practice that could benefit from a cochlear implant. The penetrance is about 10% of all people with hearing loss. And then once the indications have expanded as they have in the past few years, we're now reaching about 2% of people that could actually benefit from it. And so it's a very small number, and there's a lot of gains. If I could do cochlear implants all day, I would be very happy. There's a lot of obviously else to neurotology. But, it's a very rewarding thing to help patients with. So I do think there's some studies going out, there's going to be future improvements, there's going to be, fully implantable devices that are being worked on, which is a pretty cool thing. Some people don't like the fact that they have the external part. Obviously, a fully implantable, you'd have to talk about what do we need to do for the battery there, and the battery there is actually down in the chest. So it creates a little bit of a different surgery, but it's a very cool idea. Obviously, Baylor has the genetics department here, which is world class, a lot of funding. I think that gene therapy is going to be a really interesting thing and it's actually going to create a little bit of a question for us. If we start having treatment for some of these genetic hearing losses, should we be implanting people in both ears? Do we need to save one of the years for future developments down the line? It's something we do talked about. If we put an implant in this year, you're not going to be able to potentially get hearing altering treatment in the future depending on what the etiology is for your hearing loss, especially for genetic causes. So that's, I mean, that's a whole other can of worms. That's a very interesting question to think about. And we'll certainly be something that we learn about more about in my lifetime. Yeah, there's a lot of reasons, but that would be kind of the start.

Aaron:
There's a lot of really cool stuff happening, especially here in Texas Medical Center. So it's really great to hear that Baylor is on that road of being able to lead some of those advances and to benefit and help patients with those kinds of advances as well. And so I think it's really interesting to hear this relationship between these advancements in technology, but then also, you're saying that only 2% of people who would qualify for a cochlear implant are able to actually get the cochlear implant, especially with these new widening criteria. And so I think that one thing I'm really interested in is how do we increase access for these patients? How can we make sure that not only are patients who are coming in with hearing loss being screened for hearing loss, but then also, if they are a candidate, how can we make sure that they get the technology that they need in order to support that? And I know that you've done some work in using AI in order to make sure that people who should be referred to formal evaluations get it. What kind of role do you think your research and your work in the future will play in that?

Dr. Lindquist:
Yeah, so that's the most important thing, it's really sexy to talk about all the different ways to get five percentage points better on speech testing in a year, but how do we just get these devices for more people that need them. There's a rule that is really well known and very accurate and called the 60/60 rule, where it's basically a screening tool to help decide if an audiologist or an ENT doctor should send them for cochlear implant evaluation. And that's 60% pure tone average and less than 60% word recognition score. So, the machine learning where we look at all like the different parts of their hearing tests, and their demographics and their speech performance, and things like that helps decide, are they going to be a candidate? Ultimately, it's about just getting as many people as possible in for those evaluations, getting their hearing loss treated, whether it's a hearing aid or an implant, but a lot of it's going around and kind of improving knowledge. So, hopefully getting word out to more people that, “oh, yeah, there are those devices out there.” I think getting, like so many drug companies and stuff like that, maybe we should see more commercials for these devices. You know, I may put my foot in my mouth on saying that, but, talking to audiologists and to be like, “hey, you know, here's what we're doing, here's the current criteria.” Talking to ENT doctors in the future, we're making it easier for people to get in. I came into Vanderbilt when my mentor, Dr. Haynes had been working on a one day CI program. Tennessee is actually a pretty long state. And there's people that drive five hours from East Tennessee, down to Nashville, and they were working on a way where they actually ended up getting 10 patients who could get their imaging done outside and then send it in, and then they do an over the phone, kind of introduction, and then they come down, and they do their evaluation and surgery all on the same day, which is a huge time saver, obviously, there's the conflicting interests of making sure that people are fully aware of what's going on here, and trying to streamline their care. But telemedicine has helped that a lot and I think that just improving access, and making it easier for people rather than harder is the other way to do that. Obviously, got to be careful not to jump in too quickly and be rash about things, but it's just also about training people to help be able to do the surgery safely and reach more people that way as well.

Aaron:
It's really interesting to hear about that, spreading awareness, making sure that people know that these options exist. So, for example, if I were, I were a concerned family member, and I noticed that one of my family members, maybe my dad, maybe my mom, and my grandma, they're experiencing some hearing loss, what is the point where you think that you should, how do I one get them to see a doctor and to get an evaluation? And then if I were a doctor, and I noticed that a patient is experiencing some hearing loss, what does the process look like to referring them to somebody who might be able to get an evaluation, and then talking about the next steps of getting maybe surgery or getting a hearing aid?

Dr. Lindquist:
I think getting into an audiologist and ENT, and I believe in trying to strike while the iron is hot because people lose momentum over time if they have to wait three months to get into a doctor. But I've also , as part of my first year here and part of my practice building, you want to go meet people and just do handshakes and let them know what you do, let them know who you are and give them your cell phone number and I try to get those people in as quickly as I can because I do know that, while people have been dealing with that prompt for a long time, you do lose a little bit momentum if you have to go through that. And it's already a process with enough hoops in it to begin with. But yeah, it's about seeing an ENT, an audiologist and then being like, “alright, if a hearing aid trial doesn't work, then who are who you sending to me to see,” and they should have people that they know and that they trust to help take care of their patients.

Aaron:
I think one great thing is, we're talking about trying to increase accessibility to cochlear implants and hearing aids, let's say there's a world where everybody's finally able to get cochlear implants, and you're doing surgeries all day, what are some of the considerations that you think as more people receive this technology? What kind of support do you think that they need? And what kind of what kind of dangers or opportunities exist with that kind of utopia?

Dr. Lindquist:
Yeah no, it's a question to, interesting to think about. The other stuff we're looking at is yes, exactly, as you said, we're putting implants in people, they have magnets in them, what about if they need an MRI, down the future, down the road of their brain? So the magnet, we're working on different kinds of imaging studies to help limit the artifact from that. We know that a lot of the devices are safe to go through an MRI machine now, but it's not necessarily going to give you a clear picture of what you want. There's the electrical Bovie, which is the monopole or electrocautery, we did some work on that to show like, you know, a lot of the companies won't really support that when you have a cochlear device in place or cochlear implant in place, because they're worried about potential arcing or sending that electrical signal to the cochlea or into the device, either, damaging the nerves or to the device itself. And we know that that is safer and safer. But as more people have other electric surgery, having something that's metallic and, magnetic in your body obviously has its own challenges. And, I think part of that is also educating other doctors to be like, “oh, this person has a cochlear implant, let me just make sure that like, I can do the surgery for him.: Because, if it's a spine surgery, you have to use the Bovie electrocautery. For those, there's certain surgeries that you just can't get around it very easily or it’d be impractical or take too long, or it'd be unsafe.

Aaron:
So, talking about like having metal, is the concern like a fire? Or is it the actual device?

Dr. Lindquist:
It’s the actual device, so sending the voltage to the device, or since the contacts are made in the inner ear next to the nerves, that the inner ear would somehow have damage. And so even then, if you replace the device, you fried the nerves that are needs to help send the signal. So theoretical stuff, but no one really wants to test that. Yeah, exactly. So that's kind of where we are right now with that. And it's a great question for people that we had a big conference with the radiology folks about that a couple of months ago, for a patient who had something.

Aaron:
That is certainly something to consider, especially when more people are getting cochlear implants, having that on your radar, because I don't know, I would not like to fry somebody’s ear.

Dr. Lindquist:
The other thing is trying to make it like a little bit cooler to have them too, because they are pretty big devices, they have some now that are off the ear, so they just kind of sit on the scalp. They don't have the hearing aid thing, or that kind of shape over their ear, which a lot of people, once they're kind of ready to put down the hearing aids, they don't want anything on the ear anymore. And I'd be like kind of a mind thing where they say I don't want that. But the fully implantable one might be the other thing that would be a game changer, in my opinion. And that's going through with it's been, you know, placed into patients. And I know it's in trials and stuff like that. So stay tuned. And there might be some cool stuff out with that.

Aaron:
Yeah, changing our perception, seeing cochlear implants as cool. Some of the technology is really cool. Like, they can connect to your phone now, you can do you like Bluetooth things. And so, I think if somebody experienced some hearing loss, and then they hear some of the cool things that can happen.

Dr. Lindquist:
Yeah, you always hear about the people that are celebrities or on  notorious TV shows, or anything like that. The Great British Bake Off had somebody on. I heard the most recent season of The Bachelor has a lady with it, but I haven't watched that one. I'm relying on word of mouth.

Aaron:
That's cool because it bleeds between medicine and the real world. And when you have an implant, you're going to be interacting the world as well. And so, it's not just in your doctor's office, it's in your community, it's in your family, it's with other people as well.

Dr. Lindquist:
It’s a lot about identity too. So that's the other thing where you could talk about the deaf community, and then the hearing community too. And that's a whole big conversation. But I think just improving the visualization or people that have those devices and you see them and they become more commonplace, then that's just improving everybody's information about or knowledge about what's out there and talking then to their neighbor or their grandfather or whoever it is, :maybe we should look into that.”

Aaron:
And so you also, so you've already kind of touched on this, but one of the questions would be what kind of future research or work do you want to complete in your career? And then, yeah, anything that excites you about being in this community and something that you want to invest in, it seems like you're interested in maybe increasing accessibility and improving these outcomes, and then also this cultural progress and making sure that people who have implants don't feel othered in any way. Is there anything in particular that you want to continue with your work?

Dr. Lindquist:
I think one of the things, we talk about outcomes a lot, because there's a lot of data that you can talk about with that, in meetings and publications, and things like that. I think that one thing that would be really rewarding is to say, take someone who's maybe not performing as well as they could be, and then, even a few years after their surgery, and then rehabilitate them to get to a point where then they started using the device more consistently, and figuring out, are there ways that we can change that? Are there tricks to programming it or to using it or things like that? Or just putting in the work for people that, maybe live alone, or they don't have family that they can talk to, or other ways to kind of rehabilitate it. That would be something that I'd be really excited in. Because there's only so much you can do after the implant’s actually in. Again, it's about kind of using it, and then making sure that all the pieces are there and working. And then obviously, there's just very diverse populations that we have here. So I think that we started looking at different languages and things like that, in terms of how people do with it. And that goes with increasing accessibility, but also just figuring out, does it work the same for different, in Spanish, or Mandarin, or what have you so.

Aaron:
That’s interesting. Have you seen patients who do speak other languages? And, anecdotally, how does it go?

Dr. Lindquist:
I think it's a little tougher with the tonal languages. I know people with English and Spanish tend to do really well. But I think it's obviously an area that's evolving. And I think that we will learn more as we go.

Aaron:
That’s really interesting. Okay, so maybe some last things. If somebody is interested in cochlear implants or other hearing devices, or even like neurotology, where are some places where you think that they can go to learn about it, other than this podcast, of course?

Dr. Lindquist:
Yeah, I think American Cochlear Implant Alliance has a great website, with different pages for providers, for surgeons, for audiologists, as well as patients, speech language pathologist, all that, encompasses kind of the full breadth of who would be interested in learning more about it. That's a great place to start, I think they do a really good job about creating awareness, and also improving accessibility, and advocating as well as supporting research. So that'd be kind of my first place. Obviously, there's a lot of information out there, with varying degrees of, anecdotal stuff is always kind of tough, but certainly, there's a lot about support groups and stuff like that. But I'd say that'd be probably where I would point people first and then go from there.

Aaron:
Okay, cool. So the official stuff, and then also Great British Bake Off and The Bachelor.

Dr. Lindquist:
Exactly.

Aaron:
And then, where can people find some more information about your work if they were interested in continuing this conversation?

Dr. Lindquist:
Yeah so, just through my faculty page. Obviously, I don't think I have any, PubMed would be the only other place. You find me in the halls at Jamail, and I'll talk your ear off probably about it. But yeah, that'd be about it.

Aaron:
Yeah, our listeners will be on the lookout. They'll be trying to shake your hand and learn a little more about it in the future. So are there any other things, anything else you want to share anything? Other questions that you want to talk about at all?

Dr. Lindquist:
No, I think we covered a wide range of topics on this. And I'm very happy to share any information I have. And I just appreciate you having me on the podcast.

Aaron:
Thank you for coming. I think our listeners have learned a lot, and we definitely did cover a lot of really great information. So, it's been a pleasure to have you.

Dr. Lindquist:
Thank you.

Unveiling the Hidden World of Healthcare in the Incarcerated - A Riveting Resonance Podcast with Baylor's Justice-Involved HEAL 

Apple | Spotify | Google Play | Stitcher | Length: 44 minutes | Published: Aug. 14, 2023

Tune in to the latest episode of Resonance Podcast! Discover the untold healthcare challenges faced by incarcerated populations in conversation with McKenna and Justin from Baylor's Justice-Involved HEAL Initiative. Dr. Marc Robinson sheds light on the complexities of health care delivery in jails and prisons, advocating for humane treatment and societal perception change. Learn about the HEAL Initiative's student-led mission to educate and raise awareness among incarcerated individuals. Join the discussion on understanding incarceration as a social determinant of health. Don't miss this eye-opening and inspiring episode!

Transcript

Eileen: Hi, this is Eileen, one of the writers for the Resonance podcast, and I'm here with Justin and McKenna, who both work with the HEAL initiative. And McKenna, can you tell us a little bit about the HEAL initiative?

McKenna: Yeah. So the full name is the Justice-Involved HEAL Initiative. We're this student org founded here at Baylor and 2021. And our acronym HEAL actually stands for health education, advocacy, and leadership—and specifically, at the intersection of incarceration and health. And so, thinking about educating and advocating for the incarcerated patients we treat, specifically at hospitals in the Harris Health System like Ben Taub.

Eileen: And I know that incarceration has a really profound impact on health. We'll talk about that a little bit more in our interview today. But why do you think that is? If patients are incarcerated, why do they have a higher risk of health conditions?

McKenna: Yeah, I mean so… that is a complicated question just because there are so many, so many factors at play. So people who are less healthy, tend to be the ones who are incarcerated more. But also incarceration itself produces pretty adverse health outcomes. When you think about the conditions of incarceration, the exposure to trauma and violence, infectious diseases, you know, just in terms of like hygiene and the air that you're able to breathe in that space. But then also upon release issues with, you know, health insurance, with employment—especially if your health insurance is tied to your employment, housing. It's a really profound social determinant of health. So that's, that's one answer I would give.

Eileen: Yeah, it's a really big question and I think just like you said that people who are already in poor health and more likely to become incarcerated and then that just in turn worsens the health outcomes for pretty much every condition. And then once you're released, you might not have any resources available to get health insurance or get medications or have stable housing, all of which can contribute to poor health outcomes and I think it's really important to talk about this in the US especially, because we have the highest incarceration rate in the world.

Justin: Yeah, so I think this is something that maybe not everybody is aware of necessarily, or not paying attention to this topic. But, you know, on a per capita basis, the United States has more people in jails and prisons than any other than any other country in the world. And I think that that is a big surprising fact. And a big part of that is because we have a lot of people in jails and prisons for non-violent crime and many of them may not actually be convicted of a crime. They may be pretrial. I think it's something like sixty percent of individuals who are in jails are actually pretrial and have not been convicted yet. They simply can't afford the cost of bail. And so you know, if you can imagine as well, or you know, our population is aging. And so because of that, our jail population is also aging. And so the people in jail are also suffering from a lot of chronic health conditions as well that may or may not be properly managed in the carceral system and that certainly become poorly managed when they leave the carceral system.

Eileen: Yeah and we'll be talking today to Dr. Marc Robinson, who is a hospitalist at Ben Taub and has worked with advocacy for this population. He'll tell us a little bit more about some of the health challenges faced by patients who are in the carceral system and some of the wide variety of health services that are available and the quality of health services that are available depending on if you're in a jail or a prison, if you're pretrial or if you've been convicted—all different kinds of variables that play into those determinants of what kind of healthcare you're getting.

McKenna: I also wanted to jump in and just say, when we're talking about like mass incarceration, these are, you know, factors that are disproportionately targeting specific communities. So, specifically lower-income communities, communities of color, people with disabilities, and also a lot of people who are, you know, fighting issues of substance, use disorders, or mental illness. And so, I just think that's important to note and it definitely is a health equity issue and an issue of injustice.

Justin: And I think that, you know, we'll get to this during the talk, but I think we really have to ask hard questions of ourselves of, you know, do we want this to be a system of punishment or do we want this to be a system of rehabilitation? Particularly considering that so many of the people in our jails and prisons are there for nonviolent offenses, many of which are drug-related, you know. Do we do we truly believe that incarceration is the is the best solution? From many different angles, including a public health standpoint, from a humanistic standpoint, and then also from a financial standpoint. Does it really make sense for society to treat these people this way?

Eileen: Yeah, well you guys bring up some excellent points and I'm really excited to get into this conversation and hear what Dr. Robinson has to say. So without further ado, we'll get to it.

Eileen: And our guest here, Dr. Robinson is pretty incredible. He's an internal medicine doctor at Ban Taub and I'm going to go ahead and ask if he wouldn't mind introducing himself a little bit.

Dr. Robinson: Sure, my name is Marc Robinson. I'm an internal medicine physician at Baylor. I work just at Ben Taub. I'm a hospitalist, so meaning I just work in the hospital. I don't have a clinic. My main job is teaching residents, so running a teaching team in the hospital. I'm also one of the associate program directors in the Internal Medicine Residency. And I have a strong interest in improving the care and education about patients who are incarcerated.

Eileen: Can you tell us a little bit how you first got started working with an incarcerated population?

Dr. Robiinson: Yeah, so my background is originally in global health. I did a Global Health Fellowship. I worked in Haiti for about a year and we were debating whether to come back to the US or work abroad. And I was a medical student at Baylor, and I just really missed Ben Taub. It was my favorite hospital that I'd ever worked at and it was really the only place I wanted to work in the US. And so, I was fortunate enough to get a job back at Ben Taub. And then the original plan was to to continue doing global health work, but some of my global health contacts kind of dried up. And starting to look for avenues to work with underserved populations here in the US. And my boss at the time, Dave Heineman, we had talked for a little while about what to do and I just read the book Just Mercy by Bryan Stevenson and I told him, "Oh you know, I'm thinking of doing some work, you know, around incarcerated patients" and he just said to run with it. And so I started picking up moonlighting shifts for a couple years in the Harris County Jail just to get a better sense of what goes on there. And we—Ben Taub—being one of the largest county hospitals in Houston, we receive a lot of the patients that come from the Harris County Jail. So if somebody has a medical emergency and needs to come in, we're the ones that take care of them. So we take care of a lot of incarcerated patients in our day-to-day practice. So that's kind of what got me into it in the first place.

Eileen: And just for quick clarification. I know this is confusing a lot of times, but what is the difference between a jail and a prison?

Dr. Robinson: Yeah. A really good question and something that even I still mess up sometimes. So prisons tend to be long-term incarceration. So prisons are for people who have been found guilty of a crime and then are sentenced to a sentence usually greater than a year. And they're run by the state or they're run by federal jurisdictions. Most people in the United States are incarcerated in state prisons. Especially here in Texas, we have an incredibly large state prison population. Jails, on the other hand, tend to take care… tend to incarcerate three different types of people: people who are pretrial and who don't have enough money to afford bail to get out while they wait for their trial, people who are awaiting transfer to a prison facility after being found guilty, or people who are serving sentences less than a year. So, short term incarceration. The vast majority of people in jails in the United States are in because they're pretrial and can't afford bail. And so that's about, right now, in Harris County—it's about 80% of the 10,000 people in the Harris County Jail who are there pretrial, meaning that they have not been found guilty of a crime and they just don't have enough money to afford bail.

Eileen: And you also mentioned that you've worked some shifts at the jail. Can you tell us a little bit about the health care delivery system in the jail? I know you mentioned patients sometimes have to come to Ben Taub, the county hospital, if they need hospital care but what do they have available, sort of, at the Harris County Jail?

Dr. Robinson: Yeah so at the jail and in most jails that's usually a very simple clinic. You know, very often we in the hospital think that they're a lot more resourced than they actually are. But you know, the story of jails in the United States is there's actually no federal requirement for quality of healthcare. There is a constitutional mandate that people have to deliver healthcare in jails, but in terms of what you need to have, there's just some voluntary certifications that jails have to get. There's nothing that's actually required. So it usually tends to be very simple. Typically, like an urgent care and sometimes even less under resourced, or sorry, more under resourced than some urgent care facilities that you'd find in the facility. The care in the jails, in especially the Harris County Jail is in improving somewhat now that Harris Health has taken over. For a while, it was just run independently by the sheriff's office. But I still think there's a long way to go. It's usually very under resourced and that's why a lot of patients do get referred to Ben Taub or LBJ, the other county hospital, for urgent conditions.

Eileen: Yeah, you mentioned that there is a constitutional right to receive health care for incarcerated persons which is pretty interesting because I'm not sure there are many other classes of people in the US who have a constitutional right to health care.

Dr. Robinson: There is actually no other class of people. It's the only class that people in the United States that has a constitutional mandate for healthcare, are people who are incarcerated. It was actually a Texas… a person who was incarcerated in Texas, back in the 70s—JW Gamble—he was injured on a prison work assignment and he said that the healthcare he got for his… the back injury that he sustained led to cruel and unusual suffering. That he didn't get good enough health care and so he suffered needlessly. And actually went all the way to the Supreme Court. The Supreme Court actually ruled against him said that no you got health care but they said, "Now even though we were ruling against you, from now on, every single person who's incarcerated has a right to health care." Because they have no other choice, right? And they have no other choice. They can't just, you know, walk out of the house and go to the emergency room, or go to clinic, or go to a hospital. They, you know, they only have the providers that the jail or prison provides to them and so it's yeah… Again they're the only class of people with the constitutional mandate. And that's why I find the work important, right? So, when you're taking care of, when we take care of someone who's incarcerated at Ben Taub, we're it, right? They don't have any other choice. They can't, you know, go across the street to Methodist or Herman or St. Luke's. We're the only people that are taking care of them and we're their only choice for care. And so we got to do a really good job.

Eileen: And like you mentioned these patients don't really have an opportunity to shop around, so to speak. They don't have a choice in where they're receiving their care. Does that mean the care is free for them?

Dr. Robinson: It depends. It's been a lot of work around, especially during the pandemic, around in jails—making people not have any payment to seek healthcare. That's not the case though in a lot of jurisdictions, people do have to pay some money to go see the jail clinic. In Harris County Jail, I don't know the exact rules right now, but usually they get several free visits before they have to start paying. If they're referred to clinic, they don't have to pay. So, most of the time they don't have to pay. That's not to say that there aren't significant hurdles and burdens for people to get care in jails and prisons. So let's say you're in a jail that you're lucky enough where you don't have to pay to get the clinic. Well, you still have to usually put in a request to go to clinic. Somebody has to read that request. Somebody has to approve that request. Somebody has to schedule that request. You know, that's not to say… it's hard to see doctors in the US anyways, but it's especially hard to see someone if you're in a jail or prison and you have a medical complaint.

Eileen: Especially if it means you have to miss a meal or miss time outside.

Dr. Robinson: No, that's exactly right. I mean, you know, let's say you have just a tiny bit of money in your bank account or, you know, to spend at the commissary or, you know, buy snacks—buy little things that make you feel a little bit more human while you're incarcerated. You know, the last thing you want to do is blow a lot of that money to go see a clinic visit that you might not, you know, get good care anyways. And so a lot of people kind of let conditions fester.

Eileen: So in terms of letting conditions fester, do people generally experience worst health once they're in jail or prison? I kind of hear sometimes in the news or just sort of the popular media that, "Oh these people go to jail or they go to prison and all of a sudden they have access to healthcare that they didn't have before and so they do much better." Is that true?

Dr. Robinson: In terms of jails, no. Prisons are a little bit different story and depend state to state. So in terms of jails, I mean, the incarcerative event, being the act of incarceration, is going to make your health worse. I mean, there's, you know, some survey data showing that people, you know, over 40% of people that are taking medications entering a jail will stop taking it whenever they leave the jail. Repeated incarceration events make people have worse control of their HIV AIDS. The… just having a history of incarceration is going to raise your chance of having cervical cancer. If you're diagnosed with cancer while you're incarcerated, you're going to have a higher cancer-related mortality than if you were diagnosed in the community. So just the act of incarceration is going to make your health a lot worse. And so there's this perception that you know, jails are full of young healthy men you know, working out in the yard, playing basketball. That's not the case. I mean, when you look at the health of people in jails, it's significantly worse than the health of people who are out in the community across all disease processes—heart disease, lung disease, liver disease, infectious disease. They're just going to be sicker when you match for age, sex, gender, everything—they're going to be sicker than a cohort in the community. Prisons are a little bit different, you know. Prisons are long-term facilities. And you do have some prison systems that actually provide fairly good longitudinal care because they have somewhat of a financial incentive to do so, right? They want people to control their chronic illnesses so that they're not expensive. And so, there is some data that in Texas, especially out of the UTMB system, which controls a large portion of the state prison systems health care, that controls of asthma HIV/AIDS, at least in the early 2000s, was better as compared to the general population. They're still terrible places to be, right? Prisons and jails are awful places to be. And so, you know, I don't think it's a good argument that, "Oh these people didn't have health care. Let's you know throw them in jail or prison and get them healthcare." I think we should just provide them, good health care regardless of where they are.

Eileen: And how has covid played into all of this?

Dr. Robinson: I mean, yeah, if you were to design a place where covid would be—to have the worst covid outcomes possible, what you would eventually come up with is a jail or a prison. So you know, we had just lots of and lots of deaths, lots and lots of covid in jails and prisons. In Texas, we've had, you know, hundreds and hundreds of people die in Texas prisons and jails. Many of these people were pretrial, meaning that they had not yet been found guilty of a crime. They're not even gone to trial yet, you know, they ended up getting a life sentence. You know, many people in prison who were actually awaiting release on parole but you know, their paperwork hadn't been filed, they ended up dying of covid. And then there's some really good studies out of Chicago showing that people cycling in and out of the jail accounted for a large portion of the racial disparities of covid. And that, you know, so tracking covid in communities was a really good metric for what… how jailing affected a community.

Eileen: And you still take care of patients who are incarcerated here at Ben Taub. Do you still work at the jail at all?

Dr. Robinson: No, it's been some time. You know, I'm trying to get back in. Just with some of the changes… the credentialing is a lot different and stuff. So I'm working on getting back in, but I do love taking care of the population when they come to Ben Taub.

Eileen: Are there any specific patient encounters—obviously without breaking confidentiality—but anything you can tell us about a… something that's been meaningful to you working with an incarcerated patient, either at the jail or at Ben Taub?

Dr. Robinson: Yeah, you know, we had this guy at Ben Taub who was really sick. He had a chronic condition that was very uncontrolled. And you know, he was just an interesting guy. And you know, taking care of him… had some affiliations that you know, were really, you know, nefarious. And you know, if you just looked at a picture of him, you would be, you know. You wouldn't want to take care of him, right? And then the second you started talking to him, he was just like the loveliest guy. And he would take these Styrofoam trays that they are served their lunch on and he would draw these pictures on the trays. So I have one up in my office of a hummingbird and a flower. And it's just a… just a really good reminder that you know, don't judge a book by their cover and you know, we should just approach everyone, you know, as a blank slate.

Eileen: And I'm actually going into emergency medicine, so we a lot of incarcerated patients in the ER. And when we see those patients, they're usually wearing bright orange to mark that they are incarcerated patients and more often than not will be restrained, handcuffed to the bed quite frequently. Which makes it much more difficult to do a full exam. We often have to ask the law enforcement officer who is present if they can release the patient so that we can do all of the testing that we need to do. is that something that continues on the inpatient side or do they have a little bit more, sort of, flexibility in how they're treated?

Dr. Robinson: No, I mean it absolutely continues on the inpatient side. So, a couple things, you know, one, you know, everyone that comes into the hospital from the jail, is shackled to the bed. So with a leg shackle, a leg cuff, or an arm cuff. And usually, this is done is, you know, for safety, right? And although there's not a lot of evidence that it's needed to be done universally to every single person, but we do do it to every single person. Also everyone's put in an orange jumpsuit and identified as somebody from jail. And very often in the hospital, they're identified as a "prisoner." And you got to remember, 80% of the people in the jail are there pretrial, right? So they have not yet been found guilty of the crime that for which they are accused. So in the eyes of the law, I mean, they're really not too different than you or I. If we were falsely accused of a crime and all of a sudden, we had a medical emergency, we'd be exactly like these people. And so, we, I think we should treat them with a lot more grace than they often are. And regarding the shackling. I mean, when you talk about universal application of shackling, which is done here in the US, meaning every single person from a jail or prison is shackled, that was actually in the European Court of Human Rights seen as a human rights violation. That if you were to apply the shackles on every single person regardless of their risk of flight, or their risk of danger, you're actually violating their human rights. And I see that, you know. I see elderly people coming from the jail. I had his elderly patient who's blind, and who was shackled to the bed, right? Like the danger of this person, escaping the hospital was 0. The danger of them hurting anyone was 0. Yet, they still had a leg cuff, right? And then that limits physical exams. It limits mobility, so puts them at risk for all the different things that restraints put people at risk for: risk of dying in the hospital, risk of getting injured in the hospital, risk of getting blood clots. And so it's a terrible practice. We haven't found great solutions for it. I think it's just going to… we're just going to have to slowly change the culture of how we view these patients before it gets changed.

Eileen: And that applies even to women who are in labor, correct?

Dr. Robinson: Yeah, I mean, there's, so there's a couple of laws… so just to go back. Yeah, many women were shackled during active labor for a long, long time. Many states have outlawed this practice, but it's really not well defined. And so you know, they are there's laws on the books saying that they can't be shackled during the peripartum period. Well what does that mean, right? Is it when the baby's coming out you can't have a shackle on? When you're holding your child skin to skin after delivering can you not have a shackle on? When you can you put it back on? And so the application of these laws are quite variable. There is a federal law on the books saying that for people who are in federal prison, they can't be shackled during delivery. But this is a really small part of the population. The vast majority of, you know, pregnant people who are incarcerated are going to be in jails. And they're still you know, I can't remember the exact number—might be a dozen—states that don't have laws on the books, where people can still be shackled during delivery. So it's a big problem, you know. We need… the problem is, you need… all these laws are written by men who really have no idea what's going on, right? And so I… this is not totally related to pregnancy, but kind of paints the picture. I have a friend who's a—Krish Gundu with Texas Jail Project. Wonderful person, wonderful organization. And she talks about how, you know, they there was a law written where they… women who are incarcerated, no longer had to pay for sanitary products during their menstrual cycle. And it was seen as a big win. But she said, well, you need to provide underwear, you know, for a lot of these products and, you know… people on the Texas Jail Commission were wondering, "What are you talking about? Why would we need to do that?" And it was, she was just flabbergasted. And so, the problem is a lot of these people that write these laws one, are never affected by incarceration or two, really, you know, just can't get in the in the shoes of somebody who might be impacted by some of these policies. So, I'd really… anyone who's interested and who might fill those gaps, like really get interested in. So that's what we'll talk about later, HEAL Initiative. I love seeing students active in it because I think they have perspectives that a lot of people don't.

Eileen: You mentioned the Texas Jail Project as well. Could you tell us a little bit more about that?

Dr. Robinson: Yeah, Texas Jail Project. I mean, it's just an incredible organization. They fight passionately for people who are incarcerated in jails. So they get calls all the time from family members, who think that a family… someone who's incarcerated is being mistreated. And they just have no idea what to do. Because it's incredibly hard to figure out what's going on with your loved one who's incarcerated. And so I work with them on a number of things. Very often they call just to kind of talk through a medical issue that somebody's having in a jail to see if it makes sense. Oftentimes, it doesn't. Right now… so last year, in almost two decades, was the deadliest year in the Harris County Jail. And so we are, you know, currently collecting all the autopsy records from people that died in the jail, since they're a public record. And so kind of going through those and seeing what we find. And, you know, we found people who died of fentanyl overdoses who have been incarcerated for two months. And so they just do incredible work. So I really just can't speak highly enough of their organization.

Eileen: And as future doctors—hopefully—future residents, medical students. What else can we do to advocate for these patients and for this population?

Dr. Robinson: Yeah, I mean, the thing about it is, you know, as doctors you're always going to have a voice that, you know, for better or for worse is gonna… politicians are going to listen to you, right? And so you know, staying on top of legislative sessions, staying on top of the news around bills coming out. You know right now there's a current, a bill that's in the Texas legislature that has been proposed that any natural cause death in a jail doesn't need to be investigated. That if a crime has not occurred, then they probably don't need to investigate it. And so, this means all suicides, all deaths from people not getting their medications promptly, basically anything—those would not be investigated and I think that would be a huge loss. And so, just staying on top of things is probably the number one thing that a medical student and future doctor could do. And then calling your legislator when something it doesn't make sense or you don't like something. Because they'll listen to you. If you call and say, "Hey, I'm a medical student" or "I'm a physician and I'm in your district and I don't like this bill," they're going to listen to that, one because you're a voter; two, because you're a doctor who's, you know, potentially a donor to their campaign. So they're going to listen to you. So I… take advantage of that. Because you're going to see a side of society as a physician that many people don't see at all. Ricardo Nuila has a wonderful book out right now called "The People's Hospital" about Ben Taub and his experiences with people at Ben Taub. And I'm just… I love seeing things like that. Because you as a physician, especially in a… with a marginalized population, are going to see things that the general public has no idea about nobody. I mean, nobody who… nobody knows about shackling, right? Like, nobody knows that if you're incarcerated, you're going to be shackled to the bed the entire time. Nobody knows about that. And so, just talking about your experiences, telling people about your experiences, and then advocating for the for people who you see, I think is the number one thing you can do.

Eileen: And you are also the faculty mentor for the HEAL Initiative. So, students here at Baylor College of Medicine can get involved a little bit more directly in some education with these patients and with incarcerated persons. Can you tell us a little bit about the initiative?

Dr. Robinson: I mean, I'll let the wonderful students who run the initiative say the most about it. I will say that, you know, they've done incredible work, right? I mean, I… when you say faculty advisor. I mean, I just like kind of sign my name and say "You're doing a great job." They do all the work and… but I'm happy to take some of the credit. They do an amazing job, you know, teaching people about what a healthy life looks like whenever they get out of jail. I think the number one thing that they do is, you know, when you… they give people in jail break, right? I mean, because your day in jail is incredibly monotonous and you have no control over anything. And so, if you can sit and listen to really passionate wonderful, lovely medical student, you know, tell you about what it means to have a healthy life when you get out. I mean, that's a nice break and that's treating you like a little bit more of a human in a setting that really does its best to strip away your humanity. So I… you know, I think that's the best thing that they do, but I'll let them explain a little bit more about the nitty gritty of the… of the initiative.

McKenna: Yeah. So this is McKenna, also a third-year medical student here at Baylor, and we reached out a couple years back to get Dr. Robinson to be our faculty mentor for this HEAL Initiative organization. I think it was originally inspired by Dr. Robinson's, like, lecture given to this Care of the Underserved elective that I attended. Because I think realizing that there were incarcerated patients at Ben Taub that we're interacting with but then, you know, nothing necessarily specifically organized within the Baylor College of Medicine community to kind of engage with these populations. It just seemed like a good kind of space to get involved in and so we started the organization, I think like fall 2021, really hoping to teach some classes at the Harris County Jail. And then it's kind of blossomed into this beautiful community where students can engage with topics of incarceration and thinking about incarceration as a social determinant of health, kind of like what we've been talking about so far.

Justin: Yeah, so our organization now, we try to do two main things. So as McKenna said—and I'm Justin, I'm also a third-year medical student—the first thing that we try to do is we try to have these health literacy classes at the Harris County Jail, where we teach people at the jail, about a variety of health topics, including infectious diseases, general health, mental health, and healthy relationships. And our intention is sort of to present the information in a way that is, you know, usable. We're not trying to be very, like, overly scientific or overly formal in our presentation of the information. We really want to make them feel like this is information that they can apply on a day-to-day basis. And let's say, if somebody in their family or friend or they themselves develop some symptoms of a certain disease, well maybe they, you know, we can give them some information to equip them with the idea of they maybe know what's going on and they maybe know what resources they can pursue. So that's the first thing that we try to do as our organization. The second thing that we try to do is more focused on, you know, just the Baylor College of Medicine and the healthcare community at large, you know: medical students, residents, physicians—just raising awareness about some of the barriers to adequate healthcare experienced by people who are incarcerated. And this takes the form of, you know, we have like talking sessions where we just have a roundtable discussion. We've done film screenings where we watch documentaries that are very informative about these issues. And then we also do things like journal clubs where we try to take… or, we're planning to do these journal clubs where we were try to take like a very quantitative and sort of scientific approach to explaining, you know, exactly what these barriers look like in the incarcerated population. And then also how it affects the community at large, right? It doesn't just affect people who are in jail or prison. It also affects… just everybody in the community. And so, we just want to raise awareness so that we know, as a healthcare community, how to address some of these problems and maybe we can improve some things at the smallest level.

Eileen: And I am lucky enough also to be a member of this group, so I've gotten to teach some classes. And it's really pretty incredible, the range of knowledge that people come in with and the curiosity that they have about these different topics. I'm wondering if either of you could speak to a certain question or story of an experience that you had when you were teaching that really stands out.

McKenna: Yeah. I mean, I think every session… like I know I'm going to have a good day when I have a session in coming up. A lot of them have been over Zoom just because of some of the challenges like logistically with onboarding and coordinating with a jail system, but I also was lucky enough to go to some in-person classes as well. And just like, I remember walking in and there's a room of like 40 men in a tank all at tables and like really ready to engage with the material. I personally, I think the class I've taught the most was the infectious diseases course which Justin and Eileen both designed. And I love the conversations around covid and vaccines that we get into every time we lead this class, just because people are so curious. And also it really is a conversation just, you know, about health misinformation and just different questions that maybe people were not given the opportunity to ask to a physician or healthcare provider. And I think it's really kind of gratifying to, like, talk about these things in a way that's free of judgment and just learn what people's conceptions are about covid, especially people who experienced covid, you know, in the carceral setting.

Justin: Yeah, so for me, the class that I've taught the most as well is also the infectious disease course. I really do love being able to share that information. For me, you know, when I start the lectures, I like to say that, you know, yes, I'm here to, you know, provide this information you but I'm also here to learn from you as much as you're here to learn from me. And I find that very true. I often find myself asking them questions, what their perceptions of things are. And also, it's a great way for me as a student to learn what sort of healthcare resources they actually have access to. I can ask things like about how often they get TB testing and whether or not they have access to certain vaccines. And you know, what their colleagues or their friends, think about getting vaccinated. And we're able to sort of, you know, address some of their concerns or their questions in a very non-judgmental way, in a way that's… because the thing to keep in mind about this, this population of people is that they have historically been taken advantage of by the healthcare system in our country. And so, you know, it's really incorrect for us to blame them for any sort of skepticism or any sort of misunderstanding they may have about even the most trivial of healthcare issues. But the thing you'll find is that just through simple conversation, asking questions back and forth, you'll find that, you know, you… even as just a medical student, you can make a big difference in people's perceptions. And then your perception about things yourself can be completely changed as well, and you're able to see things from their shoes from, you know, from their side, much more effectively. And I think that makes, you know, that will make me a better doctors... that will make us better doctors in the future. Because we have a, you know, we have a different understanding or maybe a deeper understanding of the things that they've gone through and their perception.

Eileen: So, and McKenna, if someone wants to get involved with the initiative, if they're here at Baylor, who should they get in touch with?

McKenna: Yeah, I think any of us three, we I try to kind of put my phone number and email out there and… Lucky enough, a lot of people I think recently, I think have been forwarding people my way and I always, you know, put them on our email list serve for the organization. But also, you know, we try to advertise pretty broadly. I've been putting our… like, a couple weeks ago we had a film screening and kind of putting it on the greater, like, Baylor student affairs calendar. Just so that everyone's kind of aware of these opportunities. In terms of service opportunities, we're constantly setting them up and creating like a schedule of weekly classes each month and recruiting volunteers. It is challenging because we're all busy medical students, and especially the clinical students with their busy schedules, but somehow we always make it work with a team of like, you know, three, four, five students teaching an afternoon class. So yeah, I would say just, you know, reach out to me, Justin or Eileen. Or hopefully, people have started to realize, kind of, our names in this community and sending people our way to get involved.

Eileen: And what's your email first?

McKenna: My first name… so, McKenna.Gessner@bcm.edu.  

Eileen: And spell please…

McKenna: Yeah. M-C-K-E-N-N-A dot G-E-S-S-N-E-R @bcm.edu

Eileen: Wonderful. Thank you so much. Thank you guys for speaking about the initiative. I know it's something that we're all really excited about and really passionate about. I was wondering if Dr. Robinson could let us know, if there's anywhere that a student is looking to get more information about this topic, or become involved with any other organization, do more research or some reading perhaps in the academic literature, where should they look for those sorts of resources?

Dr. Robinson: Yeah, that's a good question. So, as I mentioned before, Texas Jail Project—really good. And so I know a lot of the Texas resources. So Texas Jail Project has a good website. Texas Justice Initiative, TJI, they collect all of the custodial death or deaths for people who are in custody in the state of Texas and, kind of… you can get all of the data since it's all publicly reported from their website. It's a really, really great resource. There's a couple good review articles over the past few years. So there's one in JAMA Internal Medicine, couple years ago for care for incarcerated people in hospitals. To view, just Google that, it should show up. That was a good resource that I use. There's a really good book called "Death in Rikers Island" by Homer Venters. He's the former chief medical officer of the New York City jail systems and he kind of goes through all of the different problems in healthcare in jails and does it through the lens of patients, who, unfortunately it, you know, passed away or had bad outcomes in the New York City jail system. So "Death in Rikers Island" is a really powerful book. You know, I think just getting involved or reading more about how the justice system works or that, you know, the punishment system to put it more accurately. And so I… there's a couple, you know, classic books that people everyone should read. "The New Jim Crow" by Michelle Alexander is required reading. "Just Mercy" by Bryan Stevenson is another good, kind of through the death penalty lens. Those are two that really impacted me before I got into this work. So those are the three books, I'd recommend: "Death in Rikers Island," "Just Mercy," "The New Jim Crow." There's another really good organization called the Civil Rights Corps. You can look at them. Alec Karakatsanis runs it, and they do a lot of work in kind of bail reform law suits. And so, arguing the constitutionality of bail laws and the implementation of bail laws. So, those are some things that have really impacted me and so I encourage people to go look at them.

Eileen: Great, thank you so much. Is there anything else that you would like to share with us about this population or your experience just in general? It's okay if the answer is no...

Dr. Robinson: No, I mean, just, you know, to put a cap on it. One of the reasons I do this work is just spreading the word, right? And so anything you learn, tell your family about any amazing impacting experience, you have. You know talk to it in a protected, you know—patient history protected—way about your experiences, right? Because the more we can kind of talk about how bad things are in our carceral settings in United States and how it impacts people's lives, the more the word spreads, right? And so, if all you do is learn a lot and talk about it, like that's something that's really good, right? And so I really encourage people. You don't have to, you know, change the world with it. But if you could spread the word and talk to people about it, I mean, that's doing quite a bit of good.

Eileen: And Justin, McKenna... Do you guys have any final thoughts?

McKenna: I would just say like taking incarceration seriously as a social determinant of health. Like recognizing when we talk about ACES, like Adverse Childhood Experiences, one of those is having a family member who is incarcerated and it's a really really profound adverse childhood experience. And so I think you know, recognizing the seriousness of that and bringing it up and conversations about public health and about, you know, medical outcomes. That's just something I've been trying to get people to do more in our community and just like in our profession at large.

Justin: Yeah. And I think that the way that our society sees incarceration really speaks to our values. And so, I think it's… that's why it's so important to really raise awareness about many of these issues. Because I really do think that if more people know about them, more people would be quite upset about the way that we treat the, you know, incarcerated populations in this country and the way that we handle their healthcare, And I think that we could get a lot of people on board. And so, I think it's just a matter of, you know, as Dr. Robinson was saying, just increasing awareness about these things.

Eileen: Yeah, yeah, I completely agree. We are lucky enough here at Baylor to have courses that talk about social determinants of health and often times that ends up being related to income level or race or where a person is living, if they have access to insurance. And I think that by sort of spreading the word about this, we're getting that incarceration aspect to be a part of the conversation, because people don't, obviously think about it. It's not the first thing that springs to mind when you think of risk factors for diseases. I think the other thing that's really just stuck out to me, is how profoundly this impacts all of us in the healthcare system. As I mentioned before, I am going into emergency medicine and we see a tremendous number of incarcerated patients. But we also have students in the group who are interested in all different fields. McKenna is very interested in obstetrics and gynecology. And so she has a unique interest in women's health in the jails and prisons and reproductive healthcare, especially in the state of Texas with all of the changing legislation right now. We have people who are interested like Justin in internal medicine. We have people who are interested in psychiatry and how profoundly incarceration impacts mental health and what it means to be mentally ill in America. And people who are struggling with mental illness, how much more likely they are to become incarcerated or to become homeless. So I think all of these systems really play together and I'm really excited that we've been able to start building this. I want to say thank you so much to Dr. Robinson, and to the incredible student leaders for this group. I am very grateful that you guys have been able to take the time to come speak with us today, and I wish you the best of luck.

Apple | Spotify | Google Play | Stitcher | Length: 25 minutes | Published: March 31, 2023

In this episode, we speak with Dr. Laura Detti, the director of the Reproductive Endocrinology and Infertility (REI) department at Baylor College of Medicine. We discuss two of her major research projects: ultrasound measurements in detecting early pregnancy loss and using recombinant AMH for potential fertility preservation applications. We also hear about how she uses research findings to inform clinical practice, as well as exciting future research in the field of REI. 

Transcript

[Intro melody into roundtable discussion.] 

Shubh: Hi, welcome to the Baylor College of Medicine Resonance podcast. I'm one of the sound engineers for today's episode, Shubh Desai. 

Madeline: And I'm Madeline. I'm the writer and host for today's episode. I'm also a third year medical student at Baylor College of Medicine. Today, I had the honor of interviewing Dr. Laura Detti, who's the director of the Reproductive Endocrinology and Infertility - also known as REI -department here at Baylor College of Medicine. So first, a little bit about Dr. Detti. She earned her medical degree at the University of Florence in Italy and completed her OBGYN residency there, as well as at the University of Cincinnati. Dr. Detti completed her fellowship training in Reproductive Endocrinology and Infertility at Wayne State University School of Medicine and has completed research fellowships at Yale University and the University of Virginia. She currently serves as the director of the Reproductive Endocrinology and Infertility Department here at Baylor College of Medicine. 

Shubh: Wow, that's super cool Madeline. How did you get to meet Dr. Detti?

Madeline: So, I met Dr. Detti as a part of my REI elective that I'm doing right now in the department of Ob-Gyn. And before I started the elective, I was looking into her research and was just really fascinated by the work that she does. So, I'm very excited to have her on the podcast today. Now, before we jump to the interview, there are a few background pieces of information that I think will be helpful to mention. So first, infertility is defined by maternal age. So, if patients are younger than 35, it is defined as 1 year of regular unprotected intercourse. In patients that are greater or equal to 35 years of age, it's defined as six months. 
Per the CDC, in heterosexual women aged 15 to 49 years of age, with no prior births, about one in five, (19%) are unable to get pregnant after one year of trying to conceive. Additionally, one in four women in this age group have difficulty getting pregnant or carrying a pregnancy to term. 

Another thing that I think is helpful to discuss before we jump into the podcast is AMH. AMH is a hormone called anti-mullerian hormone, and it's critical to the sexual development of fetuses and can also be used as a reference marker for ovarian reserve. In genetically male fetuses, the testes will produce anti-mullerian hormone, which causes the Mullerian — female — ducts to disappear. The Mullerian duct develops into the ovaries, uterus, cervix, and the upper 1/3 of the vagina. 

Testosterone produced by the testes causes the Wolffian, ducts to remain, which develop into the male reproductive system. In contrast, in the ovaries, AMH also plays a role in follicle development. Every month, several follicles begin to mature and the granulosa cells of the follicle produce AMH.  The AMH inhibits recruitment of follicles from the resting pool in order to select for the dominant follicle. The more developing ovarian follicles a person has, the more AMH can be produced. AMH can be measured in the blood and compared to other patients of the same age to estimate how many follicles are left in the ovaries, a term called ovarian reserve. This marker is used as one factor in guiding fertility treatment as it can help estimate how many oocytes would be extracted in an IVF or oocyte cryopreservation cycle.  So again, I want to welcome Dr. Detti to the podcast. 

[Transition melody]

Dr. Detti: Thank you so much Madeline. I'm really honored to be here today with you, and this is a new experience for me, so I'm extremely excited. 

Madeline: So we're excited to have you as well to talk about all the exciting stuff you have going on here at Baylor. So first, can you tell us a little bit about your journey in medicine and what brought you here? 

Dr. Detti: Sure. So, I'm originally from Italy, that's my accent and I came to the U.S. with the prospect of doing research for just a few years. And then I loved the system, the medical system here in the U.S. And so, from just a few years, it became over 25 years and I'm still here. And so I've been having different research interests over time because fundamentally, I am a very curious person. And I always ask why a certain action or outcome happens and why a certain response is also elicited and that has been the push to develop my research interests over time. 
So, my interests have changed from initially assisted reproduction technology but then they shifted towards the uterus and studying the Mullerian anomalies and specifically the uterine septum which has been a niche of mine and then I shifted to studying more the endometrium, and how it can impact success rates in natural pregnancy as well as in IVF. And then again, I went on to early pregnancy and then fertility preservation to find out possible causes of ovarian damage. And also to finding ways to prevent ovarian damage. So, my research has evolved together with my career and with my curiosity of clinical cases that we see every day in the clinic basically. 

Madeline: That's wonderful. Thank you so much for sharing that. It's really cool to hear about how your research affects your clinical interest in practice and vice versa. So could you tell us a little bit more about how research has affected the way that you practice in the clinic?

Dr. Detti: Sure! So when we do research, we typically come to outcomes and depending on what the results are, I typically shift my way of practicing trying to facilitate a positive outcome versus trying to prevent a negative outcome. And so, the research has taught me to think outside of the box and always expect things that might happen, and also how to troubleshoot those possible adverse outcomes that might come.

Madeline: Wonderful. And I understand you are relatively new to Baylor College of Medicine and you’re now the director of the REI Department, could you tell us a little bit about what specifically brought you to Baylor? 

Dr. Detti: Yes, so I'm extremely excited to be here at Baylor now. I think, I believe, I've been around in the United States for conferences, and also for work, and I believe that Baylor is one of the few true academic and research institutions in this country. And I'm excited about the opportunities that are here for networking and meeting these exceptional people that do research here. And that devote their life to making other people's lives better. 

Madeline: That's wonderful. And I know as a student I've also appreciated being in the medical center and getting to see the collaboration between different specialties and different people in the science and medicine.

Dr. Detti: It's very exciting. 

Madeline: Yes. Yes, I agree.
So, I want to talk about two projects more specifically that you've been involved in. First, there's a project on ultrasound measurements for early pregnancy loss that was investigating different markers, like gestational sac measurements, yolk sac diameter, crown rump length, and all of this was in order to help predict first trimester pregnancy loss. So, could you tell us a little bit more about this project and how you investigated this and what you found? 

Dr. Detti: Yes. So as I told you before, I'm very curious and I use ultrasound in my daily practice. And so what I, what I noted by doing ultrasound in very early pregnancies — we're talking about five to eight weeks gestation — you can actually see some changes in pregnancies that then they just end in a miscarriage or an early pregnancy loss. And so that curiosity of understanding a little more led me to try and research possible changes that could lead to the pregnancy loss and  in a certain way — to not prevent because unfortunately we cannot prevent the pregnancy loss that early when it wants to happen, but at least to prepare the patient and set a follow-up. A plan with the patient that makes her feel really cared for at this difficult time of her life. 

Madeline: Absolutely, and I know working in the fertility and infertility spaces, a lot of these patients are really hopeful, you know, that these pregnancies will continue and it can be quite devastating when they don't work out

Dr. Detti: Right

Madeline: So, that's really interesting that you're able to use these parameters to better counsel patients and help them have a little bit of an idea, what the odds are of this pregnancy continuing. And could you talk a little bit more about specific findings that you found in the project about the yolk sac and gestational sac measurements? 

Dr. Detti: Yes. I've always been fascinated by the yolk sac because in the beginning I really didn't know what it was there for. And many people still believe that the yolk sac just gives some nutrition to the early embryo. In reality, the yolk sac provides to the embryo two vital cell types. One is actually the oogonia or the spermatogonia. So, the, Germ stem cells, and then the other one is the red blood cells. They both derived from the yolk sac, and they start developing and just a few dozens of cells than they  work their way through the inside of the embryo and then they start replicating and producing these two amazing cell lines. And so the yolk sac, and what I found is that it can increase in size, especially when there is a genetic abnormality in the embryo, like a Trisomy 22 or Trisomy 16, that can cause an increase in size of the yolk sac. So, when you notice it at 5 weeks gestation, when the pregnancy still on going there, heart rate is there. But then again you just start preparing the patient and plan for the follow-up. And the other one is the gestational sac size. That also can predict when a pregnancy is going to a good end versus not.

Madeline: And the trisomies that you mentioned for our listeners at home that may not know as much, those are common causes of miscarriages, correct?

Dr. Detti: That is correct. 

Madeline: Okay. 

Dr, Detti: Maybe you possibly know the trisomy 21, which is the most well, known of all, which is Down syndrome. That is actually the only Trisomy that is compatible with life. 

Madeline: In another part of the- and five weeks, that’s very early, that's typically earlier than most people would get their first ultrasound to confirm a pregnancy, correct?

Dr. Detti: Correct. So that's the earliest that you can see the embryo inside the gestational sac. 

Madeline: Okay. So we're talking really early on. Okay, so does this have any implications for changing recommendations about when people who are pregnant should seek out their first ultrasound? 

Dr. Detti: So not necessarily, I mean I wouldn't be so ambitious to say that we should change and gestational time when we do the first ultrasound, it can happen, especially in the area of infertility because we, we see the patients from the transfer of the embryo when there are three weeks pregnant and then on, but it would be important. Possibly to have a patient come into the office when they're about the six or seven weeks gestation, I would say. Because at that time, it would be, it would be very nice to identify the pregnancies that are unfortunately destined to fail.

Madeline: And you mentioned when we do embryo transfers, the patients being at three weeks of gestation, can you explain a little bit for our listeners at home? What exactly that means and how that dating is done? 

Dr. Detti: Yes. So we follow nature in the IVF lab, just like just like everywhere else and the normal timing for an embryo to implant inside the uterus is 21 days or so, about seven days after ovulation. That's when the blastocyst will attach to the endometrium. And so when we consider that for the gestational age calculation, we always consider the last menstrual period. Which on a day 21 would be three weeks before. So, when do an embryo transfer we do it at exactly that that time and we prepare the endometrium for being an endometrium like 21 day of the menstrual cycle and so that's why when we do the embryo transfer that fashion if she conceives a she's already three weeks pregnant.

Madeline: Fascinating! And I think just so interesting the way that in REI you're trying to time not only the blastocyst and that side of things to be developed to a certain level, but also making sure that the endometrium and that the patient is optimized for the best outcome. 

Dr. Detti: Exactly, you want to synchronize the two parts so that something good happens. 

Madeline: Exactly, exactly. A lot of scans and a lot of looking at lab values to make sure that everything is perfect to give the patient the best chance. 
So these findings seem really important for counseling patients. And for going through with expectant management and learning how to prepare the patient for these outcomes that may not be as pleasant. What are some other areas of research in this? And this topic that you think are interesting to dive deeper into?

Dr. Detti: My interest has been mostly in the fertility, preservation field, and trying to preserve the ovarian function for longer in women and, and also trying to protect the ovarian function, when women are exposed to gonadotoxic treatments, and for gonnadotoxic treatments, that can be either aggressive surgery, or it could also be — and more often — It is chemotherapy. So treatment to battle cancer to battle adult immune conditions, sickle cell disease, and other hematologic conditions, for which, we do good to the patient on one side, but then their fertility is actually compromised.

Madeline: Absolutely, so patients that are undergoing cancer treatment or having treatment for another disease, that can be life-threatening. Obviously, it is very important. But also, having an opportunity to give them maximum options in the future in regards to their fertility is important to consider as well. So, tell me a little bit about the research that you've been doing in this area.

Dr. Detti: So my research has been translational, which means it's been on the animals and also on cell lines so far, but trying to find a way to protect the ovary during chemotherapy and also after ovarian tissue transplant. I tried to employ AMH. You mentioned it before very nicely, what AMH is. And what many people don't understand is that anti-mullerian hormone is actually an inhibitory hormone that regulates the ovulation and the also the development of the ovarian follicles in such a way that it protects the ovarian reserve of follicles. And so by using AMH, we can actually protect the ovarian follicles and ovarian reserve during chemotherapy and also during other stages of follicular development. And so, this animal studies and basic research studies have shown that. AMH indeed can decrease cellular function to the point that the granulosa cells, which are the main responder to AMH. So, they are the producers of AMH but they're also the main target of the AMH hormone. They can become completely quiescent and for quiescent, I mean They returned to the pre-pubertal stage. Basically, when there they're not functioning and they're just in the ovaries but they're not facilitating any follicular development. 

Madeline: That's fascinating. So, we're able to turn back the hands of time in a way and pause the oocytes.

Dr. Detti: I like to call it the Fountain of Youth. I don't know if we will get to that point though.

Madeline: But that's certainly very exciting!
Do we know the mechanism behind why putting these follicles in an active state preserves them throughout chemotoxic treatment?

Dr. Detti: Oh yes. So what you have to think is that the every female, mammal female, is born with a fixed number of eggs. In the human, the peak number of eggs in the ovary is about 6 to 7 million and that happens at 20 weeks gestation. So when we're still inside our mothers’ wombs, and then we only lose all those eggs due to apoptosis which is a different kind of necrosis. But during reproductive life, what we know is that for each egg, that is actually ovulated with each menstrual cycle, we know that about another thousand are lost to this apoptotic process. So, if we can find a way to keep that thousand of follicles that will go into apoptosis and eggs containing the follicles. Then we could reverse that that mechanism and keep the follicles inside the ovaries for a longer time. 

Madeline: That's fascinating. And that the implications for this research are really amazing and thinking about what we could do in the clinic potentially, many many years from now with AMH is very cool. 

Dr. Detti: I think it is. And we're trying to further develop this venue and see if we can find doses and other little tricks to make it more efficient. Now, one thing that has to be said though is that AMH is not approved to be used in the human by the FDA yet. And so, it's only for animal studies. 

Madeline: Okay. And is there any is there any progress that the FDA is making towards maybe looking at approving it, or is it still in the very early stages? 

Dr. Detti: Unfortunately, it’s in the early stages because AMH is a large dimeric protein hormone and it's very difficult to produce it in a large-scale maintaining low cost and keeping all the characteristics of that hormone to be active on its own receptor. So, we're at the beginning still, but the future is promising. 

Madeline: Certainly it sounds that way. This is what a wonderful conversation. Thank you so much for joining us today. I want to wrap up with a couple more questions, more generally about things that you're excited about in REI research and things that are up and coming at Baylor specifically. 

Dr. Detti: Yes, yes. So we're trying to remodel our division of REI. And we would like to make it a little more efficient for medical treatment and patient care mostly. Also, we would like to become more of a reference clinic for more complex, REI cases. Baylor, as you know, is one of the world renowned places for genetics. And so, we pride ourselves in taking care of all these difficult genetic cases that might present to us. And of course, we would like to expand the more the fertility preservation because we're placed in this very unique location at Baylor with Texas Children's on one side, MD Anderson on the other. So, we have plenty of good things to happen for the institutions and for Baylor.

Madeline:  And certainly there's a large need for patients who maybe are seeking care at TCH, for genetic conditions or seeking care at MD Anderson for cancer treatment. There’s so much need for fertility preservation discussions and talking through options with these patients. So, I think that the REI department at Baylor is in a wonderful place to be able to help these patients. 

Dr. Detti: We were certainly very lucky. And I feel again very honored and excited to be here. 

Madeline: Well, thank you again and then my last question for you is, could you tell us a little bit about what you're working on in the lab right now? And maybe future directions for your personal research? 

Dr. Detti: Oh yes. So we spoke about the AMH and not being approved by FDA. So, what we're working on right now is a new molecule that could mimic the effects of AMH on the ovary and on the granulosa cells. But without having all the difficulties in production of AMH on a large scale. So that's to come hopefully in the next future. 

Madeline: Oh wow! We will have to have you back for a second episode to talk about that next time.

Dr. Detti: I would be delighted to do that. 

Madeline: Well, thank you again Dr. Detti, and thank you for listening to Resonance. 

Dr. Detti: Well, thank you.

[Outro melody]

Apple | Spotify | Google Play | Stitcher | Length: 41 minutes | Published: March 10, 2023

In this episode, we talk to Dr. Angela Catic, associate professor in geriatrics and associate chief of staff of education at the Michael E. DeBakey VA Medical Center, about her journey to geriatrics, her experiences as a medical educator, and the future of caring for older adults. We also talk about the interdisciplinary opportunities in geriatrics and her perspective on training the next generation of medical providers.

Transcript

[Intro Melody]

Juan: And welcome to the Baylor College of Medicine Resonance Podcast. My name is Juan Carlos Ramirez, I'm one of your hosts. 

Aaron: My name is Aaron Nguyen, and I'm also one of your hosts and the lead writer for this episode.

Shubh: My name is Shubh, and I am the sound engineer for this episode. 

Juan: Awesome. Well, welcome guys. And today, we are going to be interviewing Dr. Angela Catic. So, could you tell me a little bit more about? 

Aaron: Yes, so Dr. Catic is a geriatrician here at Baylor College of Medicine. I can tell you a little bit about her biography. She earned her MD from the University of Missouri, Columbia School of Medicine in 2003, and she completed her residency in Internal Medicine at Beth Israel Deaconess Medical Center in 2006 as well as a fellowship in geriatrics at Harvard's combined geriatrics fellowship program in 2007. In addition, she's earned a master's in education from the University of Houston in 2019. And we'll talk about that later in the episode as well. And then, she has also previously served as the director for the geriatrics fellowship, as well as the geriatrics physician assistant program here at Baylor. She currently serves as associate professor at the Huffington Center on Aging here at Baylor and is the associate chief of staff for education at the Michael DeBakey VA Medical Center. She's also the co-PI for the Southeast Texas Geriatric Workforce Enhancement Program. It's a five-year program focused on geriatric interprofessional education in primary care in Houston and the greater Southeast Texas region. And so, today’s episode is focused primarily on medical education and geriatrics, and particularly how medical education serves as an intervention to solve some of the challenges or opportunities in geriatric medicine, including physician shortages and a rapidly growing population of older Americans. 

Juan: Yes, and as we know, this is going to become more of a challenge, as the population ages in the coming years, and it really comes down to us to really do our best for this population, medically and in our communities as well. I mean, it seems like as you know like many other faculty that we interview on this podcast that Dr. Catic wears many hats. So, is there anything that particularly stood out to you that you were like, “yes, we have to interview her for the podcast.”

Aaron: Of course. So, I've actually worked with Dr. Catic for a couple years now, and I'm always impressed with how many hats she wears. I think that it's really special because, as a geriatrician, I think that you have to wear a lot of these hats in order to effectively care for your patients because there isn't a lot of infrastructure in place to care for older patients. And so, just for some context, geriatrics, I think that it’s something that's very intuitive for people. thinking about caring for older patients, but the reality what it looks like can be very different. And so I think, when we think of like the “cutting edge of medicine,” we think of something out of Sci-Fi, something like genetics or like robot surgery.

Juan: Implanting electrodes into people’s brains.

Aaron: Of course, of course. But geriatrics, I think in my opinion, is very much on the “cutting edge of medicine” because, at no other time in human history, have people been able to live this long. And so, we've kind of created these opportunities for people to live in these advanced stages of life, but we haven't really written a script for how that can play out and how we can support these people. 

Juan: And not just help them live longer, but help them have a good quality of life as they age into the later years. And so, all of this sounds very exciting, and I think I'd love to as well as our audience, we'd love to hear more about Dr. Catic. We can scoot on over to the episode. 

[Interlude Melody]

Juan: And welcome back. We are here with Dr. Catic.

Aaron: Hi Dr. Catic, how are you doing today? 

Dr. Catic: I'm doing well. Thank you so much for having me. 

Aaron: It’s a joy to have you. Maybe let's start with a little bit about your background. Can you tell me a little bit about your journey to medicine?

Dr. Catic: Happy to do that! So, I've always had an interest in medicine. Growing up, I was very close to my grandparents. I'm an only child, so I spent a lot of time kind of hanging out, enjoying their company. And I had an interest, I thought in caring for older adults. I explored that a bit more in high school by volunteering in a nursing home, and by the end of high school, I was quite committed to a career in medicine and particularly having an interest in geriatrics. 

Aaron: That's really great. I think, in my experience talking to some geriatricians. it's especially a big source of inspiration, is the loved ones that we have. And it's really good to hear that you have loved ones as well who you have cared for and who inspired you to come to geriatrics. Is there a particular moment where you think that you thought, “hey, geriatrics is the way, particularly being a doctor, is the way that I can care for older adults the best?.”

Dr. Catic:  I think it was a couple of factors. Number one, just enjoying the company of older adults, enjoying hearing their stories and learning from them, and just the wealth of wisdom that they bring to the table. But then, once I got to medical school, it became much more real, much more tangible. And I have to say, I enjoyed all of my rotations. I didn’t have the problem of not enjoying. In fact, I was a little worried how to narrow down, because I liked everything. But, I just kept coming back to that patient population and also realized I enjoy the academic challenge. Oftentimes with older adults, it's not black and white. They don't follow our evidence-based guidelines, and I really found that something that was intellectually stimulating, And something that I thought I would enjoy doing for many, many years. It wouldn't get old. 

Aaron: Yes, that sounds great. I mean geriatrics is so, so interesting. I don't think that many people really truly understand what a geriatrician does. You kind of have to be a little bit of everything for your patients in order to advocate for them. Can you give us a little bit of background? What is, in your opinion, what is geriatrics, and what does being a geriatrician kind of look like? 

Dr. Catic: I think that's a great question. And if we were talking a decade ago, we probably would have been talking about an age. Typically, taking care of older adults, 65 years of age or older, and that really has changed over time. I think of my dad who's in his mid-70s who really doesn't need a geriatrician. Thankfully, he's quite healthy. And so, we moved away from that number, and we think much more about complexity. As I'm sure you're aware and many of our listeners, people are living longer life spans, and they're living with larger numbers of chronic illnesses. So in geriatrics, we’re really thinking about providing care for the most complex individuals, and unfortunately, that could be somebody in their 50s who has a multitude of chronic illnesses, who perhaps has some functional or cognitive impairment. And, we have many people in their 80s and even in their 90's who are working part time, they're very physically functional. And while it would be great for them to see a geriatrician, given the shortage, they don't really need to because they’re thriving and can be well served by a primary care provider. 

Aaron: Yes, that's very important, and I think that people might think of geriatrics is very intuitive that it's based on age, but it's actually very complex about the way that we're able to care for older people, and older might be different for different people. The advanced stages of life are still kind of being defined a lot, and I think that that's something that is going to be really a big challenge in our generation, in caring for older patients in the future. And so, it's really great to hear that from you. So ,what are some of the most pressing issues in geriatrics? You've mentioned that there's the complexity and the shortage of geriatricians, and I think that that's something that we're definitely going to need to address in the coming years. But, is there anything in particular that you think is going to be coming over the horizon for caring for our older adults in our society? 

Dr. Catic: I really like to think of it as a time of opportunity. For the first time in history, we’re moving from a pyramid, so if you think of the base of the pyramid, always we've had more younger individuals and the tip of the pyramid has been our older adults. And so, for the first time in history, we will actually be a pillar. We’ll have as many older adults as younger adults, which, of course, brings lots of opportunities, but also some challenges. So, I think the things that were really considering in geriatrics, as we mentioned, there will never be enough board-certified geriatricians to care for all older adults. And really, that's okay. So, I think one way we can think about this, and Dr. Rosanne M Leipzig and colleagues have written about this, is “Big G versus little g.” So, with a “big G,” we can think of a board-certified geriatrician, and these are the people who perhaps are seeing the most complex older adults, or they’re leading policy change around caring for older adults or leading educational and research efforts. And then really, we want everyone in medicine to be “little g” geriatricians. So, while they may not have a formal fellowship or advanced training in geriatrics, making sure that they have a strong base of knowledge and have those core fundamentals to provide appropriate care for older adults. 

Aaron: That's really great. I love that pivot that you did with talking about opportunity rather than challenges, and I think that that's something looking to the future, how we should really see this topic, is that there are a lot of opportunities that we’re able to empower people and support people in the future, and so I thought that that's really great. In particular, I think that you're talking about training the next generation, and I think that one really great thing that Dr. Catic has worked with a lot, is in medical education and really investing in training that next generation of both “big G” and “little g” geriatricians. And so, one thing about Dr. Catic is that she went back to school to get her master's in education at the University of Houston. And so, I was just wondering how that experience was for you? I think that we talk about medicine being… To be a physician, you have to be a lifelong learner, and you really put that into effect in going back to school. So, how is that experience, going back to school a little bit later and using those skills?

Dr. Catic: It was really wonderful. I've always enjoyed being a student. I didn't know that it was something I would return to almost two decades after medical school. But, I really believe that we have to keep learning, and to be the best medical educator I could be, I wanted to pursue more formal training. I come from a family of educators. I recognize that, to teach, we need to be trained to do that. In medicine, we have often had this theory of “see one, do one, teach one,” but unfortunately that does not bring to bear standards of curriculum design or thinking about how you evaluate your learners. And, I really wanted to have a deeper understanding of that, and I have to say I enjoyed the program very much. I found it very valuable. And I graduated in December 2019, so shortly before COVID, and there was a large focus in the program on using technology in teaching and I never dreamed how important that would become only a few months later when everything went virtual. So I felt very very blessed to have that experience before pivoting to virtual education. 

Aaron: That's good to hear. I mean, we're all kind of adjusting, of course. This is one of the challenges of the pandemic is that now we're transitioning to more kind of a distanced, virtual, asynchronous kind of teaching. And so maybe, can you tell us a little bit about how you utilize those technological skills in translating in your work is as the geriatrics fellowship director earlier and then now transitioning to your new role at the VA as a chief of staff there? 

Dr. Catic: Absolutely. I think COVID is hard to find a silver lining, but for me if there one, it probably is our increased use of technology in education. And in hindsight, we could have been doing this all along, but I think it just didn't occur to us. So I'll take geriatrics as an example to start with. Geriatrics is a relatively small community. Really across the country, most of us know each other, and yet it had never occurred to me that I could ask my colleague who lived across the US and was an expert in a particular area to teach my fellows via Zoom or a similar platform. It just never occurred to me before the pandemic. And so, I think one of the best things that has come out of that is this wealth of experts that we are able to tap into, who teach our fellows, who teach our residents, and are able to do that virtually. So, they can do it inexpensively; it doesn't require them to fly across the country. And it also allows us to bring different groups of learners together to hear these experts in the field, which is really special. In geriatrics in particular, some individuals formed something called “Geri-A-Float” where they actually have geriatric fellows from across the United States come together for education on a regular basis. And again, an opportunity we probably would not have thought about or pursued at least for several years unless we were kind of pushed to do so for COVID. And then in my role at the VA, I'm an associate chief of staff for education. We're continuing to implement a lot of this technology, even as we try to get our feet under us and find whatever this new normal is going to be. I don't think we're going to get rid of the virtual education entirely. We're seeing a lot of hybrid, which is great, because for trainees, if we want to think about them who happened to be at the VA that day, yes, they can come down to the auditorium and that speaker may be there in front of them. But if we have trainees at out at our community-based outpatient clinics or trainees at the other pavilions, who just have an interest in that topic, they're able to call in via Zoom. So I think it really has just added to the opportunity that we all have for education, and I know it's something that I found very valuable and I think my trainees have as well. 

Aaron: Yes, that’s wonderful to hear. I mean, I've actually worked with Dr. Catic on that Geri-A-Float project with our colleagues at Yale. And what a great opportunity because, going back to earlier when you were talking about everybody having a general education in geriatrics, especially making things more accessible in terms of technology, making sure that if you are, for example, a surgeon or an internist that you're able to still get those kinds of resources in caring for your older patients. I think that that's something that I'm glad to hear about your work in that and be able to help you with that as well. So, kind of circling back to medical education as well, what do you think the role of education plays in addressing some of the particular challenges in geriatrics? We've talked about physician shortages, geriatrics shortages, but maybe let's talk about a little bit about your work with the geriatric PA program. I think that that's something very interesting and kind of a novel solution that a lot of specialties that might have some shortages might implement in the future as well. 

Dr. Catic: Yeah, happy too. We are really lucky to have an amazing PA program here at Baylor. They have just amazing, trainees go through, and they have been very supportive of geriatrics for many years. So having a core geriatric rotation is not required nationally for PA schools, but it's something that Baylor has had for decades, and we are lucky enough to have all of the PA’s spend 4 weeks doing geriatrics with us at the VA. So right there, a shout out to them and really making sure that they have this exposure to geriatrics. We have taken that a step further at the Michael DeBakey by having the first geriatric PA residency program in the United States. So as I'm sure many of our listeners know, PA’s do not necessarily need to pursue a residency, like you would once you finish medical school, but it is becoming more common. So these are individuals who would have graduated from PA school but then would spend a year with us doing a residency focused on that complexity that we talked about earlier. So not only seeing older adults in the geriatric clinic, but seeing them in our community living centers, on the floors in the hospital, doing a variety of different electives including geriatric mental health, hospice and palliative medicine, so really a deep dive into that complexity. And, you know, I think this has a couple of roles. Number one, it just makes them more facile, more comfortable in caring for complex older adults, and I can tell you our graduates go into these fields that are high in complexity: spinal cord injury, caring for individuals with HIV and AIDS. So not necessarily geriatrics, but very complex. But secondly, there's a lot of them who do choose to go into geriatrics, and we recognize that training people like PA colleagues in geriatrics could be very helpful in helping to negate that workforce shortage and just spread that geriatric knowledge in a variety of care settings. 

Aaron: Yeah, that's really great. I mean, we really need allies everywhere, right? And so, it's really great to see that concrete work in investing in the education and the training of allies. And the PA’s, I’ve worked with the PA’s that you've trained and their exceptional people as well. They've obviously very caring and very passionate about geriatric advocacy. And so, it's going to take a lot of a lot of people in order to capitalize on these opportunities in geriatric advocacy. And so, it's great to see that kind of work coming through. Maybe, can we talk a little bit more about, so you previously have served as the geriatrics Fellowship director and then the geriatric residency for the PA program. And now, you’ve kind of transition to a new role as associate chief of staff at the Michael DeBakey VA Medical Center. What kind of initiatives do you think you're going to try to integrate and initiate in that new role? And how does geriatrics fit into that that role? 

Dr. Catic: So the associate chief of staff for education at our VA oversees both trainee as well as staff education. So it's a big umbrella, and I'm lucky to have some wonderful mentors as I get my feet on the ground. And I think, where I really want to increase visibility of our education service line that this falls under, is highlighting all the good educational work being done at the VA. Baylor does an amazing job highlighting the academic work of both their trainees and their faculty, and we have some equally amazing work at the VA and we want to make sure that that is recognized. So one example is in March of this year, we are going to be hosting a first annual education day. We are going to be having a poster session and giving out some prizes in various categories, including undergraduate medical education, GME, as well as for our associated health trainees. We're going to be bringing in some great speakers on education and QI topics. And I'm really looking forward to making that a robust annual occurrence to highlight that good work being done. In terms of geriatrics, as much as I would love to bring geriatrics to everything, my role here is really thinking about education across the board. I think where geriatrics does come to bear is in Age-Friendly Health Systems, which we know is a national Initiative for the VA. So Age-Friendly Health Systems were developed in concept in 2019, by a group of organizations, including the Institute for Healthcare Improvement and the John A Hartford Foundation. And really, this goes back to what we were discussing earlier the recognition that our population is aging, and we are never going to have enough formally trained geriatricians. So they said, “we want to make sure that every older adult, no matter who is seeing them in, and no matter what setting of care they are in, is receiving an excellent geriatric base to their healthcare.” And so, age-friendly systems of care are centered around what we call the 4Ms. Not candy, but the 4M’s of what matters, mentation, medication, and mobility. And we know that if those areas are covered in the care of older adults, we are covering a good portion of what's really important for them. And most importantly and what I would really like to highlight is that “what matters.” So it's by talking with the older adults and their caregivers, understanding what matters to them, and then aligning their health care to support that we can really improve the outcomes that matter to that individual in front of us. And so, this is something, it’s growing within the VA, it's an initiative within the VA, and I look forward to supporting that in my new role, as much as possible, as it really rolls out from geriatrics to our other specialties. 

Aaron: Yeah, that’s really great to hear. I mean, especially the implementation of age-friendly, I think that that's something that, across the nation and around the world, I think is something that is going to continue to progress and to develop. And so, could you talk a little bit more about your ideas about “what matters” and how you hope to help clinicians, hope to help just anybody who's around older patients to address that part of caring for older adults? 

Dr. Catic: Absolutely, so I like to tell trainees, if I have a room of trainees, I tell them, if I look at all of you and if you're in your mid-20s or your early 30s, you probably have very similar goals for your healthcare. You want to live long, healthy lives. But if I have a room of 85- or 90-year-olds, we could have as many different responses for what's important to them and what they want to get out of their healthcare, as there are individuals in the room. So, this is really turning how we think about medicine a bit on its head. We've all been trained to think problem-centric, think of an assessment and plan in a note: hypertension, dementia, diabetes. We really want to change that line of thought because, with our older adults, especially as they're living with more and more complex and chronic illness, we have to understand what's important to them. And we use a framework called Patient Priorities Care to do that that was developed by several geriatricians including Dr. Aanand Naik who was previously at Baylor College of Medicine, he's now just across the street at UT. But this framework walks us through, as we meet with an older adult, how to elicit their values. We know that each of us as human beings have core values that make us who we are. So we actually talked to them about values and from those, we work with them to craft a specific reasonable and actionable goal. I'll give you an example, so this isn't quite as intellectual here. So I may find out that the patient in front of me really values their relationship with their wife and remaining as independent as possible. And as we talked about that, that individual may say to me, “I would really like to be able to take a 20-minute walk with my wife, every day in the morning. It's time for us to be together. It's equally great because I get some exercise, which helps me remain independent, but I really want that time with her.” And then, I'm going to talk with that individual about what in their healthcare right now do they find helpful, what do they find burdensome, and I'm going to really be thinking about what changes do we need to make to help support that goal of taking that daily walk with their wife. So this person may say to me, “I find it burdensome to take a lot of medications. I find my rollator helpful because it gives me stability. And if I get tired when I'm out walking, it has a seat and so I can sit down and rest.” And it may be that this individual in the past has said, “I don't really want to do physical therapy. I don't know how that's going to help me. I already take walks.” But I think maybe they could benefit from some lower extremity strengthening and gate training. So with Patient Priorities Care, I think, “okay, I'm going to try to align their care with this goal of walking with their wife on a daily basis. And I'm going to use that in my communication with the patient.” So I could say, “Mr. Smith. I understand you want to take a daily walk with your wife, and I'm so happy that your rollator is helpful to you. But, you're still having some lower extremity weakness, and maybe some pain. I know you want to minimize your medications, but could we talk about trying some scheduled Tylenol, some scheduled acetaminophen, to see if that helps your pain, and would you be willing to do some physical therapy, which I know in the past you've been reluctant to do? But could we try that just to see if that helps you feel a bit stronger, with the specific goal of you being able to walk more easily with your wife.” And then when we see that individual back in the office, or we follow up on the telephone, we're not really following up to say, “how's the osteoarthritis in your knees, or how is your gate doing?” We're following up to say, “have you been able to take that walk with your wife every day? How's that going? Has it gotten easier for you with these changes we made to your medication regimen?” So that's really how you can think about and implement what matters for an individual and align their medical care, not around their diseases, but around what's most important to them.

Aaron:  Yeah, that's wonderful. I mean, what matters I think is a concept that is very attractive as well because it can really allow everybody to be part of that medical decision process. Sometimes it's hard to know exactly what dementia is doing in your life or how hypertension might be affecting your life. But putting in very human terms about going on walks, being with your wife, being with your family, I think that that's something that everybody can have access to. And, I kind of suspect that many of our listeners might have some loved ones who are older adults in their own lives, and so, do you have any suggestions on how our audience might be able to implement these ideas in their own lives and really support that kind of age-friendly care for their loved ones? 

Dr. Catic: Absolutely. So, I mean, it can really start out just as a conversation. This is really a human conversation before we get to the aligning, the medical part. This is just a human being saying to another human being, “I want to know you as a person. I want to know what's important to you” and having that conversation. If the listeners would like something to guide that a bit more formally, they do have a website through Patient Priorities Care called “myhealthpriorities.org.” And older adults and their loved ones can go there, and it actually will walk you through the process of thinking about “what are your values? What goals do you have related to these?” And this is information that, of course, you can have for your own use, but what we would really encourage you to do is bring that and share that with your medical providers, so they can take it that next step and align care based on what's important to you. 

Aaron: Yes, I think that's great because, as a caregiver, as a somebody who has somebody who is older in your life, you are really a big role in their life as well. And so, it's a team effort, especially in geriatrics, when things are a little bit more complicated. Everybody needs to be able to have hands-on so that you can really support older adults, the best way possible, and so, it's good hear. 

Dr. Catic: Yeah, and surprisingly, Aaron, some caregivers have had real revelations as we've had these conversations with older adults, you know, we think I'll speak for myself. I think I know my parents. I think I know what’s important to them, but when you actually stop and ask, you can be surprised, you can find out something that maybe you didn't realize was such a priority to them. And I think that's helpful, obviously for caregivers. I think it also makes sure that all the medical providers are aligned and on the same page, especially in this day and age where people have a primary care provider, but they can have a whole list of different specialty providers. And of course, with our older complex adults, we like to say they weren't included in most of the studies, and so having that to go back to that foundation of what's important can really help bring together colleagues across the discipline to know what we're focusing on with that particular patient. 

Aaron: Yes, that's very good too because I think that maybe some of our listeners might have older patients, older adults in their lives, who have gone through healthcare or some sort of challenges with that. And so, it's very frustrating when you're entering these healthcare settings that you have a cardiologist telling you one thing and you have pulmonologists telling you another thing. And, really having this grounded work that is very accessible about what matters most of the patient to streamline medical decision making can be very powerful and very important to the overall well-being of an older patient. It's something that I think that will be very important going forward and caring for older patients, so it's really great to hear your work at that and your perspective on that. So, I think that we're transitioning more towards your work as a Co-PI in something called the Southeast Texas Geriatric Workforce Enhancement Program. It's SETxGWEP; it's a mouthful, but that's some work that really addresses a lot of what Dr. Catic has been talking about the Patient Priorities Care, and then also a lot of different aspects of geriatric advocacy. So could you share a little bit about your work with them and how that came to be? And then, maybe a little about your goals with your work with that?

Dr. Catic: So, the Geriatric Workhorse Enhancement Programs are founded by HRSA and supported through that funding mechanism, and we are lucky in Texas to have two “GWEP’s” as we call them. Most states only have one, but these are scattered across the nation. They are five-year educational grants and the focus for this grant cycle was really building and spreading geriatrics in primary care. And one of the main means that we're doing that is by helping our primary care partners implement Age-Friendly Health Systems, like we have been talking about. But, this is a collaboration. This brings together academic partners throughout Houston, a variety of primary care sites, as well as really critical community partners, including Care Partners and the Montrose Center. I'm not going to name everybody because I would end up leaving people off the list, but it has been a wonderful collaboration, and as you mentioned, has several different initiatives in addition to Age-Friendly Health Systems, which is based on Patient Priorities Care for our what matters. We're also working with our dental colleagues to teach about and think about oral health. We have a huge focus on dementia, both Alzheimer's and other dementing illnesses. There's a geriatric mental health initiative. There's one looking at falls, transitions of care, and elder abuse. So it's a very broad reaching project, but I think the thing that brings us the most joy, where we're making the biggest difference, is touching trainees from a variety of specialties, practicing providers from a variety of specialties in all being able to learn from one another. So for example, my geriatric fellows, they learn from some of our dental colleagues over at UT, and in turn, I go over to UT and teach the dental students about geriatric concepts that are important for oral health. So that partnership, that back and forth has been really incredible. And we've been lucky to build these relationships, and I can see them continuing for many, many years to come. 

Aaron: Yes, of course. I mean, I think we talked about medicine as a growing team sport, but I think geriatrics is even further a team sport, and you really need everybody. SETxGWEP has really, I've worked with SETxGWEP myself, and there are a lot of people that come from across the community, case managers, social workers, everybody's kind of hands-on in order to ensure that you can provide the best resources for your patients. And so, let's say maybe some people in the audience, might be professionals, healthcare professionals might be engaged in the community and some sort of geriatric-adjacent way, how could they get involved in this kind of work and kind of advocate for geriatric patients themselves?

Dr. Catic: Probably the best place to start would be our website, SETxGWEP.org. I would encourage you to go there. We have a lot of resources, both for healthcare providers as well as older adults and their informal caregivers. So you can find information on Age-Friendly Health Systems, on opioid use an older adults, in oral health and older adults. The list goes on and on, so go check out those resources. And it also provides a link where you can contact us, and of course, if people would like to get involved, we would love to hear from them. As I mentioned, this is really a community and a growing community, and we are always happy to help build these new relationships. 

Aaron: Is there anything on the horizon coming for you? Anything that you'd like to share with the audience? Anything that is particularly interesting for you right now?

Dr. Catic: I think one thing that is interesting and that we're working on one of our colleagues Dr. Ali Asghar Ali is a real expert in cultural humility, and we are in the midst of looking at all our materials that we develop for the SETxGWEP and even going to our mission statement, to think we want to make sure that we have cultural humility built into that, that we are inclusive and what we are doing ,and that we're reaching the most high-risk populations of older adults in Houston and Southeast Texas. So, I see that as our next steps and something that we are starting a journey and we’ll be actively engaged, especially with our Community Partners who are much further along in this area, in many instances than we are in academics. So, we look forward to both learning from them and working with them as we enhance our diversity and inclusiveness within the GWEP.

Aaron: That's really great to hear because thinking about what matters most, I think that that encapsulates everything about what you are and who you are. And so having that cultural humility aspect, especially in healthcare is, especially important because you have to have an appreciation for that in order to make those decisions and understand that completely. 

Juan: No, we're great. And I think this kind of wraps up the whole, “we want to be able to take a very humanistic approach to geriatric healthcare across the system.” I think that part of the human approaches that understanding all things human, our daily needs, our values and then our background. So but with that being said, I think we're in good hands as we age. And just as a parting words or advice, is there anything that you think, is there anything that you think as medical students that we could do to facilitate the accomplishment of your mission? 

Dr. Catic: I think this generation of trainees, including medical students, but I'll be broader. I think you all are poised to practice medicine in a different way. You are poised to learn it thinking about that patient-centered care, thinking about “what matters” as the foundation, which is very different than those of us who trained a decade or two decades ago and learned and thought about patients from a very disease-based perspective. And so, this is what is going to move healthcare. This is what is going to change the care that we provide, not just for older adults, but hopefully, as we move a few years into this, and we become more comfortable providing this for older adults, for all of us, no matter our age. Wouldn’t it be wonderful when we go into a medical encounter, to have the provider talk to us about what's really important to us? How are things going at home? Are there things that we could do with our medical care that would support us in our roles as a mom, a wife, a doctor? I'm using myself as an example, and I think this generation of trainees is the one who is going to really build this and carry it forward. 

Juan: And we can already start to see some of those changes being implemented. You know, I think as part of the Baylor curriculum, we’re spending more time in the clinics. This is just through my experience. I tell the incoming class, the hidden curriculum that where you go and spend all this time and learn about the patients and learn about it in a story way, that is the critical part for you to learn to interact and talk in a very human way with patients, and that is what the really goes further than trying to memorize everything that you can and score the best score on an exam. It's the human side, right, that's really the driver of the best possible care I think. 

Dr. Catic: And I think this is a swing back. I think before my time, long before my time, it was a much more focused on the human interaction, on listening ,on the laying on of hands. And we didn't have the technology. And then we got the technology, and I think we went through a period where we were very technology-focused and spending more time looking at the scans and looking at the numbers on the computer perhaps than spending it with the patient. And now we're coming back. And of course, that technology is important. It has allowed us to progress, but we have to find a happy medium where we realize that that human interaction, that understanding of the human and front of us, is what is going to allow for exceptional medical care, supported by the technology, but using that technology thoughtfully and in alignment with what that patient actually wants. 

Juan: Absolutely. Well, with that being said, thank you very much for providing us this wonderful, human interaction, and thank you for your time. We look forward to hearing more about your accomplishments and what you do in the future. 

Dr. Catic: Thank you so much. It's my pleasure. 

[Outro Melody]

Apple | Spotify | Google Play | Length: 55 minutes | Published: Oct. 21, 2022

Dr. Wesley Boyd shares the milestones in his career that have accumulated into his current work in bioethics, humanities, human rights and psychiatry. We learn about the events that led him to co-found the Human Rights and Asylum Clinic at Cambridge Health Alliance. From there, we discuss his continuous involvement in the advocacy of asylum seekers and the impact of his work on ensuring immigrants' and asylum seekers' plea for refuge and medical care is heard and answered.

Transcript

Intro Melody

Juan Carlos: And welcome to the Baylor College of Medicine Resonance podcast, I am one of your hosts, Juan Carlos Ramirez. 

Trung: Yeah, and my name is Trung. I'm the lead writer for this episode, and I am very excited for you to get to know Dr. Boyd. 

Juan Carlos: And speaking of Dr. Boyd, in today's episode, Dr. Wesley Boyd will talk about the milestones in his career that have accumulated into his current work and professional interests. We will spend some time learning about what led him to co-found the Human Rights and Asylum Clinic at Cambridge Health Alliance. And from there, we will discuss his continuous involvement in the advocacy of asylum seekers and the impact of his work on this population in the US. 

Trung: All right! And uhm… 

Juan Carlos: And so, who’s Dr. Boyd for our audience that may not know him? 

Trung: Yes I will quickly just walk you through his accomplishments and his career interests basically before we dive into the contents of our podcast today. 

Juan Carlos: Yeah! 

Trung: So Dr. Boyd is a professor of psychiatry and medical ethics at Baylor College of Medicine. But before he was here, he obtained an MA in philosophy and a Ph.D. in religion and culture (along with) his medical degree at UNC Chapel Hill. He completed psychiatry residency at Cambridge Hospital and fellowship in medical ethics at Harvard Medical School. And then he also used to be on the faculty at the Center of Bioethics and an associate professor of psychiatry at Harvard. Additionally, he was a staff psychiatrist at Cambridge Health Alliance and is the co-founder of the Human Rights and Asylum Clinic just as Juan Carlos just told you. And he has taught extensively in humanities, bioethics, human rights and psychiatry. His areas of interest include social justice, access to care, human rights, asylum and immigration, humanistic aspects of medicine, physician health and well-being, the pharmaceutical industry, mass incarceration, substance use, among his other vast interests. He also writes for both academic and lay audiences in all of these areas. 

Juan Carlos: Wow. He wears many hats and I'm actually pretty interested to hear what, you know, what let him down this route, and I'm also curious if he teaches at Baylor although I've never come across his coursework. How did you hear about Dr. Boyd?

Trung: So the reason I (heard) about Dr. Boyd is because he gives, and I'm not sure if he gives this annually, but he gives a talk on immigration and the myths that America has about immigrants in general through the Doctors for Change group. And he was very open; he gave his contacts at the end, and he stayed for a very long time even after the Zoom was done to talk to students, and I was very engaged with him. And yeah, I just emailed him, and he said he would be more than happy to do the podcast with Resonance. 

Juan Carlos: I as well! I'm happy and excited to hear his story. And I guess, without any further delay, let’s talk to Dr. Boyd!

Trung: Yeah, let's get into it. 

Juan Carlos: All right. Sweet! 

Interlude Melody

Juan Carlos: So, welcome, Dr. Boyd! It’s a pleasure to have you on the Resonance podcast here at Baylor College of Medicine. I want to start off by asking a little bit about your background, where you're from, where you did your training, how your career brought you to the Baylor College of Medicine? 

Dr. Boyd: Well, I'm originally from Louisiana but spent most of my childhood in Florida and went from public schools there to Yale University. At Yale, I studied philosophy and actually wanted to be a philosophy professor. So I went to graduate school in philosophy at UNC Chapel Hill. While I was getting the master's degree, I realized it was a bad fitting program. And so I started looking around for other things to do, and two things happened. One, I started doing the pre-med courses that I had not done in college for the purpose of going to med school to be a psychiatrist. And I also met two professors in religion who are doing the kind of work I wanted to do in philosophy. And so I ended up switching, and after the master degree in philosophy, I ended up getting a Ph.D. in religion with them in the subfield of psychology of religion. So I finished medical school, or did medical school. I started the Ph.D. program a year before medical school and ended up staying at UNC Chapel Hill for medical school, and finished a Ph.D. and M.D. four years after starting med school. So I was in graduate school (for a) total of seven years (and) went from there up to Cambridge, Massachusetts for psychiatry residency. The reason I went into Cambridge is I was told it was the best place you could learn to do psychotherapy as a psychiatrist. 

The reason I ended up staying at Cambridge Hospital, whose name is now Cambridge Health Alliance, the reason I ended up staying there over the years is because it is a large safety net hospital. It works with poor and indigent people. We saw tons of people who lacked health insurance. Uhm, there also is a lot of ethnic and racial diversity in the patient population. And so Cambridge actually, as a safety net hospital, had linguistic clinics in neighborhoods around Cambridge to serve the local community. So we had a clinic in the portion of Cambridge that was largely Haitian Creole and had services that were offered in Haitian Creole to Haitians in that community. We had another clinic in East Cambridge, one that I actually worked in as a resident, that was Portuguese speaking. And so East Cambridge is heavily Portuguese and Brazilian but Portuguese speakers, and so we had a clinic in that neighborhood as well and then another one in a more Latino community where, of course, Spanish was the predominant language. 

And so really, (I) was being part of that hospital for many many years, which laid the groundwork for a lot of what I've done since, including working with immigrants (and) working with asylum seekers. I started doing that work specifically about 15 years ago, plus or minus. And working with asylum seekers has really become a large part of both my professional work and also my professional and personal identity.

The reason…how I got from Cambridge to Baylor…So my wife is also a physician. We actually went up to the Boston area together for training back in 1992. I went to Cambridge hospital, as I said, for psychiatry residency. She's a pathologist specializing in pediatric and perinatal pathology and got a fellowship position at Children's Hospital in Boston and also Brigham and Women's. And so she trained there and ended up working at Children's Hospital, well in Brigham as well. And she was running anatomy and pathology at Children's for about a decade. 

She came down here to give grand rounds at Baylor, I think about 9 years ago, and after giving (the) grand round, she was heavily recruited to Baylor at that time and was offered a job at Texas Children's Hospital. And I came down and, (for) a number of days, and looked for jobs here. And I didn't find one that was as appealing to me as the job that she was being offered. So she ended up saying “no.” There was also a lot going on in our family at the time. Our old, sorry, our youngest son was still in high school and we would have had to uproot him. My mother who lived with us for two decades was still alive. She would have had to move with us. So there (were) other reasons besides just jobs. We ended up saying “no,” but my wife saw that very same job, saw that very same job, that she had refused years earlier was available a couple of years ago. And our son’s out of the house; my mother has passed on. And so it's just the two of us. And we were ready for a change. And so she put her name in the hat at Texas Children's knowing that if she did, she was going to be offered the job. 

And I came down, literally the day before Baylor shut down due to COVID and did not allow anyone to come in from outside. It literally was like March 10/11/12 two years ago when I came here and was offered a job at Baylor psychiatry and then also offered a job here at the VA. And I ended up accepting the job at the VA. We started working here about a year and a half ago, right in the middle of the pandemic. And at this point, I run the ethics or co-chair the Ethics Committee at the VA. And I'm the director of the Substance Use Disorders Program here at the VA as well. So that's what I'm doing. And in addition to that, I have a faculty appointment at Baylor in the Center for Medical Ethics and Health Policy. And currently, I'm teaching a third-year elective in health policy. And starting this August, I'm going to take over running the first-year health policy elective that runs in August. 

Trung: So evidently you have a lot of interests, and your interests range anywhere from healthcare to inmates to substance use to asylum seekers. But I do see a common theme. You really love the humanitarian aspects of things, and so I just want to know, what draws you into, you know, such aspect of healthcare. 

Dr. Boyd: You're asking a great question, and I do think that there is a common theme to where I direct my professional efforts. And I think that is working with people who are vulnerable, who are disenfranchised, and who might lack a voice. And I don't want to speak for people; I would never want to do that. But I certainly want to do everything I can to help vulnerable populations. 

And so, you know, you touched upon some of the groups of people I work with. First of all, just going into psychiatry, I think unfortunately there's still a lot of stigma around psychiatry, and I will do what I can to try to destigmatize mental illness. Even within psychiatry, there's a hierarchy of patients, and I think folks with substance use disorders are actually frequently looked down upon and, yet, the evidence is quite clear that there is a heavy genetic predisposition towards substance use disorders. And also, many people who end up misusing substances have had significant amounts of trauma in their lives. Working with this population is another aspect of the kind of work I do, where I feel like I'm working with people who are disenfranchised and having a hard time. The same holds true (for) some of the other areas I'm interested in. I've done a lot of work with doctors who have substance use disorders, and doctors, who end up being referred into physician health programs. They also are (a) pretty vulnerable population. Once you get referred into those programs, you often have very little choice but to do exactly what you're told if you want to continue being able to practice medicine. So I've done a lot of work with physicians who have substance use disorders, who have been identified as having some kind of mental health issue, and then get referred to programs. 

You mentioned jails. I have written about mass incarceration and some of the difficulties that people have when they're incarcerated

And then I've also done, as I said, a lot of work with asylum seekers. A portion of asylum seekers end up in immigration detention. And immigration detention sounds nice, but basically, it is jail. And so I've been in jails and prisons (a) handful of times to meet with and do evaluations of asylum seekers who are incarcerated to try to help them both get asylum and also get released from jail or prison. You probably know especially during the pandemic that in jails and prisons, COVID has really run rampant. In most jails and prisons, there’s no ability to socially distance. There's frequently not any kind of PPE, hygiene is often lacking, and on, and on and on. So, not surprisingly, whether it's immigration detention or in jails and prisons otherwise, the dangers of COVID are dramatically higher for people who are incarcerated. And that's all on top of the fact that being incarcerated in the first place, irrespective of COVID, being incarcerated increases your health risks basically across the board. You know, cardiovascular, mental health, you name it. Almost all medical and mental health conditions get worse when people are incarcerated; they don't get better. 

Trung: I think you also wrote an article regarding the COVID situation (and) how it impacts detention centers, called “When the Treatment is Torture.” And I think, in addition to all the things, the comorbidities, cardiovascular risk, and lack of PPE and things that you mentioned in the detention centers, there are also other things that asylum seekers are subjected to in these centers including, like, isolation. Like back in the days when they still had very rudimentary understanding of how to do social distancing and things like that. So could you help us to, like, enlighten us a little bit more about that issue? 

Dr. Boyd: Yeah, and that article “When the Treatment is Torture” really refers to the notion that, or the fact that, it really refers to the fact that, in incarceration settings, in general, and an immigration detention in particular, people are being, individuals are being placed into solitary confinement, supposedly for their own good. In some cases, they'll be put in solitary confinement if they are diagnosed with COVID, and, in other instances, they'll be put in solitary confinement to keep them away from people who might have COVID. In either instance, you're being placed in solitary confinement. And I have another article that says, very clearly that solitary confinement is tantamount to torture. To my mind, the use of solitary confinement is entirely and totally punitive, no matter even if they say it's for your health or is to try to protect you from COVID. It is entirely and totally punitive. For anyone who has a mental health condition already, solitary confinement almost definitely is going to make it worse, if not dramatically worse. For individuals who don't have any mental health issues prior to incarceration, being placed in solitary confinement can cause depression, anxiety, suicidal thoughts and a condition that otherwise would be considered delirium, you know. So solitary confinement generally makes everything worse, and the thought that prisons are using solitary confinement in reaction to COVID is unconscionable. 

Trung: Yeah, I think, for me, when you mentioned in the talk a while back (that) I attended with the Students for Human Rights, I thought it was very refreshing. I never thought of COVID in that angle, like in my mind, social isolation, that's always like, that’s the way to go. But there's always a context, like, everything can be taken to extremes and like, in the context of asylum seekers and solitary confinement, social isolation, yeah, it's a form of torture. 

Dr. Boyd: And just to piggyback on that, overwhelmingly people who are put in immigration detention who are seeking asylum, the vast majority of them have not committed crimes. It is not a crime to seek asylum according to either international law or U.S. law. So despite what you have heard in the political rhetoric over the years, it is not a crime to come into this country and ask for asylum. And in fact, the way asylum law is written here in this country, as well as in other countries: if someone is seeking asylum and they're a member of a particular group, (which) could be a political group or religious group, (whether) you're gay or lesbian coming from a country where being gay or lesbian is is is going to get you either, you know, beaten or killed, and a number of other groups, if you are a member of those groups you come into this country, and you say “I fear for my life if I am sent home, I want asylum,” you are supposed to be given a hearing and (have) your case heard. And if you have credible fear, you ought to be granted asylum according to the law. 

And so I guess the reason I went on that tangent is that overwhelmingly the people in immigration detention have not committed any crime whatsoever, including asking for asylum, which I just said, is not a crime. And yet, they are being placed in solitary confinement, sometimes for very, very, very minor offenses. So, apart from COVID, solitary confinement is frequently used in immigration detention as punishment for in some cases, very minor infractions. You know, you back talk to guards and they're going to put you in solitary confinement. You are put into solitary confinement; you start pounding on the wall because solitary confinement is making you crazy, or anxious, or depressed, or suicidal, and they just lengthen your sentence in solitary confinement. So, it's used in very, very punitive ways for people who are, you know, who's quote-unquote “crime” is that they were trying to seek asylum here in the United States. One of the co-authors on one of the papers that you mentioned, herself, was a federal whistleblower because she was reading reports of individuals in immigration detention who are being placed in solitary confinement. And she's one of the people who first brought this to our attention and has really, as a whistleblower, gone public to try to get the practice stopped. 

Juan Carlos: So, it seems like there's just a lot to unpack there and that you clearly you…I guess what I'm wondering: is this sort of…their basic care? Right? So, where do asylum seekers or inmates, like, where do they get their care? 

Dr. Boyd: Believe it or not, the only group of individuals in the United States who are constitutionally guaranteed the right to healthcare are people who are incarcerated. And so you asked a very good question. Where do people who are incarcerated get their care? They get it generally from within jails or prisons. And if there is, you know, (a) serious enough need or an emergent need that can't be handled on prison grounds or within the jails, they will get transported to hospital facilities nearby ideally, right? 

The medical care inside jails is generally less robust than it is in prisons. So if you're just taking your average jail or your average prison, the care in prisons is going to be generally better, but again the…

Juan Carlos:…that, yeah, go ahead. 

Dr. Boyd: The conditions within prisons are not conducive to health. In fact, as I said, they make conditions worse, almost all the time. For example, I mean, and here. Here's some of the reasons. The food is not as nutritious as it should be, right? And so you're eating, you know, higher fat food, or calorie rich food, that might be, you know, be less healthy for you. Often, your ability to walk around and or get exercise is curtailed, right? And again, this is probably more true in jails across the country than it is in prisons. And, you know, those two facts alone plus you're in a very stressful environment, and we all know stress has both physical and mental health ramifications, so there are all kinds of reasons why being incarcerated isn't good for your health. 

And there are all kinds of reasons why being incarcerated is not good for your health. To answer your question though, where should healthcare be delivered for people who are incarcerated? It should happen right there in jails and prisons. 

Juan Carlos: It's very interesting and, you know, I guess history tends to repeat itself, but at a certain point it ought not to. Right? And what do you think is the greatest disconnect between helping us break that cycle? 

Dr. Boyd: Yeah, thank you for asking the question. This is…what I'm about to say are points that I very frequently make. And in fact, one of my colleagues, former colleagues, (who)'s up at Harvard, used to say, “oh, Wes always wants to make sure he adds the following.” And here's what I always add because it's absolutely true. And, by the way, I try not to say things that are not true, and even though I have strong opinions on things, I try to base them in facts. And I am open to being corrected, you know, if I am wrong on facts. But here's what the facts are: Immigrants and asylum seekers are far less likely to commit crimes here in the United States than native-born Americans (and) are less likely to commit murders than native-born Americans. They don't end up costing our healthcare system lots and lots of dollars. 

So, you know, one argument against immigrants that, (which) turns out doesn't hold water, is so if we just let everyone come in, they're going to take, take, take, and it's going to, for example, use up all our health care resources. I had a colleague at Cambridge Hospital. Going back up, I had a colleague (at) Cambridge Health Alliance. Her name is Leia Solomon and she documented extensively the ways in which immigrants actually bolster our healthcare system. She documented that immigrants put far more money into Medicare than they ever take out in terms of accessing medical care. 

Right? Why would immigrants put more money into Medicare ultimately and boost the holdings of the Medicare, the trust fund for Medicare. Why would they do that? Because they tend to be younger and healthier than native-born Americans. So, they're working jobs; they're putting money into Medicare through their employment, and then they might leave the country before they ever even, you know, access Medicare. But so Leia Solomon and colleagues at Harvard documented the fact that immigrants put more money into Medicare than they ever take out. They also do the same thing for the private insurance pools. So they are working jobs, putting money into private insurance and not using proportionate amounts of care. And so, as a result, they end up putting more money into Medicare, and it’s the private insurance pools than they never use. 

Immigrants also tend to be…I'll just leave it at that. I mean those are the big ones. So immigrants are not more likely to commit crimes, they're not more likely to commit murders, and they put far more money into this economy than they ever take out. There was a study that was commissioned by the federal government and ultimately never released because the presidential administration at the time didn't want it released, that showed that immigrants, I think it was over a decade, ended up putting something to the tune of $60 billion more into the economy than they ever take out. So it's not, you know, when I say that immigrants are actually good for the economy, it's not just in the healthcare sector. It is across the board. 

In fact, there is a New York Times op-ed a few years ago that said, “Let the Mass Deportations Begin.” I think that was the title of it, and you read the fine print and basically, he was saying, and as far as I can tell, the author is a white male. The author was saying that because immigrants are so good for the United States, we ought to start mass deportations of native-born Americans, get them out of the country, and then our country will be better off as a result. I mean he was being tongue-in-cheek, but his basic point, and he's just, his essay is filled with facts about the ways in which immigrants make this country a better place. 

The other thing (that’s) just completely hypocritical is that our whole country was founded by immigrants, right? There are no native born Americans if you go far enough back except the Native Americans, right? Not people like me. And so, for people to say, you know, to point their fingers at this latest round of immigrants and say, you know, they don't belong or we want them out of the country, historically, it's just dead wrong. I mean, the other part of this country is that, if you go back to 1790, there was a lot of anti-immigrant sentiment. And so, you know, and each sort of generation would have its own group of immigrants who were particularly despised, you know. It's the Germans at one point, the Irish, and the Chinese, and now it's, you know, I mean, just take your pick over the years. 

So this is, you know, if I sort of step back a little bit, I can at least appreciate it in the context of history that there's a long tradition of anti-immigrant sentiment that is just as wrong today as it was 50 years ago and as it was a hundred years ago, much less 200 years ago. 

Trung: So we talked a lot about, especially when you mentioned about misconceptions when it comes to asylum seekers. You said earlier that seeking asylum is not a crime, and these people are being put into basically jails although they did not commit any crime. I'm sure that's not the only misconception that the public has about asylum seekers and immigrants in general. And I've already read your article on “Who Seeks Asylum in the U.S. and Why” and you expressed a lot of…uhm…you basically explained away these misconceptions, and I have a list of them listed here. But if you want to go through, like, if you can just shed a light for us, you know, for us, the general public to kinda understand asylum seekers in their perspectives, instead of what’s being fed to us. 

Dr. Boyd: I think it's a great question and I just think it's easier to look outside of ourselves and cast blame outside of ourselves as opposed to looking inside ourselves and saying, oh wow, you know what, it's not immigrants who are the problem, it's not immigrants for the reason I don't have a job or I'm being threatened with getting kicked out of my apartment, or I can't maintain romantic relationships, or whatever. It's really me. 

Juan Carlos: I can see how that’s tough to chew and even harder to swallow as a society. 

Dr. Boyd: Yeah, I mean, think about the things that are the most likely to kill us. Number one is tobacco. Number two is heart disease, which can come about by way of bad diet or exercise, etc. Number three is alcohol and all of the alcohol-related ramifications that can kill us. Those are the big three killers in our country. All three of those things are things that we have the ability to make changes ourselves to try to improve our odds, right? 

Juan Carlos: I think (what) I remember when I was doing my internal medicine rotation is, this is sort of a related to diabetes and diet and exercise, is someone, one of the attendings, said that behavioral changes are going to be the toughest thing you can try to get someone to do to better their health. And I think since then it's, you know, I couldn't agree more on, that it's these behaviors that could have the biggest impact.

Dr. Boyd: Oh, sure. And, you know, I can't tell you how many times over the years I've counseled people to exercise. I can probably tell you the number of times people have actually taken me up on it. Right. So I mean I'm personally a big believer in regular exercise. I think it's really good, not only for my body, but definitely for my mind and so as a psychiatrist, I frequently would tell people, “hey is there any way we can just get you, you know, walk 30 minutes a day or anything?” And it's a really, really sliver teeny tiny minority of people who actually took me up on it. Do I think it would be helpful? Absolutely. Am I that surprised that so few people would start exercising based on my counsel? Unfortunately, I'm not that surprised for the reasons you just said. 

Trung: I feel like we talked a lot about asylum seekers, their perspectives and challenges that they face, but I think one thing that, surprisingly, we haven’t touched on is, how YOU are doing to, like, in this whole process…like, what is your, I guess, what is your role in advocating for the asylum seekers? I think our listeners would also want to learn a little bit about your job and, specifically, (is there) anything you find extraordinary, things that you found out that you didn't know before since you started your job and start to become more involved with asylum seekers? 

Dr. Boyd: So, I'll tell you what I do specifically with asylum seekers. If someone comes to me because they know the kind of work I do, and say, “hey Wes, I got this patient who wants to seek asylum. Can you do an evaluation of them to help?” The first thing that I say is they need a lawyer first. So if you're seeking asylum, you need legal representation because for anyone who's not a lawyer, a courtroom or a courtroom-type setting is a strange place with its own set of rules. And if we're all medical people on this call and we walk into a (courtroom), (although) we speak the language, you know, we are still going to be in a strange setting and the odds are going to be stacked against us. 

Imagine if English not only isn't your first language but you don't speak English AND you don't know the rules, the odds are completely stacked against you if you go into an asylum hearing without legal representation. So step number one has to be to get legal representation. Once you have legal representation, that's where I can come in or someone like me can come and help. So what I do in the asylum process is I will perform a psychological evaluation of the asylum seeker in order to support their claim for asylum. The way that a psychological evaluation can help an asylum claim is to corroborate the story that the person's telling, right because often, you know, you don't have pictures. You don't have video evidence of what happened in your home country, what you're trying to escape from. And so that's where a person like me can come in, meet with someone, hear the story and say, you know what, I think they're telling the truth. 

How can I say that? Because I've interviewed in my regular job as a psychiatrist thousands of people at this point and, although I'm sure I have been fooled on some occasions, I now, more or less, can assess pretty accurately if people are telling the truth. I can also document if there's any kind of mental health conditions, such as depression or post-traumatic stress, that has arisen as a result of what they suffered in their home country, what they're fleeing from. I can document that. And I can also state that if they were to be made to return to their home country, the very thing they're fleeing, that mental health condition could get worse. 

I also realized one thing I didn't say (or) I haven't said yet is of the people I've seen who have been seeking asylum here in the United States, overwhelmingly, they face death if they're forced to go back to their home country. If you are, for example, gay or lesbian from Uganda, and I've seen gays and lesbians from Uganda in asylum settings, and you're forced to go home, that could easily be a death sentence for you. If you're gay in Brazil, which, ironically, Brazil has had gay marriage on the books nationally for a long time, but the reality on the street for gays in Brazil is that you can be beaten and or killed if people realize you’re gay. And I've been told for example, if you're in Brazil and being assaulted as a result of your sexual identity, if a police person were to be walking by, they will either just keep walking or might join in in the abuse. And also, if you're from Central America in Honduras, El Salvador and to some extent Guatemala, and you're fleeing gang violence, yeah, they've been extorting you because you have a small business and every week they come by and they want rent money, right, or you're a teenage girl and they ask you to be the gang girlfriend, which is a euphemism for sex slave, right, and you refused, they're going to kill you. Or if you're a young boy and they want you to start running drugs for them and you refuse and you consistently refuse, ultimately, you're going to get killed. And so, when people are fleeing, you know, gang violence in Central America, (when) they're fleeing political persecution because they're a member of an opposition party in many countries, in all of these situations people face, I doubt that they go back to their home country. 

So what I can do is I can, as I said, corroborate the story. I can document mental illness if it has arisen as a result of the torture, and I can state that, “I think their mental health condition will deteriorate if they're forced to go back to their own country.” I then, after meeting with the client and performing an evaluation, getting the history, etc., I write up an affidavit. Usually they're a minor, about five to seven single-spaced pages all together. I will send it to the attorney. We sometimes go back and forth a few times to get the report as up to (indiscernible) as possible. And then if testimony is required, when they get to their asylum hearing I will testify in court if necessary. It is a tiny minority of cases where I actually have to testify. I don't like going into court. I don't like testifying at all, but given the stakes that asylum seekers face that I just was speaking about, I will gladly testify if it means there's a greater chance that someone is not going to be deported to their own country. Psychological evaluations definitely make cases stronger. The lawyers I have worked most closely with will not go to court unless they have a psychological evaluation to support their claim. 

The only data we have about the effectiveness of psychological evaluations is from around 2004 or 2005, so I'm going to quote variable data. But back then, if you were seeking asylum and did not have a psychological evaluation to support your claim, the grant rate was about 30%. So about 30% of the time people would be granted asylum. If you had a psychological evaluation to support your claim for asylum, the grant rate went up to about 90%. So that is evidence that psychological evaluations are dramatically helpful for asylum claims. And if I were seeking asylum myself, I would get a lawyer, like hands down, no matter what, however I needed to. And I would make sure that I had, you know, medical documentation from someone like me. Or if there (are) physical scars and things like that, evaluation from a doctor who does physical medicine would also be important. 

And oh, and you asked what else I do? And so that's what I do in terms of actual evaluations of asylum seekers, but in addition to that, as you already discussed, I do writings about asylum and immigration issues and I do a lot of teaching about it. So I will teach medical students and, in fact, trainees of all disciplines have sat in on the evaluations with me. So I've done didactic teaching, but I also have, at this point, I usually have trainees who are sitting in on the evaluation with me while I'm meeting with clients. 

Trung: And thank you for all of your good work. Honestly, I think, wow, whatever you’re doing, all the jobs, all the teachings, and all the advocacy, they are all amazing. And it’s something that you know, the general public, don't really think about. There (are) a lot of things…there (is) a lot that goes into helping asylum seekers, like complete foreigners in our country. And yeah, it's more than just like food, shelter and water. Yeah, so thank you. And we’re approaching the end, but like, I don't want to run out of time for the podcast and not talk about the world that we can that we live in. So, recently, like there (have) been a lot of world changing events. And even (during) the last time you gave us a talk, it was right after the whole Afghanistan crisis and the U.S. troops pulling and things like that. And now that we have the war that is happening in Europe, (I) just want to know your perspective on…like, because of those events, has there been any change in the work that you do, the people that you meet? 

Dr. Boyd: It's a great question. The war in Ukraine has not directly affected anything that I see or do on a daily basis. I'm working at the VA and I do think, despite what I just said, because I work at the VA, I know that, you know, the scenes from (the) war are going to be triggering for a number of veterans. I haven't had any (veteran) come directly in to tell me that but some of the folks who work under me here at the VA have mentioned that and see that, and so I am aware of that. But here's what I want to say about the war in Ukraine: the pictures and videos that we're seeing on television and elsewhere are absolutely horrific. And I would wager that nobody with half a brain would blame Ukrainians for immigrating, getting out of Ukraine as quickly as possible and seeking asylum, or at a minimum seeking shelter in another country, right? So I would wager that everyone listening to this podcast, who's had any exposure to the news whatsoever would say, anyone fleeing Ukraine right now ought to be helped as much as possible. 

The people who are seeking asylum in our country, and I'm not talking, when I talk about asylum seekers I'm not talking about people who are coming across our Southern border to get work, right, I'm talking about people who are fleeing violence and fleeing threats of death. The people coming into our country who are seeking asylum, overwhelmingly, in their own lives are in war-like situations. 

So I don't want to draw direct analogies to having Russian shells come down in an apartment building, but if you're in Central America and you've had one or two family members murdered in front of you by gang members, and you finally secured the means to get out and to come seek asylum, it’s as bad for you in your home country as anywhere on Earth. And so I can’t draw a perfect analogy but I'm just telling you that it is absolute terror that people flee from. And so, you know, when I'm meeting with asylum seekers and when I'm hearing their stories, I want to do everything I can to try to keep them safe and to not have them go back to their countries, where they overwhelmingly face death. 

And, you know, I mean, some people have asked me over the years, like, you know, how do you take care of yourself with this work, right? You must hear some pretty bad stories. And I already mentioned I try to exercise basically every day. I think that helps. My wife is also a physician; she and I talked a lot and we debriefed a lot. I think that helps. That said, there are some stories I've heard from asylum seekers that I won't even share with her. And she's a pathologist; she does autopsy. I mean, she sees a lot, right? But some of the stories I've heard from asylum seekers are so traumatic, I won't even share them with her. 

Juan Carlos: You know what one, I guess perhaps, positive thing that that could…has come about in recent weeks: perhaps, you know, it has sort of opened our eyes, the entire world, you know. Everyone, many countries, and everyone we kind of feel for the Ukrainian citizens. And absolutely, you know, there's no question that, you know, they have every right to be seeking asylum. Perhaps this could be like a turn, not like, you know, turning a new, you know, (a) stone, or something. But perhaps it is giving us, you know, the society, better understanding of, like, what asylum seekers go through, you know. We are seeing it develop. I mean, I don't know how many people that, you know, keep up with the news in Central America or Brazil or stuff like that. So I think this has really put front stage, you know, that many asylum seekers are seeking, you know, very legitimate threats and so, perhaps, this could help us as a society, sort of, move forward and also advocate for asylum seekers and help you in this fight.

Dr. Boyd: I completely agree. I mean, you know, my heart goes out to the Ukrainians. I can't imagine being on the receiving end of that kind of Russian aggression at the hands of Vladimir Putin, who, you know, as far as we can tell is not even getting accurate reports from his own people because they're all scared to tell him the truth. So who knows how long it's going to go on, but it does hearten me somewhat to hear stories, for example, that people here in the United States are willing to pay more for goods and services in order to support the Ukrainians And so wow, here in America, we're willing to literally pay a price for people in a country where 95% of folks in the U.S. didn't even know where Ukraine was two months ago, right? And now we're all willing to pay a price for them. If we can garner that kind of empathy and sentiment for others and for strangers who don't speak our language, you know, I wish we could do the same for asylum seekers. 

But you're absolutely right, there's no one in the world, I think, (who) would say that Ukrainians fleeing that war don't deserve asylum. And just you know, to put a coat on it, to repeat, seeking asylum is fully legal according to both U.S. law and international law. It is considered a fundamental human right. There's a document that was foundational to the creation of the UN the Universal Declaration of Human Rights (UDHR). It was published in 1948. It arose…the UN arose and this document arose out of the horrors perpetrated on the world by the Nazis in World War II. And in that document, it guarantees the right to seek asylum for anybody. 

Trung: Thank you so much. Yeah, that was very inspiring. And I never thought of it that way. Like, if we can, you know, exert the same amount of empathy and willingness to help like we are right now for Ukrainians to anyone who needs help, in dire needs, if we can extend the same empathy, like, how much better the society we live in will be?

And with that do you have any, like, closing remarks for us, you know, budding physicians? A lot of your listeners are going to be involved in healthcare, and they probably will be providing care for asylum seekers, for immigrants at one point or another. Do you have any closing remarks, any advice you would have for us moving forward? 

Dr. Boyd: Yeah, not so much advice but definitely some closing remarks. I feel very fortunate to be where I am currently. I feel like, as a medical professional, I have a voice that at least some people are willing to listen to. And given that the kinds of things that affect our health and well-being go far beyond the medical exam room into the world at large, I feel like if there are ways that we can be advocates for our patients, we have a duty to do that. I feel…I mean I… working with immigrants and asylum seekers is a large part of my identity as I said, and I am a better person for doing the work. Even though it can be painful, the stories can be incredibly distressing, working with asylum seekers, doing advocacy work on their behalf and in other arenas, it makes me a better person. What else could I want? 

Trung: Thank you so much sir, as always. Uhm, yeah, you left us with a lot of food for thought, a lot of a lot of thought provoking ideas and conversations. And yeah, thank you so much for your time. 

Dr. Boyd: Well, thank you for having me. It's been a pleasure

Juan Carlos: Absolutely. And I think one final thing that we can take away from this is hope. Yeah, that the difference is being made. So thank you very much for your time and we look forward to hearing more about your work. And thank you so much.

Dr. Boyd: You can't see me, but I'm nodding my head right now. Thank you. Take care.

Outro Melody

Apple | Spotify | Google Play | Length: 45 minutes | Published: July 20, 2022

Dr. Mariam Hull is a pediatric neurologist with a fellowship in movement disorders. She has been with Baylor for residency, fellowship, and now as an attending physician. Today’s discussion will include her experience training at Baylor, the field of pediatric neurology, her research and the implications of Covid-19 on movement disorders, and her personal take on wellness in medicine.

Transcript

[Intro melody into roundtable discussion.]

Juan Carlos: And we are here at the Baylor College of Medicine, Resonance podcast. I am one of your hosts. Juan Carlos Ramirez.

Delia: And I am your other host, Delia Rospigliosi. 

Juan Carlos: And Delia is also the lead writer for this episode. And in today's episode, we will be talking to Dr. Mariam Hull, a pediatric neurologist with a fellowship in movement disorders. She has been with Baylor for residency, fellowship, and is now a current attending physician here at the Texas Children's Hospital. And in today's discussion. We are going to include her experience and her training at Baylor, the field of pediatric neurology, all of its ins-and-outs, and her research and the implications of Covid-19 on movement disorders, and her personal take on wellness in medicine. 

Delia: Yeah, so pediatric neurology is actually such an interesting field. It's centered around treating neurologic symptoms in children as a result of infectious, genetic, and other causes. Physicians involved in this field have to hone their physical exam and their diagnostic skills, and they’re masters of observation. Dr. Hull attended the University of Nebraska Medical Center College of Medicine after which she went on to a pediatric neurology residency at Baylor College of Medicine, and she stayed here ever since. She completed a fellowship in movement disorders at Baylor, and she's now a faculty member working in her movement disorders clinic. Her other research interests center around clinical work such as studying treatment options, for various movement disorders, and she's recently captured the attention of the media for her work on functional tics and their spread through social media. 

Juan Carlos: Well, you know, when I think of a pediatric neurologist, I mean, it's a little scary, right? Because it's you know, it's such a delicate time in someone's life. It's the child, but it's also the parents, right? It's just, to be able to manage all of those things and in her field of work with these movement disorders that’s…

Delia: Yeah

Juan Carlos: So impressive to see someone working, uh, and doing it and having an impact in such a such a very efficient way. 

Delia: Yeah, she juggles so many things in the practice, and it's really cool to hear about and yeah, she's had some interesting media presences that we're going to get into. So, Dr. Hull has a really interesting career to talk about. 

Juan Carlos: Yeah, and then without keeping you too much in suspense, let's talk to Dr. Hull in her field of work.

Delia: Let's get into it. 

Juan Carlos: Cool. 

[Interlude melody]

Dr. Hull: Hi, everybody. 

Delia: So today, I guess we can just start with talking about your background. You've hinted that you have sort of an alternative background, maybe a little bit different than the traditional path. So, just tell us about you. 

Dr. Hull: Yeah, so I was born in Egypt, and then my parents immigrated to small-town Iowa, for unclear reasons as to why they chose Iowa in particular, but I ended up going to Nebraska for medical school. Before that, I didn't exactly know what I wanted to do in medicine. I had probably some hints along the way that I was going to end up in neurology. I had a roommate in college that had epilepsy and got really involved with the Epilepsy Foundation kind of at that point. But, went to medical school and initially had thought I wanted to do OBGYN. Did my rotation there for, over there it's when you're a third-year medical student--that's when you start your rotation. So, did that one first and hated every minute of it,

(All laugh)

Dr. Hull: and the residents were miserable, and I was miserable with them. So then I thought, well, maybe I want to do Psychiatry. I've always been interested in kind of that field and so did that one next. And realized that I would take the work home with me to the point where, you know, I felt like I was such an empathetic person that in the end of the day I would just feel so emotionally drained. And so thought, man, there's got to be something better than this, or maybe I just don't need to be seeing patients. Maybe that's not meant for me. And so, then I had started thinking I was going to go into radiology, and I remember it was the spring of my third year that I was doing Pediatrics. Never thought anything of it, and part of that rotation we had to do a-- some subspecialty blocks. And so, the subspecialty block that was chosen for me was pediatric neurology just by chance, and I loved every minute of it. The diseases that we were studying were interesting, the patients were just awesome to see, the families were awesome, so at that point, I just knew that that's what I wanted to do. 

Delia: Sounds like so much is just chance where we end up.

Dr. Hull: Definitely. But I think everybody, you know, when you find that field, that just clicks? It's just such an awesome experience at that point on. 

Juan Carlos: What would you say was the-- I guess the more precise thing that clicked for you? 

Dr. Hull: Well, for me it was-- it was a particular patient encounter. So, it was a little girl. Who came in with history of NF1. New onset seizure. And, um, when we did imaging at that point, saw that she had a stroke and had Moyamoya. And so then I was like, what are all of these things? What is this NF1? What is Moyamoya? There's genetics involved? And then there's critical care involved? All in the same patient. And then what do we do about things long term? And, you know, she had-- she needed rehab afterwards, so how do we coordinate all of that? So it was that particular patient encounter that just hooked me. And, you know, when I would go home, I would say, well, what else can I learn about her and the diseases that she has and the things we’re diagnosing her with? And I'd start looking things up on PubMed and then when you look up one thing you want to look up another thing, and it just kept flowing. Which, I'd never felt like that before. 

Delia: Just that insatiable curiosity, I guess? 

Dr. Hull: Yeah. 

Delia: And you had a little of everything. You've had the psychology aspect and the Radiology aspect. 

Dr. Hull: Yeah. 

Delia: Yeah. 

Dr. Hull: And I mean, I think all of the things that I was most interested in before I'm able to see in pediatric neurology, right? I mean, we look at our own imaging all the time. We do have a lot of psychiatric things that come up in neurology, too. So, all of the things that I had kind of hinted at being interested in ended up, you know, coming to fruition just in a much more interesting way, I think. 

Juan Carlos: Sounds like a very powerful motivator. 

Dr. Hull: Yeah.

Juan Carlos: To pursue something. 

Delia: One thing that has come up, even when I've been talking about pedi-neuro with people and we’re, like, discussing what we're interested in is that people's first reaction is that it's a sad field, that it would be just so sad, and “how can you deal with that every day”? How do you respond to that? And has it been just so different for you or… 

Dr. Hull: It has been different for me, and I think, um, you know in the past it probably was, right? You know, we do deal with neurodegenerative conditions all the time. We do deal with things that have, you know, long term implications in terms of quality of life and limitations and your function, but we're also, you know, changing people's lives. In just the last decade we've come out with, you know, gene therapies for SMA, for example. Whereas, before you would get that diagnosis, and you know, it's the kind of a-- it's a lifelong diagnosis. And you know that you're going to be limited in terms of lifespan and quality of life. And right now I'm co-PI on a gene therapy trial for AADC deficiency, which is a neurotransmitter disorder where we are actually injecting the gene therapy straight into deeper structures in the brain. Before, these kids would have severe hypotonia, severe intellectual disability, can't even hold their head up, and seeing these patients-- they get the therapy, and they're starting to have more head control. Some of them are able to sit independently. Some of them are able to walk independently. Some of them are have started talking. I mean, we're changing lives, and I don't know if there's many other fields that you can say that. That you can--you can see these things changing, and you can see the advances being done and you get to be part of it. 

Delia: It's almost like science fiction. (laughs)

Dr. Hull: It is! It is.

Delia: Wow. Um, since you talking about your research, what aspects of pediatric neurology do you find the most fascinating in your research? Or what are your--where are your interests? 

Dr. Hull: Yeah, so I specifically focus on movement disorders, so anything in the movement disorders, that's kind of what piques my interest. Um, I will say that with my training-- it happened to fall during the pandemic. And so, a lot of my research has kind of involved that aspect of things and how the pandemic has led to increases in something called, functional neurologic symptom disorder and functional movement disorders. And then, in particular as of late, there's been a lot of interest in functional tics that have increased. Thought to have some contribution of social media at least in that setting. So, I think in terms of research interests, it's sort of what has come up, but I've also been very interested in obviously genetic conditions that cause movement disorders, trying to find genes that cause movement disorders that we haven't been able to find yet. So, those are kind of the whole gambit of things. We do have a couple of things that we’re working on with deep brain stimulation as well, as well as some other interventions like Botox injections for certain pediatric movement disorder conditions, so it's been really fun. 

Delia: So, it's safe to say the field is evolving really fast right now. 

Dr. Hull: It's evolving really fast, and there's just so many things you can --so many things you can do. It's whatever piques your interest. There will be something there for you. 

Delia: Papers like the Wall Street Journal, the New York Post--they've been name-dropping, you Dr. Hull.

(All Laugh)

Delia: Do you want to tell us a little about that? I have to ask, what has it been like to see your case series go so viral? 

Dr. Hull: Yeah, so it's been really interesting, and I was actually really surprised how much media attention has come from this. So it's been in regards to functional ticks, in particular, mostly being seen in teenage girls where they'll have explosive onset ticks. So movements and sounds, and many of them have particular patterns. So things like bizarre, non-patterned phrases. A lot of them will have a very typical neck tick. Many of them have particular phrases that are patterned. And it seems to stem from exposure to social media of some sort. So, I think, right now, the most common things that teenage girls these days are on is TikTok, and so that's been probably the most common offender, but things like YouTube and other social media platforms have been implicated, too. And essentially what happens is, for unclear reasons, they may see or be exposed to similar types of movements and sounds and then catch them, themselves. And, it is functional neurologic symptom disorder, so it's involuntary. It's not like they're, you know, consciously producing these movements and sounds. It's a response to some sort of psychological factor so, the way their mind is processing thoughts and feelings, and it's manifested by involuntary movements and sounds. We think that there's some component of modeling because it seems like what they look at looks very similar to what they have, but it's just been spreading so fast. And we think it's because in the setting of Covid, you know, people are home and are on their phones or computers and watching a lot of those types of videos. And whether they realize it or not, they've modeled said behaviors. So, I had spoken to the Wall Street Journal about this phenomenon a little bit and a couple of other, you know, media outlets and then ended up on the Doctor Oz Show, 

(All chuckle)

Dr. Hull: which aired in January, which was a really interesting experience. But, they’re interested in this. It's-- there's even in-- and it's a worldwide phenomenon, too. So, even in Germany there's one particular YouTuber that they've kind of name-dropped as—well it seems like they all --that have this thing, have watched this, this YouTuber, but there's so many of these now. If you, if you pull up TikTock, and you look up, “#tourette” or “#ticks”. I mean, there are billions of videos out there, and then there are some of these, um, some of these TikTockers will have millions of followers and millions of views for each of these videos, too. So- 

Juan Carlos: Some of those unprecedented consequences of social media, right? 

Dr. Hull: Right.

Juan Carlos:  You know, it's another reason why I guess it's --it's just adding to, you know, when parents are afraid of their children being on social media, it just adds another dimension-- 

Dr. Hull: Mhm 

Juan Carlos: --that is really tangible. But I was curious, I'm sure this is a very multifactorial 
Phenomenon, but is there a particular age group? That is more vulnerable to--? 

Dr. Hull: It seems like it's teenagers that have been most affected by this, and we've seen that even with functional neurological symptom disorder in general. So pre-pandemic, common symptoms would be, you know, at least with functional movement disorders, it would be tremor or you might see some functional myoclonus or functional dystonia, so it may look different in other people. And then, other things that you see commonly in pediatric neurology are pseudo seizures, or non-epileptic events. So those things had been much more common, and they are common in, again, teenagers. So, there are a lot of theories as to why that occurs. Some thought is that, you know, in, during the teenage years, is when your frontal lobes are really starting to mature, and your frontal lobes, help you with executive function. They help you with coping. They help you with managing your everyday life and the stressors involved with life. And so, when these kids are exposed to something that their brain, may not know how to handle, then, it leaves them at higher risk of having some of these involuntary things happen to them. Now, that's not to say that adults don't develop this. Adults develop this all the time too, but young children don't seem to, so we think that it has something to do with that particular stage of development. 

Delia: And so usually the research around like functional movement disorders has been like it'll be in the family or something you see, but I guess like the real change now is that you could get it from a total stranger across the world just watching enough hours of it, I guess? 

Dr. Hull: Well, if you go back, historically, I mean, so this has been going on for centuries. You know, back in, if you think about the Salem witch trials-- that was mass hysteria. And so, it used to happen in close knit groups. I think besides what's been going on now, more recently, in the earlier 2000s there's a group of high-school girls in Le Roy, New York, that developed involuntary movements and seizure-like events. And again, there it was a close-knit group. So, the girls were friends or would at least see each other on a frequent basis. So you’d need that interaction, and now it seems like you don't need in-person interactions to have this type of spread. You can just be spread through visual media. 

Delia: It's terrifying. 

(All Laugh)

Dr. Hull: It is. It is terrifying. 

Delia: An argument for screen time limits. 

Juan Carlos: Yeah. 

Dr. Hull: And making sure that parents are aware of what things their children are watching. 

Juan Carlos: It is this, on the surface it seems like you wouldn't, it wouldn't really-- how do you, you know, as a parent, how do you even, you know, think of that as a consequence, you know? 

Dr. Hull: I think that's hard because it's not been seen before. So, I mean, in terms of the effects of social media. There's lots of data on, you know, decreased self-esteem and increased risk of things like eating disorders in particular in females and increased depression, but this phenomenon hasn't been seen spread that way before, so I think, you know as a parent, it's hard to imagine that something like that would happen, but it's happening. 

Juan Carlos: So, like, how do we, like maybe not how do we stop it, but how do we curve that? How do we get ahead of that? 

Dr. Hull: I think mostly parents need to be aware of what their kids are watching, and a lot of the platforms do have some form of parental-linked accounts. So, parents can link their accounts to their children’s, and then they can see what's being watched and monitor things closely. And then, just being aware that, you know, hey, if you're concerned that something is changing or something is going on with your child, then see somebody; ask for help. But that's essentially where it needs to start is making sure that you know what your kids are watching and being very clear as to what their limits are. 

Juan Carlos: This kind of gives a new, uh, I guess meta layer to prevention. Preventive medicine is the best medicine or you could-- this is another level. 

Dr. Hull: Yeah, it is another level. 

Juan Carlos: Wow. It's problems in the 21st century. 

Delia: A modern iteration of an ancient, ancient disease, I guess. So this is one way, I guess, Covid has affected your research and kind of the direction it's gone. Have there been other ways that, notably, you felt like Covid has really had effects on your research or the direction of your practice? 

Dr. Hull: Not really in terms of research aside from that. I mean, we were just seeing so much of functional neurologic symptoms disorder. We—our numbers doubled in that time frame, and that's essentially what would come in for most of the new onset ticks in teenagers-- would be this condition. So, I got really good at being able to figure out which one is which. Which one is Tourette syndrome, and which one is this other condition. Then you have this rare group that technically has both, and that can sometimes be tricky. Thankfully, so in terms of my training, I was technically the first pediatric-movement-disorders-trained person here at Baylor. Doctor Parnes, who's my mentor-- he did the adult movement disorders training, but there wasn't someone--there wasn't another ‘him’ that was here. So, nobody that was solely seeing pediatrics. So, I split my time 50% adult and then 50% pediatric during that time, and in that, since I was the only fellow and the first fellow, he was able to make the schedule such that all of his telemedicine visits would be during the time that I was in the adult clinic. And then, same thing for the adult. When I was on adults, I didn't have to worry about any telemedicine patients, so my exposure to-- to movement disorders was not dampened by any means. Which I'm very thankful for because I know a lot of other people didn't have that same experience. And I mean, I can't imagine trying to evaluate someone's tremor through an iPhone conversation because most of our patients are our on their iPhones when they're checking into telemedicine. They have poor connections, and they may be in their car, for example, so you can't analyze gait. So, I was very thankful that I didn't need to deal with that sort of growing pain. 

Delia: So speaking of differentiating the two, I don't know if this is like something that's so detailed to be hard to get into on just this podcast, but do you have any initial kind of how you approach differentiating between the functional movement disorder and the Tourette Syndrome? 

Dr. Hull: Yeah, so it's hard, and--and that's the first thing to know is that it's okay to refer if you-- if you're unsure because it does take a lot of training to be able to differentiate. But in terms of my approach, the first thing that I look at is when was the first time there was ever, ever any involuntary sound or movement. So, Tourette Syndrome, often times it's three, four, five, six, sometimes up to eight years old is when you first start noticing ticks, and it's typically a gradual onset. So, they might have a little blinking here, and then a few months later maybe that got better, and now they've got some neck movements or shoulder movements. So that's kind of how it progresses. Now with functional ticks, on the other hand, they tend to start in teenage years, and usually a rapid onset. So, they'll tell you, you know, one particular day, boom, like a bolt of lightning, I all of a sudden had, you know, neck jerks, arm movements, coprolalia, saying bizarre phrases, and they just rapidly went back-to-back-to-back-to-back. Some of them will even say that it's almost like it was seizure-like when it first started. So that doesn't happen with Tourette Syndrome, but that happens with functional ticks all the time. Other things on history, too, in particular, so functional ticks can often have specific, unusual triggers. So, some of them will say, you know, when I'm-- if I hear loud sounds, then they'll happen. Or if I --if I'm cold, or if I'm in large crowds. That also doesn't happen with Tourette Syndrome. I had one patient, that anytime she heard a German word. She would have a quote unquote, “tick-attack”, which is also—"tick-attacks” are a phenomenon that's pretty unique to functional ticks, where they have almost seizure-like episodes of several different movements and sounds that happen, kind of back-to-back where they can't function. 

Juan Carlos: It's very interesting that these triggers happen. It almost seems like, it makes me think of like, traumatic, maybe a traumatic experience married with it, you know, like a PTSD, but a very niche, a very niche space. I don't know. That's quite interesting. 

Dr. Hull: Yeah, there have been lots of studies that have looked at childhood trauma predisposing people to developing this condition, and it does seem like they’re at much higher risk. But with this particular population there, there haven't been any clear traumas that we've been able to associate-- at least in terms of a clear pattern. I mean, there are a few here and there that they did have some sort of very traumatic experience and then, this thing started, but most of them there haven't been-- hasn't been a clear trauma. Aside from, you know, the pandemic itself, right? That is a traumatic experience for most of, you know, kids, their whole worlds and our whole worlds turned upside down really fast. 

Juan Carlos: Yeah. 

Delia: So you've worked with kids and adults, it sounds like, very in-depth. What really pushed you into, you just love pedi neuro, if people ask you, peds or adults? Like, are they the same just little, or what makes you feel so special? 

Dr. Hull: Yeah, I wouldn't say that they're the same just special because the pathology that you see in pediatrics is so different, and the treatment approach is also very different because instead of just dealing with you know, one or two people, you're dealing with an entire family unit. And so, I think that's probably the thing that pushed me most towards pediatrics and especially when you know, in a child if you're able to do something about whatever issue they're coming in with and change their quality of life, that's a lifetime change for them. Whereas an adult, you know, if an 80-year-old comes in and they have Parkinson's disease, for example, you know, sure you can help them get a good quality of life, at least for you know, maybe another decade or two, but it's not a lifetime, which is just so different in kids. And it's so rewarding when you're able to do that 

Juan Carlos: Different impact. 

Dr. Hull: Mhm. 

Delia: In what is, I mean, a very stressful field, I remember being on your team in the hospital, and you talked about something called your happiness rounds? 

Dr. Hull: Joy rounds 

Delia: Oh, sorry. Joy rounds. See? This is gonna be good. Talk about it because it was a very memorable experience. How did you come up with that? 

Dr. Hull: Yeah, so I've been very interested in wellness and resident and physician wellness and resiliency. When I was in training, I had some colleagues, not in the same program as me but in the adult program, that you could see how burned out that they were feeling. Burnout is a huge problem for physicians, and some of them even quit. I mean, they got into residency, they started, and it was just too much. Some of them needed to take some time to, you know, prioritize their mental health. For me, that pushed me to want to do something more about it, and so, I started a couple of little wellness projects and did start a wellness curriculum as part of our residency program, at least on the pediatric neurology side. And then I was able to go to the AAN Live Well Lead Well program, which is a program that's solely focused on physician wellness. And there I was a group in a group of like-minded, you know, trainees and some faculty that, you know, wanted to prioritize this. And one of them had brought up, you know, it would be great if every day we thought about what we're thankful for or what, what makes us happy. And so, then we as a group had talked about well, what about “joy rounds”? So thinking about in the last 24-hours, what brought you joy? And I don't think we do that enough as in the medical field. You know, we get so busy, and we get so involved with you’re taking care of patients, which is great. But you have to remember what you're doing it for. And you have to really remember, you know, even though you might be on a 30-hour call, there's got to be something in the last 24-hours that made you smile, brought you joy. And when you start your day with that tone, it just makes such a huge difference, and the more you do it, the more you'll realize that it really does. When I first started doing it, I had first started doing it as a fellow on service, and I remember getting some of the faculty, you know, rolling their eyes, saying, “let's just get going”, and then some of the medical students and some of the faculty after being on service with me, would start to say, “wait, wait, we can't start until we do joy rounds. I've been looking for something to bring me joy every day so that I could talk about it”. So, I mean, it's just one little thing that you can add to your day that takes minutes, if anything, that will really shift your mindset from, “I'm tired,” or, “I'm stressed,”, or, “I don't know what to do,” or you know, whatever things that you have going through mind which are 100% valid when you’re, you know, in our training, to, “what brought me joy?” 

Juan Carlos: Yeah, the small victories 

Dr. Hull: The small victories.

Delia: It's harder than it sounds because I remember being on your team, and I was like, oh man, I didn't think about this yesterday. Now, what am I gonna say? Usually I would default to like dinner last night or something.

Dr. Hull: But dinner’s okay.

Delia: And I'd be all nervous, and I would just start trying to present, and you be like, whoa, whoa, whoa, whoa. Whoa.

(All laugh) 

Delia: Going too fast. We have to start with joy rounds. 

Dr. Hull: We have to start with joy rounds; that's how I like to start my days. 

Delia: I love it.

Dr. Hull: So it's all of those little things that, you know, add up. It's obviously not going to solve the issue of burnout, but I think the more we are mindful about those things, the more resilient you become. 

Juan Carlos: So once you started implementing this, did you kind of see it sort of tip the scales towards like a happier environment, perhaps if we were a little more eager to share and be happy? Was it a noticeable..? 

Dr. Hull: I would say that, within a week you could you could definitely-- you could feel the energy even change. 

Juan Carlos: I’m sure that something like that would also change like the cohesiveness of the team and everyone involved. Just happier, right?

Dr. Hull: Yes. Yeah, definitely. 

Delia: You learn something personal about each other on the team.

Dr. Hull: Right. 

Delia: That you'd never know, like who has kids. You wouldn't share that maybe usually 

Dr. Hull: Exactly, it promotes camaraderie. It promotes mindfulness. It does so many things with just that five minutes of, “hey, let's talk about something nice”. 

Delia: I love that you started doing that as a fellow. You, it's not like you waited until you were an attending and you had like, you were at the apex of, you know, the hierarchy. It shows you can start something even kind of at the ground roots, and it can cause change. 

Dr. Hull: Yeah. Yeah, it's, you know, we don't realize how much of an impact we can make. I think, even, you know, you guys doing this podcast? Like this is amazing. How many other places are doing something like this? So, you're not limited in where you are and your training or where you are in your career. As long as you find something that you're passionate about and want to start implementing change, just go for it. 

Delia: I did have another question for you about your training because you have a very unique path in that you were resident a fellow, and now an attending here in the same program. What do you think that's done for you or how has that been for you? 

Dr. Hull: Yeah, so it's um, it was sort of an interesting path for me. I ended up at the program here because when I did my sub-I in pediatric neurology at the University of Nebraska, the person that I trained under had said, “if you're going to go anywhere to train for pediatric neurology, you have to go to Baylor, you have to go to Texas Children's”. So I took that to heart and thankfully got in here, and I still had it in my mind that I wanted to do epilepsy. So, with my pediatrics training and then I did my neurology training, I had started to apply for epilepsy in my second year of neurology. And then, it wasn't until the fall when I had done my movement disorders rotation, which is actually an adult rotation with a few days of pediatrics here and there, that I realized that that's really where my passion lay. And so, I think with that, you know, I was able to already form a lot of those-- the mentorship opportunities and build those relationships that allowed me to be the first pediatric movement disorders fellow here. And I will say, you know, pediatric movement disorders is not a very common field. There aren't a lot of programs out there for it. There's just a handful, at least in the US, and so when I started looking at other programs, I realized that man, if I want clinical experience, it's going to be here because even some of the busiest pediatric movement disorder centers, their fellow, their fellows would have two full days of clinic per week. Whereas I had four full days and then another half day on top of that every week, and it was all in person and it was all full of patients, so I got--I saw everything. And I can say that I've been exceedingly thankful for that. And the same thing goes for the child neurology program here, too, it is probably one of the busiest child neurology programs. And so, you will see the most rare things. You will see the common things, and you'll see a lot of them. And I am not one to learn from reading from a book, so here you will learn by seeing patients. And, I ended up staying here as faculty I think just because, you know, I had already built those connections, like I talked about before, but also, you know, I spent all of my training here so had the longest interview out of anybody else. So they had a good idea of what my work ethic was and what my patients think of me, and so it turned out perfect. And I mean, we've got the patients. There are so many pediatric movement patients that our clinics are full. 

Delia: You can't beat Texas Children's volume. 

Dr. Hull: Yeah. You can't beat the volume here. That's for sure. 

Delia: I'm glad you've had a happy training here. That's a good, a good review for the program. For sure.

Dr. Hull: It was the best you can get for sure. 

Delia: Do you have any other questions? 

Juan Carlos: No, well, I guess I something that kind of stuck with me from the beginning, when you were describing your, your experience in the OB Gyn, and then you mentioned that you would go home with it. But then you also talked about the other side of that is, like, you're excited about pediatric neurology, and you would go home and think about it, but it's entirely different, you know this is sort of enriching and nourishing you. So is there a sort of, obviously that's like a two way thing, right? One could be good, one could be bad. Is there a way to sort of balance? 

Dr. Hull: I think that's just going to be per the individual, right? Some people are going to see patients with anxiety and depression and all of those things, and then come home and sure they'll feel that but they’ll say well, I want to learn more about well, you know, they tried all of these different classes of medicines, maybe are there other things that we can look up? Versus for me, I just felt emotionally drained after that. So I think that's just up to, you know, any given person, right? So somebody else might see kids with neurodegenerative conditions or weird genetic conditions that lead to, you know, all of these sorts of neurologic issues and intractable epilepsy, and go home and say, ahh, I can’t. I just can't. It weighs heavy on me. Whereas for me, well, let's learn about it. 

Juan Carlos: Yeah, I guess it's perspective. 

Dr. Hull: It's perspective. 

Juan Carlos: Yeah, so I guess given that perspective, are there, I guess, any parting words of advice or wisdom to aspiring neurologists. 

Dr. Hull: For aspiring neurologists. 

(All Laugh)

Dr. Hull: Well, aside from joy rounds, and incorporating joy rounds every day. I would say, you know, find something that just excites you because in the end, you know, you're going to work hard. When you're in neurology and medicine, you're going to work hard, you're going to see tough things, but explore around while you can and find something that really excites you, that makes you want to go to work the next day and makes you want to make a difference, makes you want to learn things or change things. So that's what I would say. 

Juan Carlos: That sounds like very wonderful and fair advice. I guess that's as fair as it could be in this line of work. 

Dr. Hull: Yeah. 

Juan Carlos: Well, it's been absolute pleasure. 

Dr. Hull: Thank you. Thanks for having me. 

Delia: Thank you so much for taking the time. 

Dr. Hull: No this was great. This was really fun.

[Outro melody.]

Apple | Spotify | Google Play | Stitcher | Length: 36 minutes | Published: May 19, 2022

In this episode, we hear from Dr. Niraj Mehta, founder of the Cupcake Man Project at Ben Taub, pioneer of the physician-led physical exam rounds for the Internal Medicine clerkship, and personal advocate for the importance of preserving human connection in medicine. Over the next hour, he will discuss his initiatives and share his wisdom on the power of kinship in medicine, helping us make sense of what it means to heal and what we can do to build an intimate alliance with our patients and colleagues.  

Transcript

[Intro melody into roundtable discussion.]

Juan Carlos: And welcome to the Baylor College of Medicine Resonance podcast. I am one of your hosts Juan Carlos Ramirez. 

Emily: I am your other host, Emily Xiao. 

Juan Carlos: Emily is also the lead writer for this episode. And today, we will be hearing from Dr. Niraj Mehta, on the value of humanity and Medicine, improving medical education, and the Art of healing.

Emily: Dr. Niraj Mehta is an associate professor at Baylor College of Medicine and has been a hospitalist at Ben Taub for more than 10 years. He completed his entire medical education and training at the University of Texas Health Science Center Houston. He was a full-time educator at the Lyndon B Johnson hospital for two decades where he received multiple teaching awards before transferring to Ben Taub hospital where he founded the birthday program and the physician-led physical exam rounds. Dr. Mehta is also the author of his memoir, entitled “Hopes and Fears, Dreams and Tears” in which he details his journey and lessons learned through medical school, residency, and life as an attending. 

Juan Carlos: Sounds amazing. I know when you, when you, when you mentioned Dr. Mehta, immediately I got a flashback to one of my like probably one of my fondest memories of internal medicine when he was leading those physician-led physical exam rounds and just I was just thrown away, I'm sorry, blown away by just like his grace and just how careful he was and how well-mannered the physical exam went and the patient was at ease in the learning experience and I felt like we were in this surrounded by his aura, you know.  

Emily: He definitely has some gravitas and I think we all felt it –(laughs)–. Patients felt it, and it's definitely an educational experience like no other that I've had. 

Juan Carlos: Yeah, so I guess when I, when I wonder like why you, I don't I guess I don't wonder, why you chose Dr. Mehta. But is there anything that sort of stood out to you?

Emily: I just think since we have an audience that has so many pre-medical students and medical students, it's so important to hear from a voice that really emphasizes the power that medical students have to be the first line advocates for their patients and to really be the future of medicine and to create new programs and create the future of medicine that they want to see. And I think no one really embodies that and practices by that more than Dr. Mehta. 

Juan Carlos: Yeah. It's like I think I uh, so I didn't do the birthday thing, but when I was reading through the, you know, the pre-Roundtable outline, I saw the cupcake man.

Emily: Yeah, so whoever happened to be on a service, which I was fortunate enough to do for three weeks, whenever there was birthday, he would get the entire and we would get we all sign a card, we would go get cupcakes or a piece of cake and we get a balloon and we would just go around the hospital to everyone who had a birthday and, you know, give him the cards, give them the balloon and the cupcake, and we would sing to them. And it was just, I mean incredible because who does that? No one does that in the hospital. It's such a really depressing place for so many of the patients. And their faces really would just light up, like they were so overjoyed. So many of them would cry, just tears of joy. There's always those few who are kind of just like, just waking up and we're like, what's going on? 
An incredible experience for everyone. 

Juan Carlos: That sounds very inspiring and very touching. I've never heard of anyone going that extra mile, right? For the patient. 

Emily: Yeah, which is kind of sad almost that this is, you know, such an exceptional thing. Out of the norm. But hopefully by amplifying, you know, the fact that projects like this to exist. It can motivate other people to start their own projects. 

Juan Carlos: That's very cool and I can't wait to hear it from Dr. Mehta. And I also did not know he was an author. 

Emily: Yeah, so he wrote this Memoir. That's just about, you know, his journey throughout his medical training and he gave us all a copy of it. When we finished our, you know, really long stint with him at Ben Taub, and, you know, I was reading it. He's very funny. There's a lot of poems, just a lot of stories, personal anecdotes, and I thought I'd be something really interesting to talk about as well. 

Juan Carlos: Yeah, that would be very interested. I'm looking forward to, to reading it, and if you haven't already, make sure you pick yourself up a copy of, of his “Hopes and Fears, Dreams and Tears” And I guess, without further ado, let’s have a conversation with this very inspiring individual. 

Emily: Yeah, let’s get into it. 

[Interlude Melody]

Emily: Thank you Dr. Mehta for joining us today, it’s a pleasure to have you.

Dr. Mehta: Thank you. Glad to be here uou you guys. 

Emily: Can you start by telling us more about yourself and how you chose to pursue internal medicine? 

Dr. Mehta: Sure. I grew up in Houston, Texas. You'll pick up from the Texas drawl pretty easily. Spent my whole life here since I was a little kid and wanted to be a high school English teacher, but that was a difficult conversation with Asian parents in the early 80s, and like almost all other kids back then, Math and Science was the standard outlet, and one thing led to another and I was interested in education and helping people. And here we are. 

Emily: Wonderful. And something I’ve noticed about your background is that you’ve pretty much practiced entirely within the Harris Health System, is there a reason that you chose this particular environment to practice in?

Dr. Mehta: Well, I think that we come from different backgrounds and when were exposed to different Hospital Systems throughout our medical school and residency training, we tend to have a kinship towards a particular institution or hospital. And for me, personally, it was Harris Health and wanting to take care of those that I felt had so much to give to this world, but in terms of health care, they had limited resources and I didn't want their outcomes to be affected simply based on the fact that they were in Harris's Health. Not by choice, but I actually wanted to be by choice to be able to say I'm proud of the care that I give at Harris Health. And that's why I chose to work within that system. 

Emily: Yeah absolutely, and I was just going to ask you about all these wonderful initiatives that you’ve pioneered within the Harris Health System both for the benefit of our patients and our medical students. The first being the physician-led physical exam rounds that we all do during our internal medicine core clerkship. Could you start by just telling us a bit about what those physical exam rounds are? And what inspired you to start that program? 

Dr. Mehta: Sure. So, I think that we have so much technology now that when we take care of patients, a lot of times the information that we get on a patient is on what the cat scan showed, what a consult team opinion may be, what an echocardiogram may show, and I felt that slowly but surely, we were losing the touch of spending time with individual patients. And the value of cost-effective diagnostics where I felt that physical exam rounds would add a valuable tool to taking care of patients. And a few years back I had to medical students on my service, Nathan and Evan, Nathan's actually going to be a GI fellow here at Ben Taub and at the end of the rotation, they really enjoyed the amount of time that we were spending at the bedside. And they wanted to formalize measuring a before-and-after initiative related to physical exam rounds. And then we were able to move forward from that using the JAMA Rational Exam Series as well as the Stanford 25 Model. And what I try to emphasize the most is not only measurable outcomes, in terms of cost-effective Diagnosticsdiagnostics, but what our learners and our patients get a sense of, with the time that's spent at the bedside, the sense of touch and the sense of healing powers that my doctor is spending time with me. And so far. It's been very exciting. 

Emily: Definitely. I think it says a lot that when you were leading these rounds it would take up a good amount of the patient’s time. You had pretty big groups of students with you. The fact that the patients were always willing to let all of us learn and be a part of our educational journey, I think really shows how much it meant to them as well. The investment into their care. 

Dr. Mehta: Yeah, absolutely. And I think that, you know, I try to teach my learners that the, the closest line of defense that we have to humanity and empathy and taking care of patients, is our medical students. And I hope that’s an art that never gets lost with all the technological advances, which we clearly need, but you're absolutely right. Our patients have been heavily involved and are very very appreciative. 

Emily: Yeah definitely. And speaking of all the technological advances in our education, what are some ways you wish modern day medical education could be different? Or gaps in our education that you see?

Dr. Mehta: Well, I think that the first and fundamental change that we need to have is to be able to ask our individual learners what do you think is working and what do you think are effective ways that we could improve what we're actually doing. A lot of times with medical education, we've been doing the same thing over a long period of time and/or the second aspect of medical education, that becomes difficult, is that we do a lot of theoretical teaching. Writing essays, classroom work, but we don't reflect on how that actually affects outcome at the bedside. And I think if perhaps we even asked, not only our medical students, but asked our patients because we're an academic institution, what would you suggest would be different in the way that your doctor spent time with you and otherwise. I think that that would be highly effective because we have all these surveys but how we actually measure patient satisfaction, I still think it's one of those holy Grails that you can almost gear, surveys, and questions to ask what you want to hear in return, but it's not necessarily the best way to measure a patient’s success to what their anticipated outcome should have been yeah. 

Emily: Yeah absolutely, I think that makes sense and should be common practice that if you want to best serve a population you have to ask that population how to best serve them. So, I mean, I think that makes complete sense and something that you've already sort of addressed, is the importance of that human connection in medicine. And something that I've heard you say a lot throughout my time working with you is that “Healing begins with feeling”. And so, I'm wondering what sort of experiences you had that led you to that motto. 

Dr. Mehta: Well, I think it started off with the idea of… I had a medical student back in 1998. If you remember the late 90s people were wearing these wristbands, “WWJD, what would Jesus do?”. And I actually wrote up an editorial and it was WWJD but J. Stood for Jason, who was my medical student at the time. And we had a very difficult patient, who had a complicated medical history, who required an amputation. And I'd spent over 90 minutes at the bedside trying to explain everything in detail to the patient and trying to obviously understand his point of view that amputation is no small task. And at the end of 90 minutes, he turned to Jason and he said, “well doc, what do you think I should do?” And I thought that Jason was going to collapse from heart rate variability thinking that perhaps he had overstepped his boundaries, but I couldn't have been more proud of him and it made me realize how important it is spending time. And when I brought Jason into my office and I said, “Jason, you know, he obviously trusts you more than the rest of us. What are you doing differently than the rest of us?” And he's the one who said, well, “Dr. Mehta, I do these things because I just simply think it's the right thing to do. I just feel it.” And that's sort of where I came in with the idea of healing begins with feeling. And a lot of times our medical students and residents, look up to faculty and so do patients. But I equally believe that it's a bi-directional street of education and that we learn equally from our students. And more importantly, from our patients who end up being our teachers, over the long haul. 

Emily: Yeah absolutely. And I guess on the flip side, have you had any experiences that challenged the conviction to empathy? Any really difficult patients or difficult scenarios when you kind of question how emotionally involved you are with patients? 

Dr. Mehta: Oh, absolutely. I think they're we deal with that every single day. I think the distinction that we have to make in time is the difference between lack of empathy versus professional disconnect. And in the field that we have all chosen to pursue. We do have to have some degree of professional disconnect. An act and to try to best understand what are the barriers to why we respectfully agree to disagree with each other, and then to learn from each other and be able to move forward. But I think that if we don't do that and we create this hierarchical structure of well, “I am the physician and therefore I‘m right. And you are the patient and therefore perhaps you don't understand with your cliche, Google MD degree. What's In your best interest”, then I don't really think that we change outcomes over the long haul. 

Emily: So how do you recommend balancing that professional disconnectc  enough with, you know, having that intimate therapeutic relationship with your patients, where do you draw that line?

Dr. Mehta: I think part of it comes from being able to have other avenues of decompression and asking others in the team structure, your medical students, your interns your residents, what their opinions of the individual situations are in terms of what's happening and then being able to take a step back and literally having a coach per say, being able to evaluate the situation at hand and telling you that perhaps in this situation, you're a bit too close and you need to take a step back. And I think it's hard to do when you're emotionally connected to taking care of individual patients and learners. You almost have to have a neutral party being able to provide you some feedback. 

Emily: Yeah absolutely. Something else I wanted to talk to you about was one of your other initiatives. You founded and led the Cupcake Man Project since I believe 2014. Can you tell us a little more about what inspired you to create that project and what that project is? 

Dr. Mehta: Sure. So, as you mentioned earlier, I've been privileged to have spent my medical school residency and faculty career all within the umbrella of the Harris Health system. And the first thing that we were taught when I was an intern back in 1993 by our upper-level resident, was on our paper charts to look at the patient's date of birth. And the reason we were doing that was not to celebrate their birthday, but we were looking to see when the patient may turn 65 years old, because there's limitations within Harris Health with diagnostics and therapeutics that we could provide but perhaps if they had Medicare or secondary insurance that were getting ready to kick in then we could change their outcome over the long haul. Well as it happened, when I was a third-year resident I was randomly looking at the chart having been taught that and it happened to be my patients birthday on that day. So, I don't know what got a hold of me, but I went to the cafeteria and just got a cupcake and brought him a cupcake to the bedside and said, happy birthday, and he said, “doc, aren't you going to sing?” And I got emotional the nurse, got emotional. Uh, back in the day, there were four patients to a room separated by a curtain. Other patients started to sing, and we sang Happy Birthday. And then as I started off, as junior faculty and 96 at LBJ, within the UT system and Harris health, I used to celebrate patients, birthdays individually on my services, but those were few and far between. And when I came to Ben Taub, I had a Eureka moment as part of my Baylor Master Teacher project to say, what do we all have in common regardless of our Political political affiliations or religious beliefs, our ethnicity, our backgrounds and it was the fact that we all celebrate birthdays. And I started to wonder how many patients were actually celebrating their birthdays in the hospital and how lonely it must be during such a difficult time to celebrate birthdays, especially if you're alone. And as we did a retrospective analysis and move forward, I started to measure out the idea of measuring empathy and could empathy be taught or was it somewhat just in you or not. And we started to look at the data from that and it moved forward from looking at the Cupcake Man Project and celebrating birthdays. 

Emily: Yeah, when I was on your service and you had us go running around the hospital with balloons and cards and cupcakes

Dr. Mehta: Yeah

Emily: It was such a positive experience. I love seeing the variety of reactions we got from patients. Some crying and filled with joy, other sitting uncomfortably not really knowing where to look or what to do

Dr. Mehta: Yeah –(laughs)–

Emily: But I think it's a very, very humanizing experience for both the patient and for us. Because for the patient that's such an isolating and sad experience to be in the hospital on their birthday by themselves. And for us, I think it's so easy to start to forget that the patients are real people. They're not just charts. And so celebrating a birthday with them, I think this is such a great way of- a great reminder for everyone that you know, we're all real people with these real feelings.

Dr. Mehta: No, absolutely, you know Osler said over 100 years ago, “It's more important to know what type of a patient has a disease than what type of a disease a patient has”, and the Cupcake Man Project is a reflection of really understanding an individual patient. We've celebrated over 1800 birthdays now at Ben Taub. And all birthdays are special, but the two that stand out the most in my memories is what I call the “book end” birthdays. One on the happy end and one on the sad end. On one end we celebrate a birthday where the mom is holding a baby in her hands and they both are celebrating a birthday together because she just delivered six hours earlier and that was amazing. And on the other hand, we look at every individual chart and make sure that we get patient and/or family permissions, and the situations are appropriate to celebrating birthdays. And on the other end of the book end we had a birthday where the family was waiting to turn off the ventilator on an ICU patient until it was his birthday. And to this day, I still keep in contact with that family and, you know, we couldn't hold back the tears on that day. As we got the family permission and saying, happy birthdays and exchange hugs, but yeah, it's been a very, very special and meaningful project for us. 

Emily: So this project has obviously been an enormous success, I'm wondering though, if to start this project, you encountered any obstacles. Did anyone fight back when you're trying to do this? 

Dr. Mehta: Yeah, it's funny that you ask that. So, when I started the proposal submission for the project, you know, there's a lot of moving parts. We had to get key stakeholders on board and when there's different institutions involved, it's always challenging. And in this particular instance, we not only had Baylor College of Medicine. We had Harris Health then within the umbrella of Harris Health specifically at we had Ben Taub hospital. In addition to that, we had to look at getting different parts of the project on board, which included Epic, which included the ability to have inclusion/exclusion criteria to be running the computer system every single day as busy as the Epic department is, to be able to say, we need a list by 3, a.m. every day of every single birthday in the hospital. We had to get Dietary on board to be able to say are there dietary restrictions obviously at Ben Taub we have a lot of patients with diabetes and other health restrictions. And then the logistics of helium birthday balloons and making the birthday card. So yeah, there was a lot of different moving parts and initially there was a lot of push back, the whole project took almost two and a half years to get from beginning to end off the ground. But when we finally told Administration that it would cost around two dollars and twenty cents per patient, they were on board from the beginning. And now that we've been doing it for almost seven years, the vendors cover the costs that of the cupcakes. We make all the birthday cards as part of the group building in-house with the patient relations department at Ben Taub. And we simply pay for the helium tank and the balloons. So, the current project cost is less than 30 cents a patient. 

Emily: Wow. I mean that's Incredible, I think we're all so fortunate that things were able to work out so well with all of your hard work and the hard work of everyone else involved with the project. So as someone who has now led created these two successful hospital-based projects. Do you have any advice for up-and-coming med students or young attendings of residents who want to start project of their own? 

Dr. Mehta: I think my biggest advice to medical students and Junior faculty is you know, you be you. Let the institutions and the world adapt to the individual gifts that you're going to bring to that particular institution. And that absolutely there are going to be barriers and challenges along the way but that if you're a square peg, you just need to look a little bit harder to find other square pegs instead of trying to find it fit yourself into that proverbial round hole, but it's doable. 

Emily: Yeah, absolutely. I think that you’re proof of that, that you can make it happen if you work hard enough and you really believe in the mission. Something that I wanted to loop back to that you mentioned a bit a go is the idea of empathy, and if it's something that sort of innate, or that's something that can be taught. In your Memoir, entitled “Hopes and Fears, Dreams and Tears” you have a poem in there that's entitled, “If” and I just wanted to read a brief excerpt from it. It goes, 
“if you could see through my eyes, you would not see diabetic retinopathy. But a grandfather 
who cannot see a baseball game with hisas  grandson. If you could hear what I hear, you would not hear aortic stenosis, but a woman who can no longer enjoy working in her garden. You think you see yet you are blind. Do you see what you have become? A cynical self-absorbed arrogant pawn... Hippocrates cried a tear today.”
I thought that the imagery and the language and that piece was incredibly powerful and something that really stuck out to me was I think the idea of cynicism and medicine as being something that's inevitable. Like no matter how pure your intentions are at the start, someday, you're going to become a jaded attending, you know, 30 years down the road. Do you think that there's truth to that statement or do you think that it's possible to really preserve that sort of like innocence and empathy throughout your medical journey?

Dr. Mehta: So I think it's a great question. I think there's truth to that statement and both ways, which is that. Yeah, along your journey, you are going to become jaded and you're going to become cynical, but I think that you will come full circle. For me, it was having my medical students and then more importantly, my two young daughters were grown up now, constantly reminding me that I wasn't all that I thought I was. And to keep me, well-grounded. And I think that, yeah, there is hope for medicine. And as I mentioned earlier, our closest line to everything that's wonderful and well in the field of medicine is medical students. And I try to tell my medical students every single day. Don't let us try to beat that out of you. And try to resist that and try to push back. Along the way, the things that you value and that you're chasing that you think are gonna define you and make you happy are not what's going to sustain you 30 years down the line. And the examples that are use is the MCAT score. The SAT scores at one time in our lives we thought it was a center of our world and now, we kind of just sort of reflect on it in passing. And I think what we will remember 30 years after you finish your medical school are those special patient encounters that you had at times difficult at times challenging, but that really will define you. Not the awards of the accolades that you're going together along the way.

Emily: Definitely. And speaking of the first line of defense being medical students, what are things that we can all do to build that empathy in that first line of defense? How we train that, cultivate that?

Dr. Mehta: I think the best way to train and cultivate that is to spend time with your patients. Just like if  any of us have kids, nieces, nephews or otherwise, what we value in any relationship this time that's spent. And that's something that doesn't require a lot. For a busy clinician or medical student who's always trying to multitask, get ready for board exams, getting ready to apply for residency programs or otherwise. It always feels like time is that most valuable asset. But if you sit down and spend time with your patients, you will actually understand how important it is for them to heal and the healing power of time and that sense of touch that we briefly mentioned earlier. And I think that that would be a very valuable asset. And to answer your question in terms of what could we do to cultivate some of those habits, it's basically surround ourselves with other square pegs who truly believe in that. And if we surround ourselves with people of equal value systems, we can't help but become what those other reflections are. 

Emily: Yeah, I couldn't agree with you more on that. I think it's really, really easy to have that sort of empathy and propensity for emotion with patients to kind of get discouraged really easily and really early on in our medical journey, you know. I personally had experiences where I express and empathetic statement towards the patient and had someone, you know, make a comment about how “you're not going to feel that way and five years” or “wait till you're at my age, you're not going to feel that way anymore.” And I think there's so much that all of us can do to just say words of encouragement instead and words of praise when students and other young learners are trying to build and train that empathy at all stages. 

Dr. Mehta: You know, I think you're absolutely right. And I think sometimes we forget what a stamp we put on our medical students and even our on our patients, with our words and our actions. And that they are constantly at times early on in their careers especially our students trying to emulate those behaviors. And once some of those imprintings happen, it's very, very hard to change that. And I think that's why it's very, very important to lead by action and by words and be role models. And as I mentioned earlier to also realize that it's bi-directional that we are as faculty members are constantly learning from our students and that our patients are our biggest teachers.

Emily: Definitely. So given all this conversation about what we can do differently to improve our education, to create better initiatives, to cultivate empathy in the future…what do you envision for the future of medicine? What do you hope to see happen in the future? 

Dr. Mehta: Well, what I hope to see is that in terms of the broad brush stroke of physicians, the physicians that I think are our biggest role models are the physicians who are out-patient based or clinic-based who are primary care physicians because as busy and as so-called unrewarding their job description may be and how difficult their situations may be with the high patient load, every single day. They are really spending time to learn each and individual patient and cultivate relationships over time. What I would hope is there for the future is that we have less of a disconnect between what we consider to be the inpatient world of medicine, the so-called sexy world of medicine 

All: –(laughs)–

Dr. Mehta: versus the outpatient grunt world of medicine. The difference between the subspecialty world of medicine versus the so-called gatekeeper world of medicine. And I think every single physician matters, just like every single life matters in terms of patient care. And I think that if we all work towards a team concept, then we can always perhaps aim to cure. But more importantly, aspire to heal and never forget that power of healing. 

Emily: And that's a future that I would love to see. So I think our time is slowly drawing to an end. Are there any parting words or words of wisdom that you want to leave our listeners with? 

Dr. Mehta: I would simply say that each one of us is here with a purpose and each one of us is unique and special in our own way. And I hope that in the field of medicine, if you’re a learner that you will never ever let a faculty member or someone else tell you otherwise. And if you are a patient that you would remind your healers of the extremely difficult and challenging job that he, or she has. But to be thankful to them, and then give them those bits of encouragement that all of us need so much.

Emily: Absolutely. Well, thank you so much again Dr. Mehta for taking the time to join us today. This was a fascinating discussion. I think all of our listeners will be able to take something meaningful away, and it's been a pleasure having you today. Thank you. 

Dr. Mehta: Thank you. It’s been my pleasure. Thank you very much. 

[Outro melody]

Apple | Spotify | Google Play | Stitcher | Length: 51 minutes | Published: April 8, 2022

In this episode, we speak with Dr. Jane Montealegre, the Deputy Director of the Office of Outreach and Health Disparities at Baylor College of Medicine. We learn about Dr. Montealegre’s work on cervical cancer screening and prevention, including her ongoing research on mailed, self-collected HPV testing kits. In this podcast, we explore the future of cancer screening and prevention, and how to better reach underserved groups.

Transcript

Juan Carlos Ramirez
Welcome to the Baylor College of medicine resident podcast. I am one of your hosts, Juan Carlos Ramirez.

Madeline Graham
And I am Madeline Graham and I am the head writer for this episode.

Juan Carlos Ramirez
And in this episode, we are going to talk with Dr. Jane Montealegre, the deputy director of the office of outreach and health disparities at Baylor College of medicine. We will learn about Dr. Montealegre's work on cervical cancer screening and prevention including her ongoing research on mailed self-collected HPV testing kits. In this podcast, we will also explore the future of cancer screening and prevention and how to better reach underserved groups. So, Madeline, why Dr. Montealegre?

Madeline Graham
So, Dr. Montealegre was actually someone that I met during my thesis research, my senior year of undergrad. I was writing on school-based HPV vaccination in the Rio Grande Valley, and comparing it to a really successful school-based vaccination program in Australia. So, I actually met her when I was down in the Valley and talked to her a little bit about her research and her story and thought that she would be a wonderful guest for the podcast. Okay, Dr. Jane Montealegre graduated with a degree in ecology and evolutionary biology from Tulane University; then went on to pursue her M.P.H. at the Tulane University School of Public Health and Tropical Medicine. She completed her Ph.D. in epidemiology in a post-doctoral fellowship in cancer prevention from the UT School of Public Health. Currently, she serves as the deputy director of the office of outreach and health disparities here at Baylor.

Juan Carlos Ramirez
Wonderful! So, what is she… the breadth of the work is sort of pretty expensive, right? And she addresses some pretty… some pretty serious problems.

Madeline Graham
Yeah, absolutely! So, some of her projects that she is working on right now are one sending out self-screening HPV tests via mail, so the goal of this project would be ultimately to have a way to flag patients who have high risk strains of HPV, that cause the majority of cervical cancer cases as well as some other cancers. So, ideally we would be able to identify these people and then refer them to treatment, so that they could catch these strains of HPV before they go on to turn into cancer. And then another project that she is working on is coupling HPV vaccine provider recommendations with tobacco cessation screening in pediatrician's offices. So definitely a lot of really interesting work going on. Primarily, among underserved populations and safety net healthcare systems.

Juan Carlos Ramirez
Wow, that is so cool! And the way that they are just kind of tackling many issues all at once, is impressive and thinking outside the box in certain ways. I did not, you know, we learned this in school, you know, like HPV vaccines, it is never something you think of it as being a problem in society, you know, that people cannot get a vaccine or something that is so obviously beneficial and life-saving. So this is, you know, this is part of why I love doing the podcast, I get to learn all the stuff. So this is very hopeful news. You would mention the healthy people 2030. Could you explain that a little to our listeners?

Madeline Graham
Yeah, let me double check, which does that healthy people, I do not want to say it wrong.

Juan Carlos Ramirez
Oh got you.

Madeline Graham
Okay. So, every 10 years or so, the U.S. Department of Health and Human Services releases this publication, called Healthy People, which outlines goals for different screenings and vaccination rates. So, currently the Healthy People 2030 goal is to have 80% of adolescents age 13 to 15 receive recommended doses of HPV vaccine. So, if you are under the age of 15 when you start the sequence that is two doses; if you are over the age of 15 that is three doses. And currently our vaccination rate in the U.S. is 48%. And then within that 48%, Texas actually has a lower vaccination rate of about 43.5%, and ranks 39th out of 50. And on top of that, this vaccination rate is not the same all across Texas, right? So, we have some areas that are more underserved that are even lower than this 43.5%. But, 80% is the goal, and we believe that getting to 80% would get us to… get us a lot closer to herd immunity and help to get rid of cervical cancer as a public health concern.

Juan Carlos Ramirez
Those words alone are so mind-boggling impressive, you know, getting rid of a cancer altogether from the population. And I am super happy that we get to talk to Montealegre about all this stuff and how we are going to get there because I am assuming it has not been an easy path and it would not be. It is very exciting, very exciting, well…

Madeline Graham
And topical too… oh sorry…

Juan Carlos Ramirez
Go ahead.

Madeline Graham
I am going to say and topical too, I am talking about vaccine distribution in the middle of the coronavirus pandemic.

Juan Carlos Ramirez
Yeah.

Madeline Graham
It will be interesting to ask Dr. Montealegre about parallels between COVID vaccine distribution and HPV vaccine distribution.

Juan Carlos Ramirez
Yeah, absolutely! And without further ado, let us go to the interview with my Dr. Montealegre. Welcome!

Dr. Montealegre
Happy to be here! Thank you for having me.

Juan Carlos Ramirez
Thank you for joining us. And that is wonderful to talk to you today. And get to know you and your story. And, Madeline takes it away.

Madeline Graham
Yeah. So, thank you again for being here with us today, we are really excited to talk to you a little bit more about your journey to Baylor and your work here. So just to start it off… Could you tell me a little bit about yourself and your journey to Baylor?

Dr. Montealegre
Sure. So, I am an assistant professor at Baylor College of Medicine in the department of pediatrics. And I am the assistant director for community outreach and engagement for the Dan L. Duncan Comprehensive Cancer Center, also at Baylor. I am a behavioral epidemiologist by training. I could not really figure out if I was a behavioral scientist or an epidemiologist, so I ended up kind of doing a hybrid of the two, which gets me into a really interesting area of research, looking at how individuals' behavior and particularly risk behaviors affect their health, and their health outcomes. My work primarily is in the area of health disparities. I am particularly interested in health care access and utilization. Particularly of cervical cancer prevention, sorry, repeat… or, cancer, sorry… particularly in the area of cancer prevention services, so HPV vaccination and cervical cancer screening for cervical cancer as well as some work in other screen able cancers like colorectal cancer. And, I am particularly interested in healthcare access for underserved populations, immigrants, racial/ethnic minorities… My work has always been in sort of that area and addressing inequities in the health care system and in health care… and health access. How did they get to Baylor? Let us see. So, I was very fortunate when I applied for a post-doctoral fellowship at UT School of Public Health, where I did my Ph.D. training. It was there my mentor at SPH, really was the brains behind connecting me to Dr. Michael Scheurer in pediatrics at Baylor College of Medicine. He had done a lot of his work in human papillomavirus, HPV. And I was really interested in health disparities around cervical cancer, and particularly how cervical cancer affects immigrant populations and racial/ethnic minorities because of failure to access new cervical cancer screening. Michael is a molecular epidemiologist and a very hardcore sort of analytical epidemiologist. And like I said I am a behavioral epidemiologist. So, it was definitely… It was really wonderful for me because I came into a very different kind of environment from where I had done my Ph.D. training. And I just really loved it. And I also really enjoyed the niche that I kind of filled in Baylor because it is so heavily basic science. And kind of, you know, more of the biomedical sciences that people see when there is a lab and whatnot. It is really fun to come here and fill a niche in behavioral work and also in designing and preventing… designing and implementing prevention services and that sort of thing, so that is what… so the postdoc is what brought me to Baylor to be doing some work in strict cancer and then I ended up staying because of that really neat niche that I seem to fill and which I am delighted to take on within the cancer center. That is what got me here.

Madeline Graham
So that is awesome! I feel like a lot of people when they think about research, they think about test tubes and being in the lab. I was wondering how did you get involved in behavioral epidemiology and how did you discover the field?

Dr. Montealegre
Well, it was a long journey for me as well. I grew up, I think I always knew I wanted to be a scientist and I went on the lab route in college and in my master's degree. And I really tried to force myself to like it. And then at one point, I went back to Guatemala, where I am from, for a summer. I usually was going down in the summer to do research rotations at a university there. And one summer, I was fortunate enough to participate in an epidemiological study with coffee plantation migrant workers. And we were out, and we were interviewing migrant coffee workers on the plantations and speaking Spanish and having to, you know, climb up hills and get dirty. And I realized, you know what, I really like humans. And I decided that I was going to throw my whole facade of forcing myself to like the laboratory sciences away and really join kind of more the human side of things. But I still really wanted that the number thing and so epidemiology seemed to be the fix for that. But when I realized that epidemiology could be sort of a range of things and where there was a role for behavioral epidemiology that is kind of when I had this click moment where I thought, yeah, this is what I want, it gives me the best of both worlds.

Juan Carlos Ramirez
Yeah. To be quite honest, I had not heard about behavioral epidemiology until now. And it sounds like combining, you know, behavioral psychological social issues. And that way of looking at problems with most of the population's least favorite is heavy bio-statistical analyses. Were there like it is just staggering statistics that kind of motivated you in a way you like, you know, sometimes more motivated by like, you know, this large percent of this population is at a disadvantage for whatever… was there something like that that stuck out to you in the work that you do?

Dr. Montealegre
I think where I… by pure sheer luck in early on in my graduate studies, I ended up working with very vulnerable populations, I was doing some work with injection drug users, and women living in housing projects. And I think that is really… I think that is really where I realized that where you live and the circumstances you are born into often force you into lifestyles and behaviors that are far outside of your control that lead to poor health outcomes. And, just, it was really kind of that quick moment where I just realized the forces of structures, you know, our structural environment and society and how that really kind of forms people's health. And I think that is what really… and I was seeing it initially in terms of sexually transmitted diseases and then I really got inspired with cervical cancer because it is so preventable through HPV vaccination and through very simple screening measures. It really is a pretty unique marker of inequity. And really a marker of things that exist, you know, sort of in all facets of life but it all kind of manifests itself and gender inequality. It all manifests itself in cervical cancer incidence and mortality. And it was really kind of that click I think that drew me into that area of research, was having the fortune to work with some vulnerable populations and just really realize how that is that, that happens.

Juan Carlos Ramirez
Wow! It seems like a natural, very natural progression into what sort of… yeah.
Dr. Montealegre
Everything seems natural… Our career path is interesting and when you look back, you say oh yeah that all did make sense. But, you know, while you are doing it, you know, you are still trying to find your way in the world. And I think in retrospect you look back and you really see how one thing progressed into another and it is very natural. But at the time it seemed like much unchartered territories…

Juan Carlos Ramirez
Yeah. And you mentioned something interesting that something like the HPV vaccine, it is, you know, from what I know about it is been kind of like a game changer. You know, it is probably one of the most preventable cancers, there is around, in the easiest manner. And you also mentioned that disparity or that lack of access to something as simple as that. But maybe it is not a simple, perhaps I am missing something. Is there just a major reason why something as simple as that is, you know, a barrier for like underrepresented minorities or populations?

Dr. Montealegre
Yeah, no. This is an excellent question. And it really comes down to sort of the structural inequalities in our system, right? Because cervical cancer, I mean, so I will go into cervical cancer. I know there is a lot of other HPV associated cancers but I think I was telling Madeline that we are really at an exciting point the WHO has launched a campaign to eliminate cervical cancer as a public health problem, which means getting it down to an incidence rate, that is low enough where it is no longer a public health burden. And for the first time ever we have the tools to do that. So we have an HPV vaccine, which is prevents nearly all cervical cancers. And we also think and are gathering evidence that it prevents other HPV-associated cancers, like oral cancer, and anal cancer, which are on the rise in the United States. And likely the same trends will follow suit in other countries soon. So, we have a very effective vaccine for that. And then while we had a really remarkable tool for screening, which is a pap smear, which is the big success story we all think of in terms of cancer prevention, you know. We were able to decrease the incidence of cervical cancer remarkably in countries that had high infrastructure for doing that testing. The reality of that is that because it requires a health care provider, and it requires a woman to go a pretty uncomfortable and often costly procedure. You know, the benefits that we have seen in terms of what it is been able to do in preventing cervical cancer has really been skewed toward the wealthy, within countries, the wealthy, and those with health insurance, and then across countries we can obviously see this in the countries with high incomes and high infrastructure sort of having these decreases, whereas in the rest of the world we are even seeing increases in cervical cancer. And women dying, you know, every couple of minutes from a disease that could have been caught quite simply from a simple pap smear, which is in reality, it is simple you compare it to, you know, CT scanning for lung cancer and you know all the other crazy kind of stuff we do in biomedical world, you know, it is really kind of a simple thing. We finally now have an HPV test. And I think this really is an exciting time. And I think this is what is really led us to this point where we said we can eliminate this, this is we have a simple test, that can test for the ideological agent HPV. And this can be done by women themselves. So that is the area of my work is how do we increase access to screening by having women screen themselves for cervical cancer, but we have a high precision test that could, you know, potentially be done once or twice in women's lives and that would be sufficient to screen them, and reassure them that they are have a low likelihood of developing cervical cancer. And so this test, you know, it is really just a matter of finding cheaper, easier, more acceptable ways to get it out to more and more women. So that is the exciting point that we are at now.

Juan Carlos Ramirez
Wow! That is awesome. That is awesome.

Dr. Montealegre
And with the HPV vaccine, also we are at this really exciting point because it is never before had the ability to prevent any type of cancer with an injection, with a vaccine and yet we somehow watch this, the society. Somehow we did not get the memo on how you roll out vaccination. I think we have botched vaccination on many fronts but particularly the HPV vaccine. And so it is really a time to kind of say, you know, how can we do better? And that is the stuff that Madeline and I have talked about is really how do we kind of think outside the box. We know that people cannot access healthcare. There are inequities in that. So can we use things like school-based vaccination programs, how do we get this out to communities. So it is not reliant on them coming in to see a healthcare provider.

Madeline Graham
Yeah, I love that, you brought up school-based HPV vaccination - that is kind of like a geeky area of interest of mine. So, I would love to hear your take, I know that there are many barriers to rolling out HPV vaccination on the scale that we need it, in order to get like herd immunity against HPV. But I was wondering if you think, like, what you think the biggest barrier is, whether it is accessing the vaccine or if it is once you have access to the vaccine, if there is like parental hesitation or other factors like what you think is the biggest player in this?

Dr. Montealegre
Yeah, no that is a really, really great question. And I think the answer is, it depends where and what population because we have a project the one that you are familiar with is in the Rio Grande Valley. And preventable hesitation about the vaccine is not the main issue. The main issue there is really that parents are busy, they are often working several jobs, they do not have a car, they do not have ten dollars of copay to pay a provider, and their lives are just kind of overwhelmed with survival that having sort of the additional task of being on top of their vaccinations and what not. Sometimes it seems trivial to us but the big burdens put on parents. And so what we have seen is in the Rio Grande Valley, when you have parents, have access to the vaccine for their kids in a way that really takes the onus off of them. And is there the school is letting them know that their kid needs it. The school is providing the services on site, so that parents can just do it quite easily when their kid is dropped off at school, and if they are not the ones dropping them off, they can sort of just send in a consent form. We are seeing that when we remove those barriers to access, that we are getting the HPV vaccine uptake increases a lot. Now that being said, there are plenty of areas and I think the Rio Grande Valley might be an exception in the United States more than the rule. I think parental hesitation and our growing, I mean are growing sort of vaccine hesitancy, that we are seeing is a huge, huge threat to vaccination programs, in general. And I think it is becoming more of a problem rather than less. And I think there are communities where that is the main driver of low uptake. And so, I think really, we have to get to a point I think where we are really tailoring strategies based on the populations and what their barriers really are. And we tend to kind of throw out, you know, simple solution, that is not simple, we throw out solutions and we think that they work in multiple different places and the realities that they do not.

Juan Carlos Ramirez
Instead we are getting a little repeat of history, especially with, you know, it is not more obvious than never with the… they know the COVID vaccine, and it is, you know, family members ask and then people, friends of mine who are non-medical, just like are you going to get the vaccine? Yeah, I am. I am going to get all of them, you know. And, you know, I explained to them. But it is, I could see how it could be difficult for someone who's non-medically inclined, to be confused and hesitant, you know, because there are even like people in healthcare who are like no I am not going to do it, your other reasons. You know, that could be confusing. And then could prevent someone from receiving something that is life-saving, so…

Dr. Montealegre
Yeah. And I think we really, I think this roll out of COVID is really… I think it is really shining light on our roles as people in the health arena. And really being leaders and not having that hesitation. I think it is really showing. I think things that we think for granted, like healthcare providers all are pro vaccines is a myth that I think has been busted by the government rollout. So, I think it is really kind of shining light on a lot of things that we maybe knew that they were there but really had not scratched underneath the surface and COVID is just making all of that, you know, quite obvious. So I think there is a lot of work for us to do in that area.

Juan Carlos Ramirez
Agreed!

Madeline Graham
And I think another thing too is that I have seen with the COVID rollout is that Baylor has really made an effort to find like community champions in the same way that we were trying to do by educating parents in the Rio Grande Valley. For example like posting pictures of getting your vaccine on social media and like really just speaking out about like, this is why I am getting the vaccine and using your platform. And I saw that a little bit in the way that like the program was educating parents during these seminars that then they were able to tell their friends and their relatives and really amplify the effect of your work. So it is really cool to see.
Dr. Montealegre
Yeah, absolutely! I think we need to definitely allow people to have sort of key messages that they can take their social networks. I think for learning how important that is, so that we do interventions with one person, we do not forget to amplify them through sort of that natural process of telling of… people telling their friends and whatnot. That is definitely something we have thought a lot about in terms of the cervical cancer. Screening issue with, you knows how we get people to be able to have their messages so that they can, you know, casually, informally.

Madeline Graham
So, another question I had was; how COVID has affected your research with the self-screening HPV tests? Have you seen an increase in uptake? Because people maybe are a little bit more hesitant to go into the doctor's offices and are preferring like a no contact or low contact approach.

Dr. Montealegre
Yeah, no these are really great questions. So, we have been doing this trial to evaluate the effectiveness of sending mailed kits for self-sample HPV testing to women's homes in a safety net healthcare system which is Harris Health here in Harris County. And we started the trial right before COVID started. And so we do not really have much of a comparison to go back to because it only rolled for about one month before the pandemic hit. And, you know, at first, you know, we had a pull-up of our research on hold. We could not enroll, you know, we did not, even though our intervention is something that can be done from home, you know, there was that whole, you know, limiting resources, so that all the research infrastructure could go into COVID. So that was our first halt. And then that time gave us time to kind of reflect on how we were going to have to modify our study during the COVID period. And I think, you know, we are fortunately lucky because this is, if there was a trial to be done during COVID, this was the trial. Our intervention arm is sending these mailed kits. Our control arm is just educating women and recalling them to come in for a path test and an HPV test collected by a provider. So, I think we have a little bit of an artificial inflation of what we are seeing with the mailed kits because clinics are closed, intermittently. And, you know, during the sort of the initial few months of it, closed all together. And also yes there is a lot of fear for people that actually come into the clinics. But, we think that this, the COVID pandemic, when this is all finally over, if it ever truly ends, you know, it is really going to change behaviors, these are going to be sort of lasting behavioral changes in terms of how people use healthcare. And so, I think rather than thinking of COVID as sort of the exception, we are sort of starting to realize that, you know, we are shifting towards telehealth anyway, and we are shifting towards people wanting to do things more themselves, we have seen this.

Dr. Montealegre
And many other, you know, technological advances and in healthcare, you know, pregnancy testing and whatnot, all of that. So, I think this is really, probably indicative of how things will continue to go. But, yeah, we have seen that women, when you send them a kit to their home and they do not have to come in to see a provider and they can just do a self-sampling kit from the comfort of them home and stick it in the mail and be done with it, there is definitely a lot of enthusiasm for that.

Madeline Graham
So, you mentioned at-home pregnancy tests, do you ever see an HPV test hitting the shelves of like CVS or Walgreens or something? Like would that be feasible and what are the costs of these tests?

Dr. Montealegre
You know, I do see that. I do see that happening. I think we need to be careful because if we screen women, if we screen in general, and we are not hooking people into a system where there is follow-up, really the screening is pointless. And I think a lot of the times in the screening world and in biomedical we think, oh, we have this technological fix. This is it. I think I will be guilty of this. I initially thought, oh self-testing, this is the answer to cervical cancer screening. Technology rarely is the answer to some of these complex problems that we have had. And, you know, I think with at-home cervical cancer screening, we really need to be careful that the roll-outs. I think I could see it being done that way but we need to make sure that there is a system to get people in for follow-up. So that if they do have a positive HPV test that we can get them in for, you know a colposcopy or a tap test or whatever the follow-up algorithm ends up being at the time, we need to make sure that that is all in place. Otherwise we are going to have a whole bunch of people, you know, screening, having this assurance that they have done what they need to do and we do not really have a system to follow up on them and make sure that that actually turns into improved, you know, outcomes. So, yeah, but I think so, I think so, we have actually, just last week put in an application for, to be a site for a trial of the National Institutes of Health is interested in doing the test and non-inferiority of self-testing. And I think this is one of the last little pieces of data that they need for the FDA approval of this. And I think once we have FDA approval, you know, leave it to market forces, there is going to be an explosion of things and you will be seeing this at CVS and Walgreens.

Juan Carlos Ramirez
And Dr. Montealegre makes millions and millions…

Dr. Montealegre
No.

Juan Carlos Ramirez
No I am just kidding.

Dr. Montealegre
How do we roll this out in healthcare, I wish it takes some technological advances but no really I think when public… what I really like about public health is, you know, kind of overlooked all these things, we think we have the technology and then that is all we need and then we overlook kind of how do we integrate this, how do we get this out, how do we make sure that it is equitably distributed in the population. So it is getting to the people who really need it and that… oh I am happy that that is my area of work. So, if any of that is ever built into any of this, I will definitely be very happy.

Juan Carlos Ramirez
Sure. Yeah. I am doing this; it is like very rewarding in itself. As I was thinking as you were saying sort of the unforeseen problems that could arise from something like at home HPV test hitting the shelves, HEB, CVS or Walgreens. And I thought of the example with like 23 and me. And it is not to knock the company or anything but there is had someone foreseen problems, where they had the health report and unfortunately some of those screenings could deliver a pretty hefty mental blow. For example, you know, you could screen and say I have HPV but I cannot go through with the treatment, then now I am living with this burden, with this mental burden. Is that ever or has that ever been like an ethical consideration? Sort of that market side of that at home HPV testing.

Dr. Montealegre
Yeah, no, I think that is a really important question. And I have not really done as much consideration of this. But I think, you know, we have definitely seen in other aspects. I think the example you mentioned is a really great example of sort of over screening… And, particularly when we do not have anything we can do about it, you know. If we are screening and I will go back to cervical cancer but I think it relates as well to sort of these genetic things. If we are screening and there is nothing that people can do about it. Then you have really kind of let them powerless and it becomes this huge mental burden. And then when there is something you can do about it, you know, there is a really fine line in terms of how much the health system can actually absorb, you know. Everybody is running around, doing all these tests, thinking that that is the best thing that they need to do for themselves. But, you know, is the health system equipped to be able to handle this. We have seen this. I do work in implementation of programs and health systems. And, you know, we rolled out a colorectal cancer screening program in our safety net system. And we were really excited because we, you know, duplicated the number of screening tests that we were doing and we were finding all these pre-cancers and been great and everything was really exciting and we thought we were doing a really great job and the truth of the matter is that we had not put enough work into thinking about the health system's capacity to absorb all these screening tests.

Juan Carlos Ramirez
Excellent point! The best medicine is preventative medicine.

Dr. Montealegre
And that is the beauty of the vaccine. We just need to get the people vaccinated, so we do not have all the screening problems.

Madeline Graham
And I also saw that you are working on a project coupling HPV vaccine provider recommendations with smoking cessation interventions. So could you talk about that a little bit?

Dr. Montealegre
Yeah, absolutely! So, we were very fortunate several years ago to get a secret prevention services grant to improve our HPV vaccine rates in our safety net health system at Harris Health System. And we had really, really great outcomes for that. Harris Health really does a good job of providing great care to their patients. So, they were already good to begin with but we really found sort of niche areas where we could improve processes and improve recommendations and support providers in implementing sort of proven evidence-based things that they can easily do to improve uptake for the vaccine. So, we are trying to find, like, what is your lowest hanging fruit, what is going to take the least amount of effort on you that is going to have the biggest, you know, impact, what is the biggest bang for your buck. And so we really focused on those kinds of interventions in our first HPV vaccine project. And… so when it came time to renew the grant, you know, you always have to do more with the same or more with less money and we had been thinking about this a lot from before but we really got really interested our group and what more can pediatricians do for the lifelong health of their patients because we know from our experience with the HPV vaccine that there is a lot of interest in pediatricians in terms of, you know, the lifelong health, that is exactly what vaccines are doing, right? You are vaccinating kids now. And it is protecting them through their life course. And so, there was a lot of interest in the pediatric world in doing this. And so we really started thinking well what else do pediatricians, what other roles could they play in preventing cancer. And my colleague who is a pediatrician but she is also a mother of teenagers. We were sitting around one day discussing and she says, you know, my daughter has really been talking a lot about all the kids at school vaping. My kids are little, so this is totally off my radar; I did not even realize that this was a problem. But she said, you know I wonder what is going on there and so that just really took us down this rabbit hole of… not rabbit hole but, you know, whatever one thing led to another, we really started looking into what she has seen anecdotally as kids vaping a lot at school. And we realize that this is a really big problem. And it threatens to reverse decades and decades of worth… decades and decade's worth of smoking cessation and smoking prevention programs that we as a public health community has done. Because we know that kids who vape are significantly more likely to go on to be smokers of, you know, traditional tobacco. And now we know from, again from the COVID pandemic that, you know, well and right before comet pandemic you all probably remember that we had the epidemic of faith being related deaths. So between that happening right before COVID and now COVID, where there is quite substantial evidence that shows that people who vape have more severe COVID, you know, we are realizing it is not just about them becoming smokers in the future, there is obviously near-term consequences to their health as well. And so this has been really an extreme project. It is really kind of motivating, empowering pediatricians to think about their patient's long-term health. And really give strong messages against, you know, not in the shading, vaping, we rolled out a screening questionnaire, so that that is become standard practice, that it, well child visits we now screen for vaping. We are working with the Texas quit line, that is usually or is entirely made for the adult population but we are doing some targeting… not targeting, sorry, we are adapting the Texas quit line, so that it can be used in a pediatric population, specifically for vaping, and integrating that within sort of the processes of the health system, so that providers are easily able to refer their patients to cessation services. So that is been a really fun project and I think for me the funniest part is really working with pediatricians who are wonderful people, and wonderful healthcare providers, all around. It is really hard to find a pediatrician who's not very motivated to do whatever they can for the health of their patients.

Juan Carlos Ramirez
Yeah. And I am glad you said all of that positive stuff after because it is so scary to think of like children vaping and they do not know what they are getting themselves into health-wise and it is…

Dr. Montealegre
No. And it is… and we, since we started on this project we really… I really tuned into the popular media more than I ever have in my life but it is crazy how much they are being targeted. Like pretty aggressively by the vaping industry, that is completely unregulated as of now and they are taking advantage of the years before we can actually get it together to regulate them. They know full well that the number of years is quite limited, and so the aggressive marketing towards children is insane to me. So, yeah, I think there is a lot we have to do to counter balance that.

Juan Carlos Ramirez
Yeah. And like many, many years ago when I first heard of vaping and I was like, oh, here comes a terrible idea, right? You are just; you are removing the whole smoking part because we thought that the smoking part was terrible. But now you are putting it into a liquid, you have no idea what it is. And then you can, sometimes ten times the dose, in a single paw or a couple puffs but I never saw the children targeting coming. And I guess I should have seen it coming with blueberry and strawberry and all these things started coming out. Anyway, I am glad you are working on this.

Madeline Graham
No, it is crazy. I remember. I went to high school, here in Houston, and it was just everywhere. Like everyone was vaping, like in classrooms, and it was really horrible to watch, and these kids thought there was nothing wrong with vaping, you know, because it was all the marketing around that the outreach that they had gotten around tobacco cessation was tobacco cessation. You know, no one was talking about the addictive effects of nicotine, at least not when we were growing up so… And it is also kind of tricky to screen for too. If you are asking someone about tobacco use, you need to be really careful to ask about vaping and nicotine and like other substances that they may be ingesting that they may not realize is something that you are asking about. They may even be trying to hide their use.

Dr. Montealegre
Absolutely!

Madeline Graham
Yeah.

Dr. Montealegre
Yeah, exactly! So, yeah, we have done a lot of research into sort of how you ask that, so that it is inclusive of all the terms that teenagers and kids are actually using because if you call it by the right name, they will pick up on it. But, if you call it some, you know, nerdo parent term, well they are not going to respond to that because they would not understand what you are even talking about. So, it is always fun to kind of update the terminology we use and update our provider training materials, so that providers can kind of be in the know on, what it is being called as of a few weeks ago is always changing.

Madeline Graham
I know we got a little bit off on a tangent on the vaping but I thought that was a really cool side note, I am glad we had it. Was there anything else that you wanted to talk about Dr. Montealegre?

Dr. Montealegre
Oh my goodness! I think the big overarching umbrella of all this is sort of healthcare interventions, health interventions for underserved populations is kind of the one thing that ties all of this together because there is definitely a whole lot of different interventions going on, that we do. But what really drives it together is really improving health systems and improving outside of health systems like the schools. But, you know, really improving our public health infrastructure and our health care industry to support populations that otherwise kind of get overlooked and are underserved and have less accuracy than others, so…

Juan Carlos Ramirez
Yeah, hopefully we can as collectively get ahead of that, this time around, just seems like we are always more… medicine is almost always very reactive rather than proactive unfortunately.

Dr. Montealegre
Absolutely, yes! And I hope at some point we can, you know, get to a point where we see these things happening and we prevent rather than react because we are seeing sort of the limits of that paradigm. We are kind of realizing the limitations of that paradigm. So we are definitely in need of a big paradigm shift.

Madeline Graham
So, if we have listeners that are hearing this episode and want to get involved in that paradigm shift and help these underserved communities and do research in behavioral epidemiology or cancer prevention, where would you point them to start doing some of their own research and finding out ways to get involved?

Dr. Montealegre
Oh my goodness. Wow, that is a great question. Let us see, whole bunch of videos, I think if this is something that is a fair of interest, I think kind of really kind of start digging around as to why is it that we are seeing these inequalities, what is it that is driving it, I think that is going to get you into an area that you are really passionate about, if you sort of ask the why. And then the other thing, of course, is like how do we address it, right? And I think if you start thinking about why these exist and how do we address, it kind of gets your brain going into some really fun areas of work. Thinking kind of outside of what we are doing now and really kind of how can we change it to address some of these problems? Of course! I will put in a plug for our office of community outreach and engagement at Baylor, the cancer center is doing some really, really great work in terms of health disparities, addressing health disparities, so if anybody is of interest to this, I am always happy to talk. I think that is one of my priorities and how I allocate my time is talking to people, who are interested in career in health disparities, public health, cancer prevention, disease prevention. So, always happy to have my door open or my zoom open because that is the new way we do things but always happy to schedule a time to chat. But, yeah, I think, if this is an area that is of interest to listeners, I think it is a booming area. And so I highly encourage people to take that passion and follow up on it because I think we have so much work to do as a society to sort of fix the wrongs of the past and fix the wrongs of the present, that the work is, you know, is infinite. So, I think if there is one area where you will always be making a contribution, it is certainly in this area.

Juan Carlos Ramirez
Well, we are certainly thankful that you are making contributions, and that you are proactive, and very thankful that you have shared with us all this information and for enlightening our listeners, and for your time and dedication to some very serious but very necessary problem solving.

Dr. Montealegre
Well, thank you so much, this is so much fun to talk to you. And thank you guys for highlighting all the exciting work going on at Baylor College of Medicine, for kind of letting faculty talk about what makes them passionate, what kind of led them into their wacky, a research trajectory. So this is a lot of fun and I am sure also, you know, great for your listeners to kind of hear how all these things get cobbled together to make something that looked like it was planned from the beginning.

Juan Carlos Ramirez
Absolutely!

Juan Carlos Ramirez
Oh thank you very much, Dr. Montealegre.

Madeline Graham
Thank you so much again.

Dr. Montealegre
Thank you so much.

Juan Carlos Ramirez
We wish you all the best in your endeavors.

Dr. Montealegre
Wonderful! Best wishes

Apple | Spotify | Google Play | Stitcher | Length: 40 minutes | Published: Feb. 11, 2022

Dr. Carolyn Smith will discuss her career path as a scientist as well as her time as Dean of the Graduate School of Biomedical Sciences at Baylor. Highlights will include her motivations for dedicating her time to graduate education, her goals as Dean, the challenges that COVID19 has posed to the graduate school curriculum/rotation schedules/ongoing student research, and her vision for the future of GSBS. 

Transcript

[Intro Melody] 
 
Juan Carlos: Welcome everyone, to the Baylor College of Medicine Resonance podcast. My name is Juan Carlos Ramirez. I am one of your hosts. 
 
Alice: And my name is Alice Wen, and I'm also a co-host for this episode. 
 
Juan Carlos: And Alice is also our, the lead writer for this episode. And today, we're going to talk to Dr. Carolyn Smith, as we will discuss her career path as a scientist, as well as her time as dean of The Graduate School of Biomedical Sciences here at Baylor. We will also highlight her motivations for dedicating her time to graduate education, her goals as Dean, the challenges that covid-19 has posed to The Graduate School, curriculum and rotation schedules, with ongoing student research, and her vision for the future of The Graduate School of Biomedical Sciences.  
 
Juan Carlos: So, for those of you who may not know, Dr. Smith serves at Baylor as a faculty member in the molecular and cellular biology, Urology, and she's also a member of the Dan L. Duncan Comprehensive Cancer Center. She's the director of the Tissue Culture Core and Dean of The Graduate School of Biomedical Sciences. So, she does wear many hats. She obtained her Ph.D. from the University of Western Ontario and completed her post-doctoral training here at Baylor College of Medicine before, joining the department of molecular and cellular biology as a faculty member. She has been involved in graduate school education, first, as associate director of the translational, biology, and molecular medicine graduate program.  
 
Juan Carlos: She followed roles in The Graduate School of Biomedical Sciences as assistant Dean for curriculum, senior associate Dean for graduate education and Academic Program development, and now interim dean. 
 
Alice:  Correction: She is now Dean officially dean.  
 
Juan Carlos: She is officially Dean.  
 
Alice: Yes, it has changed since I wrote. Yeah. 
 
Juan Carlos: And she is interested in finding ways to enhance the effectiveness of our graduate program by supporting the professional development of our own students and postdoctoral fellows. We feel very blessed and we're also very excited to have her on the show, but I will ask. I mean, it's very obvious. Why you chose to have Dr. Smith on our show today. Is there any reason that more so compelled you? Is it her education? Is it her career path? Is it sort of, her life story? 
 
Alice: I think a combination of things. First of all, I think her role as interim Dean and now dean of the graduate school played a huge factor in my interest in interviewing her just from a first-hand account. Our programs are, first of all, being restructured to face the ever-changing landscape of Science and to prepare future students for careers in a wide array of different fields. And secondly, I think, obviously, her research background is quite impressive as well. She still runs a lab acting as dean of graduate school. So, I think it I think it's something to be admired, and something that hopefully we will gain a little bit more insight into all the qualities she has balancing that science with her administrative goals, and yeah, I think she's a perfect candidate to interview for a podcast focus on highlighting extraordinary leaders at Baylor.  
 
Juan Carlos: I concur I completely agree with you and I just want to preface this, I guess, for our listeners, and say that her story is very inspiring. Never give up when someone tells you that, that may be the science isn't cut out for you. This is more motivation to persevere and push forward and one day become the dean of The Graduate School of Biomedical Sciences at a top institution. So, without further ado, let's talk to Dr. Smith.  
 
[Interlude melody] 
 
Alice: We're very excited to have you on the show. Dr. Smith. Could you tell us a little bit about your career background and science, what are your interests, and where did you train?  
 
Dr. Smith: Sure, happy to do that. So, I got interested in science from a very early age. Science was one of my favorite classes. I can remember going back to middle school, but that was really where I had the best experiences in class. I really liked interacting with my science teachers when I was in Middle School, and I was also fortunate to have a great uncle who when he retired from the military, decided to spend his time studying science as a retiree, and he was really great for me. He would give me books and he would have conversations with me when I was pretty young kid about science and some really kind of interesting, and, you know, maybe kind of far-out ideas, but it really opened my mind to thinking about how fun science was and how it led us really think about interesting things. So, at one point early early, when I was very small, I thought I wanted to be a pediatrician but once I got into middle school and high school, I just got so attracted into science and the idea of being able to solve puzzles, that that's really where I gravitated. I did my undergraduate degree at the University of Toronto in Canada in Biochemistry and was attracted to that because it provided me some tools to start understanding how life works and I thought that would be a pretty good way to start my education and was really fortunate to be able to get research experience. Really starting for my first year, part of that arose from the circumstances of my family. And while I was born in Canada and I lived there until I was 16, my family was moved because of my father's job into the United States when I was a junior in high school. I came into the U.S I was living on as a derivative of his Visa. So, I couldn't work as a high school student and so my parents found this summer research program at the University of Iowa, and as a junior, the summer, after my junior year in the summer after my senior year in high school. I was able to go to Iowa City and work on some research projects on amino acid transport in the small intestine. And so, really way before I should have been in a research lab doing research. That's what I got to do. So, when I started my undergraduate degree in Canada, and yes, I left Iowa to go pack to Canada, to do that degree, had a first-year biology teacher who needed a lab assistant and I wanted a job to make some money and I put up my hand and he, his main collaborator happened to I work at the University of Iowa. And so, when I said, I had been there for two summers. He thought that was Karma. And I got the job as opposed to probably 50 other people who also wanted the job. That job was looking at reproduction in insects. So, I spent four years of my undergraduate degree as a side job raising colonies of cockroaches and Locusts and then studying their reproduction. So, the lab was trying to focus on understanding that and how you could intervene in that as a method of pest control, ultimately would be the long-term application. So, I did that all the way through and then as I got into my senior year of biochemistry, I needed a research project for my senior thesis and this was quite a long time ago. So, I was working with one of the labs that had cloned the large subunit of RNA polymerase 2. Now that wouldn't be a big deal, but back then working with a gene for such a large protein was enormously challenging because handling large pieces of DNA just was not something that the technology was well-suited for at that time and that was in some ways, a very important experience for me because I did actually do all that. Well, at the cloning, it was hard, didn't have tools, didn't have kids had a lot of failures. Layers. And I remember the mentor at that point. I'm kind of suggesting to me that maybe I wasn't cut out for Science, and the kind of one of the key things for me at that point was I was really determined to prove him wrong. And so not that I made huge progress that year, but I did and I think that was a good lesson for me, in terms of developing a little bit of a hard head so that when things don't work for you in a while, when you have problems come up that you just sort of decide you're going to get through them. Whether it takes four times or you know, 25 times to get the experiments to work properly. 
 
Dr. Smith: Throughout my time, as an undergraduate. I got interested in in reproduction. So, the insects were part of that. But the insect work we were doing was actually with insect hormones that control reproduction. And I did want to move more into the area of mammalian biology. And so, I decided that I really wanted to work in the area of reproductive hormones, steroids in particular were quite interesting to me. And so, at that point, I had already met the person who would become my husband. And so, I had certain geographical constraints that I was wanting to live with. So, I was only looking at universities in Canada to do my graduate work. And so, I did go from Toronto to a city of about couple hours West of there to London, Ontario. And I did my Ph.D. there and I did my work on the proteins that are in the plasma that transport sex steroids. So primarily for me corticosteroid binding globulin, so that transports glucocorticoids and that was a great experience.  
 
Dr. Smith: I had the fortune of joining a lab where the faculty member had just come to the university and they were setting up their lab. And so, I had the chance to see how you set up a lab, how you write initial grants, how you get everything going, and because there weren't many people in a lab. Even as a beginning graduate student, I got exposed to a lot of different  
aspects of how you set up and run a lab, and as well, it was a really productive time. It was when cloning and sequencing were just getting going as major technologies – poured, probably hundreds, but it feels like millions of sequencing gels, and had to make our own sequencing reactions. It was really a time of trying to figure things out from first principles, but it was a great experience. We got lots of work done, lots of papers published, and because I had that chance to really see how things work as not. Certainly not as a PI, but someone working very closely on a regular basis with their PI. I got a great experience and a lot of training, not only in the science, but how you sort of think about conducting science at a laboratory level.  
 
Dr. Smith: At that point, I really wanted to continue my training and I was certain that I wanted to continue my career in studying how sex steroids worked. And so, I wanted to move from setting how they are transported in the circulation to how they actually get in a cell and what they do. And because of that, I was looking at some of the top labs in the world for who was studying, sex steroids, and the biology of them, and, of course, was very interested in the work that was being done by Bert O'Malley and Bill Schrader. I had read a paper there's as, in a second-year undergraduate class and it was a paper. They had published in Scientific American, and I just thought it was the coolest thing. So, by the time I'm finished my Ph.D. And I thought I had actually had the opportunity to maybe come to a lab like that I was really thrilled. So, I came to Baylor as a postdoc and worked in their lab and that's, that's sort of the early trajectory of sort of just being interested in science and then sort of finding out that that area that I was interested in was really related to steroids and how they work. So, it's been a great time. I trained here at Baylor, became a faculty member, and I'm still here. So, it's been a great place to be.  
 
Alice: Really cool! That's very, very interesting that you moved from insects to mammalian systems and then specifically homed in on reproductive hormones and their effects on gene expression. Can you tell us a little bit about what you hope your research could accomplish maybe in the fields of Health Care and patient populations? 
 
Dr. Smith: Sure. You know, what, as I, when I came to Baylor, I wanted to work on sort of unique ways that steroids worked. And I had some chances as a postdoctoral fellow to look at non-traditional mechanisms of action of steroid receptors and how they could work without actually binding to steroids as part of components of cell signaling Pathways. And that work led into a fundamental question that was really difficult to understand back when we started this. And that is how there are classes of drugs that will bind to steroid receptors and can sometimes turn them on and sometimes turn them off and their ability to turn on or turn off the actions of the steroid receptors was dependent on the cell environment they were in. So, it was a great way to bring together my interest and how receptors could work without ligands as components of signaling pathways to marry that with the idea that steroids with some types of ligands for them, could behave either as stimulators of transcription or inhibitors of transcription. And so, bringing that together, we, in conjunction with Dr. O'Malley as a postdoctoral mentor and then as I launched my own laboratory, we spent a lot of time trying to understand the relationship between Signaling Pathways ligands and these mixed responses. And that turned out to be really quite important in terms of, thinking of drugs, like tamoxifen that had been really widely used for breast cancer. And the reason for that was, you know, tamoxifen was used really widely. It was often very, very effective and then when would develop resistance to the drug and tumors would start to grow again and not only with tumor start to grow in face of the tamoxifen, but the tamoxifen became a stimulator of growth. So in in the context of people and treatment for a, you know, really terrible disease – we were seeing the same thing that we could do in cell model systems either it could stimulate a response or it can inhibit response. And so, it got us interested again in thinking about the differences that occur within tumors that sort of change that interpretation. So it's led to the concept of selective modulators for steroid receptors in particular, the work we did really establish the field that there are selective estrogen receptor modulators. And that was really the first concept for steroid receptors that there could be these dual regulators of their activity and it allowed not only folks in the estrogen receptor fields to think about this but also as we've gone on it, Now, expanded it to the Androgen receptor field, the glucocorticoid receptor field, and progesterone receptor field. Where we know in all of those there are abilities to really dial with more sensitivity or more specificity than we thought possible Agonist versus antagonist actions. So, that's one of the things I think that, you know, I really was pleased to be part of it really helped launch that field and I think it's a, it's been a really great that's emerged into thinking, more about how estrogens contribute in different ways, to development of breast cancer. And so, that's an area where I think we still have lots of things to sort out in terms of estrogen and risk profiles for breast cancer. It's pretty easy for many many folks, to think of it as estrogen is bad, with respect to breast cancer, but there's actually interesting data that suggest much more complex than that. Again, I think we're going to be thinking about receptors in context of their environment, different cell types, different stages of development and different responses. That's where I think there's lots of future within the steroid receptor field.  
 
Alice: Really cool. I also wanted to ask you about your position as dean of the graduate school at Baylor. What sparked you to, I think, pursue that position? And what do you hope to accomplish in your time as dean?  
 
Dr. Smith: Thank you for the question. And so, as a faculty member here within the college. I like many, many other faculty, was interested in mentoring students and being involved with my graduate program. And so that really wasn't very different from a lot of other people here. I got interested in getting more involved in education from an administrative perspective. When the college was thinking about how to set up a new graduate program. And the idea on this was to try and blend together the idea that we have, we trained basic scientists and we trained clinicians, and we trained clinical scientists, but you hear a lot about the gap between basic research and clinical research. And so, there was a group thinking about how to bridge that gap and my department chair, who was Bert. O'Malley suggested, I might like to participate in that group, and it fit in really nicely with my research work because we were thinking about tamoxifen and breast cancer and how to understand changes in how patients with breast cancer responded to the drug. And that was really an area where there were lots of clinical people thinking about it and basic, scientists thinking about it. We were trying to figure out how to pull those things together. So, I got involved in this group. It ultimately led to the formation of the translational biology and molecular medicine graduate program. And so, I was very involved in that program for a number of years as an associate director and help establish that program along with the directors at the time. And so that was one aspect that really kind of got me a little bit more involved in administration and then shortly after that the college was going up for accreditation by the southern association of colleges and commission on colleges and  
they needed, we needed to have a plan for bringing new training to students at the college. And we thought maybe translational medicine and translational science might be something that would be different. And so, I ended up leading the, at that time the quality enhancement program, so initiating a couple of programs at the college and that got me very interested in administration at education and from there it just grew got involved versus assistant Dean for curriculum, and then that's evolved to the position I have today. So, it really came out of my science and trying to figure out how we create programs to train graduate students and medical students to have more awareness and skills in the area of translational medicine.  
 
Alice: So because covid-19 has kind of changed the entire landscape of what education looks like and say it same is true for all aspects of Education from K to 12 to college. Obviously, it's heavily impacted graduate students as well. What are some of the major challenges that you have had to overcome is Dean during this time? And how do you foresee that any of the changes just might change the entire future of graduate programs or curve? 
 
Dr. Smith: It is clearly changed a great many things when it started last March in 2020, we were just coming into the end of our big push for recruiting in new students for the folks that would matriculated in August of 2020. And so, in many ways the timing of the start of the pandemic was as about as good as it could have been. We had finished our in-person interviews with students. And so, we could finish up recruitment through regular email and typical virtual types of communication. And our first-year students were in their fourth term. So, they were already pretty comfortable with how things work at the college and their faculty and things like that. So, we certainly have had to learn since that time how to do all of our classes remotely. And so, this has been, I think, a big learning experience for the faculty where they've had to learn how to use zoom. I mean everyone's had to learn how to do Zoom but teaching on zoom is a little different, especially if you wanted to have small group activities and things like that. So, we've had to do a lot of things to learn in that area. In some ways, it's been really great. I think we've had many faculty comment that they're actually having better discussions with students because it feels like you're talking to someone right in front of you. It's not like a big room where there's someone in the back, and you can't really see them. And so, in a lot of ways it can feel a lot more personal and so you do get more discussion and people are traveling less. And so, I think in many ways that has been a positive on the overall education programs. We have brilliant faculty here at Baylor that are in high demand, it often means many of them are gone for a large portion of time. That's just not the case now. So, in some ways it's really been a positive. If one wants to say, there's any positive coming out of the pandemic, but that's been great. I think having more of that interaction between students and faculty because you feel like you're talking right with them face-to-face. Those have been great things coming out. On the negative side of things, it does take more time to prepare classes. And, you know, there are always technological glitches. And so, we know sometimes that's just not very satisfying for students. We know it's not satisfying for faculty. So, you know, some of those things, I'm sure will be glad when we don't have to always rely on a computer screen when someone has a nice quiet room to be able to participate in a class and the delay and the disruption in the research certainly was a huge, huge event, you know, you really couldn't have imagined in any other context other than a something like a pandemic, the idea that you would sort of walk out of the lab one day and might not get back in for a couple of months. And that's really extraordinary, you know, a lot of experiments take enormous amounts of time and very careful work to get them set up. So that you can get a model system or an experimental system where you can collect good data. And for anyone who either had that up and running or was just on the verge or even really just starting in the lab and trying to figure out how they were going to set up their experiments that time away from the lab was really, really very disruptive. So that certainly is going to be a factor. Now we hoped and certainly encourage students and faculty to you know, make lemonade out of the lemon that we were all served up and and use that time to read and plan and analyze data that you had. So I'm hopeful that for, you know, many of us students faculty postdocs that, that was sort of some forced time to think about projects and, you know, develop some new ideas and maybe connect with people and experiments, you could do, once we get back to the lab. And snow where we are, where we are at this point and students are now doing all their classes remotely. We hold them for the most part. I think they go fairly. Well, I certainly think people would love to get back together though, and there's smaller groups and be able to present their data and you know, stand up in front of a crowd and sort of talk about the things that they're most passionate about. But I think you know, we've tried as well as you know, everyone at the college to make the best of it. So, there will be things we take away that we think of finally and those that will be happier over.  
 
Alice: Um. We’re all looking forward to the day when we can get back to in-person event, but I think we've been quite resilient throughout this entire situation. So I’m really very grateful for Baylor's programs and the support the day offer too.  
 
Dr. Smith: Well, I would say, I have just been so impressed with everyone and their response, and really, their resilience, and the ability to create new things. Things even better than we had before. So it's been really fantastic to be part of such a creative and innovative community.  
 
Alice: So, thinking of creating new things. Actually, I wanted to ask you. So, I know the Baylor graduate program has been undergoing a program restructuring. And for the past couple of years. Can you tell us what motivated The Graduate School to pursue such a move and what they hope to accomplish with this restructuring? 
 
Dr. Smith: Sure. So, the restructuring was something that we had been thinking about a number of people that had been thinking about for two or three years before we began to really start seriously planning on it and that thinking was motivated by the reality of science changing over time. Right? So, if you think about how medical schools and basic science departments in medical schools were set up, they were really established so you have an Immunology department, so you'd have immunologists who could teach Immunology to medical students and if you go back in science, you know, immunologist had a whole set of techniques that they use to do their work and biochemists had a whole set of techniques that they use to do their work and geneticists and so on but science has changed and evolved so much in the last, you know, latter third of the 1900s and it, you know, it just keeps accelerating and and as we looked at how graduate programs were set up and we looked at the faculty and we looked at what people were doing you suddenly realize that the techniques that geneticists use were the same that biochemistry people were using and, and people in cell biology department were using, we are sharing so much. And we're so dependent and utilize each other's resources that some of those divisions didn't make sense. So that was one component of it. We didn't actually realize it, but if you looked at the underlying data, if you had students in a genetics program, only half of them were in the genetics department, the rest of them were spread out. Out across the college. So, we thought perhaps we might start thinking about science more, as areas of scientific interest that were broader than departments. So that was part of it and of the programs that emerged from the restructuring. We certainly have several that really are very Broad and touch, really largely across many, many areas of science and research and partners with a college. So that was one part of it. The second part is we had realized, as we had gone from, the more traditional department, based systems and to biology that was much more transdisciplinary and inclusive across departments that some programs have gotten very small and some programs had gotten very big and one of the things we know to in that was that if you were a student in a large program, your experience could be quite different from your experience as a student in a small program. So, you might have fewer people to interact with. Maybe if you are faculty, that could serve on committees, do our research opportunities, and we really wanted to try and get rid of those extremes of very large departments, and very small departments, and try and create an environment where students had a much more equal opportunity to access resources, regardless of which program they joined. And then the thing we wanted to do was to try and align these areas of programs and their research with research strengths at the college. So we wanted to be able to offer robust mentoring experiences, coursework, technological and experimental support in areas where the college had a lot of depth and present that to a candidate. So that when they would come in, they have a really great experience with not necessarily the work of having to create entirely that experience for themselves and there is some value in doing that. But it shouldn’t always have to be, feel like like you're starting from scratch to do that. So those things kind of came together and we're part of the prompt for us to start the transformation and then as we started doing that, we got: Well, if we're going to look at changes in programs, let's really take a look at all the key things that we do as academic milestones and Ph.D. training and see if that's the way we want to keep doing them or if we want to take this opportunity to change them. And so, we changed a lot of the curriculum again to kind of reflect on the idea that there's a lot common between all the disciplines and we wanted to make sure that our students coming into programs had a common tool box of vocabulary and understanding of experiments and scientific principles. And that led to the creation of our foundational courses. We have a more unified view on what should happen in a qualifying exam, which is one of the key steps before students admitted to candidacy. We wanted to make sure that the graduation requirements were comparable across all the programs. So we did all of that work. Lots and lots of students and faculty continue to contribute to discussions that took place over the course of an entire year. And we came out, I think with some really great ideas and built on the experiments of our prior graduate programs where you know, programs had huge successes and some areas. And so we thought yeah. Include those in the new programs and areas where programs that this didn't work quite well. We had lots of discussions and we were able to kind of find best Solutions or what we thought and hope will become great solutions for us as we move forward. We sort of drew upon this. So I think it was a really collaborative process where we try to take. Take all the good stuff. We had learned as individual programs in the past and put them together and new programs to go forward. 
 
Alice: Oh, and we only have a few minutes left, but I want to ask you, obviously, I hopefully you'll have a very long and successful career from here out. But what do you hope to be your legacy as both a scientist and as dean of graduate school?  
 
Dr. Smith: Hey, that's a really interesting question. I hope that my legacy builds on, you know, my work as a scientist and understanding of what we need to do and have in place to do great science and then taking that and translating that into educational programs, that help students be able to do that for themselves to have available to them resources but understand how they can work within their programs and the departments to do the best science possible. And not only be trained well as scientists, but to be trained and have opportunities to develop professionally. And so, I really like, and hope that what I accomplished at my time here at Baylor is to create an environment where people can come in and do the best science they possibly can and do the training and be able to get access to resources that lets them develop to be the best individuals that they can in terms of their own professional goals. So, I really love the idea that Ph.D. training has evolved so that people can come in learn to be really strong critical thinkers, do the science that they're most interested in and then they have opportunities to develop the skills and make contacts that lets them move into the career of their choice. We used to think about training Ph.D. candidates as the next generation of faculty. And while that still is very very important, and we absolutely are committed to doing that. One of the things I really love in my current job as every year, looking at where our graduates go in terms of their employment. And I am really continually amazed to see where people go. That gives me really a tremendous sense of satisfaction that the graduate programs here, the research environment we have here. Is such that people can come do science. They're passionate about it. And then go do really great things after that. So, I hope we are taking the Baylor concepts of, you know, great science, collegiality critical thinking and really dispersing that throughout the country and throughout the world. And if that's what we accomplish, I'll be really pleased with that.  
 
Alice: And one last thing is there any advice that you would like to give to budding scientists for me, maybe an undergraduate or even earlier on in their training?  
 
Dr. Smith: Um. So, I think you know, science is a is a huge amount of fun, right? You can find, you can develop your own questions. You can develop your own way to address questions. And you can really explore. And so, it's great because you're not constrained to specific things that you necessarily have to do to be able to advance as a scientist. So, in terms of advice, for younger people coming into science, this is a great place, use your creativity, use your curiosity, nurture, those things, and then balance that with some hard work and the curiosity and the hard work generally go really well together. You can ask questions and you have the intent and the desire to address those questions and get to answers. And that kind of brings it around to a really nice conclusion. But as in many things, life and training as a scientist is not all about work. So always make sure you balance that off. Find those things that are fun that are important to feed your inner soul and keep you energized and, you know, just excited to get up every day for many people. I hope getting up every day means coming in and doing some science and then having some fun time afterwards, but keeping those keeping that creativity going and  not being discouraged and and keeping going I think is a great way to go.  
 
Alice: So that concludes my interview. Juan do you have any other questions? Well, thank you for the questions. They were great.  
 
Juan Carlos: And as always, thank you for your time and for inspiring us all and encouraging budding scientists out there and even those who are going through tough times and looking at you as an example of perseverance, and hanging in there and one day they will be leaders in science as well.  
 
Dr. Smith: Yeah, absolutely. I know all of our students can. Thank you very much for having me. It was really great.  
 
Alice: Thank you for coming.  
 
Dr. Smith: Thanks. 

Apple | Spotify | Google Play | Stitcher | Length: 61 minutes | Published: Nov. 17, 2021

If you could live without one of your five senses, which one would it be? Does one sensory system take priority over the other? It turns out, these questions are not as straightforward… and the answers will surprise! Sensory processing or sensation makes up a huge aspect of human perception. Dr. Jeffrey Min-In Yau’s lab uses functional neuroimaging, noninvasive brain stimulation, computational modeling, and psychophysics to discern principles underlying the integration of sensory information which result in perception and how sensory network connectivity varies across tasks and brain states. In this episode he discusses his academic journey, the clinical applications of his research and the insights his efforts have yielded so far.

Transcript

[Intro Melody]

Juan Carlos: And welcome back to the Baylor College of Medicine Resonance podcast. I am your president and one of your hosts Juan Carlos Ramirez, and in today's conversation, we will be interviewing Dr. Jeff Yau. Dr. Jeff Yau earned his bachelor's from the University of North Carolina at Chapel Hill in Psychology and then he went on to get a Ph.D. in Neuroscience from the University of Johns Hopkins.

Juan Carlos: Dr. Jeffrey Min-In Yau's lab is particularly interested in Human Psychophysics and his lab aims to identify perceptual and neural processing principles that unify our senses and to characterize the complex interactions between the sensory systems. The lab is also interested in understanding how human brain regions collaborate in distributed networks and how network connectivity is dynamically modulated across tasks and attention States. The lab investigates the relationship between the brain and behavior using functional neuroimaging, non-invasive brain stimulation, computational modeling, and psychophysics.

Juan Carlos: In our conversation with Dr. Yau, we'll learn all about his lab, what he does, his journey, how he got there and what drives him, what drives his curiosity to know more about how the brain integrates these different sensory modalities under varying states and locally, Dr. Yau is known as an amazing mentor and is embedded deeply in the QCB and Neuroscience programs here at Baylor College of Medicine. Let's go to the episode.

[Interlude Melody]

Kiara: I'm so happy that you agreed to do this. Thank you so much for agreeing. I'm Kiara Vega. I'm a fourth-year neuroscience student in the Daoyun Ji lab and I just want to start by asking you to tell us a little bit about your academic trajectory and research background like how you got here.

Dr. Yau: Right? So, I will start by saying, thank you very much for having me, and this is really a pleasure for me. So, with my background, I started as a Psychology major when I attended University of North Carolina Chapel Hill. And initially when I started, I was really interested in sort of, psychology. I was thinking about going to medical school for Psychiatry and then just sort of as an undergrad, through various research experiences, I ultimately realized I didn't want to go to medical school and that research was sort of the more interesting bit and we could get into the details later. But then after undergrad, I then attended Johns Hopkins University for my Ph.D., I got a Ph.D. in neuroscience and then finish there. And then completed a postdoc in neurology at Hopkins. And then I moved to Baylor and started my own lab in 2014.

Kiara: Um, what type of research did you conduct when you were at Johns Hopkins and doing your Ph.D.?

Dr. Yau: Right. So, for my Ph.D., I worked on the neurophysiology of somatosensory processing and so we were working with non-human primates and recording from electrical signals and somatosensory cortex as we were presenting basically, sort of, cookie-cutter patterns to a monkey's hand. And then we were characterizing how our somatosensory cortical neurons selected for the spatial patterns that they were experiencing on their skin.

Kiara: Oh! So, you were always interested or were, have been working with somatosensory processing for a while now. Yeah?

Dr. Yau: Yeah. So, even as an undergrad I was working in a somatosensory lab and so, in many ways, my undergraduate experience has shaped my research trajectory. And, and I can even say, my first RO1 was based on a research idea that came about as a question that emerged when I was doing research as an undergrad.

Kiara: Why was that what drew you in to neuroscience, like…?

Dr. Yau: right, so I would say that my experience with research is probably typical to many people that I know where there's sort of a series of chance events and serendipity that sort of brings me to where I am, right? And so, as an undergrad, I had worked in a number of different research Labs. I was, I started in a Pathology Lab where I was working on cancer biology, angiogenesis, and prostate tumors. And then in parallel I was working in the social psychology lab work and how people make decisions about social interactions. And then it was in my junior year of undergrad that I took a Sensation and Perception course, and at the end of this, the graduate TA, Sliman Bensmaia, who was teaching that then said, "hey, you know, you're pretty bright. Do you want to come in work our lab?" So, then I said, "cool, let's do it." And so, then I joined Mark Collins lab working with Sliman, and their lab was looking at somatosensory perception. So, "how do you perceive vibrations?" And, and then that sort of set me off, ultimately, on the path that I am at now.

Kiara: Yeah. Wow, it's pretty interesting.

Erik: Yeah. Yeah, and I was, I was, we were talking a little bit before but for anybody any of the students listening, now or prospective students listening, Dr. Yau – at least taught, I'm not sure if you're still teaching the medical students.

Dr. Yau: Yes. Yep!

Erik: ..in the neurology course, or the neuro course, learning about all the tracts and, and just we were talking about how you, you kind of liked to show, you know, how everything kind of lined up, you used was a TMS is what it's called, right?

Dr. Yau: That's right. So, Transcranial Magnetic Stimulation.

Erik: Yes, and I mean, you know, they use it in more sophisticated way now throughout neurology now, but it was definitely very cool to see you, would just stimulate your hand to move by, you know, just a volt. Yeah. It was very interesting.

Kiara: Yeah. Yeah, and he [Dr. Yau] also is a director of Neural Systems class course in Neuroscience. Yeah. I wonder how you did you volunteer for that? Because I know people, right?

Dr. Yau: So, I indicated that, that I would be interested in teaching and I think through a few years of teaching, guest lecturing, I think then. But ultimately, I indicated that was interested in teaching. I think I've demonstrated some competence at it and then I was essentially assigned to be a course director.

Kiara: Yeah. It was a really, your course lectures were really exciting. So…

Dr. Yau: Great. Thanks.

Kiara: I do think it was good. So, actually, I want to know how does one study multi-sensory processing and perception? Especially tactile information processing?

Dr. Yau: Right. So, I think, I'll maybe answer those questions sort of, in reverse order. Right? So I think that in general, the way that my lab thinks about studying perception, and for touch in particular, is we want to first be able to systematically and quantitatively characterize the way that you experience sensory inputs, right? And so, for touch, then we're delivering mechanical stimulation to the skin through very well-controlled motors that can deliver, vibrations, or indentations to the skin and then we design what are very simple, but I think elegant and, and I think well-controlled behavioral experiments in order to measure how people experience those patterns that we delivered to their skin. So, then we call this psychophysics where we're measuring their perception of this information.

Dr. Yau: Once we characterize the way that they are able to perceive and discriminate sensory inputs. Then the goal is to say, how does the nervous system support this? So, then we go and measure brain activity in different scales with different tools and then ultimately try to find a correlate to the perceptual patterns that we saw, right? So, I think just taking sound perception as a very simple example that everyone can sort of follow you. One could hear two tones "boop-boop" and then you ask them which one of those sounded like it was higher in frequency, and then we can just repeat that process, many, many, many times as we manipulate the parameters of those sounds and then through this experiment that we can characterize, how sensitive someone is to frequency differences in the sounds, what is their bias in terms of how they perceive individual frequencies? And so, we do that with sounds, we do that with touch in terms of vibrations, and then that's how we then sort of create a profile for how individuals perceive sensory inputs.

Kiara: Nice!

Erik: Well, and can I ask maybe the question that maybe some neuroscientists or non-neuroscientists rather, might be thinking because you know, I don't have any experience in wet lab Neuroscience. Are you studying, the -- how are you studying the brain? It sounds like you're basically studying the connections between neurons. Yeah, you're using fluorescent microscopy to look at kind of the neural connections in the brain or what do, what are you doing?

Dr. Yau: So, up to this point in the six-plus years I've had my lab here at Baylor, we've been using purely non-invasive methods.

Erik: Okay.

Dr. Yau: …you characterize responses in the human cortex, and so, then this includes fMRI -- functional magnetic resonance imaging, and so that we're measuring essentially, a blood flow correlative of brain activity, but as I mentioned to you earlier, the lab is moving in a direction where we want to get a more mechanistic understanding of sensory representations, and so then this is where we're moving into more animal model systems using more invasive. E-phys methods.

Erik: Okay, "E-phys" standing for electrical physiology, I guess. Yeah.

Kiara: Sorry!

Erik: No. No, it's all good. I could make sure I'm…

Kiara: Actually, that reminds me that I was wondering, um, so, you know, that humans rely mostly on vision, right? To perceive the world is—

Dr. Yau: That's debatable. But okay.

Kiara: Now that's exactly! That's the, that's my point. I wanted to ask an expert if there's really truly a hierarchy to the senses.

Dr. Yau: Yeah, right. So, I think that's a great question and when I teach the medical students, one of the, what-- if I remember during my lectures--I often say, "if you have to sacrifice one of your senses, what would you sacrifice," right? And so, would you give up your sense of sight, of hearing, touch, smell, taste, right? And Covid times, right? Losing sense of smell and taste that people can clearly get by with that. And I think what's interesting is most of us intuitively have an idea of what does it mean to lose your sense of sight. What does it mean to lose your sense of hearing? But really no one has an idea of what it means to not have your sense of touch. And so, it turns out that touch is really, really important, not only for you to sense and perceive your environment, but in fact, in terms of guiding how you would/can interact with your environment, right? So, your motor system, if you don't have a sense of touch, is going to be really, really, impoverished and you're going to have a hard time having highly coordinated actions and you can't reach out to touch things. You can't reach out to move and manipulate things without a sense of touch.

Kiara: And, and also like, you can harm yourself more easily, you know, like if you can't feel that your hand is burning or some like that. I remember everything. I'm so sorry. If we're a little tangent, you might edit this out, but I remember a house episode were this woman, she couldn't feel, she didn't have the sense of, like, tactile perception.

Dr. Yau: Right.

Kiara: Yeah. So yeah, and that's when, when I started thinking, you know how important it is. So…

Dr. Yau: Yes, for sure.

Erik: So that being said, it sounds like, Dr. Yau, would you say if you had to lose, if you couldn't lose one? You would. You want to keep I guess, proprioception goes into that, and right?

Dr. Yau: Yeah. So, when I say touch, I would say proprioception is one sort of sub-modalities of touch, although I think people would argue that, right? So, proprioception is how you perceive where your limbs are in space, right? And, but I think just cutaneous signals of the stuff that you get from your skin, that's also, you know, really intimately tied to perception, and all of that is guiding the way that you can perceive where your limbs are and also how you're interacting with things of the world. So, how well how much force you even applied to pick up an object, right? All of that is really finely tuned so that you're not just crushing it every single time because, you know, this is just the right amount of force that you need to apply. And…

Erik: Yeah, I feel like if anything robotics may have made people appreciate that more people getting into trying to, you know, emulate the hand. It's robotics. It's like realizing how much circuitry and logic is required to just do that. All right, route. Yeah. Yeah.

Dr. Yau: And so, I think to your question then of, you know, is there a hierarchy? In terms of what sensory modalities are important, I would say that it's, I wouldn't characterize it that way, right? Because I think in the end it's sort of an apples and oranges like each different sensory modality is providing you information that is specific to what the receptors are able to signal and, and so, then you will rely on some senses for some behaviors more than other senses. And, and I think what's also important, and this gets to the question of "Why do I study multi- sensory processing?" The different sensory modalities can convey redundant information, right? So, what you see about spatial information is also conveyed by your sense of touch when you touch something, right? So, I can know that this is a mug because I could see it but I can also hold it with my hand and know the shape of that, right? And similarly, what you hear, gives you temporal information in the same way that when you feel vibrations in your environment that's giving you the same temporal information. So, I think the nervous system and the really compelling questions for me are "How does the nervous system combine these redundant sensory cues over the different sensory modalities?"

Kiara: Wow, that's really interesting. It's also interesting to see how, I mean, I wonder for me, now, just thinking about these things…how humans develop this, you know, like a kid, a baby, how they develop, you know, they fine-tune their perception in order to,um, to actually be able to manipulate them, um, but something I wanted to ask you was what are the clinical applications of this research? What are you—

Dr. Yau: Right. So, I think that for us, if we think about understanding the neural basis, for how you sense and understand information in the environment then allows us to have potentially a grasp on what we can do when that ability is dysfunctional or repaired, right? And so, if we know that for example, parts of the brain are supporting both hearing and touch together, right? That we might be able to leverage that information when there were developing interventions for treating deafness, right? Or one of the ideas that we've thought about, in other labs, have also considered this as with cochlear implant patients, right? So, they've received this cochlear implant. They're stimulating the hair cells where the auditory nerves in order to drive this signal, but if they've never experienced these peripheral signals from the auditory system, then the brain might not actually really understand how to interpret that as sound, right? But if that part of the brain is/has been processing frequency information by touch your whole life, then we've thought about this as, maybe you can think of this as tactile training wheels, right? So, you pair sounds with vibrations of a particular frequency that are matched and now the brain is saying "Oh, yeah. I know that that's a 200 Hz signal." So, when you receive this cochlear input, now they can match that as sort of strengthen that connection centrally and so and, you know, I think the evidence still remains to be shown that that is, that type of plasticity is happening. But, clearly recent in just the last couple of years before showing that cochlear implant recipients benefit in trying to understand speech in noisy environments when they also experience correlated vibrations that can be delivered to the wrists, so that's one way to think about this. Just from the tactile domain alone. If we understand the neural basis for how sensory information is represented in cortex, or even in the afferent nerves, then, potentially you can develop bioengineering approaches or neuroprosthetics where now you can deliver artificial touch, right? So, you can stimulate the nerve or cortex directly and now you can bring the sensory input for people who have, let's say, imputations or people who suffered spinal injuries and they're quadriplegics, that they can't get signals through their peripheral nervous system.

Kiara: Speaking of that. Can you speak a little bit more about the neurological basis of phantom? Limb? What is going on there?

Dr. Yau: Right. So, Phantom Limb experiences are experiences of amputees or people who suffer from limb loss and despite not having that limb, they still perceive the experience of that, right? So, this could be benign sensations, or this could be in the form of pain and the current knowledge is basically that you have representations of this limb that are preserved in cortex, right? And so, just as sort of jumping back to more of a background, sensory motor cortex contains very systematic mapping of different parts of the body onto different populations and circuits in the brain. And so, this is typical. And so, you have a body map in your brain through the sensory motor homunculus. One of the long-standing questions has been. Well, what if you lose your limb? Now what happens to that body map? And for many, many years, people thought that, that body map would then sort of change and adapt, and that those neural circuits that are repurposed to represent other limbs that are still there. With amputees, now there is more and more evidence that the map actually doesn't change so much. And so that once you had this initial patterning of them back and you have some representation of your hand, for example, even after you lose your hand, your brain is still representing the hand, that's there, right? And so, then when you have electrical activity or neural activity in that cortical representation of the hand, that's still then is inducing the perception of that hand being there and doing stuff.

Kiara: And…

Dr. Yau: So, let's, go ahead.

Kiara: I'm so sorry. I just wanted to know if this syndrome, does every amputee experience it? Experience it?

Dr. Yau: So, in the, I would say that phantom experiences are very, very, common and I don't want to go so far as to say every single amputee experiences them, but they are definitely very, very common. We've worked with populations of individuals who suffer from lower limb loss and with every single participant that we've recruited a tested interviewed, they've reported that they've experienced phantom sensations at some point. That experience evolves and changes over time and so immediately after limb loss, that could be a much more acute and severe experience and gradually over time, that could be attenuated or sort of the quality of that can change. But you know, I would say that it's definitely a very common experience. I think what's more variable and I guess one thing that was interesting for us as we were doing this study was realizing just how different everyone's experience of phantom sensations and sort of phantom pain could be and there really wasn't a very standard experience or a sort of homogeneous pattern of what our participants were reporting and even in terms of the type of experiences that they have for their phantoms could be different, some reported tickling sensations on their phantom limb. Others reported feeling as though their phantoms were moving, right? And others just would report that there are, sort of, waves of sensations almost like air. That's being brushed up and down along their phantom limb. Now again, the amazing thing is they don't have a limb and they're still feeling it as though it's on their skin, right?

Kiara: And, do they feel pain?

Dr. Yau: So again, it varied, so some of our participants reported pain that was, that could be very severe at times. Often times they would be treated and therefore pharmacological interventions to try to deal with the pain. But then in many cases our participants also reported that they initially felt phantom pain, but then that would go away or that would suddenly emerge, you know, abruptly and acutely without really a clear thing that would trigger that. So, I think that again there's a that we don't know about this.

Erik: Yeah, if I could just ask a question, so well, and so as if I can ask a question on the back of you saying, we don't know a lot about this. Um, it must it sounds like, it must be an issue with the peripheral like, you know, you've got it. Everybody's experience is different because everybody is peripheral nerves, like, sensory nerves. That are maybe torn or going to be torn in a different pattern. You know what I mean? Like, is that kind of what the thought is, is like this person just has maybe a more sensitive whatever, pacinian corpuscle or whatever. The stuff are, you know? Yeah. Merkel cell.

Dr. Yau: Right.

Erik: Well, the peripheral nerves. Is that true though? Is that kind of what the thinking is?

Dr. Yau: Yeah. So, I think that that certainly is going to be part of it, right? But I think that, in addition to the variability that you see, in whatever the state of the peripheral somatosensory system is, I think cortical changes and the variability that you see in cortex is also going to matter, right? And I think that with the certainly with upper limb amputees, right? So [researchers] at USeattle, they've done a series of studies, over the last nearly decade now, showing that with upper limb amputees, cortex in some cases can remap and that remapping will then depend on how you use your residual limb. So, the part of your limb that is the remaining. For participants, amputees, who don't use their limb at all versus participants who then try to use their residual limb in different ways, right? That, sort of, the functional use of your body can still drive some degree of remapping in cortex. And therefore, the representations of the missing limbs can still be malleable to some degree.

Erik: So then the pharma-- it sounds like in the pharmacology to treat this must not just be a peripheral like lidocaine or something.

Dr. Yau: That's right.

Erik: Maybe an opiate that, that it's going to work on the sensory. What is it? The thalamus? That takes the pain?

Dr. Yau: Yeah. So, I think with pain, right? I would say that with painful experiences of your phantom versus benign experiences of your phantom, there could be very different neural systems that maybe are overlapping but also doing independent things. And so, the pain is definitely potentially just tapping straight into the neuromodulatory system related to nociception in pain and not really even dealing with the phantom representations per se, right?

Erik: Right.

Dr. Yau: Yeah. So, I think that, that's sort of a much more complex thing, as well, right? Like, yeah, and again, like if you have if you're experiencing pain of a headache, right? When you treat that with some medicines, it's not like you're treating the underlying cause of why you have that pain. You're actually just dealing with the signals that are, you know, creating that percept of the pain.

Erik: Okay. Thank you. Not to belabor--I won't belabor it. Thank you.

Dr. Yau: Oh no.

Kiara: Yeah, that's exactly. That was exactly my question about, like, having nociception.

Dr. Yau: Yeah, let me add one other thing because this is kind of a cool result that would Tamara's group and then what we've also been doing the lower limb amputees. I think its sort of worth noting, right? So, a lot of people can experience phantoms just spontaneously, just sitting there, right? But the other thing that has been more revealing is the fact that people can voluntarily control their phantoms. And so, in our studies to characterize, what part of the brain is still responsive to a phantom. What we've done is we've asked our participants as we're scanning their brain using MRI, functional-MRI. We say during this period of time, just move your phantom, roll your phantom foot and, and, then for, they vary on how salient this experience is for them. But you know in nearly every one of our participants when we sort of explain to them. "Yes. I understand you don't have a foot anymore. But assuming that you did think about moving it. Not just imagine seeing it move but actually move it. The way you would your sound foot," right? And when they do that, that's what we see that the part of the brain that normally would represent an ankle or a lower limb becomes active in this MRI scan, because during the time that they're moving their phantom limb.

Dr. Yau: And so, that again this is sort of revealing that those circuits are still there. Right? So, we've tested people who lost their limb 40 years ago and yet despite that passage of time when we say, "Hey, you know, if you can feel your phantom, try to move it and they can deliberately voluntarily move that. Then we see activity in that part of the brain that's responsible there.

Kiara: Without any proprioceptive input, right?

Dr. Yau: Yeah.

Kiara: That's really interesting. So, okay, so I want to move on and address some of the aims of your lab, which purportedly aims to identify perceptual and neural processing principles that unify our senses and to characterize the complex interactions between the sensory systems. My question is, have you been able to identify any such principles and if so, which?

Dr. Yau: Right. So, uh…

Erik: We ask the hard questions here.

Dr. Yau: That's right. Yeah, that's right. You're not you're not pulling your punches here. So, I would say, you know, this actually goes back to some of my work from earlier in my career, even going back to graduate school as well, where you know, I mentioned earlier in our conversation that the different sensory modalities can convey similar or even redundant information, right? And so, one of the things that we've been interested in is understanding what is the type of information that can be similarly redundantly signaled. So, for example, I'll give the example, the example that in vision you can see spatial information about object shapes, right? And but by touch, you also have spatial information that you can perceive with the orientation of things that you experienced on your hand, the curvature of those. So even for my Ph.D. work, what we showed was that the ways that visual cortex neurons encode spatial information is analogous to the way that somatosensory cortex neurons encode spatial information. So, they're sort of common neural codes. The way that information is represented on neural levels can use sort of analogous formats, right? And so that makes sense, right? Because ultimately, if the brain wants to combine that information that you want those different neural populations to be signaling that information using the same language. And so, then from vision and touch, we can think about spatial correspondences in sensory processing. And then with, let's say audition and touch, again, these are two different modalities that are sensitive to mechanical oscillations or environmental oscillations, right? So, sound waves and then also mechanical waves that you feel through your skin, so we spent many years understanding how the two sensory modalities interact in terms of frequency perception. So, if you have people feeling vibrations, "Bizz—Bizz" and you have them judge which one of these was higher in frequency. They can do that. Even if they don't hear any sounds. But we've also shown is, if at the same time, they're doing that, they hear a sound "Dooop," that sound will systematically bias the way that they experience those vibrations, right? And so, then what we now are starting to look in the brain and say, "what are the brain areas that are active to vibration stimulation or to sounds?" That we see that there are some regions that are, that are commonly active and then ultimately, the idea is, to go into those regions and say "at a neural level, what are individual neurons representing in terms of the touch, and in terms of the sounds? What are the computational principles that then explain how these neural populations are integrating this information between touch and sounds?"

Kiara: And speaking of neural, populations that integrate information. This makes me think of hippocampal place cells that are…

Dr. Yau: Yeah, that's right. They are combining information over many, many different sources, right?

Kiara: Yeah, multi-modal information processing. And that's pretty that, that would be another, I guess way to study that.

Erik: Can I ask a quick question, when you're talking about the neural code. How, what is our understanding of the neural code at the like, how, what's the depth of it? Are we understanding like it takes this, many neural connections to make an input like this or, you know, does that… Does that question, make sense?

Dr. Yau: Yes. So, that makes sense and my answer may not make that much sense. Okay, I would say that there's, we can understand neural codes at multiple levels, right? And so, I would say that there's very simple codes that we now have very clear understanding of those. So, for example, we know that in visual cortex, the way that visual cortex is organized, is retinotopic. So, that different neurons are organized in cortex according to what part of the visual field they're sensitive like that.

Erik: Yeah. Like a map?

Dr. Yau: That's right. It's a retinotopic map, right? And just like, in somatosensory cortex, mentioned before, there's a body map, so different neurons, and cortex are organized, according to what parts of skin they respond to, right? So, that's a code and we can exploit that. Because now if you go in and you stimulate those populations of neurons strategically and in a very fine way, now, you can evoke percepts that are localized to a particular region of the retinotopic space or two part of the body, right?

Erik: Then, which is what you would get with TMS, right?

Dr. Yau: That's right. And so, with TMS which is a much coarser method, right? We can at least activate, you know, muscle commands in particular muscle groups, but with finer methods where your electrically stimulating local populations of neurons, you can actually induce these artificial sensations that then you could spatially control, right? So that's one level of neural coding that we know that we can play around with. I think a little bit beyond that you can say, what features of what information are these neural populations tuned for separate from just a location in space, right? And so, then you we know that there are neurons in the visual system or the somatosensory system, that may be tuned for different bars at different orientations. And so, if you evoke activity in those, you might be able to reduce the perception of a contour, like an edge that is oriented in a certain way or curvature that's in a certain way, right? And so, then that's sort of getting at, again, some neural representation, some code of information that how that maps activity, and then you can leverage that in order to generate percepts or to manipulate percepts

Erik: So, it sounds like we're, I'm just trying to think for a coding analogy. It's like we're at the python level but we're not at the like, the, you know, machine language level of looking at, because that's what I'm saying is like what's the what's the depth? We what you're talking about is spatial representation, which I think is important but like understanding at the bit level if you will, that's when you talk about code. I was just wondering oh, yeah, you know, especially because I don't have a finger on the pulse of development or progression in this.

Dr. Yau: Yeah. Yeah. So, then I think to your, to that question, it gets more subtle and more sophisticated too, right? Because we could talk about for a given neuron, well, we say that this is sensitive or a particular type of information. What about the activity of that neuron relates to that? It's not just that information is represented in a "wamby-pamby" sort of arbitrary way, right? There is, it could be just the total numbers, right? So, it could be a rate code. It could be the particular temporal patterning of that activity that is conveying the specific information and so that I think is actually getting to coding, right? It's actually the way that that activity relates to this specific information and then you can even start talking about, you know, how much information. What are the bits of information that are contained in these neurons' activity?

Erik: Okay. So, we are getting there, that it sounds like.

Dr. Yau: Yes, and this is something that for decades, you know, neuroscientists have been working towards already.

Erik: Okay. Well, maybe they need a better PR agent, right?

[All laugh.]

Kiara: Yeah. Honestly, yeah, like for example, in our lab, you know, we study hippocampal Place cells and the way that we try to decipher a kind of the neural code is based on firing rates, right? So, yeah, like you said, there are you can study the neural code. There's just like so many levels to it.

Dr. Yau: Yeah, right. Yep.

Erik: Well, thanks for, sorry. That was a getting us on a tangent. But thank you for answering my…

Kiara: I think that's a fascinating question. Yeah. Okay. So, how would you explain synesthesia?

Dr. Yau: Right. So, synesthesia, just define it for everyone is the sort of the atypical experience of some sensory inputs that often results in sort of confusion, or at least a re-representation it as some other form of information or so, for example, you could potentially associate, you know, certain letters or colors with particular or letters or numbers like the visual form may be associated with particular colors, right? So, this is a grapheme-color synesthesia and people synesthese who experience that do that automatically and it's something that doesn't really require that they tried to do that. And one thought is that these types of experiences just reflect some atypical connectivity between again, neural circuits that are representing this information, right? So again, if you have neurons that are tuned for spatial form information in the brain, and then there's other neural populations that are tuned for color, normally these may be somewhat segregated, or at least, they're not, they don't connect and communicate with each other in a obligatory forced manner, but in individuals with synesthesia one possibility, is that these neurons now based on some type of you know, atypical connectivity are now communicating in a forced way. So, that now when you activate one population, the other one is also activated and therefore, you get this associative experience.

Kiara: That's interesting in the context of you saying, you know that different sensory pathway is they, they, convey redundant information, you know, so maybe there are some crosstalk, right?

Dr. Yau: Yeah, so that sounds right. I think that and, and, this is maybe a debatable semantic point but…

Kiara: Right.

Dr. Yau:  …in many ways you can say that the way that our nervous system normally wants to combine multi-sensory information already reflects a degree of synesthesia in everyone, right? Now, this is sort of a natural normal thing. But yet there's also ways where that gets sort of integration on steroids and that's where you have information that normally doesn't need to be combined or isn't even naturally associated, but yet, because of the way that the biology now is wired, that becomes integrated.

Kiara: Right. That's really cool. Another question that I think is interesting is how do we process sensory information when we're asleep? Is it the same as being consciously aware?

Dr. Yau: Right. So, now we are moving away from my expertise. But I mean, I think that…

Kiara: [Laughs] Sorry.

Dr. Yau:  No, no, I mean, I think in some sense I would think about this as one we definitely are able to process sensory information while we're asleep, right? So that's, you know, undeniable. I think then, what then is important to consider is sort of an issue of processing that depends on awareness or processing that leads to awareness, right? So, if you play a sound while I am sleeping, there are parts of my cochlea is definitely going to represent that information signal through my auditory nerves, go through many subcortical regions, whether my auditory cortex is active to that sound, I don't know, right? But, but maybe there are parts of primary auditory cortex, that is still going to process that. But then, the higher order areas that are responsible for how you understand that information? How you make decisions about that information…

Kiara: How you perceive, right?

Dr. Yau: That's right. That's right. Those may be the ones where, you know, they're tied to conscious experience or tied to awareness. Those are the ones that maybe will not be processing that during sleep.

Kiara: Exactly. So, the way that we process sensory information might be more or less the same but then our perception is tied to our, our, brain state, you know, whether we're conscious or unconscious. So, that's kind of interesting.

Dr. Yau: Right. But we're, and I would say to that, right? I think you can maybe divide this process into sensation, which is just the signaling and encoding of this information versus perception, which is your experience, your decoding of the activity pattern into and making use of that is some sort of cognitive way, right? And so, maybe the sensing part is always there, even when you're asleep, but maybe there is still attention, is going to negate that to some degree, right? But then now you're sort of sensing part of that though or the perception part of that, right? How you understand that whether or not you're even aware of that, that may be, what is really sort of cut off when you're asleep or you know, cut off in a way that it's doing something else, right? Because again when you are sleeping, it's not that your brain shuts off, there are still spontaneously activity patterns, there is still structured activity patterns. And so, you know, whether or not you're aware of that and experience that, that's I think the challenge of understanding sleep.

Kiara: Yeah. I have this as an optional, you can answer if you know any, if you know about it or not, but what can you tell us about sensory processing? When the brain is, it is in an altered state. So, like either an extreme stress or under the influence of something?

Dr. Yau: Right. So, I think this is a very interesting question that, you know, I think philosophers have wondered for centuries and, and, and then also, I think more recently from a, you know, neuropharmacology psychiatric perspective. It's also had more of an awareness and interest, right? So, for example, the use of psilocybin and as a intervention for treating different Affective disorders or mental health disorders, I think sort of highlights the potential utility of this. And so, the limited understanding I have is that, especially if we sort of link this to sensory processing, right? Is that there may be a very clear modulatory effect of states and these chemical intervention modulators on the thalamus. And so, the thalamus is sort of this relay station where it's connecting to many, many different parts of the brain, many different sensory areas. Its providing bottom-up, sensory information, that get projected into these subcortical areas. It's receiving feedback from all these higher-order areas and primary sensory areas. And so, if so that gives this sort of the very important hub quality, right? And so now if you have some sort of neuromodulator that's influencing the activity of thalamus and the way that the hub is now relaying information, and again, integrating information or separating information…now this, you know, singular hub could potentially already explain a lot of the different experiences that you have under these altered states.

Kiara: Yeah. I had read that; I had read a long time ago that it actually increased the crosstalk between brain regions that usually wouldn't be and yeah and connection with each other. So I thought that'd be pretty interesting.

Erik: Well, in, so Dr. Yau, I guess maybe you would have just left Hopkins before they started. Were they doing the ketamine trial for depression while you were at Hopkins? Because I know that's one. Hopkins is starting to get into a lot of, right?

Dr. Yau: Yeah, so Hopkins, I think Bayview, right? They were doing a lot of these types of studies. I think during the end of my postdoc, they were starting to do some of these words with a ketamine also with psilocybin.

Erik: So yeah, so it'll, it'll, be interesting. We'll see what happens.

Kiara: Yeah, they're, I mean, so far, the results are promising. I think, and this is a bonus question. But which is your favorite sensory pathway?

Dr. Yau: Well, I think from this conversation is probably clear that I spent much more time thinking about touch than other sensory pathways, so sensory systems. But in the end, I think, you know, what's also clear, hopefully from this conversation, is that part of what I've been focused on with my own research in my own interest is not just focusing on touch, per se, as a sole, you know, model system for understanding sensation and perception. But really looking at how does touch interact with other sensory modalities, right? And so, with that then I've also tried to keep knowledgeable about the visual system in the auditory system and then understand how do these different sensory modalities relate to each other and how do they interact with each other? So, because ultimately, we can you know, maybe end on this sort of high-level thing, right? The way that we experience the world is truly a multi-sensory experience. And so, you know, if you look at sensory neuroscience, historically, people have said "let me go study one sensory modality. Let me go study one particular question" and they really drill down in this reductionist way, which I think is very, very, helpful. We've learned a lot in that way, but it really doesn't reflect the way that we normally experience the world. So, I think moving into an ecologically valid understanding of the neuroscience of perception. I think, then it kind of requires that we take into account. What is happening normally? What are the natural statistics in our environment and multi-sensory signals is really a sort of the common the way that we experience the world. So, this is where…

Erik: By ecology, you said psychological, are you talking about…At what level of ecology are you talking about? Just sorry, I was confused by…

Dr. Yau:  Yeah, so, by ecologically valid, I mean sort of behaviorly valid in just your normal experiences.

Erik: Okay.

Dr. Yau: Right? As opposed to, again this very reductionist, lab controlled, we only do one thing in isolation from everything else.

Erik: Oh. Okay, right. Gotcha.

Dr. Yau: So, like, even as we sit here, right? Like, you hear me speaking, but then through the camera, you can see my mouth moving, right? So, there you have visual and auditory information that's correlated. And so, then it almost doesn't make sense to necessarily think about speech perception in hearing alone or speech perception from lip reading alone. It's really, you know, the natural way that we experience is information is this multi-sensory signal, right? Yeah. So, the way that we experience touch, and this is something that you can try with people at home listening. This can try, you know, if you have your hand, and you brush this over a surface, right? You'll feel the vibration. So, you understand the texture that is under your, your, finger, but you'll also hear the sound of your interactions with this surface, where you hear that each "Sch-sch-sch-sch-sch!" And so, if you brush your hand over different surfaces, you'll actually hear the quality of that sound change, right? It goes from "Scha-scha-scha-schuh"  and become lower frequency, or if it's rougher you'll hear a different type of sound. And so that also tells you that the way that we experience vibrations by touch is really correlated with the way that we experience sounds that are tied to those interactions. And again this, this sort of motivates why I'm interested in understanding how our nervous system combines sound and touch information with respect to these types of environmental cues.

Kiara: What are the brain regions where you say, you would say these multi-sensory pathways converge?

Dr. Yau: Mhm. Right. So, the traditional view, right? The, sort of, textbook view is that you have brain areas that are dedicated to different sensory modalities individually, and then you do a bunch of processing and then these higher-order areas and posterior parietal cortex and frontal cortex or sort of the juncture of parietal-temporal lobes. Those are, sort of, the higher order areas that this information is being integrated. I mean that's certainly true, right? That you have more of this convergence in those areas. But I think over the last two decades, now, it's also becoming more obvious that even these areas that are traditionally thought to be primary sensory areas that are dedicated to modality can be clearly modulated at least by other sensory modalities in very specific ways, right? So then in that sense, you can argue, and people have argued, right? Is there any part of the brain that's truly uni-sensory or is really everything, reflects some multi-sensory convergence in some way or another? And I think that then the question moving beyond where the brain is happening. But I think the more interesting and more difficult question is, what is actually happening in those areas, right? What is the information that is being combined? What are the computations that are underlying, this combinatorial process?

Kiara: Yeah, precisely. I agree and do you study these brain areas to kind of understand the computation,

Dr. Yau: Right. Yeah, so, you know, I think part of what we've been doing with, you know, the non-invasive methods, functional MRI is to try to even just identify where are the brain areas where I mean, the brain is large and he could just sort of blindly stabbed in and say, I hope that this is here, but, you know, I think using some invasive way that's at a macro scale, we can at least identify this part of the region is a candidate region where this information could be coming in. And then the goal would be to use the more invasive methods, that give us a finer scale, measurements to be able to say, you know, what is that activity? What are the neural correlates? What are the computations? But even from a behavioral side, and you know other colleagues that we have here at Baylor and other institutions have developed very rigorous quantitative frameworks for understanding perception behavior, which at least allow us to infer these are computations that the nervous system may be using or maybe implementing that support this information processing and these types of behaviors, right? So then in that sense, we already have a guess at what might circuits of the brain be doing. What are the computational principles that underlie this behavior? And then now, the goal is go into the brain and see, is there a correlate of that? Is there evidence that neurons and sort of biology is actually implementing those types of algorithms?

Kiara: And you mentioned initially that your lab was thinking about moving into more invasive methods. Right? What would be your ideal experiment using these more invasive methods and what type of invasive methods are you actually thinking about?

Dr. Yau: Right. So, with my training in graduate school, we were doing awake recordings in non-human primates and macaque, monkeys, right? So, we would drive micro electrodes into somatosensory cortex and then record extracellular voltage changes. And it's a basically we are in the process of resuming that type of work. And the idea would be, you know, getting down to neurons, individual neurons, or recording activity from groups of neurons. And so now we can look at multi-unit activity, look at local field potentials. And you know, try to again relate, the activity patterns to the sensory information that we're providing, right, to the skin or try to relate the activity patterns that we are measuring to the behavioral reports that the observer in this case, you know, it could be human observer or an animal observer, could be reporting at that and try to look at again. How does that activity relate to their behavior? Their perception? Right?

Kiara: Hmm. Ideally, would you be able to perform these experiments on humans or…?

Dr. Yau: Right. So, we are ready with the non-invasive method were sort of developed with the behavioral paradigms. We're developing some intuition for where the brain is, could occur the computations, even predicting fMRI signals, right? We have come up with encoding models that allow us to do that. We're, in addition to these non-invasive approaches, where started collaborations with neurosurgeons here at Baylor, or with neurosurgeons and other institutions, including at Hopkins, where now we can potentially record, invasive activity or record activity, invasively in human volunteers, and then we can again start to ask questions related to local field potential recordings from ECog in humans or even you know, invasive penetrating, electrodes in human volunteers. What is the electrical activity that we're measuring? How does that relate to stuff that they're feeling on their hands?

Kiara: That's great. So those are all the questions that I have for you. I've learned a lot. Thank you so much.

Erik: Same. Same.

Kiara: Yeah. Thank you so much for doing this. It's been a pleasure. I don't know.

Erik: Yeah, you know. We appreciate your time. Yeah, and sorry we couldn't do this in person. But you know…

Dr. Yau:  Sure!

Kiara: I think this setup worked out actually pretty fine. Yeah.

Dr. Yau: Okay, great. Well, this is great. I enjoyed this very much and if you want to talk more, I mean, clearly, I'm happy to talk, right? So, I think that, you know, if there's anything that you want to follow up on, I'm happy to talk some more.

Kiara: Definitely. This has brought up a lot of questions that I hadn't even thought of before about multi-sensory processing. So, thank you so much.

Erik: Yeah, thank you.

Dr. Yau: Okay. All right. Take care!

Kiara: You too. Have a good night.

[Outro Melody]

iTunes | Spotify | Google Play | Stitcher | Length: 53 minutes | Published: Oct. 13, 2021

In this episode, we take an inside look at how Dr. Kris R. Lehnhardt and his team of engineers are preparing the next generation of astronauts against the health hazards of space travel to the red planet. Dr. Lehnhardt shares his journey from his home of origin in Canada as an emergency medicine physician to spearheading the Human Research Project efforts in the Lonestar state, as a senior faculty at the Center for Space Medicine and as an Element Scientist in NASA’s Exploration Medical Capability arm of the Human Research Program at the Johnson Space Center.

Transcript

[Intro melody].

Juan: And welcome to the Baylor College of Medicine Resonance podcast. I am one of your hosts, Juan Carlos Ramirez.

Eileen: And I'm Eileen Williams, another host.

Juan: And today, we're going to be talking about engineering, human spaceflight, exploration, and medical capabilities with Dr. Chris Lehnhardt. And in this episode, we will take an inside look at how Dr. Lehnhardt and his team of doctors, scientists, and engineers are preparing the next generation of astronauts to manage the health hazards of space travel to both moon and Mars, and possibly beyond. Dr. Lehnhardt will share his journey from his home of origin in Canada as an emergency medicine physician to spearheading the exploration medical capability efforts in the Lone Star State as a Baylor College of Medicine senior faculty member in the Department of Emergency Medicine and in the Center for Space Medicine, as well as his role as a lead scientist in exploration medical capability element of the NASA Human Research Program here at Houston's very own Johnson Space Center. Welcome to the episode.

Eileen: It's a pretty impressive list of qualifications and achievements. Dr. Lehnhardt--pretty amazing--he actually started out, received his Bachelor of Science in Biomedical Sciences from the University of Guelph in Guelph, Ontario, Canada in 1999 and his MD, followed by his residency in emergency medicine at the University of Western Ontario, Ontario in 2003 and 2008 respectively. He also completed the space studies program at the International Space University in Barcelona, Spain in 2008.

Juan: That's so cool. So, professor, Dr. Lehnhardt, has a lot of interesting skills and professional interests, of which include emergency medicine, as we mentioned before, extreme environmental medicine, aerospace medicine, wilderness medicine--he does teach in the wilderness medicine elective, Emergency Medical Services, and medical education.

Juan: The NASA human research program of, which he's a lead and an element scientist focuses on enhancing the health and performance of humans in spaceflight in preparation for an ultimate voyage to Mars.

Eileen: Which is crazy. I can imagine that involves a lot. The main five things that they focus on are International Space Station research and operations integration, space radiation, human health countermeasures, exploration medical capability, and human factors and behavioral performance. Seems like it covers a lot of ground there.

Juan: Yeah, lots--perhaps, lots of moving parts and something that I can only imagine is insanely complicated. I mean, medicine alone is already complicated.

Eileen: Yeah, definitely.

Juan: Yeah, when physics is a factor, you're just like, "oh my God."

Eileen: Yeah, I took the bare minimum of physics that I needed for medical school. So I am very impressed by people who are at that level. I think, I think it'll be really interesting to hear Dr. Lehnhardt talk about all of those things. And I know you also, you took one of his classes, is that right?

Juan: Yeah, I did. And just it's the human space exploration in medicine or some variation of that. But there are, you know, two electives and you take one which is pretty, pretty vague and a lot of old NASA scientists and Baylor faculty who also have a joint appointment at NASA. And also some physician astronauts, too, that just come to class and they share about, you know, their work and what they're doing, sort of cutting-edge research. And there's the second part, the second elective really dives in pretty, pretty detailed--and that's how I sort of came across Dr. Lehnhardt's work, a little more in depth. There is a Space Medicine Interest Group here at Baylor that kind of introduces people who aren't in the space medicine track, which--there is a space medicine track. It's just so interesting to see this other side of healthcare from a very outside the box perspective, you know, it's like "How do we solve problems with, you know, health problems here on Earth? Okay. Great. You know, those are challenging. Now, how do we do that in space with limited everything?" I can imagine how, you know that task being so--it's so demanding, you know, because essentially you're trying to create or come up with the Swiss army knife for, you know, for space travel. You know, how do you maximize, you know, efficiency and safety with so little?  

Eileen: There are so many challenges inherent in that--not to mention the fact that most of your astronauts are probably not also going to be physicians. So then you're dealing with limited space and limited personnel. I think it'll be really interesting to hear Dr. Lehnhardt talk about how to address some of these challenges and I know that he is a great teacher, so I'm excited to hear him explain some of these concepts for us.

Juan: Yeah, sort of give us an inside look at what it takes, really plan for these inherently complicated and dangerous things.

Eileen: We're really lucky here at Baylor to have these opportunities to get to work with doctors like Dr. Lehnhardt and to be right next to NASA and have this space medicine exploration track. I think it's a pretty unique opportunity.

Juan: Yeah. For sure. And for Baylor students and non Baylor, students, non-medical students, and just anyone interested in cool science and being on that leading end, I think you're really going to enjoy, as well as I am, right here about Dr. Lehnhardt work and how it can impact all of our lives in a very positive way, and inspire the next generation.

Eileen: Let's get started.

Juan: Cool. Let's go to the episode because we've talked too long already and let's talk to Dr. Lehnhardt.

[Interlude melody].

Juan: And we are here with the Baylor College of Medicine Resonance podcast and we are now joined by Dr. Lehnhardt. Please welcome Dr. Lehnhardt.

Dr. Lehnhardt: Thank you, pleasure to be here.

Eileen: Very glad to have you. I'm Eileen. I'm another one of the writers and producers for the Baylor College of Medicine podcast.

Juan: Yeah, and as we've mentioned in the roundtable, today we're going to discuss Dr. Lehnhardt's role in engineering human spaceflight exploration medical capabilities.

Juan: And if you are not a space nerd, like we are, and you haven't heard about all the cool things that the NASA is preparing to do, Dr. Lehnhardt's spearheading the element, NASA's human research program and he's here to share with us all about what he's doing. But if you haven't heard of Dr. Lehnhardt--could you take this time, Dr. Lehnhardt, to tell us a little bit about your background? What motivated you to pursue a career in medicine and human spaceflight?

Dr. Lehnhardt:  So it's a--it's a long story. So I will start at the beginning but I won't go too long. So if it's not evident yet from my accent, I'm originally from Canada. And as a small kid growing up in Canada, I had a passion for spaceflight. And I was really enamored by the space shuttle and all the different missions that NASA was doing and the Canadian Space Agency--there is a Canadian Space Agency and it's, it's kind of small compared to NASA, but they like to say that they punch above their weight. So they, they are very active in the space world. The Canadian Space Agency had astronauts and I always thought that would be really an amazing opportunity to be an astronaut and that was something that was a big interest to me, but I had no idea how to get there and how to even pursue it.

Dr. Lehnhardt:  So when I was a kid growing up, my favorite fields were in the biological sciences. And so I had thought about medicine and one of my guidance counselors at the time in high school said, "Why don't you look at the profiles of Canadian astronauts and see what they did? And then maybe you can do human spaceflight stuff." And one of the Canadian astronauts was a guy named Dave Williams and he was an emergency physician and I thought cool, I'll be an emergency physician and maybe I can go to space.

Dr. Lehnhardt:  So, my initial thoughts were not exactly well thought out, they weren't terribly mature, but they got me on the right path. And so I did all of my undergraduate training and medical training in Canada at the University of Guelph first, and then at the University of Western Ontario. And then I did an emergency medicine residency, which in Canada is a five-year residency and one of the opportunities I had during my residency was to spend some of my elective time focusing on an area that was of particular interest to me. And for so for me, that was space medicine, but to broaden it a little bit more, it was about the medicine of extreme environments and how we provide medical care in extreme environments. And so during my residency, I got to spend time learning about aviation medicine, about diving medicine, about military medicine, and about space medicine. And I just loved all of it. And so I eventually tried to steer my career towards "How do I become involved in the medicine of extreme environments?" And so I ended up here at Baylor as a faculty member in the Center for Space Medicine. And I now work at NASA as the element scientist, which is the lead scientist for exploration medical capability. And our job in exploration medical capability: we are a part of the NASA Human Research Program and we focus on the design of medical systems for space exploration. So now I get to take that passion that I've had about space and about medicine and space and I get to try and come up with the systems or help to come up with the systems that astronauts are going to use when we go to the moon and Mars to take care of each other.

Juan: It's a very compelling story and I think it's only the abbreviated version, but from sort of your spoken words and your passion and your background and career track, you seem to have pick up the picked up an impressive, an extensive list of accomplishments in the realm of extreme medicine, as you just highlighted, and space-related activities. But I think--is Physician Astronaut still on the--your professional bucket list? I--I'm guilty to ask, but I feel like there's a lot left in the tank of for Dr. Lehnhardt.

Dr. Lehnhardt: Yeah, don't feel bad about asking. I tell everyone I meet that I want to be an astronaut. I'm not, I'm not shy about that. So I would personally love to do that still and it's still something that I will apply for and continue to try and do for as long as I can. And then maybe eventually if no one else will pay for me to go to space, maybe I'll figure out a way to pay for myself to go to space. So commercial human spaceflight is starting to come online soon and there's a number of different companies now that are looking to fly people to space. But ultimately, yes, I think that my, my goal would be to be the doctor in space that's taking care of the other astronauts. But if I get to--if all I get to do is stay on the ground and help NASA to do that, I would consider that to be extremely fulfilling.

Juan: Which is also no minor accomplishment. But you mentioned your lead role as a lead scientist and element scientist. Could you explain to our audience what an element scientist is, and sort of what your role… what your… how does your work on a day-to-day or if you could provide a detailed description of how you integrate the exploratory medical capability element medicine and engineering.

Dr. Lehnhardt: It's a, it's a really fascinating area because my background is not in engineering. And… but yet I get to work every day with scientists and engineers and clinicians who are trying to tackle this really hard problem of, how are we going to take care of people in space when we can't come home again? So, the example we always use is the mission to Mars. And if you think about the mission to Mars, we're going to have a spacecraft that's going to be pretty small. What you see on the science fiction movies like The Martian, of this enormous spacecraft where everyone has tons of room and they can all float around really easily.

Juan: --Hermes--

Dr. Lehnhardt: That, that may be the future, but it's not where we are today. And so our plans for Mars are going to be a small spacecraft and a small crew and they're going to have a very long trip to Mars. It's going to be anywhere from six to nine months just to get there. And once you start going to Mars, you can't just stop and turn around and come home again. So, what we have to do from a medical perspective is we really have to think about, can we predict the number of, can we predict the number of conditions or the types of conditions that are going to occur from a medical perspective? And can we make sure that we have all of the stuff on board to diagnose and treat and manage those conditions? And can we predict that so far in advance that we can plan the entire mission? So that we have, not only the stuff, but the people on board, who can execute the tasks and use the stuff so that we have real capabilities.

Dr. Lehnhardt:  And it would be like, for example, saying that you are going to have all of the supplies and all of the staff, you need to run an emergency department. You'd have no capability to change your people, get new equipment or change your equipment, and you'd have to run for months and months at a time without any additional stuff. And so it's a, it's an extremely complicated problem. But in essence, from a, from a mathematics perspective, it's what we call the "backpack problem," which is the--you have a limited amount of space or resources you can have; how do you select the highest yield things? And so my team that I work with, I provide them with leadership and guidance from a scientific perspective and they do the work of designing the systems and trying to predict the conditions that are going to occur so that we can make sure that we have all the right stuff when we go and we have all the right skills on board to take care of everyone for these really long missions.

Eileen: Well, I can imagine, I can imagine that even just trying to run an emergency department on Earth would be very challenging if you couldn't change any of your equipment or any of your people, but I'm sure there are also extra health challenges that come with working in space. Is there any particular health risk that's more critical than others on a long-term space, space flight? And what do you do to mitigate these risks?

Dr. Lehnhardt: It's a, it's a complex problem because there are a number of hazards of space flight that we have to take into account. And they include things like the lack of gravity, the high radiation environment of space, the isolation and confined nature of a spacecraft, the distance from Earth, all of these things are the are the hazards or the types of hazards that we face.

Dr. Lehnhardt:  Everyone's got their own personal favorites that they are most concerned about. The ones that my group focuses most on are related to the distance from Earth challenge, which comes with the inability to return home--so no evacuation, the inability to resupply due to the distance and the time, and then the lack of communications with the ground. And so as you go further and further away from Earth, you no longer have real-time communication. So you can imagine trying to have the conversation we're having right now if after I said something, I had to wait 10 minutes to hear you say something. And then you had to wait 10 minutes to hear me say something. It becomes a very long and boring conversation very quickly. So the, the distance from Earth hazard is the one that that we focus on the most in exploration medical capability because it's related to our system design problem. But all of the hazards work together. So, for example, some of my colleagues in the Human Research Program focus on the synergy between the low gravity environment and the high radiation environment, and the effects that those may have on the human brain in the way that people think and execute tasks. And so, we have other colleagues in our group, in our program, who focus on the counter measures that people need in terms of nutrition and exercise to stay healthy and productive during their missions.

Dr. Lehnhardt:  And one of the biggest problems that we have is that when you look at each of these problems in isolation or each of these risks or challenges in isolation, you might come up with a great solution that works for that one thing. But can I take all of those individual solutions and can I fit them all together or integrate them all together into a small spacecraft that has limited mass and volume? And so it's the actual integration of all of these things that is where the rubber hits the road, so to speak. And that's where the biggest challenge is. How do we define what the, the highest yield stuff is to take with us? And how do we make sure that we manage as many problems as we can, given our resource constraints? And so the example that I use a lot is sometimes it--when you're designing something like a spacecraft, the designers of the spacecraft will come back to you and say, "I can't possibly fit all the stuff you want me to take. Show me what you're going to get rid of." And then we suddenly have this whole thing where everyone's fighting about their favorite thing and what they believe they need to have to manage their individual problem. But we really need to be able to do is take a systems look at everything and say "what is the thing here that gets me the least bang for my buck?" And that's probably the thing that's going to come out of the system.

Dr. Lehnhardt:  And so a lot of the work that that my team does and the work of the human research program is not only trying to identify and characterize the risks and come up with countermeasures or solutions to those risks, but it's also integrating all of those things together into one comprehensive system and figuring out how we're going to fit it all on this small spacecraft that's gonna go to Mars.

Juan: Wow, it's very complicated. As students of Baylor College of Medicine, we have the luxury of taking space medicine electives. And I took the elective this last, this last term, and I--you spoke about essentially what you just said and a term called "trade space analysis" and this involves, you know, the integration of all systems, right, basically systems engineering to--for risk mitigation. And that largely involves devices or technology. That--my question is, sort of, to what extent do you incorporate soft skills and do that risk mitigation? So, you know, sending an emergency physician and Mar--to Mars or not. Does that play a heavy role in that trade space analysis?

Dr. Lehnhardt: It does, and trade space analysis is really about helping us to try and come up with the optimized solution to a given problem. And one of the challenges that we have seen is that in many cases, there's a belief that if we if we fly a laryngoscope, that someone can intubate someone in space. And that's a not an unreasonable belief if you're flying a physician. But if you're flying a non-physician or someone who's had minimal training and how to do that, we know that that is a difficult skill. And one that we spend a lot of time learning before we actually practice it on patients. And so the need to incorporate what we were referring to as the knowledge skills and abilities into our capabilities matrix for this system is very important. So our goal is to not only identify the stuff that we would need to take, but also the skill set needed to make that capability real. The example I'll give you is: one requirement you may have for a medical system is that the medical system has to be able to provide intravenous fluid resuscitation. Well in order to do that, we need to have not only the bags of saline and the IV's and the lines and all this kind of stuff, we need to have a person on board who has the necessary training to do that task or—maybe and/or--we need to also be able to help refresh the skills of that person in doing that task or maybe even teach it to them for the first time. So to keep this example going, if the person on board who normally takes care of, everybody is a doctor, but the doctor is the person who gets sick, then one of their crew members, one of the other astronauts is going to have to be able to place the IV in that doctor. And as a result, they may have to learn how to do that on the fly. So we may have software that we could use on board that the astronauts would be able to do just-in-time training. They'd basically be watching a YouTube video, for lack of a better term, and figuring out how to put an IV in--and then they put an IV into their colleague because that, because they would have to do that. So, the skills were important, the ability to maintain the skills are important, the ability to teach new skills on the fly are important, as well as the training that we do before they go. So, how can we best prepare them on the ground to be able to execute those skills in that environment?

Dr. Lehnhardt:  So ultimately a system design, the system has to include the operators of the system and those, those people are going to be essential in executing the tasks that make the capabilities real. Having a laryngoscope that no one can use does not mean you have the ability to do airway management as a capability on a spacecraft.

Juan: It also reminds me of what you had mentioned during your course is that dilemma of taking an AED--you know, how often do AEDs get used? I mean astronauts are relatively healthy but you just never know. It seems like a lot of pros and cons to "Do we need it? Do we not need it? Can this person do it?" So and it also sounds like, from what you were saying, is that cross-training is becoming a very important thing. I know NASA trains them in like first aid and I'm not sure what the extent of basic capabilities, but there will likely be some continuous training en route and back, I assume.

Dr. Lehnhardt: Very much so, and when you think about the size of a crew to Mars, so, right now, some of the mission designs that people are looking at are four crew members, maybe six crew members. There's an awful lot of skills and knowledge that have to be available to those folks on board and it's either got to be in their brains or it's got to be in their computer systems that they can access or in their checklists in a way they can access it in a very rapid manner. And they have to be familiar with all those protocols and all those procedures and they have to be able to do all of those tasks. Just in that small number of people.

Dr. Lehnhardt:  So, the astronauts of today and the astronauts of tomorrow, are absolutely cross-trained and will be cross-trained in lots of different areas. They will have many different opportunities for refresher training and just-in-time training during these long missions. And some of that frankly might actually end up being really valuable to them because one of the arguments are one of the, the points we've heard from some of the astronauts is there's actually a reasonably good chance on the way to Mars that you would get bored. Because it's not like there's actually that much to do every day on the spacecraft. So, so that ability to learn new skills, to cross-train to run simulations and practice using different skills--those may actually end up becoming kind of fun activities or we can design them in ways that they're more entertaining and fun activities than they might have otherwise been. Because it might, in that sense, be multi-purpose. It helps with their isolation and confinement because they are they're learning something new and interesting. But it also makes sure that their, their skills are up to speed for when they need to execute them either in an emergency or some other contingency.

Juan: Right,  so it sounds like there would consistently remain engaged and it's probably good psychologically, as well. I just can't blend it to words of "astronaut" and "bored" together. I don't, I don't think they go. But, yeah, very good point, and it just seems like on, on that path that this, of not being bored in the psychological aspect--does that, is that taken into account during your risk mitigation and planning? Or is that just there's another piece of the pie that needs to be solved?"

Dr. Lehnhardt: The, the psychological countermeasures that are being considered in the Human Research Program have to do a lot with the selection of the of the right people for these kinds of missions. And, and so there's a, there's a phrase or a term that gets used a lot, which is "the exploration mindset" or "the exploration skill set." And that's people who don't become bored easily. People who don't have problems being in small groups, and living with small groups of people for extended periods of time. People who are very collegial and easy to get along with. Those kind of expeditionary skills are very important and so we have to make sure we select the right people to go. Then we have to train them appropriately and part of that training is how to deal with the psychological challenges of isolation, and confinement, and being in an environment, where frankly, everything around you is trying to kill you.

Dr. Lehnhardt:  You have to be, you have to have to be able and be prepared to deal with that and to face it during the mission. But then there's lots of research going on into, during the mission how can we give them extra things that will assist their mindset? And so, it may be simple things, like yoga and meditation type exercises. They're all kinds of advanced technologies that we're looking at to, with things like virtual reality. On the space station today, the astronauts have really good communications with the ground, so they get to speak with their friends and family on a regular basis. How can we make sure that they can maintain some communications with their friends and family? Even when they're really far away. All of these different things are the mitigation strategies for dealing with the psychological challenges of space exploration and all of those have to be incorporated into our broader systems. So, if we develop a system that requires virtual reality for psychological challenges, then I can use the same virtual reality system for medical training, or I can use the same virtual reality system for some kind of maintenance on a piece of equipment that breaks inside the spacecraft.

Dr. Lehnhardt:  There's lots of different ways to blend and meld together the different types of capabilities and countermeasures that we develop for psychological issues, for medical issues, for lots of different, what we call crew, health and performance challenges.

Eileen: It sounds like everyone on the team is wearing a lot of hats. We've got astronauts now getting medical and yoga training. I think it's really interesting to consider how people fulfill these different roles. You mentioned earlier that you don't really have a background in engineering, so I was just wondering what it was like for you when you really started working with a lot of engineers? How you got into that mindset and how your work is really able to synergize between the two different disciplines?

Dr. Lehnhardt: It's a, it's been a really great experience for me, learning how to work with all these different folks and be truly interdisciplinary. And looking back on it now, if I could go back to myself when I was a kid and say, maybe you should go be an engineer, maybe I would have done that. That seems like it would have been a cool job as well. But one of the things I realized very quickly in my work, was that the doctors and the engineers typically approach problems in a different way. And so I realized that one of my tasks as the as the lead scientist for the group was to try and make sure that I could understand both sides and how they approach problems differently and find the commonalities between them so we could build a bridge between the engineering side and the medical side.

Dr. Lehnhardt:  And so where that I think is, particularly interesting, is, is that mindset for how they approach problems. And from a physician's perspective, especially in the emergency department, when I see a patient and they have chest pain, the first thing I do is I think of all the terrible things that could be happening to them. And my job is to figure out that they don't have any of those terrible things. And the engineering position is: what is the most likely cause of the chest pain?

Dr. Lehnhardt:  And the most likely cause of the chest pain is not one of the terrible things, because the most terrible things don't happen that often. So the engineers approach a problem from the likelihood and consequence associated with that condition, or that problem, whereas the physician side of me is the "come up with a differential diagnosis, identify the worst things on it, and then rule all of those out." And so what I've actually found in myself is that my practice in medicine now uses a little bit of both. I still think about the worst case scenario, but I also think about, more about what's most common and most likely. And so I'm actually using that bridge, if you will between engineering and medicine in my own daily practice in emergency medicine. But by understanding where each of the different groups is coming from, you start to be able to understand how you can help them to communicate better with each other.

Dr. Lehnhardt:  And one of the things we realized is that the medical community communicates in terms of what the worst possible outcome could be, the engineering community says, but how often does that actually happen? And do I need to design or build an entire system just to deal with something that may never occur? And what we have to do is find that happy medium between the two where we can get to what I'll refer to as an acceptable risk profile for any given condition. So maybe I can't rule out the worst possible things because I don't have all of those capabilities on the spacecraft. But at the very least, I should be able to identify the highest likelihood conditions and manage all of those to a reasonable point.

Dr. Lehnhardt:  And so it's that, finding that consensus position and being able to back it up with a rationale and the evidence that justifies the need for it, allows the engineers to then say, okay, I hear what you're saying. I understand why you need it. We're going to go and build it for you.

Juan: Sounds like a fine line to navigate, especially given time constraints.

Juan: If, if you will, what is one of the, like, the coolest projects, you were able to work with engineers and---lately? Or to date?

Dr. Lehnhardt: So I think that the, the most---What I'll say one of the, one of the really rewarding projects that I worked on, is one that we call autonomous medical officer support software and and what that is, is a software capability that allowed us to take astronauts, who had never performed a particular complicated medical procedure before, and we could use this software to guide them through how to do this procedure from beginning to end. And while we were doing that, we didn't allow anyone on the ground to talk to them.

Juan: Wow.

Dr. Lehnhardt: And what we were trying to demonstrate was that we could--and that's where the word autonomous comes from--in an autonomous fashion, we could help non-physician astronauts to perform medical procedures without any support from mission control. And that's really important when we start talking about the types of communication delays that we're going to see on the way to Mars. We need them to be more self-sufficient and what we're calling Earth-independent. And so this ability, this software, what we did was---one procedure that we wanted to be able to have astronauts to do, was we wanted them to be able to do ultrasounds for the kidneys and bladder. And the reason we wanted them to do that is because one of the problems, some of the problems we occur and see in spaceflight are related to either urinary retention or kidney stones. And so, we had to be able to know that the that an astronaut could perform one of those tests without the ground having to tell them "move your probe 3 centimeters to the left." We had to have them be able to learn how to do the task. And so they open up the software, they turn on the ultrasound, they follow all the procedures and they got a bunch of really good kidney and bladder ultrasound images, which they could then transmit to the ground for someone on the ground to read and interpret. And they did all of that on their own without any prior training or knowledge of how to do it.

Dr. Lehnhardt:  And so to me, that is the, it's one of the first real demonstrations that we've ever seen in spaceflight of astronauts performing complex medical procedures on their own, in the way that we would see it when they go to Mars. And so that to me was very rewarding.

Eileen: That's, that's pretty crazy and difficult to imagine, but very impressive. I'm wondering how you see that technology affecting us here on Earth. It seems like people who are in other extreme environments could also use similar types of strategies.

Dr. Lehnhardt: That is the, the ultimate goal, is to--we want to take stuff on Earth and use it in space and we want to take stuff in space and use it on Earth. And so, the application of a lot of the work that my team does on, on exploration medical capability has a lot of different applications on the ground in remote environments or in austere environments. And so you're absolutely right. It's, it's easy to imagine a world now where some would be able to have software on their phone or on their tablet, have a portable ultrasound device that they could take almost anywhere in the world and they would be able to use that software to guide them through how to perform any reasonable type of ultrasound exam in a fashion that would allow them to take care of that person or diagnose that condition in that environment.

Dr. Lehnhardt:  So I would love to see applications where you could start deploying software like this into all sorts of different environments, where--if they have access to all the experts then, great use them--but when they don't and they're on their own, we should be able to help people take better care of themselves, anywhere in the world.

Juan: Wow, that's very interesting. I've tried to keep up with technologies that NASA creates and how they're implemented on the ground. You mentioned earlier the virtual stuff, being able to teach someone virtually, I could possibly see that being translated during these sort of difficult times where everyone segregated. And, you know, we are medical students and we, we had to reduce our clinical time or clinical exposure because of these things. And I could see that possibly being I think where, well, we can teach who virtually and, and it won't be just like a like a "sign in to zoom" kind of thing. So it'll be like a very hands-on virtual experience. Thank you for sharing that.

Juan: So as sort of, as a way to conclude this, this awesome interview and we hate it to end, but we wanted to get… so a very inspirational tone for those who haven't already been inspired. What advice would you have to, sort of, dreamers out there who aspire to one day, do what you do? And may one day, one day want to set foot on sort of a celestial body--moon, or Mars, or beyond?

Dr. Lehnhardt: I think the advice that I always try to share is that the, there's lots of different niches in medicine and there's many different ways for people to find the area that they are most interested in. And for me, my niche is fairly specialized and, and not something that a lot of people do. And when I was going through medical school and residency in Canada, one of the, when I would tell people that my interest was, was space medicine, I got a lot of blank stares from people. Or, they would tell me that "you can't do that" or, or "why would you do that; why don't you just go be a cardiologist?" And, and I had to try and explain to people that what I was trying to do was to bring together different areas of interest, or passions, that I had in a way that I thought was going to be fulfilling. And that was a little bit out of the norm, I think, for a lot of the people that I was talking to. And so they couldn't see a world where I would get to do that. And frankly, neither could I. But at the time, I just knew that I--this is an area I wanted to pursue. I knew that it existed and that other people did it and I was going to find a way. And so that's my general advice to people in, if---regardless of what the niche is, or the thing that you're interested in, find other people out there who share that passion with you and then figure out how to do it.

Dr. Lehnhardt:  And so, for me, what I did is I literally sent a cold email to a doctor who worked for the Canadian space agency and I said, "I think I kind of want to be you someday, can you help me do that?" And he did. And he was my first kind of foray into the world of aviation medicine and diving medicine and space medicine, and that's what started all of this.

Dr. Lehnhardt:  And so, finding those people who can help you is really important. The other part of it, though, is finding the other people who are, who are your peers, who are like you and want to do similar things. And for me, where that was, was I had talked to some of my mentors and done a number of different training opportunities that I could find in, in aerospace medicine. And when I'd exhausted those, one of them said, "why don't you go to the International Space University?" And I was like, "That sounds fake. What is that?" And I've discovered that it's totally not fake and I went and it was great. And what it was, was there was an opportunity for me to learn all the stuff about space that I didn't know because I've been focused solely on the medicine in space and I got to see the broader, the broader community, if you will, of people who are interested in human spaceflight. And that helped me to find all of these peers and fellow space nerds, if you will, who I could commiserate with and share my passion with. So I didn't---the mentors were really important in helping me to find the opportunities to do the things I wanted to do. But my people, if you will, the space people, were the ones who helped me to really discover my passion and keep it going and to seek it out.

Dr. Lehnhardt:  And it was after that opportunity, that I started to truly try to pursue space medicine as part of my career. So the---people might tell you that what you want to do is a little bit different, but if you find the right people to help you along the way and the right people to share your passion, that's going to go a long way towards driving you to where you want to be.

Dr. Lehnhardt:  The last thing I'll say on that though is, I could have never imagined in a million years doing this job for NASA. It was inconceivable to me. So if someone had said to me 10 years ago, "Where do you think you're going to end up?" I would have been completely wrong. So the last piece of advice I would give is always seek out opportunities and in a lot of cases, try to find a way to say yes instead of saying no.

Dr. Lehnhardt:  And for me, when someone came to and said, "Hey, there's this job at Nasa. You should apply for it." I could have simply said, "Oh no, that's---I couldn't possibly do that. I won't. I won't get it." Instead, it was like, maybe I should give this a shot and put my name in and see what I can do. And, and thankfully, I was successful. So, the the willingness to stick your neck out there and, and be rejected is a big part of trying to figure out here you want to go. And just to bring this whole thing full circle, lots of people who apply to be astronauts are rejected over and over and over again and they keep coming back. So you can't be scared of that rejection if you want to get to a to a truly unique position.

Juan: Absolutely. I give you agree with you wholeheartedly and you're just, you know, further convincing all of us that---that we hope that you continue to apply, because you've shown the resilience and you're not giving up, and you're doing all the work. And then one day it'll be like, we interviewed Dr. Lehnhardt and now he's in Mars and we're going to try to get a second interview with the 20 minute delay. But thank you so much for sharing. I think it's very inspirational, very informational. And I think our listeners will really appreciate it.

Eileen, do you have any other questions?

Eileen: Yeah, I just, I wanted to say thank you to Dr. Lehnhardt. It's been so valuable considering how we can blend different styles of thinking, giving us sort of a new perspective on things. I did have one final question. I know you were just saying that you can't necessarily predict the future and probably would have been wrong 10 years ago—yet, I'm still going to go ahead and ask you, where do you think space travel and human spaceflight will be in the next 20, 30 years?

Dr. Lehnhardt: 20, 30 years is a long time so that's a, it's a, it's anybody's guess. If you had asked anyone 10 years ago, if we could land rockets they would have said that you were crazy. And now we are landing rockets like once a month. So, it truly is amazing to me that, the pace of technology change. However, the rate-limiting step in all of this isn't necessarily the technology as much as it is the, the humans. We are the rate-limiting step for a lot of these missions.

Dr. Lehnhardt:  And even the mission of Mars is a great example. If we really wanted to build a rocket today, that could go to Mars and take people there, we could probably do it. Can we keep them alive and healthy and productive for the entire mission? That's where I'm not so sure. And so, the focus that we have on technology right now is fantastic. But the, the shifting of that focus towards the health and performance of the people is critical.

Dr. Lehnhardt:  And so, the--what I hope to see, and what NASA is trying to do is, is a mission to Mars in the, in the 2030s that is in the commonly referred to as "the Mars vicinity," meaning the first mission to Mars may not land on Mars, because landing on Mars is actually super hard and we don't really know how to do it yet from a technology perspective. But can we send people into deep space? Can they live in deep space for long periods of time? Can they be healthy and productive while they do it? That's the most important thing for us to determine. And then we can keep going further and further after that. So, I would love to see humans in the Mars vicinity in the 2030s, healthy and happy and productive.

Juan: Same here.

Eileen: Spoken like a true space lover and doctor.

Juan: Well, thanks again, Dr. Lehnhardt. Just one more, add--sort of an admin question for our listeners: if they want to get a hold of you or seek more of your information, is there a website or an email that you could point them to? Or a perhaps a website?

Dr. Lehnhardt: Sure. So my---I'm on the Baylor faculty pages, so you can generally find me there. I'm on Twitter as "Aerospace doctor," so "Aerospace" and then "DR." So you can always, I always post space and, and health stuff on there. And then lastly, my NASA email and my Baylor email are both public. So it's my first name (K-R-I-S) dot last name (L-E-H-N-H-A-R-D-T) at nasa.gov.

Juan: Wonderful, thank you so much. Well there you have it. Please feel free to reach out to--if you'd like to pursue your dreams. And we really appreciate your time.

Eileen: Thank you so much. You know, this is a busy time for everyone. It was really wonderful to get the chance to talk to you.

Dr. Lehnhardt: It's been a pleasure. Thanks a lot.

Juan: Thank you.

Eileen: Bye.

[Outro melody].

iTunes | Spotify | Google Play | Stitcher | Length: 39 minutes | Published: Sept. 15, 2021

Dr. Margaret Goodell discusses her research interests and career path through the years. We ask her about how she foresees her research on hematopoietic stem cell differentiation may impact future patient care. She also discusses what she thinks comprises good science and advice she has for aspiring researchers. 

Transcript

Alice: Hi everyone. We're welcoming Dr. Margaret Goodell to our podcast today and we're really excited to have her. She's been a pioneer and a leader, in multiple fields, in research at Baylor. And without further ado, let's jump right into it. So Dr. Goodell, well, happy to have you on our show today, can you tell us a little bit more about yourself and how your research interests have evolved over time?

Dr. Goodell: Well, thanks for having me. It's really a pleasure to be here and talk to you and the broader audience that's out there. So I've been at Baylor for about 20 years and before that I did my Ph.D. in England and my postdoc in Boston. And even though I did my Ph.D. in England, I actually grew up in the Midwest and so I was able to move around a lot during my sort of upbringing and training in science. I started out in my Ph.D. actually being interested in stem cells. In those days, I was working on embryonic stem cells and I remember having to persuade my thesis committee why they were of any value, because nobody really had worked on them and nobody really knew very much about them. And I said, well, they have all this potential and you could use them to make a new mouse and all of this stuff, and they didn't really get it for a while. But then obviously it became very popular (embryonic stem cells did). And then I decided on my postdoc to work on hematopoietic stem cells and that really launched the line of investigation that I've been doing ever since.

So when I came to Baylor, I had the view of really studying the fundamental mechanisms that regulate hematopoietic stem cells, that really regenerate all of your blood cells continuously throughout life. And even then stem cells were not really a buzzword, they were something I thought had a lot of potential, I was interested in how things regenerate, and how it's essentially a program of development that is ongoing even when you're adults. So it's a special window into that developmental process, which I thought was very fascinating, but it wasn't a very popular field either in hematopoiesis or anything else. Although, there were pockets of people that were interested in regeneration of skin or liver or muscle. And so there were people that were interested in stem cells. But really it was a few discoveries about embryonic stem cells and induced pluripotential stem cells that galvanized the whole field, and really captured all of the work going on in stem cell biology that was going on at the time. And I was already maybe five years into my faculty position here when that really happened. So I got to really ride this wave of excitement in the field. So that was fortuitous. And I guess that's one of my lessons for the audience, which is that you have to choose something you're excited about and decide to work on it and be determined even if it's not really popular at that moment because you don't know, you know, it could be something that becomes really popular and you might be able to contribute to the growth of that field, which I feel that I did and my work did, and I also benefited from all the other external interest that was going on at the time. I guess I would say it was a lucky break that I was interested in that and then it all came to fruition because of a lot of other events that we're going on at the same time.

Snigdha: I was wondering if there was like anything in particular that sparked your interest and stuff?

Dr. Goodell: So I don't really recall a moment where I decided what was interesting about them. When I was doing my, when I was ending my Ph.D., it was the time of increasing interest in the concept of gene therapy, and gene therapy has obviously had its real ups and downs; and really the people who were interested in stem cells were from the gene therapy field because they viewed stem cells as the vehicle for it. Because if you could modify a stem cell then you could make any therapy more permanent. If you could re0implant them into the body. So my interest
was more basic and more fundamental, but I ended up going to a gene therapy lab as a postdoc because that was where you had to go if you wanted to study something like stem cells, that's how unpopular the field was at the time.

Snigdha: So the next question I wanted to ask was, did you have any role models or early influences in life that pushed you to go into science?

Dr. Goodell: I really didn't come from a scientific family or anything and you know there wasn't really anybody around me who was interested, but I think I showed early interest in it and I had a grandmother who was always sort of trying to identify things in us, in me and my sisters that we were interested in and would send us books. The days of books, you know, you could read a book when you were 7 years old or 10 years old, instead of going to the internet. And I think I really enjoyed that literature and it kind of got me hooked. And so by the time I was finishing high school I knew I wanted to do something in science. I didn't really know, I was interested in astrophysics, as well as biology and ended up going into biology. But it was kind of unformulated, just that I really enjoyed science. I think it was the inquiring nature of it, wanting to understand how things work.

So my undergraduate degree was kind of unusual. I started out as an undergraduate in a small liberal arts college in Connecticut and then I decided to do a semester abroad in England in London at Imperial College of Science and Technology. And the way that the British education system works, they put you into the extreme end of sort of research if you're in science very early on. And so when I got there, which would have been my junior year abroad or my first semester of my junior year abroad, I was actually starting to read scientific literature already; which, if I had been back at in Connecticut I still would have been reading textbooks. And so once I got into scientific literature and really started reading things in depth, I got super excited and then that summer I stayed for a year instead of a semester, and then I worked in a lab at summer and then basically have been working in the lab ever since.

So, for me what really cemented? It was not just reading science the way that we're taught it, you know, in undergraduate classes in college which I actually found kind of dry but it was understanding how it works. How research works from the laboratory perspective. Not just getting in the lab but really being able to read the papers and understanding how the discoveries went. What got me super excited, this seems like ancient literature to you guys, but I did a big section when I was in England on regulation of bacterial gene expression. And it's kind of a very simple system, it was like Lambda phage and how Lambda regulates its gene expression and how different bacterial genes are regulated. But it was just super exciting at the time and I read the whole series of literature about how these discoveries were made. And so for me, it was also kind of insight into how a series of studies lead to a greater understanding about a biological system. And so being able to put that all together, that was kind of the magic for me.

So that's a great question too. So I was finishing my postdoc and I started to go on the job market and I cast a wide net. I find when I'm trying to recruit people a lot of people have very clear preconceived notions about where they should go for their job, which as a general piece of advice, I think that's kind of a mistake because you really, there's not that many academic jobs in any given time, you really have to go where you're going to get the best opportunity, meaning a good starter package and a good environment, the combination of those two things. But I didn't have any preconceived notion having grown up in the Midwest, you know, having been trained partly on the East Coast, lived in England for a while. I sort of just was able to look at anything and when I looked at a number of places, it really helped me prioritize. What was going to be important in an environment. So I don't think I really had a good sense of what was going to make a good scientific environment at that time when I when I started looking for a job, but it was really through the process that I understood that better. And in the end it came down to two top choices. I had another fantastic offer from a place which I won't mention. But you would say is ranked extremely highly. And what it came down to for me, in fact that other place offered me a little bit more money, a little bit better start up package, etc., but I thought that the mentorship that I would get here at Baylor was, was going to be better. It was a gut feeling on the basis of the people that I would be working with and I think that was absolutely the right decision. I've never looked back, and even realizing that that was the right decision and the mentorship that I did get has allowed me to sort of use that as a guiding principle in my own behaviors going forward. So I try to be a great mentor. I try to recognize great mentors and really utilize those principles in my whole professional life.

Snigdha: So were there any particular challenges or obstacles you faced as a young scientist that influenced your career path? And if so, how are you able to overcome or adapt?

Dr. Goodell: You know there's always a lot of challenges. There's a lot of grant rejection, there's a lot of paper rejections. I actually just tweeted about this a couple of nights ago because I was counseling one of my students who got a grant, her training award rejected, brutally rejected, there was some not very nice comments on it. I just saw this is not necessary, sometimes reviewers are really just not very nice. On the other hand, I thought well this is a great training opportunity because this is really how it works in the real world and you have to be resilient.  And a lot of PIs we joke about this all the time that it does take a lot of resilience and being determined that this is what you really want to do, that you're doing the right science. I remember a grant that I had that I considered — the work that I'm doing now is still stem cell biology, but we started working on this one gene called DNMT3A. It's a DNA methyltransferase. And when we sort of stumbled upon this and really started working on it, I realized that it was super important and now I feel that it's probably some of my best scientific work, the whole body of work that has evolved from that discovery is really what I think is some of my finest work. But I could not get a grant on it. I submitted an R01 four times. And every time I was absolutely brutalized by the reviewers and they said, "oh, there's work that's premature", "it's not very clear that's supported" and etc. It took publications from other labs in the field to show that the work was, in fact, incredibly important. Again, this was another example of sort of a serendipity and being in the right place the right time and working on something before it became really popular. And all of a sudden this became one of the most popular genes in the field. And all of a sudden, I didn't have any trouble raising money for it anymore. So, it's, it seems kind of sad, but I knew that it was important. I knew that this was the right Gene to work on and that these were the right experiments to do. And so I was able to dig in and keep working on it. That whole discovery was really about 10 years ago. So really mid-career. But you know, you're still continuously having to overcome those kinds of challenges, I would say.

I would say it a completely different challenge, though, is in a way more interesting. Which is, what are you going to work on? And how does that evolve over time? And I've thought about that a lot because there have been other lines of research that I've been really excited about and then decided for one or another reason not to continue working on that because at any given time you only have so many resources. You only have so many people and you really just can't do everything. And so this DNMT3A project is a great example because we had just had a Nature paper in a different area of interferon signaling and its impact on stem cells that I realized was also really a great area. And I was determined to write another grant on that and keep working on that. But this DNMT3A project started happening and I just didn't have enough resources, people or money, to work on both of these big, big projects. So I sort of put all my chips onto this other thing. So, it's sort of made me realize that sometimes these choices are a little bit like gambling or playing cards, you know, it's the Kenny Rogers song, you gotta know when to hold 'em and know when to fold 'em and you have to make choices. They're not always going to be the right choices but you, you have to sort of put your chips on, you know, this particular hand that you've got at the moment. Or you have to say, well, I know this is cool work, but I can't get anybody else to think it's great, I can't get the paper published where I'd like it to be because these reviewers just don't get it, whatever, whatever. And, and then you just have to move on sometimes and work on something else and maybe that area will be more ripe another time. I think you really have to evolve as a scientist. You have to allow your work to evolve, you can't think "I'm going to work on the same protein for my whole life", unless it's a really fabulous protein. It's important to evolve but yet that decision is a hard decision every time you have to face it, right? Am I going to go in this new direction? Am I going to get funded in this new direction? Should I stick with what I know? And people know me for stem cells, they've known me for that forever, will I ever get funded for this? This DNA methylation thing? I don't know, but you have to, I guess, you have to have the courage of your convictions and be willing to be courageous and do something else. Even if that means to give up something else, it's also potentially very fruitful.

Erik: Actually can I ask a follow-up on that? Really, as a PI, a lot of what you're doing is sort of managing other people. Would you say that's a correct statement?

Dr. Goodell: Absolutely, and you're really not trained for that at all. You might have had an undergraduate working for you or something like that but you're not trained to run a team of 10 or 20 trainees and staff.

Erik: So I guess my question is, how did you learn how to manage? Where do you think you picked up the skills? Because you run a very successful lab, I mean, by every measure. So, I think that would be great for our listeners to hear because I think it's something everybody should be thinking about.

Dr. Goodell: I don't think I necessarily did a great job in the beginning and I didn't really have any courses or anything like that and there is a lot more emphasis now on training us to be good mentors. And I think that's a wonderful thing and hopefully all of you, when you're in the position, will take advantage of that. So how did I learn to do it? I learned from my other mentors. So I learned from the guy who hired me who was my chair, basically. I learned from looking, watching other labs either do things I didn't think were the right way to handle it, or were the right way to handle it. And I also realized that there was more help available than I realized at first. So, for example, when I did have personnel problems, there are people whose job it is at Baylor and all professional institutions to help you deal with problems; and they have strategies, they have other places to go to. I've done everything in my career, including you know, encouraging people that I knew to seek help for mental health concerns, you know? And I mean, that's something that isn't really discussed. But there are great resources for that. People might have had other issues going on. And so once you kind of get into it, you realize that even if you don't feel like you're a good manager, that there's a lot of help to be found if you seek it. So, that's one thing. And then I guess the other thing is again, kind of returning to first principle – it sounds kind of silly, it's like that Kindergarten book, right? It comes down to treating people the way that you would want to be treated yourself. And once you really incorporate that into your philosophy, I think it makes a lot of difference. And even when you get frustrated with people, you have to think, well, I'm frustrated, maybe they're not working hard enough in the lab or whatever. But why is that, is there something going on with their life that they're not telling me? Maybe their grandmother died or maybe they really don't like the project and this isn't the right lab for them. Maybe the technician needs a different kind of a job because she's just not motivated in science anymore and yet she hasn't figured that out. So once you really put that as your sort of guiding principle – that you really have to treat everybody as you would want to be treated, that's your North Star. And I think that has helped me be a good mentor both in my lab and in dealing with some people now that I'm a chair of a department, I feel the same way.

Erik: Well, thank you, I think that's great for people to hear something.

Alice: Our last question that we were hoping that you could answer, is a little bit more science- heavy. How does your knowledge, our knowledge of how stem cells differentiate, how do you foresee that impacting the future of patient care?

Dr. Goodell: That's a great question, the stem cell field definitely exploded because of the promise of stem cells for various kinds of therapy and I still think we're getting there. It is taking a long time and it will continue to take a lot longer, but I think the impact is many-fold. From a very basic science perspective, understanding the mechanisms of how stem cells differentiate has given us insights into other things. So, for example, in cancer, because many cancers are fundamentally – at least cancers of the blood, hematologic cancers – are thought to be a combination of both a block in differentiation as well as something that drives those cells to proliferate inappropriately. And that you really have to have both of these sides going on at the same time in order to cause a leukemia. And so this gene that I studied now, DNMT3A, that's really important and its major role is to permit efficient differentiation of stem cells and so it seemed to be really an interesting gene for regulating stem cells. But once we discovered that it was also important in cancer because it's frequently mutated in cancer, that gave us really fundamental insights. Now it turns out it's a tumor suppressor so it's not very easy just to kind of fix it to cure your cancer. But, nonetheless, it's given us a lot of insight into how these particular malignancies arise and to think about how one could effect that change with drugs or other approaches for cancer treatment. So, yes, one point is that stem cell research can help in areas outside of just regenerative medicine, because it's giving insight into normal development and also cancer. In terms of regeneration I do think we are getting closer to, let's say, the long-term goal of tissue replacement in certain circumstances and there are better and better protocols for taking embryonic stem cells and differentiating them down towards specific lineages. Lots of work in neuroscience to do that and you can get fairly pure cultures of certain neurogenic lineages. It's kind of hard to just implant them by injecting them into a brain right now but we might really get to that point where you could use some of these cells and sort of patch a tissue in a way. So it's still a process but there's a lot of research in the field, a lot of excitement and I think we're getting there, there really will be a great tool. Stem cells will be, in general, a great tool for regenerative medicine and for therapeutic purposes.

Alice: I think it's really fascinating. Actually, I'm not so familiar with the history of stem cell therapy and stem cell research, but I believe it has been decades since the discovery of differentiation from fibroblasts. Is that correct? And since then, can you describe some of the progress that the field has made and what are some of the biggest challenges to bringing it to patient care?

Dr. Goodell: So I would say there's a few times in your scientific career where you'll see something come along that shocks you as an investigator. You're reading this paper and it's like "oh my gosh I can't ever imagine that that happened" and IPS cells were one of those. PCR was one of those revolutions, absolutely revolutionizing things. In fact it was kind of thing where people thought "well, that's so obvious, I should have thought of it myself" when PCR was developed but nobody had. And obviously it really transformed everything you do. And I think CRISPR is another example of something that most of us could never have envisioned, and it comes along and just like wildfire just transforms virtually everything that all of us are doing in the lab all the time. So IPS cells was like that for the stem cell field for sure. But in the very beginning, they were virtually impossible to harness. People didn't really understand how they were made. Could you make them from any cell? Could you make it from an adult skin cell, a skin cell from a baby? Could you make it from a hepatocyte, a blood cell? People were just sort of trying everything. They were then trying different genes. Well, you know, these four genes could do it, but could you use a micro RNA or could you use a combination of three genes in a drug? And then really what is this the process, is it an epigenetic process that resets it. And does it really reset it back to completely normal or only partly normal? So, all of these questions were really the focus I would say in the first 5, 6, almost 10 years really trying to understand how that works. And now the field is really maturing and focused more on, OK, now let's make something really productive out of them. Can we not only make a cardiomyocyte, but what does that cardiomyocyte do in terms of its normal function? Mostly still, when you differentiate embryonic stem cells, you get something that resembles a differentiated cell that would come out of a newborn or even a fetus. So it's not really something that you can use to replace in an adult because actually the function of those cells is a little bit different so people are still trying to overcome that gap, how far can you take them. But it's evolving all the time.

One of the other really exciting developments in the field was realizing that under certain conditions you could put embryonic stem cells and a few other things in the media and you could actually get these self-organizing bodies, something that looks like a little eye that you can develop completely artificially, these eye cups.

Erik: I had a question if there's time, I want to respect your time, but I had a tag-along question about your research. So DNMT3A. So obviously I've already shown, I'm not an expert on it, but I was just wondering if I'm understanding it correctly, if you could expand on it because I think it's really cool. So it basically helps in stabilizing – it's only in the nucleosome. Is that correct? First off?

Dr. Goodell: It's in the nucleus and what it does is it puts DNA methylation all over your DNA. And DNA methylation is just a mark that helps regulate the gene expression. And what it does is it puts it in very specific places and we still don't really understand how it knows where to go and when to go. And if you don't have it there, the way that we think about it is that the methylation in general, as a very broad brush stroke, is important for shutting down the expression of genes. So a very simple way to think of the purpose of this DNMT3A protein is that it's very high in the stem cell. And then as soon as the stem cells is told to differentiate, it has to go and shut down the stem cell program, and if you don't shut down the stem cell program, you can sort of get a little bit of differentiation. So, it'll start to go down that let's say the red blood cell lineage and make red blood cells. But it still thinks that it's kind of a stem cell and it gets confused. And then that's probably why if you don't have DNMT3A those cells are then more easily transformed down a malignant lineage because they're trying to be something, but they're also thinking that they are a stem cell that continues to proliferate.

Erik: Okay. Okay. And so was I understanding correctly that it also is thought to maybe have some function in like the phase of DNA within the nucleus? I think that's what I was starting to read about that I thought was really interesting, and maybe that's how people are thinking it might be affecting expression levels as well and whatnot?

Dr. Goodell: That is possible. We do think that, so, one of the papers that we published recently, we showed that there are large regions in the genome that have little or no DNA methylation. So, I would say that, first of all, almost all your DNA has a ton of DNA methylation it's just covered with it as a mark, okay? Just like peanut butter on your bread, whatever. It's just like all over it. And yet there are these little pockets that don't have very much methylation and those are important regulatory sites and DNMT3A is definitely important for changing that state. So making sure that there's the peanut butter over all those little holes. But what we found, this is another example, actually, of sort of following the research, even though it's not strictly related – we started looking at DNA methylation in general. Where is it in the genome? What is it doing? How is it regulating things? So, in a way it's a little bit tangential to what DNMT3A specifically is doing, is asking what DNA methylation is doing. So, when we looked really closely we saw not just these tiny pockets that lacked DNA methylation but large tracts of DNA that lacked it. And I'm talking about 10 KB or 20 KB which are really large chunks of the genome that don't have DNA methylation that, before our paper, nobody knew that these large tracts existed. That paper was a few years ago. And so, then we thought, well what are these large tracts for? We call them canyons because they're like Grand Canyons, like really big and they have a little river in them, there's always a gene in them. So it's kind of a nice analogy and so we kept thinking hat are they doing? What are they doing? And we think those canyons are there for a number of reasons, but in our recent paper, we showed that they are sites of 3D chromatin interactions. And that several of these can be interacting together. Sort of like the center of a flower that these pieces of DNA are all coming together and sort of locking together around these big tracts of low methylation. And we suggested it might be a phase transition type of event that's also got polycomb proteins and other things involved in it. That was our observation and that's an area I would love to go into in the future as well.

Erik: No, I think that's amazing. I think that's a really novel and cool way of thinking about it. When I was reading I was like well, that makes a lot of sense when you think about it, kind of manipulating the phase like that to be regulatory. But I guess you're not even speculating about regulation, but are you? I don't know.

Dr. Goodell: We do, we actually think – so those canyons exist in two states and I'll give you another one of my crazy analogies in a second, but the canyons exist either in an off state or in an on state, and the ones that are involved in these really long-distance, 3D genome interactions, which are megabases apart – so it's like multiple megabases, which is also like a scale that wasn't envisioned before – it's the canyons that are involved in those really long-distance interactions are the ones that are in the off state and not the ones that are in the on state and it's not random. So, it does seem, I'll give you my other analogy of these canyons and what DNA methylation might be doing. Again I was thinking a lot about DNA methylation as a mark and how important is it and it's even interesting to think about where it came to be evolutionarily and how it's used in different organisms and things like that. And when I really thought about these canyons, what I kind of realized is that the genes that are in these canyons – I mentioned that there's like a river in them – and if you look at what those genes are, they're always the most important genes in the genome. There's a gene called PAX6 which is critical for eye development. If you knock out PAX6, you won't get any eyes. Okay, so PAX6 is one, it has its own special, little canyon. It's just sitting there all alone, protected in this big void of DNA methylation. Almost all the Hox genes, which are involved in embryonic development, have their own little canyon. Many other transcription factors that are really important regulators have their own canyon. So I was really realizing these are all really special things. And in fact when you want to turn on one of those important genes, you turn it on like gangbusters, right? Everything gets turned on and all the transcription factors are landing there at once. And they're turning it on and then later, it has to be turned off.

So I was probably on one of my flights – now we're not flying anymore, because COVID – but I started thinking of these canyons. When they're on they're like the busiest airport on the planet. So it's like JFK Airport in New York, or our Houston airport is a pretty busy airport too, or O'Hare in Chicago used to be the busiest airport, and when it's daylight time that is the busiest airport. But when the Earth rotates and that's out of the sun there's not very many plans are landing in Chicago O'Hare anymore at 3 o'clock in the morning, right? Really not very many and so that airport is shut down. So I started thinking about these canyons as sort of permitting, basically, the runways and that the methylation around it is the structure that allows that runway to have the lights  bright on when the planes are landing and the lights off when they're not landing. And so it's kind of the infrastructure around it. It might not be the landing pad itself, but these are structures in the genome that are really allowing everything to be landing at once when it needs to be on, you know, everything is going. But when needs to be off, everything is off. And it's sort of a big structure, that only the biggest airports, the biggest cities, the most important cities are allowed to have one of those special canyons of special genes.

Alice: I'm really tempted to ask this question now. I think we have a tiny bit of more time, so I'm going to ask two subparts in the same question. One, are there any other regulators that behave, as far as, you know, like DNMT3A. And two, have you guys considered looking at any other lineages besides hematopoietic stem cells.

Dr. Goodell: Great questions. So there's no other gene that really acts exactly like DNMT3A, that is so special for – at least in the hematopoietic lineage – for the stem cell and has such a clean function. However, there are other genes that have semi-overlapping behaviors, and so one of them called TET2 and its purpose is to remove the DNA methylation that DNMT3A and other proteins put down. So it's interesting, it's the opposite side of the coin and when you knock it out it has a overlapping phenotype to DNMT3A. So it has a similar role in cancer and it has a related role in regulating stem cells too, even though it kind of has the opposite molecular or biochemical function. It removes methylation instead of putting it on, it has a similar outcome in terms of what it does for the stem cells.

Alice: So as you were mentioning, it's a regulator for a lot of different important genes in different lineages. So I was wondering, is there a potential, do you think, for it to be heavily involved in many processes throughout the body?

Dr. Goodell: So we know that it's also involved in differentiation of embryonic stem cells. In fact that's one of the places its role in differentiation was first discovered, and we have suspected that it plays a role in some other lineages. But that hasn't been looked at that carefully for a number of reasons. There is evidence from some other labs that it may play a role in skin differentiation as well. It certainly may play some other roles but that's another area that would be worth looking at in more detail.

Snigdha: It was really great to hear from you about your research and I really love your analogy – the flower one, and the airport one, those ones will probably stick for a while. But yeah, it's really exciting to hear about your research and your career path. Did you have any final words of advice for students who are looking to start their own research years?

Dr. Goodell: I would say research is really fun and it's forever varied and that's really one of the privileges of working in this area. During the pandemic shut down that we're in right now, some readers may be listening to this in the future and not be in that any longer. But that's where, you know, we're recording this in the middle of our pandemic. I think a lot of people have asked whether they're happy in their jobs, whether this is something that they really want to be doing long-term. I feel we're very fortunate, in research, the pandemic has actually pointed out exactly how important research is and has offered many new opportunities for really great questions that should be addressed outside of stem cell biology as well. I think as a career it offers a lot of flexibility, it offers constant change, you always have new people coming in your lab, you always have new people to work with. There's always new exciting ideas. You're able to evolve your research, you're running your own little business. It's your own little business. And as long as you can continue to raise money for it, you can keep producing your products and your products are your papers that you sell to the community and you try to get the journals to publish. So it's very satisfying in that sense, as a career. Also, I have three children and I've had to manage that through being a PI. I started my family after I had been a professor here for a couple of years, and now my oldest is at college. So it also offers a lot of flexibility and I think that's great and research, you know, it's not really a 9 to 5 job. Unfortunately, it's like an all-time job. I'm always thinking about it. I'm often on my email at strange times the day and night, but it also means that I don't have to be in at 8:00 a.m. every day and I have flexibility. And that has helped manage having a family and that flexibility has been nice, you know, during the COVID era and things like that. So I would say it's really a privilege. It's a great career and it's a lot of fun if you don't get too down when you have the few setbacks that you have, you just have to keep plowing forward.

Snigdha: It's really awesome to hear from you. We really appreciate you taking the time out of your busy schedule. You know, you have a lot going on especially right now during the pandemic. But again, thank you so much. It was amazing to be able to interview you for this.  

Dr. Goodell: Well thank you all for having me. You had great questions and it's a fun opportunity to talk about some of these things that I think about, don't really talk about very often.

iTunes | Spotify | Google Play | Stitcher | Length: 46 minutes | Published: Aug. 26, 2021

Dr. Richard Hamill will discuss his journey from teaching, to being the residency director of internal medicine at BCM. We’ll ask him about his experience teaching, his work, and his views of how medicine has and will continue to evolve.

Transcript

Erik: So anyway now the bureaucracy is out of the way if you have any questions for us - If not, I've already hit recording on our end and I'm recording video and audio. But the video will not be a part of it.

Hamill: All right

Jason: So what was your career journey? I guess as a doctor

Hamill: As a physi-?

Jason: As a physician, as a teacher, as a - yeah - as a residency director, like what was that Journey?

Hamill: Well, so I went to medical school at Wayne State University in Detroit and then I stayed there and did my training as a resident and I ended up being a chief medical resident there. So I got the opportunity to teach for that year, which I really enjoyed and then I went off did my fellowship in infectious disease at University of Wisconsin and I actually did three years. Normally the fellowship would be too but I did three there. The third year was mostly in the lab. I did have the opportunity to do some teaching there. I taught, for instance, the endocarditis block, you know, our lecture for the medical students and micro, so I got to do it there. And I actually - one of the kind of memorable Grand rounds I did, there was the – I took care of the first patient with HIV in the state of Wisconsin. And he was a patient who was admitted to the VA there. And so, I gave Grand rounds, the first Grand rounds on AIDS at the University of Wisconsin. So, you know, I thought that was kind of cool. I still have the handout from that.

Hamill: Then I came to Houston in 1985 Dr. Musher actually, you know, interviewed me for the job and I heard that was kind of memorable because that he picked me up. I had never met him before, you know, and he picked me up at this dumpy Hotel on Holcombe and his big blue Chevy. I don't know if you guys have seen that Chevy convertible that he drives – an old Chevy with a white convertible – he still has – 1950 something. You know, I like the people, Dr. young, Dr. Musher I met at the time. Kind of my wife and I wanted to change so I came here. I told her when we came down and be five years here and we've been here now thirty, you know, so we liked it here. You know initially when the reason I came to the VA was that when I first started, the VA was a nice opportunity because you could see patients, you could teach, you could do your research, and nobody really bothered you, you know. And back then, you know, things weren't near as strict as they are now, in terms of, you know, you didn't have to round every day without staff and those types of things. But I did enjoy teaching and I, you know, I tended Morning Report quite frequently then, and I spent three years as the associate chief of the medical service while I was at the VA and I was, for a long time, the chairman of the curriculum subcommittee, for the Residency program. And then in 2006, the person who is charge of the Residency program ahead of me, Dr. Levy decided he wanted to go over the dark side and join the law profession (he'd been going to law school at night). And so, I was put in charge as chairman of the recruitment committee for that position. But then Dr. Greenberg was the acting chair of the medicine at the time. And I told him well, you know, I sort of would like to apply for the job so he made me step down as chairman the committee ultimately I was chosen to run the residency program. You know, I'm glad I did it. I had been involved prior to that with a group called the mycosis study group. And so, we did a lot of studies for fungal diseases. And at the time, you know, this was early on in the HIV era, we saw a lot of patients in Houston with cryptococcus, histoplasma, and HIV. So we were one of the highest enrolling centers in the country and a lot of different studies particularly for cryptococcal disease but you know as therapy started coming out for HIV and stuff, those patients became fewer. And so it became much harder to do those studies and things. I think the transition to the educational program was kind of a natural one for me. I still get, you know, to do my fungal things and still get to participate. People still call me for all the complicated fungal infections – I mean, I got an email yesterday from one of our former trainees who has a patient over at MD Anderson, who had some questions about, so I still get to do that. But I also get to teach and kind of run The Residency program too.

Erik: Well, I'm curious because, I actually went to Wisconsin for undergrad and I'm from Illinois, so also from the Midwest and I'm always kind of interested to hear what attracted you to, you know, the VA and then Baylor specifically that, you know, you felt like maybe you - I don't know if there's anything you felt like you couldn't find in the Midwest or elsewhere on the coast or something.

Hamill: Well, you know, we liked Wisconsin; Madison was a nice place to live. No, my wife is still mad at me for leaving there; she thought it was Heaven on Earth, you know, because she had grown up in Detroit, her dad was a fireman in Detroit. She had grown up in Detroit, so leaving, Detroit was like, great for her. But, you know, because of Wisconsin was so nice, people wanted to stay there, and there were no jobs. A lot of the guys who had finished the fellowship program ahead of me were working in ER's and stuff because they couldn't get an ID job

Erik: Really?

Hamill: Yeah. And you know Madison is kind of a small city, you know. It's not like Houston is and it's not a very diverse city, right?

Erik: Definitely

Hamill: And so, you know, I think just Houston offered a lot more opportunity for my career and Madison did at the time. And that was borne out, I think about by my career trajectory. I couldn't have done the type of research I did at a lot of other places with the support I had here, and the diversity of the patient population that we had here. Very few places in the country have that, and even the ones that do – I don't think everything's not as concentrated together as it is here. So it makes, you know, getting around pretty easy and it makes life pretty easy because you don't have to, you know, run all over town. The other thing about Houston the medical center which I think is kind of unique is the fact that you can live so close by. I still still living a pretty nice part of town in a lot of major medical centers, you can't do that. So for the first four years I lived here, I actually rode my bike to work every day because I only lived a few miles away. And I'd still I have a ten-year-old car that only has 48 thousand miles on it because I hardly drive

Erik: Even in the heat you'd bike in, huh?

Hamill: Well, back then – Houston wasn't as bike friendly back then. So the reason I quit was I actually got hit by a car.

Erik: Oh my goodness. Oh my sorry to hear that.

Hamill: But, so there are a lot of opportunities here to do research. You know, the Infectious Disease section I think a Baylor is always been very strong, you know, and good colleagues at the Infectious Disease community here in Houston is good. It's very collegial, maybe a little unlike Cardiology or something.

Erik: Gotcha
Jason: Sure, yeah, what was one of your most difficult patient cases

Hamill: Couple different things – I think one of the disease's I think that's really difficult to manage is coccidioidomycosis. And I have a patient actually, I'm following in the clinic right now, I think is was one of the most difficult ones I've had. He's a young man who had been diagnosed with cocci when he was in the service in California, about three or four years ago, and at that time, he had pulmonary disease, CNS disease, cervical spinal disease, thoracic spinal disease, and he had to have thoracic surgery, spinal surgery, and was treated in California. And then he came here and he been off medicines for a while and he relapsed. And when he got here, he had exacerbation of his cervical disease and he developed hydrocephalus. And so he had to have a surgery for his hydrocephalus and we treated him with high-dose fluconazole which is sort of the guideline directed therapy for his meningitis. Well, he was on 1200 milligrams a day and all his hair fell out, and he got upset from that. So that's one of the side effects of fluconazole. And you know, I have some friends out in the Arizona, who deal with a lot of this. I talked to them and ultimately we started him on posaconazole, and so far he's been doing pretty well on Posaconazole. But, you know this is a difficult disease to treat will never be able to cure him with the present drugs and he's got to be diligent about making sure he takes his drugs. So that's a tough one to treat.

Erik: So is the main reason that it's tough just because we have better azoles and antifungals to treat the other diseases where it's just not there?

Hamill: Well, yeah, just the ones that the ones we have just aren't effective for cocci. I mean, so far right now, cocci meningitis is considered an incurable disease and it's complicated even in patients who you can manage them, you know, you never cure their CNS disease. So there are still at risk down the road for hydrocephalus. I've had three patients now who I follow – we don't see a lot of cocci here, but I've had three patients of the few we've seen who've required shunting or some other Neurosurgical procedure for management of the hydrocephalus because it's such a common complication. So it makes it difficult to manage. And it's a very humbling disease. And then some of our HIV patients early on in the HIV era – it was very depressing, you know? And because we didn't have great drugs for these patients. If we had the drugs available back then – if we had the drugs we have now back then, we would have done a lot better with HIV because they took their medicines, you know. Early in the HIV era, we didn't have a lot of knowledge about the pharmacokinetics, for instance, of AZT. When that one that was our first drug available patients would wake up every four hours at night to take their medicine because we thought the half-life was short, you know. And they did it, they set their clocks. They got up at every 4 hours at night to take it and they did fine. But then they got after 20 to 40 weeks, they all got resistant, and we just bounced from drug to drug to drug like that. But ultimately, we had nothing to offer them. So it wasn't until we could get combination therapy and we could actually start curing these. And I have two patients right now – or one, at least (I had two and then one died last year). But back in 1996, we got combination, they were on their death beds, but both of them – they were alive for years afterwards after we were able to get the protease inhibitors.

Erik: When you talk about HIV gets me to think, because I mean I know you said that you were in your fellowship when HIV was kind of first being realized and coming into the scene so I guess it probably didn't get you to go an infectious disease because you're already doing it. But did you feel like that sort of endemic caused more people to go into infectious disease? And I'm asking this question because of COVID, I'm wondering if we're going to see a bunch of people who want to be infectious disease doctors because you know it's everybody's you know it's the thing sort of to learn more about and treat.

Hamill: Yeah, you know I think it probably was. It's what's interesting – we had the graduation virtual graduation for our ID fellows the other night, and Dr. Fauci actually had put together a video for all the graduating ID fellows in the country. And so they showed it at our virtual graduation the other night and he brought up an incident that happened back in the early 80s. Dr. Petersdorf, who was at the University of Washington and was a very well-known ID doc then, had given an address at the Infectious Disease society meeting saying that there were too many ID doctors back then, and that they'd all be culturing themselves and treating them because there were just too many of us. Well, I mean that was literally in the doorstep of HIV. Then since then, you know, we've got leaked layers disease, we've got SARS and we've got MERS, we've got covid. And you know all these new diseases that people wouldn't imagine back antibiotic resistance and infection control is tough, global health. So I think, yeah, I think probably HIV did have an impetus for people to go into ID back then because a lot more people; we have a lot more women have now too, you know, which I think is one of the nice things about the field because I think – we graduated six fellows this year and all of them were women. So I think it's been a nice opportunity for women, unlike some sub-specialties, like Cardiology which are very heavily male dominated, you know, ID's allowed women to come in.

Erik: They're going to think you're coming at – you have a vendetta against cardiologists. I'm just joking.

Hamill: It's not as interesting of a subspecialty as ID.

Jason: We both remember – I mean, we're one of the few students who actually attended the lectures. I did want to ask though, why is it that you still put up with teaching us medical students?

Hamill: Well I wondered – I got the evaluations yesterday actually from the last, you know, the last group actually. You know most of them were recorded from the year before – I only gave 2 in person. And, several times over the course of the years that I've given these lectures, the students complain about the TV lecture. Because they say that, what I tell them, they don't believe – they don't believe it. And what I tell them is has to do with BCG vaccination, you know? And the public health response to that and what I tell them is what's in the guidelines, but they don't like it because they think it's discriminatory. And I got one of the, one of the evaluations yesterday, said, well, what he said, was, what's not in their ID first aid book, or whatever the dumbed down version of the book reviews. Well, I'm sorry but it's not the public health response, you know BCG is pretty well laid out, you know you ignore the BCG status when you do PPD testing, or when you do T-spot testing nowadays. That's the way it's supposed to be done, but these books and their thought is well that's discriminatory. Well, it's not and it kind of – it's a little bit irksome right when the students are bellyaching about that when they don't really know the data. And then the other comment that they got this time was, well, I was teaching them stuff that only ID fellas need to know. So, I'm teaching them the ID that they're going to see when they get in the clinic. Because if I teach them, they will be seeing it and they don't know because they haven't been the clinics yet, but you guys have now or you will be you will see these things. So that's the one thing that bothers me about it. I do miss not interacting with the students in class – I like that better? I don't, I don't like giving Zoom lectures because it's fun to interact with students so that's why I do it. And I'd like to round on the ward still, you know, a lot of program directors around the country don't round because they don't have time to do it. But I don't like that because you don't get to interact with students. And you know, I like clinical medicine, so I want to continue that, and I think I have something to impart to you. There's, you know, there's been this movement for hospitalists to do all the rounding in medicine now in general medicine. The man who actually got me interested in joining the mycosis study group used to be the chief chair, chief of general medicine over at UT. He was actually a pulmonologist Jorge Cirrosi. He wrote an editorial in annals of internal medicine a few years ago because he still rounded on general medicine and he was 70 something. We still have something to offer, we have some insights, you know, we may not be able to get the patient out of the hospital as quick as maybe a hospitalist does, or something, but I think we have some history and some insights and like this, you know, that that we can give you guys that they may be beneficial in an approach to Medicine still, because we've seen a lot more than you guys have.

Erik: Definitely, definitely. I didn't realize that there was a move for hospitalist to do all the –  most of the rounding.

Hamill: Oh yeah,  and that's the way it is at a lot of places. You know if you but I mean, if you look at who's running a been table now, it's mostly the hospitalists. Dr. Greenberg and I were the only ID people, I think, now who rounded on general medicine there. Several of the Endocrinologist did, and I think one or two of the nephrologists. But mostly, that's all it is. And at the VA, you have more of the subspecialists, but there are moving away from that as well. But that's nationally, that's the trend. But I enjoy it and I think we still have something to add.

Erik: And I think Jason, correct me if I'm wrong, but were you also trying to ask about like the fact that the years, because when Jason was saying he attended all and I attended most I did watch them all, you know in some manner, but some of them I did stream. And I think we're also curious just to know as somebody who's been teaching a long time and has seen streaming become more of a thing, like, do you like that, or are you indifferent or do you despise it?

Hamill: Well, I don't despise it but I, you know, I like I said, I enjoy interacting with the students. I'd rather they'd be there than often in the Netherlands, you know. You know, when I went to medical school, I had a big class (there were 256 of us). Most of us went to class, but not everybody did; we had a scribe service back then that you could pay for. We all paid for it just to augment our notes, but most of us went, but I went to socialize with my friends, you know. The way our medical school is set up, we had a we were broken up into 16 person labs, you know and so, you know, that was your social unit. I mean we had potluck dinners, and picnics, and we went on vacations together and stuff, you know, that's why I went to, that's why I went to classes. But yeah, I don't, you know – you sit at home and you look at zoomed all day long, I mean I hate it right now. Excuse my language, ha ha, I hate this. Yeah, everything Zoom right now. I am sitting up here in my office. I come here every day, our house is under construction right now, you know, so I can't stay at home. My office is a mess and stuff, so I got I come up to work, well several days. I'm the only one up here, you know, and it's lonely. And that's not the way medicine should be.

Jason: For sure. I definitely feel that the like I went to class mostly to see people.

Erik: Yeah, yeah.

Hamill; And I think it's helpful too because, you know, you can ask questions and people come up afterwards and stuff to talk, you know.

Jason: It doesn't take like a, you know, six emails to get one question and you can just ask it and, you know.

Hamill: So I miss that.

Jason: Yeah, for sure. I guess, I was wondering how is it different from teaching like us medical students compared to residents? Is it different is it not different? It's a little different because, you know, there's a different level of sophistication. But you know, I've had medical students who are phenomenal or better than the residents, you know, so it's not a hard and fast rule when I round on infectious disease service I do like to have a fellow on the service with me because you can talk about a little bit more sophisticated topic, you know. And so for me, that's good because then they challenge you a little bit, but on the whole I think, the way I do rounds, it's good because I think we can address certain aspects of different patients at different levels, right? And so, it's always good to make us think about the basics, but you can get a little more sophisticated. You know, there's, you know, there's that RIME acronym, they, you know, you guys are familiar with RIME

Erik: I don't think so.

Hamill: Okay, so theoretically, that's how we should be, evaluating you guys, putting you on the RIME scale. R is reporter, I is interpreter, M is manager, and E is – I don't know teacher or explainer or something like that. So yeah, as a first, you know, when you're on your first clinical rotation as a medical student, you guys are pretty much reporting what you find. It's very satisfying to me to see a student start to be able to interpret the values and certainly manage it, you know. They tell me the patient has hyperkalemia, they know to give kayexalate, and insulin and glucose and what have you.

Jason: We talked about fungi, I guess a lot in the lectures too, so why are fungi your favorite class of microorganism?

Hamill: Well, because they call cause cool diseases, right? So, you know, right now, a lot of the stuff, there's a lot of stuff out there about COVID, you know. But, I find it boring because, you know, I mean, I know there's a lot of things that can happen to patients with COVID, you know. I mean, besides having respiratory things, they have GI things, they have hematologic things, they have thromboses, blah blah blah. But I don't know; they don't have these weird skin lesions like people with fungi get, you know. And they don't have all these weird manifestations. And there's not cool epidemiology like there is with fungi, right? The epidemiology is really neat. The other reason I like it is because nobody else does. So, I can see myself as an expert so people will come to me with questions because you know I've dealt with it and that's where my expertise is and stuff. You know, and it's kind of cool that, you know, you see these diseases that have weird manifestation and they are – sometimes they can be very difficult to manage. And I think we don't – sometimes people, I don't think look at the little bit deeper into these diseases. For instance with cocci now, I think it's becoming pretty clear with cocci that if somebody has a very bad cocci infection that there's something wrong with their immune system, and people don't think that way. They think well, he's got bad cocci and we got to treat it. But I think we're finding now more and more that there's something wrong with their immune system. So actually, in the New England Journal of Medicine last week, they had a case description of a child who had disseminated cocci and had a bad infection and it turned out they ended up treating the patient with some of these immune modulating drugs, as well as interferon gamma, and the kid actually did very well. And then they genetically, they looked at him and he had truncation of a gene that allowed for – that caused the decrease in the interferon gamma production. We don't look as carefully into those things as we should in those patients. So I think anybody that has disseminated cryptococcosis, histoplasmosis, coccidioidomycosis, who doesn't have something obvious – we should, we probably ought to be investigating them because they probably do have something wrong with them. A lot more sophisticated than we can usually get.

Jason: Yeah, so fungi, pretty cool.

Hamill: Yeah, they are.

Jason: Yeah, kind of different. No, definitely – I when I was learning it I definitely felt like the clinical manifestations are like, very different from like bacteria. I feel like bacteria were like, very like, clear. Like a lot more clear out of in, like, a picture of what, what they did, but fungi really were like kind of all over the place with clinical manifestation

Hamill: But I think you know, a lot of times if you take a good epidemiologic history and patient you sometimes get some clues, or look at their underlying illnesses.

Jason: Hmm do you have a favorite fungus? We've talked about cocci a lot.

Hamill: Like yeah, I like cryptococcus. I think is probably my favorite. I mean if you can if you effectively treat somebody with cryptococcus you can help them a lot. It's probably not the most interesting in terms of its clinical manifestations but it's the most satisfying to treat sometimes

Jason: And then, okay, the next question I have is kind of fun one: as a residency director for like so many years, how have you seen students suck up to you?

Hamill: I don't know. I don't think they suck up a lot. Occasionally there will be a student though you know who want to talk, come in and talk you know, more than the typical. It's clear they want to stick around or something, but it doesn't happen too much.

Jason: Okay. Okay, cool. I mean it's like I feel like I've a lot of times, like, especially during lecture like okay, like no one really liked knows like your title or whatever, like, during lecture and be like, oh yeah, like, by the way, like Dr. Hamill is like the residency director and then they're like, oh like now he's like actually listen to him and I was like – what the, like why would you not listen, you know, why won't you listen to him before?

Hamill: That's right.

Jason: Why don't you attend his lecture, like you know, a six of the classes is attending his lecture? I don't really get it but it's fine.

Hamill: Does that give me more credibility or something?

Jason: I don't know. I don't know, it's fine.  Anyway, that's just a fun question. I guess after practicing, like medicine and teaching for so many years, what do you say is the most rewarding part of your job, either the medicine or the teaching?

Hamill: You know, I think just seeing how you guys mature over the years, you know? I mean, I've seen a lot of students come and go now and a lot of residents going go, and I always get sad, you know. We had our graduation two weeks ago for the residents, you know. We see them; unfortunately, we didn't this year, but most years we see them packed into a room on the first day, you know. They sort of have this deer in the headlight, look, you know, there's nowhere to go. But, you know, I usually round at Ben Taub in the end April-May, you know, of each year. And when I have a third-year resident running a ward team then, it's very satisfying to see how well they've done. You know, I would trust most of them implicitly with my life, you know, because they've done a great job and I think that's the most satisfying thing to see them come very raw and over just three years, you know, work very hard, work with a lot of camaraderie with a group, you know, and become just very, very competent physicians. That that to me is tremendous. We put out a lot of good physicians. Then to see them go on, you know, a lot of, you know, my residence now are, you know, they're faculty here and stuff, to see them being successful and stuff like that, you know, it's just very satisfying.

Jason: I mean, there they literally is a new class of interns, they're starting like what next Wednesday, right?

Hamill: They start Friday, but they're here now.

Jason: They're here right now?

Hamill: And just before you got on, I was just finishing up our bootcamp online. But we had a camp today with them. Yeah, I met him all, we had a drive-through in front of the McNair building on Thursday and Friday for them to pick up their white coats, and so they're all in town and a next Friday I think they start.

Jason: So they have the same look, the headlight.

Hamill: Yeah, yeah, although you can't see them all in one room.

Erik: Has COVID changed anything about how like it's going to be structured or is it going to be pretty much the same way?

Hamill: Well, you know, I mean, it has changed the orientation completely, right? Everything is online now. We had our orientation yesterday morning, it was all online. All the Baylor, orientation's online. Except for you know we have to do a donning and doffing gown thing for them, you know? And we certainly are doing the n95 Mask fitting now. And yeah, you know we have to have them socially kind of separated in the team rooms and stuff, which to me is unfortunate because you guys have been through medicine, right? I mean, you know how it is when you're in a team room, you sort of through osmosis you pick up things, right? A little things you know, how you put this order in? What is this low potassium mean? What is it? And we don't we're not going to have that because kids are going to be scattered around a little bit more, so I think it's going to be detrimental to their education. So I do really hope that we get through this thing pretty fast. Actually, myself and Amy Angler. I don't know if you guys know Amy, she just graduated from the medical school. She's gonna be one of our interns. She and I were interviewed yesterday by a woman from the Houston Chronicle. There's going to be an article in the chronicle I think this week or next week about the interns starting in this era. Look for that.

Jason: So I guess, what has been like the least rewarding part of the most frustrating part of your job?

Hamill: Well, I think the amount of paperwork over the years, and the amount of regulatory things that have occurred, you know. I feel bad for the residents because we're just – we're always hitting them up with, you know, you got to do this training and that training and stuff that they never had to do in the past. This year was particularly bad because, you know, three of the four hospitals that they train at all had CMS things. And so they had to do a tremendous amount of training that really was duplicative but all three hospitals required it, right? And so they had to do it on multiple occasions for all. Plus you know, they have ACGME surveys, and they got to do duty hours. They have to do training on compliance and they got to do ethics training and human research, and HIPAA, and I mean, there's just a huge amount of training that they didn't have to do before. For all this training, they could be taking care of patients, and they could be getting so much more out of it. So that bothers me and then all the paperwork, that's involved nowadays. The other aspect I don't like, is that just in case there are disciplinary problems, you know. We don't have many of those, fortunately, but we do have some remediation issues occasionally with residents and that's very unpleasant because as a whole these kids are pretty good and yeah but sometimes people just can't put two and two together, you know. Yeah that's just not satisfying.

Erik: Well I've heard a lot of – we've interviewed quite a few people who have sort of been around long enough to see the paperwork build up and have said, similar things. But I've also talked to some people who have said, you know, doctors have always had a lot of paperwork to do it just you just used to handwrite it. Are you talking specifically about like EMR stuff? Or - because like notes in general, you've had to take since the beginning, right?

Hamill: I think the paperwork burden is more the regulatory documents.

Erik: Gotcha.

Hamill: So, when I trained, obviously all the records were handwritten. I don't think that was optimal. The hospital where I did my residency at the time, had the largest inpatient oncology population in the country, bigger than MD Anderson. And so we would see patients, that would have a chart about 2 feet high.

Erik: Wow.

Hamill: And you had to go through the chart every time these patients were admitted and calculate how much doxorubicin they had gotten, so we'd stayed below the 250 milligrams per meter squared, you know. So you might spend hours going through the pages of this chart, trying to find that. Well, the EMR certainly facilitated that type of stuff. But on the other hand, it's taken people away from the patients and patient's rooms because they're sitting in front of computer because there's so much a data available there that they sit there and get it all, instead of being with a patient. I think that's the major thing that that I don't like about the EMR and that's been commented on. You know we had Robert Wachter or who's the chair at UCSF and he wrote that book, the digital doctor. It's a good book but one the pictures he has in there, one that the daughter of one of his patients had drawn his back is to the patient looking at the record, you know. I mean that's been an unsatisfying component of this medicine these days.

Erik: Definitely.

Jason: Even as a med student, I feel like I can just be, like, in the mornings, I'm like, I can be in front of the computer, like the entire morning up till it rounds and like, forget to see the patient. I have to like, time myself, like, okay, I just could spend like 20 minutes and then anything that I don't get in the 20 minutes, I just going to see the patient and then I can come back to, it's fine. I don't have to get like every single little thing. But yeah, that's definitely something that I've noticed, like even for me like oh my gosh, is like so much stuff in the morning. There's all these new labs like all these new all these new tests.

Hamill: You know, some of the residents couple years ago, it applied for one of these ACGME grants, back to the bedside grants, and had developed this program to, you know, interview patients about things other than their medical issue, you know, where they live, how they grew up. If they were a veteran where they would Branch the service they were in and do they see combat or something. But that's sort of been curtailed now because of this COVID thing because you can't get everybody in the room now, to listen to those stories, you know. Which is unfortunate because that program was highly liked by the residents. It's unfortunate that this whole issue is sort of taking us away from the bedside again. We want to minimize our exposure to these patients. I had an attending when I was on a fourth-year student for infectious diseases. He was a world-renowned infectious disease expert, but he was a jerk. But one of the things he told us was you never sit on the patient's bed and you never touch patient except to examine them. Subsequently he went all over the off, the dark end to the dark side. It's one of those people that gave a massive infusions of vitamin B12 and you know chronic fatigue syndrome blah blah blah stuff, but he was just wrong, you know, you touch patients, she said in their bed, you talk with him. That's how you connect with your patient.

Jason: I remember – it was during one of your lecture, you had said this kind of like – I don't know, it was in response to a question and you said almost subconsciously, like, "sometimes it's nice to touch your patients". I forgot what the response – what the context was. I just remember you saying that? And yeah, I yeah, I definitely remember that though.

Erik: There was – I actually saw lecture of, I think it was another physician from UCSF doing like a TED talk about sort of the healing touch of like just even just like a pat on the shoulder or like, you know, just human contact.

Hamill: Yeah.

Jason: Especially now during covid, especially the patients who have covid. It's like I feel like I'm sure like nobody touches them; we're gowned up and like have goggles and like

Erik: can't see their loved ones.

Jason: Yeah, can't see their loved ones.

Hamill: It's like they're lepers right?

Erik: Last question or last two.

Jason: Yeah, maybe like last question. I guess how have you seen medicine change over time?

Erik: We've already talked about EMR. But yeah, but any others?

Hamill: I think part of it is, you know, like the hospitalist movement. I mean there's good and bad for the hospitalist movement. It clearly is more organized and stuff, but there is too much of a push nowadays to get patients in and out of the hospitals. You know, I remember, when I was a resident, you know, we rotated through the VA to, you know, and back then, the patient in the hospitals were in big ward's, you know. You didn't have individual rooms and so you might have 20, 24 patients in a room. Well, at the VA, you know, these guys were all vets, you know? And a lot of more World War Two vets. So they'd sit around telling War Stories all day long and they never wanted to leave the hospital? They didn't want to be discharged and they stayed around for months and months, you know. But, you got to see the natural history of disease to, right? You got to see things work out. Nowadays patients are kicked out of the hospital so quickly that you don't get to see the stuff. So five, six, seven years ago, I was running on general medicine in July and we admitted a young man from Kingwood who had a family normal guy, you know? But he was admitted with aseptic meningitis, he wasn't real ill, you know, we thought maybe it was West Nile, but all the testing came back negative as he was being discharged. I asked the house staff will get a typhus antibody on him. Well they didn't and he got discharged and he was supposed to come see me a couple months later, he never did, but this was July, he showed up in January. He was fine, but I got a typhus antibody then. Well, his IgG tighter was off the wall. So the house staff and students, never knew that, right? Because I didn't remember who they all were and stuff. And yet I found out what that guy had, you know, and it helped me because down the road, I've seen more patients like that. So five, six years ago, we had one of the guys who's head of General medicine that you at San Francisco VA, who's Gupreet Dhaliwal. And if you guys get a chance, you should Google him and see some of the stuff he's written. But he came as the visiting Professor Chief residents at the end of the year, we get to invite a visiting professor. And he was the visiting Professor, so his lecture was from good to great. And we talked about was what you guys need to do, is you need to keep a list of all the patients, you see, then periodically go back in the record and find out what happened to them because you certainly don't know when they leave the hospital and when you find out about that then that's what makes you great. Because you found out you seen what happened to your, either to your therapeutic intervention, or your diagnostic things and that's what that case sort of demonstrated to me. So that's been I think one of the major problems with medicine and DRGs and stuff like that trying to get patients out of the hospital and not being able to see what happened to them. Unless you make a real concerted effort to do. Then if you make that effort, you're going to learn a lot more.

Erik: That's pretty interesting. I didn't think about that, the longitudinal course of patients, you really miss out on it.

Jason: Literally one of the patients that we have right now, we suspecting like an autoimmune cause, but everything's being done outpatient. We're trying to get her out.

Hamill: Yeah.

Jason: In the clinic and everything's been done outpatient. I'm like, I really want to know – she's got like elevated ESR; that's the one test that's come back already. Everything else like we're just we're going to discharge her and then follow up. You know she's gonna have to follow up outpatient. I'm like I am dying to know like what she has actually.

Hamill: Well that's why you got to write down her name, medical record number and then find out what happened to her because then you'll learn something.

Jason: Yeah, yeah

Hamill: Either you're on the wrong track or you were on the right track.

Jason: I guess, last question. So what do you see in the future of medicine?

Hamill: Well, you know, I don't think, I think there will be more of a telemedicine impact on medicine, but I don't think it will be to the extent that it is now. I mean, I think we'll come up with a vaccine for this COVID thing, or treatment or both. And I and so we'll get through this. There may be other pandemics in the future. But I think what this has taught us is that we can respond pretty quickly and that the scientific Community can come up with treatments and stuff like that, so, I mean this will be short lived. But telemedicine, I think we'll have a more impact. I think we will unfortunately probably move more and more away from the bedside, less into inpatient medicine, more to outpatient medicine because we can do so much more as an outpatient work people off. I'm hoping that people will still see the intellectual challenge in medicine and not, you know, not get too cookbook-y about it because sometimes we seem to see that. But I still want people to enjoy it. You know, like I do. I'd like to see the regulatory environment not get so burdensome so doctors don't want to practice. Because you know, I mean I've enjoyed my career, and I want young guys like you guys to enjoy your career, and I don't want to have people make it so burdensome or so difficult that it's like a job and not a, you know, a hobby or something.

Jason: That is the dream for the job to be something that we really love and really enjoy.

Hamill: But I think you can do that, I mean. But you got to you got to take an effort to make it what it is.

Jason: Definitely, definitely.

Erik: Well yeah. And I mean do your point of what you said earlier about how you you like teaching because you think you have a lot to kind of teach us who have not seen nearly as many things as you, I think that's absolutely true and that's one of the reasons we were really happy when you decided to be interviewed by us, we really appreciate and we do think you have a lot that we can learn from. So we really appreciate your time, we know that you are busy, so thank you.

Jason: Appreciate you teaching us also all about the even the diabetic feet. Yeah. And we're not just saying that because you're the residency director, okay.

Hamill: You know I tore this thing out today. Can you see that? Oh drinks. Yeah. Oh man you got we have two new faculty members starting at the VA in July. Two of our fellows and ID section and I want one of them to get interested in diabetic feet. As they're saying here, you know, in the last 20 years, there's been no change in Canada, absolutely no change in the incident to diabetic amputations for diabetic feet. Whereas other things, you know, have improved a lot, so we need some work on diabetic feet.

Jason: Yeah, some new innovation. Yeah, yeah, alrighty. Well yeah, thank you so much once again.

Erik: Yeah. Thank you.

Hamill: Have a good day.

iTunes | Spotify | Google Play | Stitcher | Length: 40 minutes | Published: June 30, 2021

Dr. Joanna Fields-Gilmore discusses her work as a family medicine doctor and training in the Compassion and the Art of Medicine Elective.

Transcript

[Music] 

Erik: And we're here.

Juan: Yes we are.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.

Juan: I am another host, Juan Carlos Ramirez.

Karl: And my name is Karl Lundin. I was the writer for this episode.

Erik: Yeah and so today we're going to be talking with Dr. Fields-Gilmore about her experience as a family medicine practitioner and Karl

Karl: So yes, we are going to be talking today to Dr. Joanna Fields-Gilmore, one of the wonderful faculty members we have here at Baylor College of Medicine. Dr. Fields-Gilmore is a family medicine specialist. Family medicine is a very important field; when people think of the classic community doctor, that's a family medicine doctor. They do it all: they take care of adults, they take care of kids, they take care of pregnant ladies and babies and all that stuff so really kind of the jack of all trades type doctor. So it’ll be cool, we'll get a chance to talk to her and get some sort of insight into that particular field of medicine and what it's like to be kind of integrated in the community as a physician. We'll also get to know Dr. Fields-Gilmore more personally, kind of hear about some of her background and what brought her to Baylor which will be really cool stuff. And we'll also get to hear about the course that she recently took on as the director of which is Compassion and the Art of Medicine. It's a really cool elective course offered to first-year medical students in the fall every year, and then also second-year medical students kind of come in as sort of small group facilitators for the class. So it's kind of a fun time.

Juan: It’s a great course. I took it actually. It's more a lot along the lines of just understanding people a little more. It's not just like their illness, systemic issues you know just problems that are going on in the world that affect people's health even here in Harris County. I remember some of the speakers that came over to talk to us like directors of homeless shelters and stuff like that. It's really good, kind of like an eye-opening experience too and I think you take a lot away from that. It’s a big slice of humble pie too.

Karl: Yeah. I think it kind of once again gets to sort of a part of our medical education that we sometimes don't think of; you know a lot of it is focused on book knowledge, on learning these various scientific and medical facts and problem solving skills and all that is very important to the practice of medicine, but another important thing about medical practice is the relationship you can build with your patients and with the community and how you can really learn from your patient how to best care for your patient. And so Compassion and the Art of Medicine was really, I also took the course, really valuable in sort of offering a chance for us to expand our perspective and develop some of those compassion and empathy skills. Because when you have a patient come into the room and you talk to them, they're bringing a whole lot of experiences of life with them and it's important for you to be able to reach out and try to learn and understand that patient so that you can best treat them and best manage their care. And we're going to get into her vision for the course, kind of what the course is all about and some of the cool stuff involved around that too. So it should be a good conversation.

Erik: Yeah, yeah definitely. Well, without further ado, Dr. Fields-Gilmore.

Karl: Well Dr. Fields-Gilmore, thank you for joining us for the podcast today. We appreciate you working through some technical issues because we are actually recording this, for those of you that don't know, during the Covid 19 sort of social isolation period of time, so we're having to do this virtually. But we appreciate you joining us today.

Dr. Fields-Gilmore: Thank you for having me.

Karl: We're glad to have you. So we thought we would just start off by asking you to tell us a little bit about your background, your education, where you grew up, all that sort of stuff.

Dr. Fields-Gilmore: Well I'm a native Houstonian. I was born and reared in Houston, and then I went off to Nacogdoches, Texas to do my first stint of college. So I got my bachelor's there and then in Indianapolis, Indiana for the for my second graduate degree and medical degree and then off to California for residency training. So I've been a couple of places. I've also been to Africa, did some work there while I was a fourth-year med student and also with one of the professors that I worked with when I was doing one of my graduate degrees. And my experience after residency, I was a national health corps scholar and in that experience you have to do four years of service time and no, they don't pay any student loans while you're doing that service time, which I'm doing in rural areas. And so I was in Laredo, Texas, which is right across the street from Nuevo Laredo, and if you know anything about that and the drug cartels and those kinds of things that were going on. Just a really interesting experience so far, because everything has been with underserved but just a lot of different areas and a lot of different regions that I've worked in. So it's been interesting.

Karl: Yeah, it sounds like you had a lot of different experiences in a lot of different places. Sounds kind of cool, you know lots of opportunities. Just out of curiosity, how long were you in Africa and what were you doing there more specifically?

Dr. Fields-Gilmore: So at Indiana University School of Medicine you had the opportunity to go to Kenya to do some work. And for me, I did not end up going to the traditional place that they go to in Kenya for Indiana University School of Medicine. I ended up doing missionary work so I ended up doing an Africa inland mission and I was in Kajabe. So Kajabe is an hour outside of Nairobi up in the mountains, and I went there right after they had their internal unrest. It was kind of like a civil war, if you will, where the largest group the Kikuyu was warring with the another group because of the election that they just had. This was in 2000, between 2008 and 2009. And so I went there right after they had that. It was kind of iffy whether or not I was going to be able to go because it was so dangerous. And so that was a different experience because the people that we saw were people who were coming in from having been internally displaced: what you would call refugees but they called them “internally displaced people” while I was there. And I went and we gave medical care to the people in the internally displaced camps, but they also made their way up to the mission hospital that I was a student physician at.

Karl: Wow. How do you feel like that kind of informed your subsequent experiences in your practice as a doctor?

Dr. Fields-Gilmore: You know, I'm going to tell you when you are a fourth year medical student you’re, I mean throughout your whole experience, even now I'm an attending I've been out of residency for a while and I didn't, you know, I've been working for a while and you still don't know everything. So when you're up for the amazing… it's scary, it's exciting, it can be fun and if you go to a different country and you get some down time you're able to explore. You get to know a different culture; hopefully you learn a little bit of the language, but when it comes to the medicine you're a fourth year med student and you know, you have a lot more responsibility in that situation than you do when you're here doing your clinicals in America. 

Erik: I'm curious, what ended up making you want to come back to Texas eventually? Or did you always want to come back to Texas?

Dr. Fields-Gilmore: You know, I had no plans to come back to Texas. I was going to stay in California. I came back because of family. I helped my family: we had some illnesses and some people passing away, and I came back to help my mom and ended up staying here for a whole lot of reasons that had nothing to do with wanting to stay for medicine. So I'm here. I mean I just bought a house.

Erik: So was there anything particular about Baylor that made you want to come and become a faculty here?

Dr. Fields-Gilmore: I'm going to tell you this: I have always wanted to be in the Baylor family. I wanted to go to Baylor's undergrad, I wanted to go to Baylor for med school, and I wanted to do residency at Baylor. So when I was finishing up my service as a national health corps scholar, I was looking around and I had an opportunity to be a partner for a clinic, which is scary in and of itself because you got to put a bunch of money in. You have to decide whether or not, you know, do you think this clinic is going to thrive or die? You know, lifestyle. So lots of decisions and Baylor looked like they had an opening, so I said, “Ha ha ha ha, I'm gonna try,” because I hadn't been accepted by Baylor up until now so I was like, “Ah, this is just, you know, a formality; I'm just gonna fill this out.” And I went for the interview and everything and actually I had got no emails that they picked another candidate. And so I said, “Okay, well well…” And me being the kind of person I am, I always want to know well if I didn't get that position then I want to know what would make my application stronger. And I think that this is something that anybody can learn from: if you don't get it the first time, then find out what makes you a stronger candidate so that if you want to try again then you can try again right. So you need to do more volunteer work, you need to do this that and the other… And I emailed and I got the email back and it said, “Oh no we wanted you! You got the email on mistake! We want you to start.” And I said, “Wow! I've got the job!” And so all the other, if I had at least two or three other opportunities, I said, “Okay, I'm going to go with Baylor because I'd always wanted to be a part of that. 

Karl: Oh that's very nice, that's very nice. In terms of the field you chose: you're a family medicine doctor right which we were just wondering first of all, what interested you in family medicine? And then what do you feel some of the unique opportunities you have and challenges in that field? Because it's kind of like, I'd say personally for me, my perception of family medicine is you are the closest interacting with the community as a whole. 

Dr. Fields-Gilmore: So I have a master's in public health, and I earned my master's in science and my master's in public health. I earned it before medical school. So when I got to medical school, I was older; I was non-traditional because I had two math degrees prior to that and worked and everything before that. I love public health! Absolutely hands down, a lot of public health and programming was my area, and I just really enjoyed it. And so for me, as I was going to medical school I knew that I wanted to do something that kept me involved with the community, okay, and would allow me to have that interaction with the community. So family medicine was one of those, one of the three or four on my list of what I wanted to do as far as matching was concerned. And so my because my personal mission statement was to serve the underserved and affect positive change in any community in which I served, so that's where I wanted to be because I wanted to continue to be able to do the public health things, do a program right, and try to make some mass changes. Not just one-on-one change, but do some programming and things that would hopefully help a whole community.

Karl: Yeah so do you feel like, what are some of the more unique opportunities or kind of the unique aspects of a family medicine doctor's position that allow them to do that in the community?

Dr. Fields-Gilmore: So over the years, because I'm not just going to focus on the Baylor experience, it has been helpful when you're, when physicians, especially family medicine and internal medicine, when they're able to do different types of programs that meet the needs of the community. So if you go into a community and you see that there's a lot of one type of disease, and it may be some lack of education knowledge or access to a resource. And if you can improve upon that to then improve that area, then that's what makes the job as exciting. To wake up in the morning and to continue to do, you know. And so that's a positive aspect of family medicine is being able to have that. With Baylor it's quality improvement projects, it's working with the students, and when the students have projects to work on with the community residents as well. So that is what the opportunity is, and that's what makes it good. 

Erik: It used to be more of a tradition to have actually in-house visits from physicians, and I could see, you know, where you'd actually go into people's homes and see them rather than coming to the clinic. As a family medicine physician, is that something that you would want to see come back, or do or do you think the current way that we do things where, you know, people come to us is the best way to do it?

Dr. Fields-Gilmore: I think that having a mixed bag is good. So when I was in medical school, there was one doctor… What’s her name? It was doctor… Obeime! Mercy Obeime, and she's big time in Indianapolis. I worked under her and shadowed her and was a student of hers for a long time, and she had an, I don't know what her position was… She was a medical director and a bunch of other titles and stuff. But she had the doctor's bag, she had an old school doctor's bag, and one of the things that she did amongst all the other things that she did was she went to people's homes. And so she had a clinic, she had her own clinic, it was thriving, she had mid-levels and she had another physician who worked with her. She was affiliated with the hospital; like I said, she was a medical director, she did a bunch of volunteer type of programming, she even had a foundation, they would go to Africa. So she had a lot of stuff going on and she did some home visits. When I was training in residency, we did home visits. So I think that them coming to the clinic is good because you have a more controlled environment and it's safer actually, because sometimes you never know what you're gonna walk into. But also going to see where someone lives, because we did that and I think… I can't remember… I think we did a home visit in medical school, but I know we did it in residency, especially for our diabetic patients; we went to their homes, we looked in refrigerators, you know. We did their foot exam there, we did all of that. So it's something that is done, you know. It can be done.

Erik: Well that's good to hear, and the fact that you were doing it, I guess maybe I just don't understand it enough; it seems to me that it's always just clinic visits and the home visit is being phased out, but maybe it's not. Would you say that it's not actually as gone as maybe like, for instance, I might think?

Dr. Fields-Gilmore: I think that because you're at an institution right now, the area where you are in your training, you're not seeing it then it doesn't seem like it exists. But you got to remember that you have a whole life ahead of you in this, and you will see a lot of different things you know like, “Oh they never did that there, but they do that here.” And now you know I tell people I switched around a lot. I didn't stay in one spot, and I know some people there they are successful when they go from undergrad to medical school to residency and they stay in one spot. If you can move around and if it's good for you and if it's successful and it makes you know, your curriculum vitae look good and all that, move around because you're going to have different experiences. And I think that that's it.

Erik: Yeah actually Karl and I both took a number of years off, so I think we both agree a lot with that sentiment.

Karl: Definitely. So a little bit of a change of topic, but one of the reasons I reached out to you to schedule this interview is because I actually took your Compassion and the Art of Medicine course my first year in med school, and I enjoyed it a lot. I understand you recently took over that, and we were just interested to ask you some things about that. Like what interested you in the course?

Dr. Fields-Gilmore: So I applied for the course because I had done the Healer's Art with Dr. Michelle Barrett, and she's a UT physician pediatrician, but the healer's art course has both Baylor and UT students. And you know what you guys experience in residency, in medical school is completely, completely different than what we experienced. We experienced a lot of the things that you guys now are able to report on; if somebody does something you can anonymously report. And so we endured that. And so when I was invited to do Healers Art, I was like, “Wow, they have something where you can actually just, you know, get some things off of your chest and you're not gonna get in trouble for it,” and I could be a facilitator for that. And I was actually really scared to be a faculty facilitator, but it ended up being wonderful. So then when I saw the Compassion and the Art of Medicine course director position opened up, I was like, “I could probably do that,” and I was chosen. So that's what made me do it, because this type of thing, it was not even in the stratosphere of the universe for medical schools to be thinking about how people, how the physicians feel, how they're training trainers. They didn't get somebody to ask you how you felt; you get up and you go to go do what you got to do and, you know, make sure you get your grades. Nobody asked you how you felt and how did it feel when somebody that, you know, as a student you cared for died or something. Nobody. Yeah you just kept going, and so I was like, “This is awesome that Baylor's doing this.” I just was really excited about the fact that this was being offered to the students because it wasn't offered for when I was training.

Erik: And do you want to explain what it is just in case there are people that are listening, or either one of you I guess. Just a brief synopsis.

Dr. Fields-Gilmore: Karl, you do it.

Karl: Yeah yeah; it did occur to me that we should probably provide some context. So Compassion and the Art of Medicine, it's basically a really neat course they offer at Baylor where first year students come in, and there are second year students that also come in and they facilitate actually, but the first year students they come in and basically there will be different guest speakers talking on different topics. And they all kind of have to do with, I guess what you call like the “softer side” of medicine, right. Not so much about like facts and figures and scientific data on patient treatment, and more about how to treat a patient as a human being, how to treat each other as human beings, as physicians, as other health care providers, and how we can sort of keep in mind our interconnectedness and have a holistic approach to the way we conduct ourselves in a medical environment. So, for example, we had a speaker come in, a doctor who talked about his own experiences as a parent of a child with a certain, like I guess you call it like developmental and health issues. I think she was deaf-mute, was that the correct um expression? And just kind of getting insight into what that family's experience was like and what we can do as physicians to help people in that situation and provide the best care in that situation. And I'd say really more than anything it's about developing your empathy, right? Not just your clinical acumen, which we're learning in other areas. But here we're learning how to be an empathic doctor and a doctor that really knows how to reach people where they are and be with them in their struggles. 

Dr. Fields-Gilmore: So that's my view, and the one thing that I emphasize, because I don't know whether or not it was emphasized before I became the director, is because in medicine all of our brethren, we have been trained and we are often trained to ignore ourselves. And now that we're in this pandemic with covid-19 and you see all of our brethren who are passing away who are not getting their protective personal equipment and things of that nature, it's important, it is paramount, and Karl knows I say this, you have got to take care of yourself because if you don't give yourself compassion, you cannot give compassion to your patients. And so that's the thing that I bring to the table which I know for a fact has not been something that has been trained into physicians is, you know, don't be the martyr. Yeah, the reason why you can be a hero is because first you be a hero to yourself, take care of yourselves. If you, you know, go take a walk, I tell them go call the grandmom, if the grandma's still alive. Walk the dog. Those kinds of things. Do that self-care, because then you're able to be in the present and be in tune for the patients of what they need. So it's very important that we take care of ourselves.

Erik: Yeah that is, yeah. Do you have any, and you mentioned already how important it is, especially during this time, because, you know, of what's going on. Have you found it harder because of that, or do you like, maybe just because I'm sure many people are working longer hours now too?

Dr. Fields-Gilmore: I think that just like everything, everybody else and every other position, we're all on edge and so to be aware of that and to be aware of your own anxiety, to be aware of your own concerns, is really important for your health, for if you have family to take care of and then for you to be able to take care of the patient that you see. Also, to be a positive advocate so that you are protected to be able to do the job. Be smart about the job and be an advocate to be able to get the things that you need so you can do the job, so you can live to do the job. It's very important.

Erik: Okay, yeah. No I agree. So we kind of already covered this, but what would you kind of summarize is the kind of experience you want students to get out of the Compassion and the Art of Medicine course?

Dr. Fields-Gilmore: You know every year, I think it ends up being different because it takes, actually it takes a life of its own. As far as the theme, I start off with saying I think I want y'all to do to talk about each speaker, and then for some reason they all end up having a theme that goes together. And they don't talk to each other. I've said this before, I'm like, they don't talk to each other, they just ended up, that year ends up being about; this last year we ended up talking about homelessness a lot. So basically, for the course I talk to the speakers and I just, I go to them and I ask them to talk about different thinking for as far as what they, where they're coming from. So if it's a clinician, you know talk about these types of experiences. If it's, if it's, because sometimes we don't have just physicians, we have different types of people in the community coming in, and I ask them just kind of because you want people to talk about what they're good at. And that's how I approach the course each year, and it ends up being just really good. Because I don't, I try not to, I try not to control too much of what they're gonna say. I mean of course I say, you know you can't be saying a whole bunch of stuff that you're not supposed to say. You know, these are students! Don't be unprofessional, but, and because you know that’s what is so great: we all want to talk about compassion, we all want to talk about the stories, the antidote to stories that we have about our experiences with these, with our patients, and with the people that we interact with in the community. We all want to do that, and we don't really often have a chance to. And I'm not sure if a lot of people are able to talk about these things at home. You know, you gotta adhere to HIPAA, but you don't really have an opportunity to talk about that too much. You just keep doing the job, and so a lot of doctors and a lot of people in healthcare love talking about their experiences and imparting that wisdom. So I guess that's kind of a lesson in and of itself: the approach, instead of like having a set agenda, you kind of let the speakers to a certain extent help bring the agenda in the same way you should probably act with a patient. You don't just come in and say this is how this is going to be, you kind of see where they're at and let them help participate in the encounter. 

Erik: Okay, that’s very good. Well, to switch gears a little bit, to more generally talking about health care, we were curious if you have any thoughts on the contrast between private and public health care? Yeah, and just what your experiences have been in those spheres.

Dr. Fields-Gilmore: In private healthcare you have a lot more leeway than in public. Because you have some limited resources, you kind of have to make decisions and decisions are made for you about what can be done because of the limited resources of limited funding. Both if you're serving the underserved, you're serving the same population, okay same population the private sector. And like when I was working as a national health corps scholar and I was in the rural areas, they didn't have access to the gold card in Harris Health, right? They didn't have access to the Harris Health system because things like the Harris Health system exists in a lot of major cities. There's the, I think John Peter Smith or something like that in Dallas. So you've got that in a lot of major cities, right? Where the underserved can have access to care and they don't pay very much at all, but in the rural areas they're resilient. When I was in Laredo, when people needed procedures and things they would have bake sales.

Karl: That's great! I love that!

Dr. Fields-Gilmore: Yeah, they have bake sales to pay for that cholecystectomy or something like that, you know. And it's a different approach, the population, depending on how they get, how they have to go about getting what they need, you're gonna have a different type of mindset in your patient, right? And so you if you think about that, because if you have access to something, you're always able to get lab work and images and health care, and you don't really have to pay for it as opposed to, in order to get that lab work you have to find the money, you got to ask family members, you gotta have a bake sale, you gotta, you know, go to the church. So it's just, it was different experiences. Public health and public access to care and private, but both, I was serving both in both areas.

Karl: So would you say it's kind of like, for the underserved population specifically in kind of the public health system, you can not worry as much about the cost for basic kind of care things, but maybe you don't have as much freedom, whereas in the private the main concern is, “How are we going to pay for this?” but we can kind of do whatever I think is going to work best? Does that kind of make sense?

Dr. Fields-Gilmore: A little bit, but not, you know that might be five to ten percent. Because you're still worrying about money, okay. You, with the patients worry about the cost of things either way, okay. Because again, because in the public sector there's no, there's not a lot of funding. There's not a lot that they're going to get, right? This is what you get, and so then they end up having to figure out what are they going to, how can they get the money to get what they need. And then who do they access. Because they're so used to having this system where they have this access, this easy access to this; now they got to figure out, “Well who in the private sector can they contact?” Do they have a sliding scale? Are they going to work with them financially? And all of this other kind of stuff. So those are those challenges. And then they start thinking about, “Let me have a bake sale.” 

Erik: Are they the same? I mean, I guess this is probably going to depend on obviously each private and public hospital or clinic you're working at, but do you find a similar amount of like patient load in each one?

Dr. Fields-Gilmore: Yeah, you do. It's just a lot of people who need, a lot of people who are in need either way. 

Erik: Yeah okay.

Karl: I guess this is another thing we touched on a little bit, but just and kind of in general, how do you feel uniquely as a doctor we have power to impact the local community in a way that maybe somebody in any other position in the community doesn't?

Dr. Fields-Gilmore: I think that if you know and you learn and you're training how to make those connections, and you learn how to not just think about going to work. So that's why in the course, I try to have different types of people come and speak different perspectives. Because if you're not careful, you as a training physician will only think about, you'll have tunnel vision basically; like this is when you have a lot of different ways in which to get some things done. You can collaborate with a lot of different types of people and just have a lot of different connections and have a broader network. And so that's really important in order to get stuff done that you want to get done, that you need to get done, and then when things come about that you see need to be done in a community or with people and patients, then you have that network and connection and you can hopefully make it happen. I mean, and that's why I tell y'all in the class, sometimes it's not gonna work out right. Do not take that home and let that eat you up, because you know we're only human and you do the best that you can with what you have. But if you work really well at making connections with people, then you'll have more access as a physician and then hopefully you can get some things done when the time comes. 

Karl: And I guess that kind of ties back in with the concept of self-care…

Dr. Fields-Gilmore: Right!

Karl: And making sure you're taking care of yourself, because if you take care of yourself you're going to be more likely to love your job, enjoy your job, have the energy to make those connections, just do those initiatives to really push to get things done for your patients in the community. 

Dr. Fields-Gilmore: You're gonna care! 

Karl: Yeah exactly. Yeah little thing called burnout we're trying to avoid.

Dr. Fields-Gilmore: Exactly.

Karl: So I guess we're getting close to the end of the interview, doctor. We really do thank you for your time, but we do have one last kind of big, broad question for you which is: just how do you think we can most effectively demonstrate compassion  in our daily lives towards patients, towards the people we interact with in the medical field, and just in general? Like, what is compassion to you and how can we demonstrate that to others most effectively?

Dr. Fields-Gilmore: I think the most important thing to have to be able to demonstrate that compassion and to have it there at your fingertips is to always reflect that upon yourself, your family, your own experience. Think outside of yourself, think outside of your family, think outside of your own experience, and then say, “What if that were my mom, my son, my daughter, my, you know, what if that were me?” And then go from there, because you know, you, like I say in the class, you're gonna be tired, especially as a training resident. You're gonna be really tired and you're gonna have a lot to get done in a short amount of time and somebody's gonna be trying to give you their whole life story sometimes. And you're going to have to take the take a seat and take a moment, and you may not be able to sit there, listen to the whole story. But like they tell you when you're training, the history is the most important thing, right? You got to listen and even if you don't get the whole story right then and there, at some point you're going to have to listen. And sometimes you don't want to listen, because listening is the hardest thing to do. And then when you're really tired, you really don't want to listen you, just want to get it done. You just want to get the labs on, you want to get the images done, you want to figure it out, but sometimes you can't figure it out from the labs and images because you hadn't even sat down to talk to the patient. So just remembering that if it were you how would you want to feel, and I think it's also important the more experiences you have. I've been a patient, you've been a patient, you know, you were a kid, you were, you know, a pediatric patient, you'll be a patient as you grow older, and as you grow older you're going to have more experiences with the health care system because that's just the nature of growing older. And I think that's one of the reasons why a lot of your older doctors typically show more compassion, because they have more experience with the healthcare system as a patient. I think that's something that we all need to remember, and it's really hard if you don't have experience with healthcare as a patient. It's hard to understand when I'm talking to my students at residency, and there'll be something like, I had a preceptorship, I was precepting a resident and this patient's legs were like swollen and when your legs are swollen, yeah they hurt, I mean. And if you've never experienced that, you don't know that. So if, you know, my residents are like, “Oh we're just going to do this and just send them home,” and I'm like, “Have you ever had your leg swelling like that!? That is painful!” Like no, we're not just gonna do that. So that's important, to just think, “If I had this situation happening with me or if it was happening to my mom or my grandmother or my brother, you know, how would I, what else could I make you do?” You know, and one of the things is just asking more questions outside of just the health questions, you know, “How are you feeling?” That's “How are you feeling?” like “What's your pain level?” But “How are you feeling,” right? One of the things that I am learning consistently is with patients, it's not how you make them feel but how you make them feel. Yeah okay, so patients remember that they remember how you make them feel, because our goal is to get those numbers right. Our goal is to get those labs right. Our goal is to, you know, if you're a surgeon, you're going to fix it, but how do you make them feel? 

Karl: I mean I've already seen that a couple times in my very limited clinical experiences where sometimes it's like, doctor, in your example, “My legs hurt,” right? And yeah, they want you to stop their legs from hurting, but they also just want to feel like you actually care about them, you actually are empathizing or sympathizing. You're there with them in the struggle, and yeah. I get what you're saying when it's not about how they feel, it's about how they feel, you know.

Dr. Fields-Gilmore: Yeah. Exactly.

Erik: Well, I think that's really great advice for anybody, for everybody that's practicing medicine. I think we could all work on being a little bit more empathic. And so we really appreciate you taking the time to talk with us, because we know that you're busy right now. So yeah.

Karl: Please stay safe, you know. We appreciate what you’re doing.

Dr. Fields-Gilmore: Yeah yeah. Y'all stay safe. Y'all keep learning and listen, we're going to get through this Covid 19 pandemic. And we're going to have so much more information, it's kind of, I mean it sounds, it's kind of interesting to learn all this stuff, and we're learning things every single day. So that's what we kind of as scientists and physicians and, you know, and if we like that kind of stuff, but we don't like it the way it's happening, okay? We would rather not it be happening this way. So we're going to get through this. We are, so just stay safe, and you know, take care of yourself. Take a walk, do some exercise, drink plenty of water, and get some sleep.

Erik: Exactly. Well thank you.

Karl: Thank you very much. 

Dr. Fileds-Gilmore: Alright bye-bye.
[Music]

iTunes | Spotify | Google Play | Stitcher | Length: 38 minutes | Published: May 21, 2021

Dr. Anthony Maresso and Dr. Barbara Trautner will give their insight into the use of phages to combat the epidemic of antibiotic resistant bacterial infections today.

Transcript

[Intro melody into roundtable discussion.]

Juan Carlos: And here we are this is the Baylor College of Medicine resonance podcast. I am your host Juan Carlos Ramirez.

Sabrina Green: And I'm Sabrina Green.

Juan Carlos: And Sabrina is the head writer of this episode. And today we're going to be discussing phage therapy in the 21st century featuring Drs. Anthony Maresso and Barbara Trautner. But before we interview them we want to give you a little a little background. Sabrina would you mind kind of sharing what our phages anyway?

Sabrina Green: Sure! This is my favorite topic so phages or shortened for bacteriophages are viruses, but don't let that keep you from don't let that put a bad image in your mind because these viruses only infect bacteria. They don't infect human cells. And they're the most abundant biological entity on the planet and you'll hear in the interview a little bit more about phages. But right now just giving you a basic overview. There's estimated to be 10^31 phages on the planet. So this is more than anything, like if you combine bacteria human cells everything it's still not as much as there are phages on the planet.

Juan Carlos: And it's like what like Avogadro's number? When we think of viruses or bacteria phages and we always think like terrible things, especially right now, right? So this recording is taking place at the time of the coronavirus, right. So when we think of viruses we think of, you know, catastrophe and illness and but very rarely do we think about them being used as like treatments or in clinical setting.

Sabrina Green: Right and that’s why I think sometimes they can get a bad name. But these viruses have been studied since the 1900s and there have been no instances of phages ever infecting a human cell. So they're completely bacteria infecting viruses and they've actually when they were first discovered they were used for phage therapy. So phage therapy is
using these viruses to treat infections in humans or animals.And this actually predated antibiotic. So antibiotics the discovery of penicillin was in the 20s and so phages were actually being used in the US and in other countries before even antibiotics were discovered and continue to be used in the Republic of Georgia at the Eliava Institute. So here in the US they actually aren't they are not FDA approved for clinical use but they are used in agriculture and they're considered GRAS or generally regarded as safe. So very safe, but still we still need clinical trials in order to get them FDA approved for clinical use

Juan Carlos: I wonder what it takes to get them approved? I think its got to be like a lot of fear. and you know now I think we're just very scared of them.

Sabrina Green: If phage were just discovered today I think it would be a lot easier but because and it's funny though because we have so much research so much data out there about phages with the history of it still kind of makes it harder for it. I believe this is my opinion, for it to be approved for clinical use but like I said, if you were to discover it today, I feel like people would be just amazed and excited and we would start clinical trials right away.But in the U.S. It's still considered experimental. There are centers though that you can get phage therapy. Like if you have an antibiotic-resistant infection and you've taken antibiotics and there's really no drug that seems to be working you can get experimental approval for phage use and that is how these centers are actually getting patients to be treated with phage.

Juan Carlos: Cool. Well, I mean I'm pretty new to all use the use of bacteriophage in these clinical trials and to treat people with resistant bacteria. I'm hoping to really learn a lot more today through Drs. Maresso and Dr. Trautner!

Sabrina Green: So that's the history. So what are we doing now with phage at Baylor College of Medicine? So we have TAILOR or tailored antimicrobials and innovated Laboratories for phage research. This is a service center at Baylor College of Medicine that's developing phages suitable for clinical use to help treat these vulnerable patients that get these antibiotic-resistant infections that nothing else can treat. They're also providing phage for other uses too in agriculture for instance. So joining us today will be Dr. Anthony Maresso. He is an associate professor at Baylor College of Medicine and he came from he got his PhD from the Medical College of Wisconsin, and then he got his postdoc at the University of Chicago in 2008 and shortly after he joined Baylor College of Medicine has been working in bacterial pathogenesis mostly but recently has been working with phage. So treatments for antibiotic-resistant infections using phage.

Juan Carlos: And we'll also be joined by Dr. Barbara Trautner who received her Bachelor of Arts from Princeton University her MD from the University of Virginia medical center, and she is currently a clinician at the VA Michael DeBakey Medical Center. She is a professor of Health Sciences services and research she is also a professor and director of the clinical and Health Services Research and she's board certified in Internal Medicine and comes very highly decorated with numerous awards and it's a pleasure to have them both here. So without further ado, let's get into the episode.

[Intro melody into episode.]

Juan Carlos: Welcome.

Anthony Maresso:  Thank you for having us.

Sabrina Green: Can you both tell us about yourselves and how you got interested in science medicine and research?

Maresso: Barbara you can go first.

Barbara Trautner: OK, I’m Barbara Trautner I’m an infectious diseases physician in the clinical practice at the Houston VA. I became really interested in research really late. Along the ways when I was an infection diseases fellow. And I was required to do a year of research. But I found the research was so directly relevant to improving my patients care. That really touched off a love of research that eventually inspired me to apply for career development award in the NIH followed by one from the VA and eventually completing a PhD in clinical investigation.

Anthony Maresso: My interest in science started when I was actually very, very young perhaps three or four years old. I recall being fascinated by the natural world in particular animals and reptiles and my father used to take me fishing my mother too at times and when I when I recall was maybe being four years old and catching a fish and just remarking at how slimy it was and wondering why it was that way. Why did it need to be slimy to be in water? And I don't think I've ever sort of wavered in my interests since then. I knew that I wanted to do something that would allow me to interrogate the natural world and so science was a way for me to do that. The interest in medicine. That is applying science to the benefit of alleviating disease in humanity occurred somewhat later. I wanted to be for the longest time a veterinarian, but then I worked in the veterinary clinic and I found that that was something that wouldn't allow me to dig deeper into real problems and then my mother got sick. She was diagnosed with lupus.

And when I recall from that was that she had really no ability to explain what was happening to her and neither did her treating physicians and that's when I sort of realized that I could use my interest in science to try to enhance levels of knowledge for things like this. Research is just a natural extension of that. So everything fell in line from that point forward.

Sabrina Green: Thank you very much for answering that how did you and I'll start with Anthony first get involved with phage research? And what do you find most interesting about phages or phage therapy?

Anthony Maresso: So to be to be honest, I've been I've been interested in phage ever since I was a postdoc at the University of Chicago, but sometimes when you get into research you are you have to sort of work on what the environment that you're in you have to kind of work within the confines of that environment. And so I've always had my eye on kind of the properties of phage because they're so such fascinating little, little creatures, but I had to be practical in being able to do the science in the particular lab I was in. So I've always had an interest in it from that point forward, but I came into it more concretely when my colleague here, Dr. Trautner and another colleague of ours a virologist Dr. Ramig sent to me a proposal that they wanted to submit to I believe it was the NIH and in that proposal they described how they were gearing up to use phage which are viruses that attack bacteria and they're very good at killing bacteria as a possible treatment for infections with a bacterium called Pseudomonas aeruginosa, which is particularly troubling for those that have Cystic Fibrosis and are badly burned. This organism can exist in those environments and infects those wounds. And I knew that at that point that this was the sort of an opportunity to finally get involved with my laboratory in this field of research because I had some extra seed money that the college had given me to do that.

And so it was just more or less an opportunity. An interest early on but not being able to take advantage of the opportunity until presented to me and Dr. Trautner and Ramig with an initial grant seeking my expertise really in bacteriology, which is my primary field of interest allowed me to then enter the field and it's been wonderful since then.

With respect to phage therapy goes back to the to what I started with when I talked about how I got interested in science, which is phages are are this, perhaps the world's greatest predator of bacteria. Antibiotics are often what people think of as killing bacteria, but phage have been co-evolving with bacteria and learning how to infect their cells for nearly two billion years. And so they've in essence perfected this process and so if one thinks sort of outside the box a little bit one realizes that phage can be potentially used is a way to control bacterial populations. And to clear bacterial infections even but the real the real benefit of phage unlike sort of chemical antibiotics, which do not have the ability to change in real-time. Their chemical structure is fixed in space and time. Phage are not bound by that limitation because the basis of their change is mutations in their nucleic acid, and they will acquire mutations with time just in their normal replicate of cycles and some of these mutations can be used to our advantage to improve the ability of a phage to target a particular bacterium and actually makes it make it more efficient at killing. And so the real difference here is that phage can be evolved in real time and adapted in real time to confront bacteria in real time. And it is this advantage that bacteria have used against us the fact that they adapt so quickly to our antibiotics become resistant to them and render them inefficient. But phage can be changed in about the same amount of time bacteria can and I think it's sort of incumbent upon us to explore the science of whether that can be used to develop antimicrobials to bacterial to treat bacterial infections in patients were antibiotics of sort of not been able to help them.

Sabrina: Dr. Trautner. Do you want me to repeat the question?

Barbara Trautner: Phage research has a little bit of a serendipity in it and maybe also a message to our students about how to prepare to go to scientific conferences because there's no science to preparing to go to a scientific conference so that get the most out of it. I was working with probiotics a benign E. coli as a way to ideally prevent urinary catheter colonization in persons with spinal cord injury and thus prevent symptomatic catheter-associated urinary tract infection. But I got really nervous what we're good probiotic because it was a weakened strain of E. coli, but I thought it could make people sick in the right setting. So then I said look at colicins which are antimicrobial product secreted by the E. coli that can kill other strains of E. coli because of the colicins are really just parts of phage that have entered into E. coli genome and that it makes these phage parts that kill other strains of E. coli.

Well, so it's pretty easy for me to get from there. Wouldn’t it be really cool to work with phage as a way to kill the resistant bacteria in people’s bladders that are causing UTI? And  then I looked up phage I didn't have a background in anything related to phage. I look them up on the web and I couldn't believe how cool they looked like they were the coolest looking little animals. And Anthony said he wanted to start out as being a veterinarian. Actually I did too until I realized animals couldn't talk to me and then I switched my sights to being a doctor.

Phage are the most amazing cool animals and kind of like the bacteria. I feel like they could all be my pets just like all the bacteria that I worked with. So the way I really got in the phage research though is why you have to prepare for scientific meeting. So I was going to a meeting on device-related infections and I think I had some little piece to present but I was clearly the junior person among the presenters. So I looked up every other presenter and their last two papers and one of the people so I could have conversations with them about their work. It was a small conference room about 25 speakers. So one of the people I looked up have been doing studies with trying to prevent urinary catheter colonization by the pseudomonas just like I was studying that he was using bacteriophage for it. And so we struck up a conversation. He worked at the CDC eventually I sent my research the technician from my lab to his lab learn how to work with phage and it was all because I had read his papers before I went to the conference and heard him speak.

Sabrina Green: Cool. I didn't know that story. Thank you!

Barbara Trautner: Yeah, I can shoot original papers by Rodney Donlan. He's at the CDC and the first author is Fu and it was a bacteriophage cocktail to deal with pseudomonas colonization of urinary catheters. I just couldn't believe how relevant it was to my own work. They were working with the same silicone type catheters. They were using real urine. They had encountered a lot of the problems I had encountered and so we really had a great conversation that took off from there.

Sabrina Green: So actually phage therapy has been used before and it's still used in other countries. Why do you think it is not in use in the US but still widely used in Eastern Europe and are there actual roadblocks to getting phages approved for use in the US and what do you think these roadblocks are? I'll start with you, Dr. Trautner.

Barbara Trautner: Yeah, people don't trust it. And I think it's because not only did it come from Eastern Europe, but until very recently they were not good clinical trials and there were a lot of people a lot of the phage studies are a little bit like some of those overly zealous case series you see of weird things like vitamins or something. That just doesn't end up working. To be specific, I got a email from someone wants help with their mother who's got a just organism in a wound and they're looking for help with treatment and I said we would be glad to help but I really need to talk to your treating physician first her treating physician first so I can look at the situation see is that, you know amenable to phage work. I gave my cell phone number and asked the doctor to give me a call. I haven't heard a thing. I mean, they're just suspicious of phage. They won't give me a call. I try to reach out to them. I think cause they're alive. I think people don't know what it is. And there's a lot of quackery out there that gets mislabeled as appropriate medical care and I think phage are getting lumped in that group, unfortunately.

Sabrina Green: So you think a lot of doctors feel that way or just the general public?

Barbara Trautner: Oh, no, I think it's doctors. I don't think the problem is with the general public. I mean, you know you have those are the radio and they managed to convince the general public that all sorts of things are good for your health. I think its doctors and the suspicion of a living organism. I think people hear experimental and they think I don’t have time to mess with that. I don’t want to do that. And I get that. I mean I'm a practicing clinician. It's so hard to find time in your day to do anything even slightly different because you're very overwhelmed with what it is. You got to get done that day. So we need to make it really easy for practicing clinicians to access phage therapy that is experimental with us doing the work for them.

Sabrina Green: Okay. Anthony.

Anthony Maresso: Yeah, I would agree with Barbara and what she said, but I would also add that. I think there are two other major driving factors that have sort of suppressed phage science and phage therapy and in America. Not directly suppress. This is just a sort of an indirect product of just what happened. The first is history. So phages  were discovered in the late about 1917, 1919 by two scientists and they described this unique activity where they could see a clearing of bacteria on a plate with some bacterial extracts and drop of water and they wondered there is something in this that's killing these bacteria and so it wasn't really realized till much later about 20 years later these actually viruses that do this, but we now know that they were they were in fact discovering and finding phage and so it became this because bacteria were killing people on at a regular rate. I mean normal healthy people would die from bacterial infections and scourged children, for example, all over the world. There was great hope that this thing that was discovered was somehow going to prevent people from dying from bacterial infections. And there's even a book Lewis Sinclair. It's called Arrowsmith. They describe this process where this guy discovers basically what it amounts as phage. He's going to use it to save the world from a plague-like bacterium. And then what happened was people jumped into it really quickly industry sort of jumped into it. They didn't really know what they were working with. This was before the time of like very controlled trials. Very controlled science very wild west type of ways of doing scientific and it many of the early investigations of the use of phage didn't work. And so the American Medical Association essentially wrote it off as being too inconsistent, but the reason it didn't work is because of the nature of what it actually is. It's a complex organism that goes through a life cycle of infecting bacterium. And you have to understand that life cycle to help make it work. Now let's flip to antibiotics. Penicillin the activity of that drug was discovered in the late 1920s. That story is well known about the growing of the mold on the plate in a clearing bacteria. So what happened was there was an excitement around that. But it took 20 years almost 20 years actually about 15 and World War II soldiers were getting infections on their wounds with bacteria for a company to actually figure out how to synthesize penicillin chemically in the lab. Once that happened that changed the course of modern medicine because it became evident that you could very quickly make chemicals that killed bacteria, and it could be standardized and then that could be scaled up and you can treat millions of people by doing that.

And so everybody that was sort of a pharmaceutical company at that time jumped into this exact process. Find chemicals that destroy antibiotics synthesize them and standardize it and then scale it up. And that's the Golden Era of antibiotic discovery and making what we call the classic years of antibiotic discovery. But no one really realized that one day that bacteria would become they would change and throw that entire industry on its head. But society got ingrained in that process in that mentality that you had to make a medicine. It had to be a chemical structure. It had to be standardized and it had to be scalable and that's the only way you would make new medicines, right. So a lot of it really is history. This is what society sort of accepted whole generations believe that this was the way to do it and when you grow up thinking that that's the way you do it and something else is offered as an alternative. It's hard to change. In fact, you have to have a generational change in thinking for the sort of that to become the realization and a new way of doing things. But I think the other reason which is a lot less sort of lengthy of an answer is phage every phage in and of itself is a different biological entity and you cannot apply a universal process to all phage. And when we in fact try to do that, it fails we have to understand the properties of individual phages and tailor them to specific infections and to specific diseases. And that is where we will find the consistency. We need to sort of get excited about this as a treatment.When the old model is applied to phage like antibiotics, it doesn't work. So in order for phage to sort of become accepted we have to sort of reinvent a new model to evaluate them from and so it's really a two-part answer.

 Sabrina Green: So what do you perceive to be the future of phages and they're used to treat infections in humans or animals? And can you talk a little bit about TAILOR which is a project that maybe Anthony can talk a little bit more about. So, Dr. Trautner.

Barbara Trautner: The future of phage. It’s uncertain. It’s truly uncertain. I spent a lot of time thinking about it. Sometimes I jot down notes in the car. How would I have applied phage in this clinical situation. I’m on the medicine team right now at the VA. And I think about where would phage have helped us and where would they have not helped us? They have such a narrow therapeutic window. And the bacteria and phage tend to co-exist. So any particular bacterial strain is going to become resistant to the phage its exposed to fairly fast. So I feel there's going to be certain clinical scenarios where they're very helpful. In a few doses maybe for stabilization, but maybe not so much for most of the longer-term treatments and then there are other settings where someone suffering from an intractable infection is gone on for a long time and we may be able to tailor phage that help us and that's just help us gain ascendancy with the person's immune system working together along with antibiotics.

I don't think they going to have, they are not going to be a replacement for antibiotics. They don't work the same way as antibiotics and we're going to have to have very good clinical trials that are rigorous that test phage in these very various scenarios before we see them come into practice. That’s why I thought about the future.

Anthony Maresso: Yeah, and I'll bet that I agree and I would add two additional parts, which is I think there's a scientific part and then there is a medical part. I think the scientific future of phage that is the sort of study of phage is going to be rather robust. It's estimated that there are 10^31 total phage on planet Earth. Which is more than the noble amount of stars in the observed universe. Each of those phages estimated they have 70% of its genome uncharacterized. And in fact those genes have no annotation or known resemblance to anything that are in the databases. So one really interesting scientific part of phage research is we can use phage as the largest repository of unique biology on planet Earth. The genes that they encode are likely completely unique because of what they have to do to prioritize their life cycle dominant over the bacterial one.

And I think that will be a rich source of scientific investigation in the future. The medical one is going to be I think bore out by the science as Barbara mentioned clinical trials, but also the basic science needed to investigate how phage work whether they synergize with the antibiotics what elements of phage will be more effective and what context can we apply the phage to. I think when the research is performed and we have more answers along that line will have more clear answers as to what the future of sort of phage therapy will be.

Would you like me to comment on TAILOR?

Sabrina Green: Yes.

Anthony Maresso: Okay. So it's I'm glad that I have the opportunity to talk about something that we've done in the laboratory, which is this TAILOR initiative which stands for tailored antimicrobials and Innovative laboratories for phage research. So what Baylor College of Medicine is done is they've sort of taken some of our work and decided that they would invest in it. And so we were able to create this initiative whereby if anyone has any particular bacterial problem, and it doesn't necessarily have to be an infection of a patient an agricultural problem where bacteria are a nuisance. It could be an environmental problem contamination or just interest in phage biology in general, but certainly as it also applies to clinical medicine. What we're able to do is use basic science techniques to sort of enhanced properties of phage. Use directed evolution to make phage more specific to a specific bacterial problem and then learn about how we can adapt that to solve problems that bacteria cause in the real world and it's a great team of young scientists in my laboratory. Sabrina is a part of that. Dr. Trautner is a part of that. Dr. Ramig a virologist colleague is a part of that and Dr. Terwilliger who is the project manager and what we hope is that people will come to us with bacterial problems.

And sort of work with us to find ways in which we can apply phage to solve those problems. Maybe we'll get lucky and we will solve some of them problems. But what I think will come out of it is a lot of basic science that will help us learn about how we can tailor phage to be better at solving some of these bigger problems. And then also learning just about the natural history of phages. They co-evolved with bacteria, which is a fascinating topic.

So physicians that are out there that are listening to this. If you have a challenging clinical case where antibiotics are not going to work or they've been tried and there's really no other hope the FDA does allow in some cases the compassionate use of experimental therapeutics to try to save the life of patients. And in this case, we could adapt our phage to the specific bacterium that your patient has make sure it's safe and clean and doesn't have any undesirable properties and is efficient at killing at the bacterium and we can ask the FDA for permission to be able to use this as an experimental therapeutic for your clinical case. And that's one of the components that TAILOR is trying to bring so if you're interested in those possibilities, you can contact myself or email the TAILOR Group, which I think there might be links and stuff embedded in this podcast or you can contact Dr. Trautner as well. We'd be happy to try to talk about how we can help.

Sabrina Green: Okay, the last question since this podcast really goes out to students who are probably looking for labs to rotate in. Can you talk a little bit about the way that you approach mentoring you both have won awards or gained recognition for being really great mentors as well as researchers. So, Dr. Trautner, can you talk a little bit about your mentoring approach?

Barbara Trautner: I'd be glad to. Mentoring is my passion. I have several passions, but that's certainly one of them is one of the best things about being an academician is the opportunity to mentor why it means so much to me is because I was so lost as a fellow as an infectious diseases fellow. I felt that I just didn't know where I wanted to go next with my career. I had a young child. I had no sense of why I was bothering to complete the fellowship because I didn't know my career goal. I didn't really have a sense of what academic medicine would mean and I was saved from that morass by a really good mentor who was our ID section chief new at the time and met with me and basically sat me down and said to me Barbara you're destined to be in academics. This is what you're going to do and it was so helpful to me. I stayed in the fellowship. I did an extra year to learn how to do research. I applied for the career development award, ended up in the Ph.D program all because of that one good Mentor followed by subsequent really good mentoring team. So I want to deliver that to other people. I don't want them to feel lost like I was so I like to work a lot with people at the postdoctoral level, which is the clinical fellows because they still can take so many different career directions and they can use so much guidance in that but I have mentees from all levels including some in high school.

Anthony Maresso: It's very difficult question to answer but I think what I would say was there's just no greater honor than being able to being able to train the next generation of scientists. These individuals are going to be the future leaders of our country. And they will be the future leaders of our planet and we have some really big problems to solve not just in medicine but in population explosion, in averting wars, sustainable agriculture and probably at some point in the future interstellar travel. And all of that is going to require capable scientists and I view my role as just sort of passing the torch on.

If I had to give advice about an approach to take and I'm not so sure that this is the best approach but it is what has worked for me. It is that I think you have to have an absolute belief in the people that you are working with you have to believe in their skills and their talents and in their determination and that they are going to try to find ways in which they can better improve the state of all humanity.

That's going to be different for each individual person and you have to have a personality that is able to resonate with each of their individual personalities and never ever give up on them. That's a rule that I steadfastly go by is that you have to try to find what they're really good at enhance that and subtly try to improve upon their limitations and it is different for every person. It's an individual challenge of itself and I have to say that it is much more challenging than the science itself, but it is the most rewarding part by far.

Sabrina Green: Thank you, both for talking. But thank you. Dr. Anthony Maresso,  Dr. Barbara Trautner. I'll talk to y'all later.

Barbara Trautner: Well, thank you for including us for organizing this thank you Juan Carlos for working with us.

Juan Carlos: It's been a great pleasure having you both. It was a pretty awesome. I always learn something new and I'm just kind of pretty fortunate to be part of this effort. Thank you so much.

Maresso: Thank you.

Trautner: Okay, thanks. Appreciate it.

iTunes | Spotify | Google Play | Stitcher | Length: 50 minutes | Published: April 9, 2021

Dr. Andreas Tolias discusses his journey into artificial intelligence research and how he and his lab are developing cutting-edge algorithms from discoveries in neuroscience to better understand the brain’s perceptual inference and decision making, along with the many challenges. Dr. Tolias and his lab have one goal: to harness the algorithmic power of the visual system to generate the most cutting-edge algorithms to better analyze data and gain deeper insights into the mysterious and mathematical complexities of the most evolutionarily advanced sensory organ.

Transcript

[Intro melody into roundtable discussion.]

Erik: And we’re here. 

Juan Carlos: Here we are again. 

Erik: Yes. So, uh, this is the Baylor College of Medicine Resonance podcast. I am one of your hosts Erik Anderson.

Juan Carlos: I am another host and the lead writer for this episode, Juan Carlos Ramirez.

Kiara: And I am another host, Kiara Vega.

Juan Carlos:  Along for the ride. (All laugh). 

Kiara: Along for the ride, yes. 

Erik Anderson: Kiara is going to educate us about any Neuroscience that we get wrong in this.

Juan Carlos:  Fill in the gaps for today.

Kiara: I hope my PI is listening – (laughs) – so he can be proud. 

Juan Carlos: Yeah, ‘cause today we'll be talking about the advent of using methods in artificial intelligence to understand the brain and Dr. Tolias will discuss his journey into artificial intelligence research and how he and his lab work developing cutting-edge algorithms from Neuroscience work to better understand the brains perceptual inference and decision-making.

Erik: Man…yeah…

Juan Carlos: Ooo!

Kiara: Yeah, that’s a lot.

Juan Carlos: Yeah, so I guess it would make better sense to start off by defining artificial intelligence and when it began. It’s, it's like a buzzword in everything nowadays. The theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages – sort of, the Inception of artificial intelligence was created to tackle these problems and the first development of the electronic computer was in 1941, which was followed by the first stored computer program in 1949. A man by the name of Norbert Wiener was the first to theorize that all intelligent behavior arose from feedback mechanisms. And they, after that the Logic Theorist designed by Newell and Simon in 1955 was considered the first AI program to ever be created and subsequently, Dr. John McCarthy, which is well known in the computer science and machine learning environment, is an American Computer scientist who coined the term ‘artificial intelligence’ and held its first conference in 1956. So, we're going to way back in time. 

Kiara: Yeah.

Juan Carlos: So, it's nothing new, really. It's just now we're figuring out ways to use artificial intelligence, especially in the biomedical space. Yes, that shows a lot of cool promising techniques. So, how has artificial intelligence changed the way we approach biomedical research and life in general? Well, hopefully, Dr. Tolias can answer a lot of these and in the cutting-edge world, but in general, the use of machine and computer vision, speech recognition, language translation, monitoring tools and robotics, and healthcare, financial investing. It's, I mean, it's everywhere.

Kiara: Everywhere.

Juan Carlos: But recently, we’ve made lots of strides in the biomedical space.

Kiara: and another development that I know that AI is being groomed for is Diagnostics, like, to play a very big part. 

Juan Carlos: Yeah, especially when we have, nowadays we have so much data, you know, so much data. We don't know what to do. We have to parse through all this data and it could take lifetimes for a one sole human being to accomplish in one PhD but the data analysis in biomedical research has really accelerated the pace at which we analyze data, and it really has fostered discoveries unattainable by previous methods. Dr. Tobias’ lab utilizes a subset of artificial intelligence called machine learning to decipher the network-level principles of intelligence. He is part of this collaboration of neuroscientists, physicists, mathematicians, and computer scientists focused on brain research for a machine intelligence to engineer a less artificial intelligence. This group is called the Neuroscience Inspired Networks for Artificial Intelligence (NINAI) or NINAI, right? 

Erik: So, it sounds like artificial intelligence you’re just saying, that you know, is a computer. Like a logic machine that is artificial. 

Juan Carlos: Yeah, artificial intelligence is kind of an umbrella term for using machines, right? Computers, right? To perform tasks that otherwise humans would normally do, right, but to a much better degree.

Erik: Yeah, because I mean that was in here when you were talking, because you were talking about Turing. I imagine were talking about one of the first computers, because yeah, I think I always just had an amorphous idea of “Oh, yeah. I know artificial intelligence. I've seen Steven Spielberg AI films.” (Laughs)

Kiara: The robots!

Erik: Yeah, robots! Exactly. That's what I think. 

Kiara: That’s what I thought.

Erik: Yeah, totally but – 

Juan Carlos:  Sky Net!

Erik: But It really is just any computer, it sounds like, and then the Deep learning, is just, yeah, I guess, feedback mechanism that you can just feed. 

Kiara: You said that they use machine learning? Yeah, to reverse-engineer. Right? 

Juan Carlos: Right, right. So, to create algorithms that are going to – 

Kiara: - kind of put to extract the principles from the biology and try to – 

Juan Carlos: - understand how the brain just makes everyday decisions important decisions – 

Erik: - with the idea being, I mean, this is obvious, but anybody… I guess I'm not trying to come at anybody that hasn't made this connection, but the idea being that – (laughs) I guess I am – that the brain is a giant computer. (laughs) So, you can study it likewise. 

Juan Carlos: Yeah, and so he'll tell us a lot about his background, what brought him here, but I will have to preface the interview with: there's a lot of deeper learning – no pun intended – that one would have to, sort of, read up on to fully understand what he's trying to convey and it's an action-packed episode for sure. Just have to keep you on the edge of your seat. And then it's also very positive, right, for the future. So, there are a lot of good takeaways.

Kiara: It’s amazing, I mean, it's been called a ‘moonshot’ what they're trying to do in his lab. 

Juan Carlos: Really?

Kiara: Yeah, because, well besides the projects where they’re trying to reverse-engineer principles, biological principles, and then instruct machine learning algorithms. They're also trying to image the biggest volume of the visual cortex in mice that has ever been. But yeah, they, that's why okay, what they're doing is so amazing and it's so ambiguous that they have, they have the competency, the materials, and the people to just kind of make it work or that's the that's the goal. Right? It's very, very hard to do trying to do. 

Erik: Yeah, there is an MD/Ph.D in the lab, that I think just recently left but presented his data at my seminar and they call it like the ‘million-dollar Mouse’ because – 

Kiara: Platinum mouse. 

Erik: Yeah, the Platinum Mouse, is that it? 

Kiara: Yeah, that's it. 

Erik: (laughs) Okay. I'm thinking of the million-dollar man! 

(All laugh)

Kiara: Close enough!

Erik: I need to check my references 

Juan Carlos: in the future though. 

Erik: Yeah, in the future. 

Kiara: Yeah, Platinum mouse. Yeah, that's one of the mouse that they used to image the cortex. And they're actually like, reconstructing it. They have these collaborations with Princeton and other labs where they’re trying to reconstruct a 3D model with using electron microscopy. And then also 3D modeling these areas of the cortex.

Juan Carlos: Makes me want to join us live now.

(All laugh)

Kiara: Yeah, his lab is amazing.

Juan Carlos: Well, without further Ado. Let's prepare to get our minds blown by some very fascinating work in Neuroscience. Let's go to the episode. All right.

[Interlude melody]

Juan Carlos: Welcome everyone. My name is Juan Carlos Ramirez. I'm your host of the Baylor College of Medicine residents podcast. I am here today with Dr. Andreas Tolias. Welcome, Dr. Tolias. 

Dr. Tolias: Nice to be here.

Juan Carlos: I have to be honest. I've been, I've been kind of looking for this moment for a long time and I've been telling people “we're going to have Dr. Tolias come on the show for the second season” and when they ask me about you, you've done like so many things in such a short amount of time. It's kind of difficult for me to tell people exactly in a few sentences who you are. So, if you wouldn't mind could you explain a little bit about your background or yeah, where you went to school. 

Dr. Tolias: Yes, right. So, I did my undergraduate degree at Cambridge University in Natural Sciences and then my Ph.D at MIT in Systems and Computational Neuroscience and then some post-doctoral training in Germany at the Max-Planck Institute in Tübingen also in Systems and Computational Neuroscience. And I study how the brain works, how the brain computes information, and how it gives rise to intelligent behavior. Particularly, I study visual perception or visual inference, how is it that the brain is capable of doing all the wonderful things that enable us to see the world. Although this sounds like a very simple problem to us, it’s the exact opposite. It's actually a very complex computational problem. It involves large chunks of our neocortex – in some primates up to 50 or 60% of the neocortex is dedicated to processing visual information system. So, it’s mathematically very complex what it is trying to do. In my lab with my collaborators were trying to understand how these, what are the algorithms of the brain and how it implements them to give rise to intelligence. We think that these, if you want algorithms that learn, are going to be generic. There will be similarities with maybe some differences but similarities with other things that we do in cognition, decision-making, and other sensory perceptions. In parallel, we're trying to build models of the brain. These are sort of machine learning models or AI models that to try and mimic the brain’s capabilities. For example, we're trying to build a model that's capable of doing visual recognition of objects in par with what the human is capable of doing. So that's sort of our, if you want, the aim is to understand it at the systems level and computational level, but then test this understanding by building models that are then dealing with the real-world complexity in trying to solve, you know, these interesting problems.

Juan Carlos: Okay.

Dr. Tolias: So, that sort of, I think, describes…so of course you know I work at different levels of the systems. We go all the way from individual cell types: What is the function? How they’re arranged? How many cell types there are in the brain? You know, the molecular level: try and identify transcriptomally how they are, how they're assembled in circuits and how these circuits function, you know, when animals either see visual images or make perceptual decisions on those images or movies.

Juan Carlos: Wow. So, I'm more familiar with the wet lab side of research and you know most of the time when people go into the lab, they have their experiment, and they have certain readout that they're looking for. So, like, short-term and long-term goals. What does that look like in a day in life for you in your lab? 

Dr. Tolias: Yeah, so in my lab there is a wide range of expertise and it's a very collaborative lab.  There are people who have expertise in a molecular level, other people the cellular and systems level, circuits level, you know, doing uh, very complex in-vivo recording experiments where we can record on the order of 10,000 neurons simultaneously from an awake, behaving animal, using neuron imaging methods. And also, people with very strong machine learning and computational skills to help build models to help analyze this data. So, it's a very collaborative lab and each project, usually, you know, every person in the lab, whether a student or post-doc or senior researcher has their own particular project they’re working on but they collaborate with other people to get this kind of bigger pipeline in place so we can really finish a particular question or address it to a certain extent. So, it's not, you know, people work individually on their own project and some people are more on the experimental side, others are more on the computational side or machine learning side or AI side, if you want, but really most of these projects involve a lot of collaboration back and forth, people sort of help each other.

Juan Carlos: So, it sounds like you have almost every capability.

Dr. Tolias: Well, not all, but we also have an extensive network of collaborators here in Baylor, but also in Europe and in Canada and other places here in the United States. We work together because we do not have all the expertise locally. So, that works very well. Some people have more expertise in machine learning and deep learning or AI or people in microscopy and stuff like that.

Juan Carlos: So that's in your lab, but outside of your lab you work with physicists, mathematicians, computer scientists.

Dr. Tolias: Yeah, a lot computer scientists and physicists as you said. We have a very strong collaboration in Tübingen in Germany and another one in New York and Columbia University, Toronto University, and Cornell where there are some physicists there either working with the technical side of things or the imaging side or more on the computer side or deep learning side. 

Juan Carlos: So, you have all these people coming together to focus on Cutting Edge brain research projects. And is this, I think I’ve looked it up, it’s called NINAI?

Dr. Tolias: Yeah, so we have an organization that we formed a few years ago is called NINAI which is basically the umbrella organization that enables all our team that is very extensive. It involves people from the Allen Institute in Seattle, Princeton, Cornell, here in Houston Baylor, you know, Rice University Tübingen, Columbia University, New York, and Toronto the Vector Institute, and we kind of collaboratively work together in understanding how the visual cortex gives rise to inference. By inference I mean, like how it enables the brain to effortlessly recognize things like objects or compute the depth of objects that basically allows you to see the world. 

Juan Carlos: So, basically, it’s making these innate decisions that we kind of do very effortlessly.

Dr. Tolias: Unconsciously! That’s right! Experts call this unconscious inference. There something called the Moravec’s Paradox, which is: things that are very difficult for us like memorizing things or let's see playing chess or solving math equations to some extent.

Juan Carlos: Playing Go.

Dr. Tolias: Playing Go, you know, when they go on computers now in AI systems are much, much better than any human and they can learn very fast. There is for example, you can take a computer, even let’s say the size of your laptop program it using deep learning to solve how to play chess and beating the world champion in a few hours, which is quite impressive. 

Juan Carlos: Garry Kasparov was the first victim. 

Dr. Tolias: But now with deep learning its more impressive, but even more interesting if you create an image for, let’s say banana, you know, versus an apple you can effortlessly say ‘this is a banana’ or ‘this is an apple,’ but modern AI system, they're very easy to fool in ways that for you, it would be like a joke, you will never be fooled. This is called the Moravec’s Paradox. It seems that stuff that are innately easy for us or children, you know, how to walk, how to hold this bottle and drink from it, you know, without putting too much pressure, too little pressure and having it fall. These are very easy for us but they're very difficult for robots or AI systems but things that are more difficult for us, like playing Go, they’re very easy. This is a paradox and why it's like that and some of it is really what you were saying earlier. We think that in the course of evolution, let's say we had millions of years to evolve very good neocortex that does very advanced vision to survive because you’re in the jungle and you mistake a tiger for food or something you'll get eaten out. So, you won't survive. You don't have time to think about it, it happens very fast. So, we evolved to be visual geniuses, if you want, and we can effortlessly do it and we're studying very complex mathematical problems very easily but things that are like more modern like 3,000 years ago came up with Go in China and try to figure out how to play, they’re not intuitively obvious to us, so we need to think about it probably using parts of our brain that are more recently evolved like the frontal lobe. So, in some ways, we’ve perfected some aspects of our intelligence, this innate intelligence, and you have even some animals when they're born, they can immediately do some of these tasks. So, I think that is one hypothesis why there is this difference.

Juan Carlos: Often times, we take for granted how difficult these tasks are for a computer to do because we’ve been doing them effortlessly for so long and sometimes, we don’t understand how difficult or what an accomplishment it is for something like AlphaGo, or the stuff that’s going on in DeepMind or even a Canadian group that publishes that they have created an algorithm that can detect cats out of YouTube videos, you know for us that's very easy.

Dr. Tolias: Exactly. You know, it seems like in the last few years, especially since 2012, there has been like a renaissance of artificial neural networks or deep learning that is, in a very crude level, trying to approximate how the brain solves these problems, you know, so it’s built by artificial neurons, connective synapses, these synapses undergo plastic changes due to some objective function, maybe as exactly the way the brain works but in some ways its similar, and then they enable engineers and computer scientists to build these remarkable algorithms that are already influencing our everyday lives when we go do a Google search or we talk to Siri or we talk to Alexa, it’s kind of background , there is some sort of artificial intelligence network around it.

Juan Carlos: Yes, algorithms are everywhere! They run our lives.

Dr. Tolias: Exactly.

Juan Carlos: We can’t really survive without them nowadays it is but I think it's more interesting to understand the power of algorithms and AI and machine learning in biomedical research. So, such as AI in Neuroscience and how they’re kind of driving each other: we understand the brain, which helps us build better algorithms to better understand the brain

Dr. Tolias: Yes. Exactly. It’s kind of a circle. Our lab, and our collaborators work at the interactions between Neuroscience and AI. So, on the one hand we're using deep learning which is, let’s say, the most successful form of AI right now and may probably change, to model the brain and get insights. We use the same tools that people, let’s say to program a computer to play Go, we use it to model the brain, and build predictive models of how the brain works and then try to understand how the brain works by using these tools because don't forget that, you know, with modern Neuroscience we’re capable of collecting very large data sets. In deep learning, it’s really, sort of, if you want success is the ability to analyze and make inferences when you have large data sets, especially with a lot of labels. So, for example, we could experiment where we show a lot of stimulation to an animal, record their activity through the model of transfer function. Now then we use this method to model the brain and gain some insight and the hope is then by understanding something about the computation of the brain that we can build smarter AI algorithms that then can maybe not just analyze our data better but also can be used, for example, to recognize faces or do voice recognition or to do more robust analysis of all other sorts of kind of data. So that's kind of the goal here, is to go into this. But at the very basic scientific level, you know, we’re not ourselves, you know we’re not trying to, we're trying to like, learn the basic principles, if you want, and then reverse engineer the brain out of the principles, and putting these principles into some demonstration that, you know, this information that we learn from the brain can be used in successfully advancing machine learning. 

Juan Carlos: So, aside from studying and enhancing studies in the brain and learning how the brain works better. Do you suspect that we can use these algorithms to, uh, to further enhance or at least accelerate some research in other domains like cancer? 

Dr. Tolias: Yeah! Yeah, for example, you know, I think that's the goal, right? Umm, okay. There are two things I want so say there: One is that modern, let’s say you look at cancer research. You know we have a lot of technologies now to collect a lot of data including, let's say single cell sequencing or large studies where, you know, we do DNA sequencing in humans, and we look at their different types of phenotypes. So, you know, basically this is my personal view, you know, biomedical research is very successful in developing technologies that are relatively cheap to collect a lot of data, but we do not know how to analyze it and we don't know how to understand this data. The whole field of, let’s say genetics and molecular biology is based on this idea of you know, we, we think very serial, you know, causal manipulations are done one gene at a time. We don't even know how to think of this High dimensional gene or protein interactions that happen and most of the diseases are very multifactorial based on many genes, in combination of genes and environment in ways that we don't even have the right, you know our brains did not develop how to analyze this is and maybe we don’t have the right mathematical tools but what we have is the capability to collect a large amount of data. So, now with deep learning, if we have a lot of labels in these data. For example, let's say we sequence all everybody and we record their phenotypes, and we know in 10 years who’s going to get cancer or not.  So, we do this chronically. It's possible to build a model for now that's going to predict who's going to get what you want some sort of Black Box model that, you know. But the problem is that old-age Alzheimer’s is a good example, right?  Like, if we could follow, we could, let’s say record everything that someone eats now, how much they exercise, what is their DNA or their relatives, who they talk to – we monitor them 24/7 and we collect all this data for 20 years, 30 years, and we say ‘okay, who is going to deteriorate at what rate?’ Maybe we can build a predictive model from now that’s going to predict: ‘this is gonna happen to you, this is gonna happen to you, this is gonna happen to you’ but the problem is that it's a very complex data and we don't have the time or you know, we can collect large data but to do this very chronic data collection, we haven't built a society to do. Now there are countries like China, is trying to do stuff like that because there is a very top-down system. So, it is easy for, you know, someone to give an order and everything is done systematically. 

Dr. Tolias: Now, the brain though, in vision, we did not evolve to look at DNA, you know, sequencing letters and understand what the relationship between that and Alzheimer’s or cancer but we’re very good recognizing images. So, if we understand, but we don't need a lot of labeled data – we do a lot of unsupervised learning and we do inferences by understanding something deeper about the data that is not just this brute force with simple input/output labels. Let’s say, a child can learn the concept of an apple from a few examples whereas a machine with a modern deep learning algorithm needs thousands of these examples to really become good at it. At least that’s sort of, those are some recent developments. They are generally speaking, this is, you know, they’re not very robust. Should we understand how the brain learns from a few examples of vision, then maybe we could come up with ways that instead of the input being images is DNA sequences, but based on the same principles of learning, you know, of drawing inferences in a more causal, you know, maybe even suggesting experiment like a child may learn the concept of an apple because it knows something about curvature because he has to touch that apple. So, that’s more causal manipulation. The brain is wired to from a few examples an learn robustly, and maybe we can translate those algorithms to other domains where instead of being images in a robot touching things is if you want an AI scientist that looks at this data, let’s say, an algorithm, but instead of having original to look at images it reads sequences of DNA and looks of behavior in some other space, you know, phenotype, or how much people eat lead or what is their habits. Then maybe even do some perturbations where, you know, the way the child touches the apple, we may make suggestions or change your life, you know, it sort of tries to learn from a population level then builds an understanding of what causes cancer, let’s say, that the human it would be impossible for you to do because, it's just because we did not evolve to process that kind of information. Then once we have these models, these predictive models that train on few examples for you know, then maybe we can analyze these models and then we can gain an insight to have what’s called externability/interoperability from the models. So, that's kind of a very long-term vision that may take decades to achieve but I think that sort of, we may see that happening within our lifetime. You know, there are doctors and scientists that are machines, basically, that are much more capable of interpreting what learning about this data and gain some insights and then they tell us.

Juan Carlos: That’s something that I’ve, kind of uh, I mean, aside from kind of blowing my mind a bit, I’ve been reading this book called Deep Medicine by Eric Topol and it kind of touches on some of those ideas – that we just don't have the brain power and the speed but we can design models that do this for us. And then from there we can create these predictive models, as you were saying, but it does, it also talks a lot about the challenges but in your opinion, what are what do you, what do you feel is like the greatest challenge?

Dr. Tolias:  I think one immediate challenge is organization and accessibility to the data. You know, for example if you go into a hospital or even a big research organization or even a big biotech company or a firm, I’m not sure they have the data organized in ways that are easily accessible to computer scientists to be able to build these models and the problem right now is, this is a particular problem because these algorithms – not the ones that I’ve been talking about before which is a more vision for the future – but current algorithms work very well with your very large data sets and unless you have this very large data, so, let's say you want to build a system that predicts, maybe better than any radiologist who’s going to get cancer or not from a mammogram and is much more accurate, right? So, it has a much lower false-positive rate and false-negative rates. Now, that algorithm is trained on maybe 10 million data points. It may, like, reach that performance but let’s say it trained on a million, it may not. And then what is the quality of this data? Because it’s going to have to be annotated. For example, we have to have chronic data where we say, you know, this person did this test at this point in time, the doctor decided it was negative. Next year, they came back in and the doctor wasn’t sure and the doctor did a biopsy and it was still negative but this other patient was positive. So, you need these chronic data, so you need a very well-organized system of the data well-annotated by humans, right now and then well-organized in a way that you know, and we're not talking about data sets that are very large necessarily, although they are very large but not very large by computer science standards. Even from my lab, we have much larger data sets that we collect in an experimental lab, but I think they're just not, you know, the way hospitals have been built and the way their software works and the way that data science works, they were not built for this type of deep learning, if you want, or modern AI analysis. They were built for doctors or individual scientists or statisticians to download some of these data for you as a doctor to find this patient, his history, you know, and it was like what a human-based interaction, you know, it wasn’t for large-scale science, and I'm not sure what’s going to solve this problem, you know, I don't think, I think that's a challenge and all that. That's a challenge that everybody, including here at Baylor, is worried about and thinking about and as I said, you know, it would be interesting to see which country or which organization, and it may have to happen at a very large scale at the federal level where someone, you know, gives incentives or motivation for very large-scale project like that. The NIH has projects like that, you know. The other thing is that people understand the importance of these, so there's a lot of open accessibility to the data. For example, I forget, but some hospitals now, as long as the data is deidentified based on regulations that you have to abide by, they want to make them available to the world because, you know, this could save lives, you know. So, many people are very protective of this, and protectionism too, can be bad. People are very protective of their data and other people are not and they work together they’re going to win right? So, it will be interesting to see how these things evolve and also maybe if you want to have impact, especially in a country like the United States that is very multicultural, you have to be careful that this is also, you know, there's no biases built into the model because of different genetic backgrounds or different nutrition in different people. So, it needs to be done in a very sort of organized way, I believe, but in a large scale, and I think that right now is not, uh, it's a challenge as far as I can see. Now, I think there is an improvement in the last few years, like, I think a group from NYU did something with mammograms that had many thousands of images and Google, I think had something like that, recently collaborating with I don’t know how many hospitals. You know, DeepMind is working on that with NIHS.

Juan Carlos: I think this, kind of, has spawned an area of what is called ‘medical intelligence.’ And so, it's the gathering of as many data regarding the health of people in the now, like fitness trackers, you know. For me, I'm obsessed with a fitness tracker to my heart rate, how much I sleep, when I'm stressed, all these things, but I look at it and you know all I can really draw from it is “Well, I didn't get enough sleep on that day and maybe that's why I was tired. I was cranky”, all the stuff, and in the long term it may usually lead to stress or whatever but an algorithm gathering all this data and analyzing it can tell me “Oh, you’re at an increased risk for diabetes” or something. So, I think that's an underlying spawn of a new enterprising, if you will. But as you mentioned earlier, there is some friction or you, you mentioned that there are algorithms that could be really good at detecting radiological graphs of patients that can tell them much better than a human that you have a certain diagnosis. So, this kind of instills fear in some people, you know. I’m surrounded by medical students here at the Baylor. They even have electives that focus on how to adapt to the uses of technology in the clinical setting. So, how would you, how would you respond, or can you comment on people having this fear?

Dr. Tolias: I think it’s just, It's actually not just for the medical students. I think there's a fundamental problem with the educational system not just in the United States but around the world. For example, if you study biological sciences and medicine, you do not get trained as the, let’s say, mathematical or computer science or physical sciences. You know, you don’t learn programming, you don’t learn – and I’m not saying that every doctor should be like, able to program these things – but you need to be educated enough to understand the limitations and the expectations because these things are not, I mean, if they were perfect, you just press a button and it would be game over, nobody would go to medical school to just cover up with being everything integrated but not right now. Maybe that's what it will be sometime from now but it’s not going to happen, right. So, I think right now is a more scary situation because people need to be educated, and starting from undergraduate to medical school, as you said, there is the lack of the programs to educate people, do you know what I mean? And, it is an issue, I’m not going to say it’s not because eventually, let’s say you are a doctor and someone like you that is interested in this thing, reads, is educated, and understands it, then you’re going to do this as your Ph.D., and then say, you become a radiologist – now you'll be able to adapt to these things, understand them better versus one that is used to, like the old-fashioned way of doing things, right. So, these would be assistive technologies in the beginning. Like, you know like assistive driving, like Tesla or something like that, but I think it's very important for the doctors to have an understanding on how these things work so then they can also know how to trust us, but even more important, it can actually contribute more effectively to the researcher that’s being done. For example, what it would take to – and not just doctors but like, administrators and the problems are similar, administrator in the hospital, I’m not sure they’re trained like that, so they don't really understand or even systems administrators like data scientists in hospitals, right. What does it take to organize your data? What should I do as a CEO of a hospital? So, then it gives me a competitive advantage to my patients to bringing AI technologies, so it’s not so much of a fear of, you know, “oh, people are going to lose their job”. I don’t think that’s the problem right now. The problem right now is that some people may not be getting trained in the right way to be able to fully function in this great new world. 

Dr. Tolias: Laughs out loud. Do you know what I mean? I don't know what Baylor is doing particularly but there is worry in many places, you know, you need for example, maybe you should have courses in deep learning. You should have people, you know, like how people take statistics, which is kind of more traditional statistics and learn about Analysis Of Variants or epidemiology, you know. This is a different form of statistics. I think you need to get trained in this stuff. So, you have some understanding of what these technologies can and cannot do, but also it enables especially people who are interested in research to contribute to this because it’s not like the doctor who doesn’t know will be able to do this kind of research, that’s impossible. You know, people that are experts in deep learning or computer science are the ones doing it. But you need this synergy between varying fields.

Juan Carlos: Yeah, ‘cause I always used to have, I kind of shared the same fear before, you know, I started reading more but I guess I'm a little different. I helped I wanted to be a software engineer when I was a kid and all that went away and life happened, and now I'm kind of back in a position where I realized that it's becoming more important. 

Dr. Tolias: Oh, yeah. You have an advantage now. You know, even if you want to a doctor, your software engineering background now, it's going to give you an advantage over, you know, other people because you are the one that is going to be capable of being more in driving seat to make these decisions “What should be useful? What should be used?” which can contribute to research because, you know, we’re entering a new era. I feel the educational system, even if you go to like, even engineering schools and you take biology courses, I’m not sure in the curriculum how much computer science they do or if they even have to know how to program. You know, even if they understand, you know, the fundamental things about, you know, data science. So, these are important, right.

Juan Carlos: I think when it, kind of, uh, cemented in my mind that I was going to pursue even on a personal side, just kind of, learn on my own since I was a student. I was doing some graduate coursework at Hopkins. And then I was also in a lab that breast cancer research that collaborated with a bioinformatics lab, and we had lab meetings once every two weeks or so, sometimes informally and I think half of the time we spent trying to understand each other from the wet side – the biological side – through “how do we use these algorithms to better understand this RNAseq data?” so from then on, I noticed like, I realized I have to learn! I have to yeah, not just because I want to be an M.D/Ph.D. but just as a researcher, I want to be able to have that capability to do at least some part, some of that analysis in-house.

Dr. Tolias: Exactly. You as a biologist or let’s say, scientists that are biologists, you have the intuition to setup the right problem. But in computer science, because of their background, does not or intuition can take many years to develop, longer in some cases than learning technical skills like how to write software, right? So, if you and that engineer don’t talk the same language, you have a problem because it’s not like you give someone data to analyze and something is going to come out. How you set the problem and then knowing what the limitations or what kind of problems from the technical side are, can be solved. So, you need both you and the engineer have to sort of come together and you need to understand a bit of the tools that they use are capable of or not capable of, and what are the limitations, and they need to understand what biological data is, what the format is, and I think that is lacking because, as you said, you know, maybe when you were at Hopkins you guys would meet with Engineers, every week or every few days and kind of discuss and you would read each other's papers or other papers in the future. So, you need that kind of synergy can get things happening, otherwise, it will be very hard, and not only hard, it can also lead to errors where people like, you give someone the data and they don’t know the limitations, they discover stuff that is just artifacts, you know, and then you're not, you don’t understand the result and you don’t understand the limitation or the technical stuff that gave rise to it. You know, why it could have been over-fitting the data or, you know. 

Juan Carlos: Right.

Dr. Tolias: You know, it’s dangerous too. So, the lack of people that can understand both fields and talk to each other. It's not just slowing down progress, but it can also be dangerous. You can read papers that are like, wrong because of this problem.

Juan Carlos: Wow. I think I certainly see some medical schools, at Baylor here, we have a strong kind of focus into making that change, more of like a technological push. But, when I was doing my interviews, I interviewed at Sinai in New York and it was explained to me that part of the curriculum there for every medical student is to learn how to code a little and I was like “Wow,” I was pretty impressed.

Dr. Tolias: Yeah, some people are more pushing in that direction, I guess. I don’t know the details but yeah, that’s impressive.

Juan Carlos: Well, for me it was like it's something that was a, I saw it as a pro. Yeah something positive, but not all medical students would have shared that. But I think now, because AI has either been glamorized or it's been used as a scare tactic. I'm not sure I did think maybe to leave me to listen to this podcast specifically this episode over and over to sort of, learn that yeah.

Dr. Tolias: Yeah, and I think people like you should be given the opportunity to sort of, follow it, especially if you’re very interested in the research.

Juan Carlos: I'm excited to see what, what happens in the future because it's, in essence, all of this is all to improve the quality of human life, and the use of AI and machine learning in medicine is to improve the quality of human life for patients and for ourselves too. Uh, so the idea of just having, having that fear and rejecting it and creating friction for it to be incorporated into our medical system, it seems counterproductive, but I think for everyone for our listeners that kind of had a fear or maybe a further interest in enhancing your computational skills and how that could possibly improve even the way you look at problem solving, I think it’s a lot different. I think somewhere just looking into what the positive impact of AI are is a good start heading that, you know, it's all that we can share about that today. 

Dr. Tolias: Yeah, it’s great to be here. 

Juan Carlos: So, there you have it. This has been a revelation in AI with Dr. Tolias. You've heard it from the expert’s mouth what is going on and what the limitations are in the field and highly encourage everyone to pick up the book Deep Medicine. It breaks it down very simply and helps you understand a little bit more about the use in health care or in research. And so it's all we’ve got for today. But uh, it'll take some time for my brain to unpack all of this information. But I really, I really appreciate you attending. 

Dr. Tolias: Thanks a lot. It was my pleasure.

[Outro melody.]

iTunes | Spotify | Google Play | Stitcher | Length: 59 minutes | Published: March 22, 2021

Dr. Michael Kauth talks about his research in LGBT Veteran health, involvement in LGBTQ advocacy, educational career, and trajectory. We asked him about his involvement with the Montrose Center on the Board of Directors and current efforts to support the LGBTQ community. We also discussed issues that members of the LGBTQ community have accessing proper healthcare and the role of stigma in quality of care.

Transcript

[Intro melody into roundtable discussion.]

Juan Carlos: And welcome to the Baylor College of Medicine Resonance podcast. I am one of your hosts, Juan Carlos Ramirez.

Snigda: And I'm your other host, Snigda Srivastava.

Juan Carlos: and today we'll be talking with Dr. Kauth, and we will be learning about his research and LGBT veteran Health, his involvement in LGBTQ Advocacy, educational career and trajectory, we’ll ask him about his involvement with the Montrose Center on the board of directors and current efforts to support the LGBTQ community here. We will also discuss issues that members of the LGBTQ community have while accessing proper health care and the role of and stigma and quality of care. So, welcome!

Juan Carlos: So, Snigda, why Dr. Kauth?

Snidga: So, as a student, a second-year medical student at Baylor, I took an elective course in the LGBT Health Care literacy, and that's how I met Dr. Kauth. He was the course director for, for that elective and through that course, I was exposed to a lot of really interesting topics regarding LGBTQ health and advocacy, including lectures on topics about Healthcare considerations for men who-have-sex-with-men, women-who-have-sex-with-women, LGBTQ youth health, and a lot of other various topics. Through this course, we also had an incredible panel with LGBTQ patients at the Montrose Center that he organized, and he's actually been a member of the board of the directors for Montrose Center for over eight years now. So, having someone who's so involved in the community and advocacy was really inspiring. We also had a panel with Baylor physicians in the LGBT community, which is awesome to see as an aspiring physician in the LGBT community and so I really loved that course, and I thought that dr. Kyle could be an excellent person to interview for this podcast.

Juan Carlos: Yeah, and he seems to be very active, you know, in many different areas and really kind of spearheading the LGBTQ here at Baylor and you know is really speaks to our like diversity and inclusion here at Baylor. It's, we all feel very loved and this is just very interesting and very necessary stuff that has to be done. But you mentioned a little bit, he does some research in LGBTQ Veteran Health. 

Snigda: Yeah, so he is also part of the VA as well. So, he's a psychiatrist there and he's also done a lot of research and has published, like publications and edited a book recently in 2018 on transgender health for mental health professionals, which was really cool. He's also an author! 

Juan Carlos: That's right! His latest book is called The Evolution of Human Pair-Bonding, Friendship, and Sexual Attraction, and this book really presents us an opportunity to see an evolutionary history of romantic love, male-female pair bonding, same-sex friendship, and sexual attraction drawing on sexuality research, gay and lesbian studies, history literature, anthropology, and evolutionary science.

Juan Carlos: Dr. Kauth’s book also talks about employing evolutionary theory as a framework, close same-sex friendship as examined as an adaptive trait that has harnessed love, affection, and sexual pleasure to navigate same-sex environments for both men and women, ultimately benefiting their reproductive success and promoting the inheritance of traits for friendship. There are certain chapters that consider the desire to form close same-sex friendships and ask if this is embedded in our biology concluding that most humans have the capacity to form loving, meaningful, and sexual relationships with men and women. Furthermore, this book takes on a unique interdisciplinary approach and is essentially, is essential for reading for those studying and working in sexuality research in anthropology and sociology, evolutionary psychology, and gay and lesbian studies. It will also, will also be an interest to marriage and family therapist as well as sex therapists. So, it's kind of an all-encompassing book. Sounds very exciting and it's only 224 pages of exciting – exciting cutting-edge research. Snigda, any thoughts?

Snigda: I think it sounds very exciting I'm really looking forward to hearing what the audience thinks.

Juan Carlos: It sounds very exciting, I mean, his book just came out in November and we're all excited to see sort of the what the community thinks about it, but it would come as no surprise that the book will be very exciting to read. Dr. Michael Kauth is, like we’ve mentioned, the director of the LGBT Health here at the department of the VA and a professor of Psychiatry and he has authored several things, and this would be also another one of those that would be nothing short of exciting. So, without further Ado, let's talk about LGBT health and Veteran health care and LGBTQ disparities with Dr. Kauth. Let's go to episode.

[Interlude melody]

Snigda: So, welcome Dr. Kauth. 

Dr. Kauth: My pleasure to be with you. 

Snigda: So, how are you? How are you doing? First of all, this is during the time of covid-19 and the whole quarantine coronavirus thing. How are you doing?

Dr. Kauth: I – I'm I'm okay. It's certainly strange times right now and I miss interacting with people face to face. That's probably the hardest part. I can, I can do my work from home, that is not nearly as satisfying as being able to interact with real people. There's just an energy around people that you don't get by talking online and seeing them on video.

Juan Carlos: Very strange times. 

Snigda: Yeah, super strange. How has that affected your work like day-to-day?

Dr. Kauth: A lot of my lot of my work at least at the VA is virtual because I work at a national level and I talk with people all over the system, and so that really hasn't changed much. That work continues. My work at Baylor though is a little different, that tends to be more face-to-face and teaching classes and interacting with students. And right now, that, that doesn't happen in that way. We don't have face-to-face meetings and lecturing and teaching is done through Zoom, which works but, it's a little weird not being in the same room with people and sometimes having a delay in the communication. It's an adjustment to be able to make that work but people I think are generally patient and willing to work it out because frankly that's the way things have to be right now.

Snigda: So, can you tell us a little about yourself and how you became involved with research and advocacy and LGBT health?

Dr. Kauth: Yeah, certainly. I'm a clinical psychologist by training. I'm a professor in the department of Psychiatry at Baylor and do teach at Baylor. Most of my work, though, has been at the VA and I've got two major roles there. I'm director of the LGBT Health Program for all of the VA and we oversee to Health Care policies and some clinical support programs and generally work to try to get clinicians to follow best practices and policy. The other major role at the VA is I'm co-director of a research and education center called the South-Central Mental Illness Research, Education, and Clinical Center or MIRECC – that's a mouthful – and our Focus there is on finding innovative ways of delivering best mental health practices in the U.S. I was, I was raised in a very small town in Kansas, a town of 4,000, and went to school as an undergraduate at Wichita State University. And that was a great experience and in kind of towards the end of my undergraduate career or maybe the beginning of my master's program in psychology, I came out as a gay man, and that was in the early mid 80s and HIV/AIDS was really hitting the east and west coast about that time. It was just beginning to reach the Midwest, in fact, it was actually already there, and people didn't know it, but it was already there, and it was really frightening people, but that HIV/AIDS certainly was affecting me and my community people, that I knew, and I began passing out condoms on campus and volunteering for organizations to increase awareness and knowledge.

Dr. Kauth: When I was in my master's program as a graduate student and doing a practicum at Community Mental Health Center, I started seeing HIV patients in part because I really wanted to, I wanted to help and in part because regular staff members were afraid of seeing those people, they were afraid of getting the virus through this having them in the office. Which was sad, but I started seeing mostly men with HIV and started to realize quickly that there wasn't a lot I could do as a therapist with meeting them weekly. What they really needed was greater social support. They needed to be connected with other people. It helps them. They were very isolated. They were afraid to tell other people that they had HIV. They were afraid of being discriminated against – all understandable. And so, what I did was I organized a support group. I was the very first support group for HIV people in Wichita, Kansas and that support group became quite popular and morphed into two other support groups of different variations. We were meeting in the basement of a Unitarian Church and that, that carry on for a little more than a year, I think, and about that time, I was ending my time in Wichita. But I was connected with other people in the community who were delivering other services to HIV people like dental services or physicians who were willing to see HIV people or funerary services. There was a guy in the Social Security Administration office who was really good at helping people with their disability claims, and we pooled our work and founded a nonprofit organization to be an umbrella for all of these services called and we called it AIDS Support Services not – not a cool name, but that's what it was and that was really rewarding and gratifying and soon after we formed the nonprofit and I left to go to school at the University of Mississippi to finish work done on my degree. While I was there, I really got my first taste of research and I spent a couple of summers working with an HIV researcher at the University of Mississippi School of Medicine in Jackson, Mississippi. And Dr. Jeff Kelly, who is a psychologist, and he was working on an idea to change social norms within large groups of people, mainly gay men who went to bars and changing social norms around using condoms using the Diffusion of Innovation model to do that. It was a great experience. Probably the most fun job I ever had because I had got to go to bars and talk to people about sex and grab free drinks from the bartender. Didn't get paid a lot. But that experience also taught me how research works. How a big research organization functions and it was very welcoming there. I realized it's not something that I wanted to lead myself but I really like to be part of research. I enjoy working with really bright people and analyzing data and writing papers and that gave me, kind of, my first taste in publishing so, that kind of got me started both in advocacy and research in this area and it told me also that you know, I can make a difference. 

Snigda: That's a really powerful story! It's awesome that you're able to, like, make such a big difference. Even as you're saying like even as someone who doesn't have like an amount of power that you would necessarily need for like policy change, but you can make like real change in the community. That's super inspiring to me also, and I guess Juan too because we're both very interested in research as well.

Juan Carlos: Anything research we’re always like ‘tell me more.’

(All laugh)

Dr. Kauth: It's a fascinating way of life. It really has the brightest people involved and that's stimulating. It's super stimulating the be part of that world. Also, a hard part and money kind of, didn't like, was that, that constant cycle of anticipating the end of your funding and preparing working on getting new funding, that part wasn't so fun. I really enjoyed working with people who are doing research and being part of the research. So, now I kind of have the best of both of those worlds. I get a hard-money paycheck from the VA and I get to work with researchers on their projects as an operational partner and helping them craft their work in a way that can help with policy and help with best practices in healthcare.

Snigda: Do you have any stories from your early advocacy work of people that you interacted with that like, really left a mark? 

Juan Carlos: Like a role model figure?

Snigda: Yeah! 

Dr. Kauth: Yeah! Several. The faculty member who was leading this HIV work at the University of Mississippi, Dr. Kelly – amazing individual and the clarity of his writing really helped me a lot and learning how to write and how to very concisely and be persuasive and communicating your ideas. He's also a very passionate person and wanted to make a difference and I really enjoyed seeing that passion. I guess also the passion of the whole team because like I said in research you have to worry about where the funding is coming from often people in research aren't getting rich. They're not making a lot of money and they're doing it because they really want to because they want to learn. They want to learn new things. They want to communicate those ideas and they want to make a difference in the system. So, and being part of and riding along with that passion was just super stimulating and super helpful. That's something I wanted to do. 

Snigda: Yeah, that's amazing. That's such a cool story. Juan, did you want to take the next question? 

Juan Carlos: So, I guess the reason she asked me is that, as a as a veteran myself, I’m kind of always interested to see what people are doing for the veteran community and it and this question is kind of based off of one of your last or recent publications in the American Journal of Public Health. I guess I’m just kind of wondering what your most fascinating ideas or questions that you have in regard to researching and LGBT and veterans in their access to health care, in your experience. 

Dr. Kauth: Yeah. What is really interesting to me is trying to figure out how stigma and discrimination, especially within the military, contributes to health disparities among LGBT veterans. There's been some great work done recently by Ilan Meyers to conceptualize a model of how the this occurs and he calls it the Minority Distress Theory and the idea behind this I think is very helpful because it helps us kind of think through these steps and how health disparities that occur but it also provides us some possible pathways of interventions and the idea is that larger kind of distal stressors like stigma within society as well as individual more proximal kinds of stressors, our personal experience with stigma and discrimination, the internalization of those experiences, both of those things individually and together contribute to maladaptive ways of coping like drinking too much, eating too much, not exercising, doing drugs to manage anxiety, and poor health seeking behaviors. It also contributes at a larger level to barriers to accessing healthcare because it’s not thought of as something that's terribly important. All of those things collectively together lead to differences in health outcomes with stigmatized populations like LGB people and T people as well. And I make that distinction because there's another group of folks who kind of expanded on that model and conceptualized the Gender Minority Stress framework that looks very similar to the Minority Stress framework that also conceptualizes how transgender individuals can end up with greater health disparities, poor mental and physical health outcomes compared to non-transgender or cisgender people. How do we intervene? How do we build up people's resilience to moderate those poor health outcomes to minimize the internalizations of these negative experiences? It's very hard at a to kind of reduce those larger societal messages of stigma and discrimination but we can, at a personal level, help people cope better and to engage in more healthy behaviors and healthier ways of coping with those stressors, even if we can't reduce the stressors themselves. 

Juan Carlos: It's wonderful. It's especially given that, you know, it's not, it's no secret right? That the military isn't that touchy-feely environment that really allows anyone who wants to seek help right? To seek it before they separate from the military and then once you separate those, those opportunities to get help are you even lessened or more lessened or more scarce, I guess you would say, and so I mean, I personally know a lot of people who revert to unfavorable coping mechanisms, and you know, it's just kind of a slippery slope from there. 

Dr. Kauth: Yeah, and this is not just an issue for the VA. A lot of people have them stick and belief that the VA sees all veterans. We do see all veterans who come to our doors, but the majority of veterans get their health care from private practitioners who, unfortunately, don't always ask about military service and they aren't aware of how military service may put people at increased risks of certain health conditions and they need to ask those questions and they need to follow up and find out that information. I think that's true for sexuality and gender identity as well. If Healthcare Providers don't ask those questions, then they don't know that somebody may be at risk of particular health conditions. They can't follow up. They can’t address those issues. You know, kind of the intersection of those identities are also important and can put people at even greater risk. So, LGBT veterans may be at even greater risk of some mental and physical health conditions compared to non-LGBT Veterans because they got that double or triple dose of stigma to deal with. 

Juan Carlos: Oh, yeah. Yeah. It's a lot to deal with mentally.

Dr. Kauth: One of the things that I've learned about advocacy is that you can't be a one-person show. You're not effective if it's only you. You are most effective if you expand your capacity, if you inspire other people to be advocates themselves and pull them and broaden the scope of your work and let them do their thing too. So, one of the one of the exciting parts of advocacy for me, at least within the VA is helping to change the culture within VA. A lot of Veterans, as you probably know, think that the military and the VA are kind of one in the same. They’re just two ends of the spectrum and they're very different and have different policies in place and slightly different cultures. But there's some of that military culture that is brought to the VA and some larger societal culture that's part of the VA and I am working to try to change that and to create a more welcoming friendly environments for people who feel stigmatized by providers to have conversations about sexuality and gender identity. So, patient know that this something that they can, and they should be talking to their Healthcare Providers about because it has health consequences and that they're getting their needs met.

Juan Carlos: Yeah. So, I think for like a veteran having someone who is openly receptive or just simply asking, you know, it's like “Yeah, great! Let's talk about it. I've been dying to talk about this” and it’s just laying it all out there. Just that act alone. I think it's therapeutic. But you're right, you know, like more physicians need to know to ask the right questions when it comes to this patient population. Yeah, and then in your advocacy, this is sort of, are their organizations or are there certain things that you've done that are now sort of in place in practice? What is or could have been the most rewarding and highlight of your advocacy?

Dr. Kauth: Uh. I'll share a couple of things. One of them met at the VA, one of them at Baylor. You know, in my work in the VA and trying to change culture, one of the things that I'm most proud of and I think we'll probably be most effective is we managed to get identified with every facility and LGBT veteran care coordinator. Some facilities have more than one and it is their job to assess the needs of LGBT veterans at that facility and work to provide all of the services that we need to be providing for those veterans at that place to connect with community organizations to educate staff and to, more generally, create a welcoming friendly environment for LGBT veterans. It's those people on the front line that will make the most difference in the system. Doing policy, issuing a policy, asking people to read it, is not going to do a lot. It's the implementation of that policy that makes the difference and it's those people at the front lines who do it. So, I'm very, very proud of that work. And what is rewarding is to get messages from those people in the field of various facilities who send us photographs of like Pride events at the VA, which they've never held before. 

Snigda: That's awesome!

Dr. Kauth: And to see it happening is really, really cool. Yeah. 

Snigda: Wow, that must have been really hard to like, get that approved.

Dr. Kauth: It is it is difficult to get changes made but it is possible. Yeah, the VA can be a really neat and flexible system sometimes, but it has a surprising amount of flexibility. There are a lot of good people in the VA who want to do the right thing. And it's not always easy to know what the right thing is. But one of the things that I've learned in my career at the VA is persistence counts and if you're persistent you will win, and you just have to keep hammering with the right message to the right people enough time and you can get your message through and you can make things change. And it is possible. 

Juan Carlos: One thing there is a military, which is kind of fitting, right? Is that saying, ‘the squeaky wheel gets the grease.’ So – 

Dr. Kauth: That’s right! (chuckles)

Juan Carlos: If you just continue and you stay persistent and you're adamant about change and it'll happen.

Dr. Kauth: Keep hammering home! This is what we need to do. This is the right thing to do for our veterans and people listen to that message. 

Juan Carlos: That's awesome.

Dr. Kauth: Yeah. Let me, let me share an advocacy story about Baylor. I mean, I came to Baylor in 2007 after Hurricane Katrina. I've been living in New Orleans prior to that and yeah, things were bad, and my husband and I decided that we couldn't stay there. We needed to move for a variety of reasons and through my job at the VA I was able to transfer my position over to Houston, which was a wonderful transition for me in a lot of ways and immediately got involved with Baylor, who seemed very eager to partner with me. I started lecturing in classes and a couple of years later, I took over the Human Sexuality class from Dr. Basinger. We've been running the course for several years because they were really interested in the topic and they felt like that this was material that wasn't being covered in some of the other courses and I agreed with them and I thought it was a cool idea and was really excited by their eagerness to do something and so, together, we wrote the course. We developed the proposal and sent to the Curriculum Committee and they approved it, which was great, and I've been offering the LGBT Health course since 2014. That's been really great, and it's been due to student excitement about the topic and wanting to learn more. I really enjoyed that, and the visibility of the course has made me a magnet in some ways that lots of students even faculty member with faculty members will come to me and ask advice or want to share ideas about expanding LGBT Health interests or activities at Baylor which has been pretty cool. It's thrilling to see like the BCM Pride Group engaged in activities or the graduate student group engaged in activities and more visibility of LGBT health issues and in other courses or other activities that are going on on campus. It's been huge explosion of activity since 2014. I don't know if that was me. I don't want to take all the credit for it. But I think the existence of visibility of that course helped make it possible – gave some room on campus for other people to decide, you know, maybe I could do this too and they did.

Juan Carlos: Well, we appreciate your modesty in the impact and implementing such big change. 

Snigda: Yeah! 

Juan Carlos: I know that, at least in our class which is about 200 students, they're very interested in how to manage LGBTQ patient encounters. And so, when you were mentioning about faculty and students’ sort of seeking out information from you, I'm sure there would be a large majority of our students now who would be interested in: 1) Is there a course? And they would probably really, really interested in doing an elective on that and then 2) following your work and advocacy, and then 3) getting involved, so – 

Snigda: Yeah, as a student that took your course, yeah you were being modest for sure, that course was actually, it taught me a lot. I was already interested in the topic and I guess maybe the people that take the course or a little self-selecting in that way, but I learned a ton from that course and it also made me a lot more optimistic about like how much we can actually impact LGBT Health as like, hopefully future Physicians, and yeah, I just honestly, I want to echo what those students said like about how you're like you are the perfect person to be teaching this course, you know? Given how much experience and knowledge you have in the field. So yeah, I love the course.

Dr. Kauth: Thank you! That's good to hear. I'm very glad to hear it. Thanks for sharing that. You know, you don't always know what impact you have on other people. Mostly, you don't know. You hope for the best, but I do see effects like you, in particular, inviting me to be part of this podcast, which is a really cool thing. And I appreciate that, and it probably wouldn't have happened if you hadn't been in my course and I've seen other people do things too that leads me to suggest that they were inspired and that's, that's really gratifying to see.

Snigda: So, when we, when we were like taking your class, we talked a lot about how you kind of mentioned this already, but stigma and a lack of proper knowledge on LGBT Health can affect the quality and access to healthcare for LGBT patients. Is there any advice that you would give students or physicians in the healthcare field to reduce those disparities?

Dr. Kauth: Providers and students are in a perfect position to be strong advocates for people who have little voice in the community. People who get into Healthcare want to help. They want to make a difference. They want to make people better. And so, they're already advocates in a way. It's just because since you're just directing this in a different way and how they can get involved is to get informed, learn more about the topic, and be knowledgeable. A very important way that they can be advocates is among their colleagues and when they hear anti-LGBT statements, even jokes, say, “You know, that's not okay. I don't believe that. I don't want to hear it. I think that's wrong. That's not the way I practice or live my life” or whatever to feel, whatever it is that you say that kind of put a stop to those statements. As a colleague, that has a very powerful message amongst your colleagues. So, I encourage people to do that behind-the-scenes. Other things that Healthcare Providers can do and stuents can do is get involved in LGBT issues and they can do that in a number of ways: participating in events like Pride events, volunteering your time in LGBT organizations, giving lectures, volunteering in other ways. Giving money is helpful, and in your practices, being sure to include resources and information that's important to the LGBT community. I like to tell the story in the class because it's sad but it's true. I’ve been in Houston since 2007 and seen a number of healthcare providers myself for different reasons and out of those probably 10 or 11 different Primary Care Providers, only one of them ever had LGBT patients and some of those providers had advertised themselves as friendly to the LGBT community. So, I found that really surprising and odd. If there isn't material or information in the environment that recognizes LGBT people, they're not going to feel that they are respected there. And so, all of those things together can help make a difference and are, you know, relatively easy things to do. If you do just one of those things you can, you can make a difference. 

Snigda: Yeah. I'm always amazed at like, how much of a difference even a small thing like a pamphlet can make or a poster just to make people feel like comfortable sharing what they're going, with like going through. 

Dr. Kauth: Yeah, absolutely. And that reminds me of a story about the VA but one of the things that we have done was try to increase the presence of LGBT in the Healthcare environment. And there was one primary care provider who told me, this was a couple of years ago, he had one of our posters as a screensaver on his monitor. They don't allow this anymore, but they did at the time and the message on that that poster that was on his monitor was “We serve all who serve.” And it had a rainbow dog tag as part of the poster and you know, a patient that he had been seeing for a long time in his office and saw that screensaver and said, “You know, I have to tell you I'm a lesbian” and he was a little taken aback because he first he hadn't asked about her sexuality before and so he felt bad that he hadn't done that. And he was a little taken aback because it was the screensaver that made her feel comfortable that this was a space where she could talk about her sexuality and she hadn't been able to do that before. 

Snigda: That's incredible. 

Dr. Kauth: So, it can be a very small thing like that, that communicates to people that this is a safe space. This is something that is okay. I can talk about these issues.

Snigda: That's yes, that's amazing. Uh, I did some work as an RA in undergrad with advocacy and I also kind of noticed that like, just like, passive things like that, like a poster on the wall could make such a big difference like someone might not even realize that they're going through something and they'll see a poster and they’ll be like “hey, wait a minute, that’s like me” and that can really get things going. It's pretty amazing.

Dr. Kauth: Yeah. Absolutely. 

Juan Carlos: Posters and pamphlets, I mean, they do an awesome job. They sound great. I'm more interested in the active stuff and you mentioned that there's a lot of active advocacy just so that we can try to prepare for future events and maybe have the podcast cover the events, what are the biggest events that we do here at Baylor?

Dr. Kauth: Yeah. There are Pride events that occur in June. This season probably won't be face-to-face activities on campus, and I don't know yet how those are going to be morphed into something that's online and virtual that can still involve people. It's unclear. But I've noticed that around the city, around the country, face-to-face events are being canceled. And that's, that's a little sad. Yeah, but those kinds of annual events are places where people can get more involved and visible. I'll tell you one of the most powerful things, I think, that has been happening for students is in new student orientation for first-year students who are coming in. There are a series of group discussions organized around different topics that have included wide range of topics and especially LGBT health and they offer these at different times so they can involve different groups. You all may have participated in some of those. I don't know. I've been involved for the last couple of years in leading some of those small groups, but it's not just me. There are other faculty members who have come in and led those groups too and I think it's a great way of introducing to students the connection between sexual orientation and gender identity and health issues and why those are important health issues and how to think about health in those ways and how to create a more affirming kind of clinical practice. So, very early on, kind of, lays the groundwork for students thinking about LGBT health issues in a very affirming kind of way. Hopefully they get more content information later on in their training. I don't know but it's a great foundation to begin with and so I encourage other faculty members and all of the incoming students to take part in those kinds of activities.

Juan Carlos: Well, yes. Yes. I guess I meant when this COVID, you know, lockdown gets sorted.

Snigda: Yeah, so BCM Pride has a few events that they do every so often like every two or three months. They recently had like a like a Valentine's party where they had a lot of like baked goods and there was like a tea party. It was, it was great. That was super fun. But yeah, they if you, I think if you join the BCM Pride Facebook page, they do a lot of advertising on there. So, if anyone's interested who's listening, that would be somewhere to check out. Yeah. Dr. Kauth, I think you wanted to say something. 

Dr. Kauth: Well, I would just add to that, that of course, you don't have to be an LGBT person to participate in LGBT activities or in BCM Pride. You can be an ally and allies are incredibly important. So, there are far more allies than there are LGBT people. 

Snigda: Right! So, I think we've covered a lot of really interesting themes about LGBT health and advocacy. Dr. Kauth, is there anything else that you would like to share with our audience?

Dr. Kauth: Uh, let’s see… I did want to, I did want to share this, that while back here, you had asked about mentor role models who really helped put me on an academic path. And this was a Social Psychologist at the University of Mississippi, Dr. Dan Landis, who taught the human sexuality course for undergraduate and graduate students, and I hadn't thought of myself as an academic up to that point, but he was very much an academic and focused on human sexuality. I enjoyed taking the class as a graduate student. I actually was a teaching assistant for a year after that and we, Dr. Landis and I became close and one of those years he decided that he wanted to put together a proposal for protecting human sexuality and invited me to help draft it, and the textbook never got published. The publisher didn't pick it up, but the experience taught me that I could write and I had something to say and it was a lot of fun, especially writing about human sexuality kinds of issues and so, I really valued that experience. It taught me that it was important to make connections with faculty members who are working in areas of your interest. They're real people and they have lots of, lots of information and experiences to share and can provide you opportunities that you hadn't ever thought about and those opportunities will open up new doors for you that you hadn't considered and so writing those, writing those chapters convinced me that I could write other chapters, I could publish, I could write a book, and eventually, I did. I published my first book in 2000 on Theory of Sexual Attraction and I am now working on my fourth book that will come out later this year. It is going to be called The Evolution of Human Pair-Bonding, Friendship, and Sexual Attraction that will be published by Rutledge and it is such a rewarding experience to do something like that. But I credit Dr. Landis for putting me on that pathway with showing me that this was something that that I could do. 

Snigda: That's so inspiring to hear and yeah, it's really optimistic for some students just starting out to see someone who's been able to like really make such a big difference and has still like maintained so much like modesty in spite of all the success. But yeah, this is this is really inspiring for me. 

Dr. Kauth: Well, and I have to say, if you want to make a difference, you can't do it for yourself. If it's only about yourself and getting that positive feedback, you will not end up helping people, you'll just be looking for that kind of positive feedback, the positive interaction. Like I said earlier, you can't know what effect that you have on people. You have to hope for the best and let them do their own thing. What you can do though is, you can plant seeds with other people. You can, you can give them information that can Inspire them that can help them see things in a different way and that's the best you can do and then look to see what effect that has and that's its own reward and looking back and seeing how you have affected other people at a distance. They've gone off and done their own thing and they made a difference themselves, but it's a very delayed kind of gratification and you have to be willing to accept that in order to I think to be an effective change leader. 

Juan Carlos: So, I have a kind of question, just out of curiosity. Currently at the moment, we're kind of going through learning disabilities and autism spectrum disorders, and I have been chatting with a colleague of mine Priscilla Bigner who does work in mental health counseling and aspiring clinical psychologist, and so, we know that kind of autism spectrum disorder are more likely to, sort of, be transgender and identify as non-conforming, but would you be able to comment on what research has been done into dealing with sort of autism spectrum disorder and transgender?

Dr. Kauth: Uh, certainly. Research has shown that people who often identify as transgender or gender-diverse have a higher prevalence of learning disorders and tend to be more on the autism spectrum. Why that is, is not clear. The connection between the two is not clear. It could be a process that is parallel to gender identity issues and just happens to co-occur. I don't know that there's any kind of causal connection and similar to research and things like attraction among people. There are a lot of things that are associated with a prevalence of same-sex attraction that, how are those things causal and how they're connected isn't always clear and I'm not sure that we can make a lot of that information just yet. I think it’s; I think that the process of how people think about their gender identity, their internal sense of self is, probably both a biologic process and a social process and there are things that happen within our bodies allow us or kind of shift our thinking into “this is part of me, or this is not part of me.” And this is consistent with how I think about myself or not consistent with how I think about myself and then in society we get messages about how we should interpret those basic and biologic senses of this is consistent with who I am, this is not consistent with who I am, and in terms of how we think about our gender. But we don't really know what the causal connection is to why some people have a gender identity that's congruent with their sex assigned at birth and why some people have a gender identity that's not congruent with their sex assigned at birth. It’s probably a very complex process where we're only able to find like associations at this point or things that kind of occur together with people who have a transgender identity. I know that doesn't really answer your question that that's really the best that we know at this time. These are things that tend to go together and that's all we know. 

Juan Carlos: But yeah, you know, it's just, these are things that we kind of think about as we're learning, and we learn about gender identity and that development and then disorders and cognitive development. So, if one isn't aware that they're developing this way, you know, there's, you're kind of prone to not being able to identify in a certain gender. And then that will likely predispose you to some increase risk of – 

Dr. Kauth: Sure! Sure. You know, I would add to that, we really don't know a lot about causes of sexual attraction. Why are some people gay, some people bisexual? Why are people heterosexual? We don't really know. The current research tells us that there are some things that tend to be associated with same-sex attraction, but they're probably not causal factors; that they're just correlative factors. However, there's been like zero research on causes of heterosexual attraction because that's the normative attraction and in society, we don't feel like it's important to investigate things that are normal or typical. They need no explanation because they just are, and that's really the wrong way to think about it and it's an empirical question. How did we get this? What causes this? To understand how we are who we are. 

Snigda: Yeah. I think that really gets to the whole idea of like baselines, I guess and how we decide what a baseline is. And yeah, it just makes me think a lot but that's, that's super interesting and I'm definitely gonna look out for your book what it does come out. It sounds really fascinating.

Juan Carlos: Well, you seem to have a way with words and shifting paradigms at an Institutional level. So, hopefully we will see kind of a wave of change going into in favor of the contents of your book.

Snigda: Alright! Well, any last thoughts?

Dr. Kauth: No, it's been a pleasure talking with both of you. I've really enjoyed it. And this has been a wonderful experience and I'm excited to have the opportunity to share my work with other people and glad that you're interested. Thank you. 

Snigda: Thanks so much! 

Juan Carlos: It has been a pleasure having you on the podcast show, Dr. Kauth. Hopefully, we'll have you on again and discuss your books and future endeavors and successes and thank you so much!

Dr. Kauth: Thank you.

[Outro melody.]

iTunes | Spotify | Google Play | Stitcher | Length: 56 minutes | Published: March 4, 2021

Dr. Sandra Haudek discusses her journey from a career in research to clinical education at Baylor College of Medicine. We will learn about the Foundations Basic to the Science of Medicine course and a little more of the personal history of the woman behind it. We will also discuss wellness, her dancing hobby and her past experiences with stem cell research. 

Transcript

ERIK: And we're here. This is the Baylor College of Medicine Resonance podcast. I'm one of your hosts, Erik Anderson.

JUAN: I'm another host, Juan Carlos Ramirez.

KARL: And my name is Karl Lundin. I was the writer for this episode.

ERIK: Yeah, Karl, you might have actually been the writer for the most episodes right now. You're number one.

KARL: I want the award at the end of this year, I always knew I was the greatest. This is good confirmation.

ERIK: Yeah. We're very modest here.

KARL: Oh I know I am. 

ERIK: Uh, so yeah and actually though, speaking of modesty, the person that we were just saying how just nice of a person the instructor that we interviewed on this episode is . . . 

KARL: Yes, today we're going to be talking with Dr. Sandra Haudek. And yes, she is one of the nicest people in the world, very kind, very modest person, also happens to be the director of the Foundations of Basic Science and Medicine program at Baylor. So basically that's kind of like the first year courses, lectures, you'll take in sort of the Basic Sciences things like, you know, biochemistry and that sort of stuff they give you . . . 

JUAN: All of the things we love.

KARL: Yes, who doesn't love some good biochemistry. Um, no, but that Anatomy, you know kind of the foundational content you need to know before you can go into the clinics as a medical student so that a lot of the stuff that's like tested for on the MCAT, things like that. Yeah, really great person, really great to get a chance to talk to her. In addition to being academic director, she also has a pretty interesting life though, we got into. She of course has a pretty extensive research background. She's not Ph – er, she's not an MD, she's a PhD, so she comes to Medicine kind of by way of basic science research. We’ll talk a little bit about, that get into some interesting topics there. She did some research on cardiac inflammation and fibrosis, some interesting research involving TNF as a mediator for some of these phenomena and then probably at least, for my year of med school – me and Erik's year of med school – the most popular lecture she taught was on the topic of stem cells, which she also has a little bit of research experience and it is also a very interesting topic we get into and she has some really cool insights and ideas about that.

ERIK: Yeah. I remember she was really excited when she taught us – did we – just had like, I think just one lecture on stem cells, but I remember she taught it and you could tell how enthusiastic she was about – I mean, they're very cool, I mean, don't get me wrong, so it's easy to be enthusiastic about it.

KARL: We had a lot of passion, and also passion, like, kind of a rat surrounding some of the interesting not just scientific issues. But also there's, like, stem cell research is a great place to explore a kind of the intersection between, you know, scientific philosophical and sort of ethical issues as they interact when we apply scientific principles and scientific discoveries to healthcare, right? To medical treatments, which is a very important, but often maybe not as much emphasized part of our education.

ERIK: No. Yeah, I think you're right. 

JUAN: And she's kind of like the epitome of, she's not a busybody but she does so much, right? We really have no excuse, like “I don't have time for this”, “I don't have time for that”, she actually balances life quite well and kind of pushes it in all directions. Yeah, cuz she also organized or organizes the Scholastic – yeah. I'm gonna edit this out. Actually, but what I'm trying to say, but I don't remember it is the Scholastic Research Symposium. She organizes that.

KARL: I do vaguely remember talking or hearing about that. Although once again, I'm not the big research guy. Sitting in the room with the M.D./Ph.D.s, you know, I'll cede that to you for –

ERIK: We should know it all.

KARL: But yeah, Dr. Haudek, very interesting person. Very wonderful human being too, I think we’ve all had some real positive experiences. She just always is a very kind friendly person, always willing to help you out. I remember one time – she would just do these nice things for our class. One time she brought in a big old platter of cookies and there's all these different cookies and treats and sweets from, Dr Haudek. Like where were these cookies where are these sweets coming from she like, “oh, you know, I had a little get-together this weekend” and we kept trying to talking with her about it and we kind of got hers like, “oh, well, it was my birthday this weekend”. “Well, Dr. Haudek, you didn’t tell us it was your birthday!”. And so of course, later in the day we surprised her during histology. We all sang Happy Birthday to her and it was just a very sweet moment and well deserved for a very wonderful human being. Also, an amazing ballroom dancer. Apparently. Yeah, that's another thing she'll mention briefly in her last lectures, but interesting thing we’ll get into in the interview today. She also, her and her husband are involved in the world of – I guess you call it competitive dancing, although apparently they haven’t competed as much in the last few years, but it's another interesting little thing we get into; and also talking about kind of how you can have an intense hobby like that and have that be an important part of work-life balance in some of these kind of, I guess high-intensity fields like, you know, the professions in science and medicine; or it's easy to get absorbed in your work, but it's important to always have other things in life, too and we get into that a little bit as well.

ERIK: Sounds like a good talk.

JUAN: Let's get over to the episode.

ERIK: Yep. All right.

JUAN: Here we are. Juan Carlos Ramirez, one of the hosts for the Resonance podcast, the Baylor College of Medicine.

KARL: This is Karl, I was the writer for this episode and thank you for joining us Dr. Haudek.

DR. HAUDEK: My pleasure to be here, I really like talking to you.

KARL: Yes, we're very happy to be talking to you. Dr. Haudek, for those who don't know, she is the course director for Foundations of Basic Science and Medicine which is kind of the first set of courses that students start on here at the medical school; and also a very wonderful and kind human being, and we thought it'd be lovely to have a chance to talk to her today for this podcast episode. So Dr. Haudek we thought we'd just start out by asking if you could tell us a little bit about your background.

DR. HAUDEK: First of all, I maybe thank you for having me here. I really enjoy telling you and your colleagues more about me, my personal life, my professional lives, my interests, and so on. 
I am originally from Austria. I was born and raised in a town called Innsbruck in the Alps. So I was told I could ski before I could walk with, like, Innsbruck was a town where the Olympics were twice. But I was 10, my family moved to Vienna, the capital of Austria. No mountains, no skiing. And so I had to start dancing.

After high school, I went to the University of Technology in Vienna and I started genetic engineering with an emphasis on biochemistry, of which I graduated with a Master's degree. We do not have Bachelor’s degrees, at least at that time. You just go to the Master's degree right away. And after the Master's degree, only if you have a Master's degree, you are eligible to enroll in a Ph.D program, which I did I enrolled in Vienna in my Ph.D program and that was biochemistry. And I started this program and I had the opportunity to go and explore a different country. I always wanted to be in an English-speaking country. I always wanted to be somewhere else. I traveled a lot my whole life. I was very interested in learning about other cultures and other people, so I really really like this opportunity to go for one year to Dallas, Texas and work at UT Southwestern.

That one year turned into six years. I did finish my PhD, yes, and then after I finished it – actually, I had to go back to Austria to finish it and defend it, but then I was offered the postdoc position. My mentor was Dr. Brett [Giroir]. He was, you can see nowadays, in the White House talking about the COVID 19 testing kit incidences. Yeah, it was interesting for me to see him now on TV. 

KARL: That's very interesting.

DR. HAUDEK: It is. After six years in Dallas, I was ready to move on. I knew I wanted to stay in the US. Also, because I met my nowadays husband in Dallas and we both decided to stay in the US. And we applied all over the US for jobs, and it was Houston where we both had an offer, and be both very good offers. And that's how I came to Baylor.

KARL: So was biology, biochemistry – was that a passion that you always had, even as a child?

DR. HAUDEK: Actually, it was chemistry. My high school, I had a teacher who really really influenced me greatly. I just loved the way she talked. I loved her lessons, was very easy for me to learn it. And I actually wanted to study pharmacy, it was my real passion – organic chemistry, pharmacy, yet in Austria at that time, pharmacy – I didn't know much about industry at that time. But working in a drugstore was not my future and vision and so I decided not to study pharmacy, but keep it a little bit more open. So I started chemical engineering.

I think that the drug before I started chemical engineering. Yes. And then in the last years of my study I had my first course in biochemistry and I learned about DNA and proteins and I thought “oh, this is really cool because I love that thing”. And so I took an elective in genetic engineering and I took electives in biochemistry. And also I graduated in chemical engineering and knew at that time that my PhD should be in Biochemistry.

KARL: Interesting. So it's kind of a process of experiences one leading to the other.

DR. HAUDEK: Exactly.

JUAN: And you get to use those skills to this day.

DR. HAUDEK: Well, I forgot a lot of it. I remember a few years ago. I went back to Austria and I had to go through all my books and course notes and everything, and I had notes in my hand and I don’t remember ever writing them.

JUAN: I think some of us feel that way about six months ago in med school, perhaps they can – when did I write this?

KARL: So did you want to ask a little bit about her research experiences, Juan?

Dr. HAUDEK: Okay, so my research experience. When I accepted my PhD advisor position in Vienna, I knew that I wanted to study a topic in Biochemistry, and I knew that I would like to go to an English-speaking country. And so when I first met him, Dr. Hans Weiler – I am still very close with him today – he told me that he has this project which involves investigation of the transcriptional aspects in the promoter region of the Tumor Necrosis Factor Alpha gene with special emphasis on Nuclear Factor Kappa B and AP1 transcription factor protein-coding regions in the baboon compared to the human. And I remember sitting down looking at him and the only thing that I really understood was it somehow involves a monkey?

Well, everything else sounded great. And so I decided I'll go for it and I'll do it. And this is how my most intimate relationship with TNF-α or TNF started, because TNF has been my protein of Interest throughout my whole research career. I started with the role of TNF in sepsis, and it’s purely genetic engineering – sequencing and identifying promoter of the transcriptional regions in the promoter region in sepsis. And then, after a few years from sepsis, I was interested in TNF in the heart, during heart failure specifically – not just to sepsis – and that is actually what brought me to Baylor. Dr. Douglas Mann, he used to be Chief of Cardiology at Baylor. So he was interested in TNF in heart failure. And that was also the reason why I came to Baylor, to work with him and his group.

And from there on, after my postdoc was finished, I stayed at Baylor and I moved into the Michael E. DeBakey Heart Research Center, which was located or still is located in a Methodist Hospital in the Fondren building. So my lab and my office for more than 15 years was on the sixth floor in the Fondren building in Methodist, and I was interested in chronic heart failure. And during that time TNF was a little bit pushed into the background because I was more looking into general cytokines and growth factors that influence the differentiation of precursor cells or stem cells into fibroblasts or other cells in the heart, not specifically cardiomyocytes, but other cells. And so that's how my journey into stem cell research started.

After a few years after identifying factors and identifying a stem cell source in the bone marrow and in the blood, I circled back to TNF, and in my last research here – so I investigated specifically the TNF signaling cascade in those precursor cells. What makes them differentiate into a cardiac fibroblast or what makes them differentiate into a monocyte or macrophage. So here TNF again.

KARL: Interesting. So I – and forgive me, I don't have a super large amount of, fund of knowledge in this area, but is the main interest in fibroblasts because they'd be involved in scarification of the heart tissue?

DR. HAUDEK: Yes. Fibroblasts were always underestimated because the focus was always on the cardiomyocyte, and only in the in the late 2000s the role of the fibroblast was acknowledged. It was not just the structural cell, but it actually has some function, some very important functions. And yes, it is most important also in acute myocardial infarction where some of the heart tissue dies off and the scar tissue forms. And yes, it's the fibroblasts who mediate the scar tissue. And yes, I work peripherally on this, but my main interest was fibroblasts during chronic heart failure such as on the hypertension.

So I worked with mouse models that received angiotensin infusions or surgical mouse models in which their aorta was constricted or mouse models with mini infarctions. And then observe over time how fibrosis develops and what the process is for scar formation in acute heart failure. How detrimental it is in long-term chronic disease development because the more fibrosis you have the more elasticity is lost, and the heart needs to overcome the resistance and pump harder. And so long-term, you do want to inhibit fibrosis in a chronic condition.

KARL: That makes sense. And it probably could also derange some of the contractile activity if it's interfering with the constriction of the myocytes and the organization of the myocytes. So that actually sounds really interesting. So, basically you were exploring the role that these fibroblast have in chronic heart failure patients and – just real quick. How does TNF circle back?

DR. HAUDEK: So TNF signals through two different receptors, receptor 1 and receptor 2. Receptor 1 is highly investigated and it's also the receptor sought to be signaling apoptosis in cells. Whereas TNF receptor 2 is thought to signal positive effects of TNF in cells in general, but the role of TNF receptor 2 is less much, is much less known that of TNF receptor one. And so my goal really was to sort out the differences between those two receptors, which was kind of difficult because you really had to work with knockout models because they were – most antibodies available for inhibit, or most Inhibitors of TNF that are available target both receptors and don't discriminate between the two.

KARL: So by knockout models, basically, you would find a mouse lineage that had one receptor functional but the other receptor not functional and sequence it. 

DR. HAUDEK: Exactly.

KARL: Interesting. And did you find anything you think is particularly noteworthy you'd like to share with us?

DR. HAUDEK: Well the way in our studies, it was the TNF 1 receptor that was detrimental. I confirmed but there was, but again it was one specific myocyte process that has the option of either differentiating into a monocytes or into fibroblasts and there are those M1 and M2 macrophages in the middle – I don't want to go into detail – and the TNF really made a significant difference in which of the two outcomes it can steer the differentiation.

KARL: Okay. And the monocyte would be the more beneficial outcome, whereas the fibroblasts would lead to the more chronic heart failure type outcome?

DR. HAUDEK: It depends on the situation. Sometimes you want one, sometimes you want the other. So in an acute model for instance, you first want to have the monocytes that clear the wound, and clear off debris, and want – you need inflammation to start the baseline for good scar formation. It’s a timely asset, the inflammatory cells in the heart, and then after they have done their job the scar formation process starts. Now, that’s in acute infarct. Now in chronic infarct, in chronic heart failure, you do not have cardiomyocyte self-death so you don't lose cells, so there is no need for scar formation. So fibroblasts that would develop in long-term heart failure would deposit collagen in between cells, and does make it sticky in between cells and influence the mechanical aspects and electrochemical aspects between cells and that contributes. So in long-term heart failure, you want to inhibit fibrosis actually and also only have a minimum amount of new cells as well.

JUAN: What if something like this discovery in acute versus the chronic, what does that sort of mean for in the clinical setting? Is that change therapy or – ?

DR. HAUDEK: And again, it's been a few years, so everything I say is the status of a few years ago. So I have that disclaimer. Myocardial infarct, in the beginning, was the first target of most clinical trials and also stem cell therapies. However, nowadays even so myocardial infarct is very prevalent. If a patient receives adequate care within a certain amount of time, which is pretty standard today, the survival chances are very very high. In other words, today, if a patient seeks help adequately and timely, the patient will survive the infarct. However surviving infarct is the first step – then afterwards comes the long remodeling phase, the adjusting to it, the regeneration of the tissue. So a lot of problems – long-term chronic problems – happen three to five years after the infarct. So now that most patients survive we have increased problems of remodeling and long-term impact. So just go back in time when people died of a heart attack, then there was less prevalence of remodeling and long-term failure.

KARL: Yeah, your heart was just gone.

DR. HAUDEK: The second thing is – obesity, diabetes, one of those really classical clinical scenarios that are very prevalent nowadays. They all impact heart function in a chronic way. Hypertension for instance. A lot of people have hypertension and this, in addition to treating their hypertension diseases and symptoms, their heart is the one suffering also because the pressure is higher on the heart and the heart has to work a lot harder against that long-term hypertension. So eventually, yes, there will be mechanisms that will lead to heart failure.

JUAN: With people that have the, sort of, these predisposing factors like obesity and hypertension, the set, sort of does that change the timeline of when they need to seek help or or when these remodeling issues occur after the myocardial infarction?

DR. HAUDEK: That is a very good comment. I have to say I have not been working on this in the last five years, so I'm not really up to date. But yes, I do know that current research is really geared towards how to influence that remodeling phase. And also how can you reverse adverse remodeling back to normal? There is a lot of research going on in that direction.

KARL: So I think you touched on stem cell therapies in this discussion. I’m wondering if you could kind of discuss how that kind of circles back in here. And some of the issues surrounding that you may encounter.

DR. HAUDEK: I love the whole stem cell topic. Also, I never – I do not consider myself as a typical stem cell investigator. I am always peripherally working with them. I think the closest I ever worked with stem cell was in the late 90s in Dallas, but I worked with mouse embryonic stem cells and I tried to differentiate them into cardiac myocytes; and it was a side project, Dr. Shuar and I we worked on this together. And for a whole year, I tried everything, every protocol, everything and I think I only saw like three beating cells in this whole year. So that experiment was a failure.

KARL: So three that contracted like muscles, that actually had a contractile to them? Okay.

DR. HAUDEK: These typical signs for cardiomyocytes, you can see it easily in the in the dish if cells are contracting then they are most probably cardiomyocytes. And so that was my first long-term experiment with embryonic stem cells and even though it was a failure and we did not continue that project and I never picked up on it, but it really set the stage for me to really think about what are those cells? Why do we work with them? And what did I actually try to do? Now again, this was in the late 90s, meanwhile, there are protocols out there how to differentiate pluripotent stem cells into cardiomyocytes. Plenty of them. So today probably would be an easy, easy process. However, it really intrigued me, and at that time, while I was doing it, I did not think about it that much but afterwards – maybe in the early 2000s – I revisited this project. I don't know that it's just me that if something doesn't work, I'm very persistent and I always go back and think about what went on and so my interest sparked in embryonic stem cell research.

And also I never did it again in the lab myself. I read up on the literature. I got involved in discussions. I researched on my own and then also expanded into adult stem cells and fetal stem cells. And I started talking, first to family members and then to friends, and then to others about what do they think about it? And I realized that many people either did not think about it at all or had a very non-scientific view, and that intrigued me even more. And so I started in the Houston community going around to schools, retirement communities, other communities, and talked to people about stem cells and I realized there was a huge need because in the 2000s, early 2000s was really the hype of stem cell therapies and stem cell supply and I think during the elections for president, I think it was President Obama, it came out that in his election communications, he had to make a statement about stem cells and that intrigued me a lot. It's like, why would that matter for a president? Actually, it was under President Bush that the big stem cell debates started. But why would that matter? Why would that be a stake in the election? Why not talk about cancer or obesity or something – why stem cells? And so that that made me look into this and also other people around me are interested. So to come to a point, it was my goal to educate the public, and private, and students about what stem cells really are, what you can do with them, what is their promise, why is there such a hype about it? And what do we do now?

JUAN: Yeah, I think one of the most memorable things that you've said to us as a medical students while you're teaching these stem cell lectures is to – you really challenged us to think about, you know, stem cells and know more about it obviously for medical school, but to sort of dive into the ethical hurdles that have been brought up in the past and then the present and what we think will happen in the future. To think about these things as physicians. How do you think that's kind of changed in the past and now, and sort of going forward?

DR. HAUDEK: First of all, I don't think it has changed. I think it's the same hurdles, the same ethical decisions, the same problems. I do have to say that I only have this one hour with medical students and there is a lot of scientific knowledge I probably should emphasize more on while teaching the first class. And so I – every year before, up to the minute before I enter MacMillian, I'm thinking “am I going to talk about this today or not?” Because, so far I’ve always decided for yes, I'm going to do this, because in the end there are always a few students who are impacted by what I say. There are also students who are totally not impacted and they receive email saying, like, why you do this, it was absolutely not relevant, and I should just quit doing this. So I get both messages. But I do think that this is my one and only opportunity to bring it up. And so I think I will keep doing this.

My goal here is not just to challenge students about thinking about stem cells, but also in general challenge students to not take everything at face value. I think it is really important, the critical thinking and having an opinion about anything, and I use stem cells. But anything that they have to make their own decisions in life, what do they believe in and whatnot. And that goes through their medical training, through their basic science training, through whatever other training everyone has. And so I'm very passionate about this, yes. I wish I would have more hours.

KARL: Well, I think it's valuable. Often throughout science and including the medical field we can get tempted to think of just the very cold, factual, logical scientific side of things, but we really especially in medicine kind of exist in an interface with very high ethical implications, and a lot of the decisions and things we have to think through and make decisions about are going to involve taking scientific information and an ethical framework and sort of trying to interface between those two to do, you know, what we think is right for the patients and for society. So I think it is a valuable exercise to consider the ethical implications of what you're doing as a scientist.

DR. HAUDEK: Thank you. Yes, I would like to continue also with the induced pluripotent stem cell technology that is now readily available. The discussion has mellowed down a little bit because more and more people really take advantage of IPS cells and kind of step away from the embryonic stem cell. It has its own set of problems, granted, but it does not have the problem of the destruction of an embryo. That is a huge, huge, huge advantage over all the other ones. Now with the adult stem cells there has never been that problem to begin with –there are other ethical problems, standardization problems and things, but with the IPS technology I think that will go forward and that will be the future of stem cell therapies. In combination, and I want to really emphasize, that in combination with tissue engineering. Stem cells alone, by itself, will have a big impact but the greater impact will be the combination of stem cells with scaffolds, with material, with equipment, with devices, together.

KARL: You’re talking about, like, so this is a gross simplification. We don't just have the cell that's maybe been induced to differentiate around a certain pathway, but we might have some sort of mesh framework that the cells are provided to grow around to help shape the structure that they're trying to make – is that what you're saying?

DR. HAUDEK: Exactly. So it is absolutely necessary to collaboration between scientists and clinicians, but to involve engineers, to involve engineers knowledgeable about different materials. Physicist who can calculate a nanotechnology to make very, very thin fibers for instance. 3D printing, 3D printing opens the door to having these 3D scaffolds where cells can be seeded on and then as a whole can be used in an application. So I think in the future this is really where, in my personal opinion, will be the greatest impact.

KARL: And also just a real quick point of clarification. You mentioned induced pluripotent stem cells. So I’m wondering if you can just explain really quickly to the audience that may not know what that is and how that differentiates from the traditional embryonic or other types of stem cell.

DR. HAUDEK: Okay, so that embryonic stem cells stem from zygotes. Actually the zygote divides into a morula and a blastocyst, and then you destroy the blastocyst and take the cells and culture them in a tissue culture plate. And those are your embryonic stem cells. Embryonic stem cells and IPS stem cells are both very highly potent, very high – so that's why they're called pluripotent. That means it has the capacity to regenerate every single cell type, every single of those 220 cell types that are found in the human being. That's why they are super potent. Now, the more often a cell divides and the more often it differentiates, it loses that potency. That's why in an adult organism the stems cells that we isolate are only multipotent. Because they have lost already the capacity of making many cell types. So they usually, they stay within their germ layer lineage. They cannot go to others. Once they move further, eventually, the endpoint is the fully specialized cell.

Now, IPS technology is a method in which you take a fairly differentiated cell, like fibroblasts for instance, and you genetically manipulate that cell to go backwards, which is against every nature mechanism. You use a viral vector to induce the expression of certain transcription factors, specifically, four transcription factors and those four transcription factors are named after the person who invented it and that was Shinya Yamanaka. So those transcription factors are called Yamanaka factors. And so the expressing genes, those Yamanaka factors, are induced into an adult cell and their expression is forced; and by doing so the cell is forced to differentiate backwards into an original pluripotent cell. That's why they are called induced pluripotent cells. So it's going backwards against nature to the same point where embryonic stem cells are, or supposedly are. Now once you have this dish – so you started with fibroblasts, and you have a dish of pluripotent cells, and then the pluripotent cells you can make all the 200 different cell types that you want. And so you only have to have the recipes to do so.

KARL: So the basic advantage is going to be instead of having the ethical implications of potentially having to destroy an embryo, you can take some cells from an adult. And before those stem cells weren't going to be as useful because they only had a limited range of things that can differentiate into, whereas if we can use IPS you can go back and use those cells from an adult theoretically in the same way that we could use in embryonic stem cells. Is that the basic advantage?

DR. HAUDEK: Yes. Thank you.

JUAN: I think it would be nice to sort of switch gears. You also have this side of you that many people don't see – that work-life balance that that is kind of, you set up as a kind of as a role model for us to sort of work on both our professional and then pursue the things that make us happy outside of our scientific pursuits. But in your case, I think it's still somewhat professional. Would you care to elaborate?

DR. HAUDEK: Well, thank you very much for calling me your role model. That that really makes my day because that's really what I want to be.

JUAN: No, absolutely.

DR. HAUDEK: Thank you. Throughout my life, I was always very curious and very open to exploring different aspects. The switch from research into education was a gradual switch. It was not one day to the next, and I did it because – not by default, it was an active decision. I did have opportunities to continue in research, but I actively decided against it. I like – I enjoy working with individuals of any age and any level from students to faculty. I enjoy the one-on-one meetings, enjoy the social aspects, I enjoy the communication. And this is really what's driving me – what has driven me into education and what is still driving me today. So my first advice for life-work balance is really enjoy what you're doing professionally and in your life and in your private life. Yes, we all work hard. But if you really like what you do, it's not really work. If that makes sense.

JUAN: Agreed.

KARL: Definitely.

DR. HAUDEK: I really enjoy going to work. I really enjoy the things that I do and so that is already part of my balance. Now I am also open, I talk about what I think and feel, hopefully in a respectful way. And I always assume the best in the other person in front of me.

KARL: I think that's a good principle.

DR. HAUDEK: Yeah, we are all equals kind of, I feel we are equal so I often ask students for advice. My biggest interaction is with the MS1 students during the course, but I really like that some of the students during in their fall-up years. They still come to my office every once in a while and tell me hey, you know, I'm doing this and that or just ask me how you are and then  I ask them for advice and say hey, I just did this in the course and I got terrible feedback. What am I doing wrong? So I appreciate that.

As for life-work balance in its essence. Yes, at home, I think it's important to have a supportive partner with whom you have general interests in common, but also who complement each other. There are things I hate to do, like cooking. That’s my husband, and I do the laundry for him because he doesn't like to do that one, so we complement each other. But we do have a common hobby and that is dancing in our case and it is very important to keep our hobbies alive and not move it away because work takes over. So for instance we have a rule we have training every Friday evening for years. There is absolutely nothing that can make me stay on a Friday and work longer than six o'clock. Usually I stay until seven or eight some days but not on Fridays. I just have, even if the deadline is not reached, I have to go home because Friday evening is dedicated dancing evening.

KARL: And you say hobby, but this dancing gets pretty intense. You guys go to competitions and stuff like that. Right? Could you tell us a little more about that?

DR. HAUDEK: It used to be very intense. Unfortunately after hobby, it stops being intense. I started that as a teenager, you know, Vienna is a city to dance, the Viennese Waltz comes from the city. We have, during Carnival – we have more than 300 public dance events in Vienna. Every weekend, you have a choice of 10 different ones, and so it is pretty standard in Vienna to go and learn how to dance. But here in Houston, you learn to play soccer or football. In Vienna, you learn to dance period. I continued dancing after that initial learning. When I came to the United States in my mid-20s, I thought I would start horseback riding or something. So in my mindset I thought okay, this is not old, and then I was in Dallas and I couldn’t resist checking out that one single dance school that exists, but actually they were two dance schools in Dallas. And so I thought, okay, you know just at least go there once and check it out. And coincidentally on that one day, there was this person from Holland who danced there as well, and we immediately clicked and we started to dance. 

Well, make this very short that person is now my husband. Dancing went into dating, then went to marriage. So for many years, we stayed social dancing. It's a hobby. It's great exercise, great cardiovascular exercise. It is very social, you meet people. Importantly, it's a hobby that you and your partner together. And I think that also contributes to the work-life balance; you do something with your partner together. And now around 2008, I think we started to become interested in joining competitions. And this is when the really intense time started. And if intense, I mean five evenings per week training. Lessons with trainers, going through the country to different competitions, get your points, get into the system.

And once you are in this, it's just – your mind is set in this, and your ear towards, and it's not just dancing. It's then you have to have to dress up, and you have to have the makeup, then you have to have the connections and the trainings and I think be moved up the chain. And actually I admit I am quite proud of it. We made it into the final six, so our best placement was this international amateur competition for our age group and our type of dance, and that was really a major, major achievement. And our goal was to become among the top three. I think we had good chances. We were on the right roll and Harvey hit. Our house got flooded two feet underwater. And with that, everything changed – you don't have time to do anything other than working, then most necessary things, and taking care of your house, and taking care of your family. And even though everything is great again, we have not found back into the momentum of competitive dancing. 

JUAN: But you still do it?

DR. HAUDEK: We still social dance, at least twice a week.

JUAN: Well, I guess now because of the COVID social distancing dance . . .

KARL: Are there talks for virtual dance competitions, virtual dancing, right? 

DR. HAUDEK: It's not competitions. They have been canceled, unfortunately. Our dance school has virtual training sessions online and I have a group class where you're just do what the instructor’s doing. Or you can have a personal one-on-one question where you literally put up a video and you dance and the instructor gives you feedback on how you dance.

KARL: Wow. That's great. People still finding ways to stay active even in self-isolation.

JUAN: It really highlights, right, what's important . . . 

DR. HAUDEK: Social socializing is important, but I also believe exercise is really important – at least it's important for me. And so since we don't dance that often anymore, I started little bit running. Yeah. I'm not sure if I could call it “running” running. I mean those two months that I run every other day.

KARL: So Dr. Haudek, just changing gears a little bit, talking more about some of your educational work at the school and kind of some of the new roles you’ve taken on in the past few years with the undergraduate medical education office and all that I was wondering if you'd be willing to explain some of that to us give us some inside information, you know.

DR. HAUDEK: So while I did my basic science research, I was always interested in education and I always reached out teaching graduate students mostly in the lab, and in the classroom and then one day in 2010 I met Dr. Goodman. He took me into his wings, or under his wings, and he made it possible for me to start lecturing in the Foundations course. And every year, I had one more or two more lectures. So I went from one lecture at the very beginning to my maximum, I think, of 30 lectures a year ago. But that really changed my life and that really influenced me of making the active decision, devoting my time hundred percent to education. So in 2017 was when I made that final step and I started in the foundations course. It took me two years and meet everyone to get used to things. So in 2018, 19, two years ago, so I course director and it is really an all year-round job. So if you ask me what my typical day looks like I really have to divide it into the first six months, January to June, and into the second six months, July to December.

Let's start with July to December. This may be the most applicable to you. I sit in class every day. I meet with students every day. I write exams every day. I talk to faculty every day. I make schedules. I put out fires. I communicate with everyone. I make sure everyone is where the person is supposed to be. And it's a 12-hour day during that time, it is a really long time. And most of my other projects I work on are kind of reduced during those six months because my primary goal is really that course. So I still do admissions interviewing every Friday. I still participate in curriculum development every Monday. But many of my other things are kind of on the back burner.

Now in the other six months when I do not have to sit in the lectures, I have so many different things to do. And that is also part of what I like. First of all, I do need to write up all the documentation for the Foundations course, but I'm also involved in the faculty development. I am the director of the peer coaching for educators program, which means we support faculty in their teaching skills. We teach them how to be a good teacher. I'm also involved in other faculty development like faculty awards, guidance, I advise people on promotion or I give a lot of workshops for faculty. I'm also on the faculty Senate and I organized three conference. As you know, I organized the Taub and James K Alexander medical research symposium. I organized a symposium for educators, annual educational showcase. This year, new, I organized – or I tried to organize, it was cancelled due to COVID-19 – a regional conference for educators. So that takes a lot of my time.

I do not come in to work on weekends. I really try to stay home. However every weekend I do work from home a couple of hours and I prefer doing things like reading documents or writing; something that I can do sitting on a sofa or not on a desk. I do that throughout the year and yes, once a year again – cancelled due to COVID-19 – or this spring, I go to Vienna to give my stem cell course, two weeks. So that keeps me also busy, on another course. So I'm wearing many different hats depending on which day you run into me. That's what I do.

JUAN: I guess it's fair to ask if there's anything you don't do.

DR. HAUDEK: clinical work. I don't do clinical work. But I do work with clinicians a lot, faculty and student. So if I walk along the whole way down the hallway, I recognize most faces. I apologize, I do not remember the names of many people and especially these medical students. I don't remember MS1s, or 2s, or 3s, because that also changes pretty fast, but I do remember faces and so when I walked down the hallway I just smile and say hi to everyone because there's a highly chance we know each other.

JUAN: It's safe to do.

DR. HAUDEK: And again, that's the part I enjoy of doing and if I have time and if the other person has time, I love to stop and say hi and follow up on what's going on right now. 

KARL: Definitely the nice part of teaching, those relationship you can build with people. 

DR. HAUDEK: Exactly, yeah.

KARL: We've enjoyed it a lot learning about, you know, stem cells, broken hearts, and the art of ballroom dancing, I guess – can we call that episode, at the title of the episode. Thank you very much for talking to us today. We really appreciate you.

JUAN: We really appreciate it.

DR. HAUDEK: As you know, I'm open, I try to share my experiences, and my pleasure. Thank you.

JUAN: Thank you.

iTunes | Spotify | Google Play | Stitcher | Length: 46 minutes | Published: Feb. 4, 2021

Dr. Elaine Fielder will talk about the experiences and turning points that led her to pursue pediatrics and emergency medicine. She will talk about her role as the director of the pediatric clerkship at Baylor and what considerations she has when designing the curriculum. She will explain what interests her about teaching, and what she hopes students will take away from their clerkship.  

Transcript

ALICE: Alright.

JUAN: Well, welcome. My name is Juan Carlos Ramirez. I’m one of your hosts here at the Baylor College of Medicine Resonance Podcast and I am joined by some wonderful guests today. 

ALICE: Hi, yeah, I'm Alice. I'm also a student at Baylor in the MD/PhD Program and a member of the Resonance Podcast group; and today we’re talking with Dr. Fielder who was the Pediatric Clerkship Director from 2013 to 2019 and is now the Pediatric Residency Program Director.

DR. FIELDER: Hi guys.

JUAN: Welcome.

DR. FIELDER: Thanks.

ALICE: Hi, so Dr. Fielder, can you tell us a little bit more about yourself and your career interests and how they've evolved over time?

DR. FIELDER:  Sure. So first of all, thanks for inviting me. I think this is such an honor and I am a huge fan of podcasts and listen to them every time I get in my car. So yeah, so a little bit about me so I am a pediatric emergency medicine physician at Texas Children's and at Baylor, and I did my undergrad at Texas A&M, whoo! Any Aggies out there? I graduated in 2000 and I did med school at UTMB in Galveston. I went on to do my Pediatrics residency at Arkansas Children's Hospital. So University of Arkansas for Medical Sciences, and then I came back here to Texas, to Baylor, to do my fellowship in pediatric emergency medicine or what we will call PEM. And so I finished fellowship in 2010 and have been here on faculty since 2010 in the Department of Pediatrics and in the specialization of Peds emergency medicine.

So that's sort of my career path and my interests in Pediatrics. It's a good question. I think I was a big fan of everything in med school. I was one of those, when I did my surgery rotation I thought I wanted to be a surgeon and I did internal medicine and thought I wanted to be a medicine physician and, yeah, every subspecialty I liked and I did Peds fairly late in my clerkships. And when I did it, I knew. I knew that it wasn't just a “I love everything I'm going to want to do this too”. It was a different feeling that I got. Yeah, that's sort of my trajectory into Pediatrics.

As far as PEM, or peds emergency medicine that was another one where in my residency I was fortunate enough to train at a hospital where it was very resident driven, Arkansas Children's Hospital has one of the largest or one of the most I think founded or solid Life Flight programs in the nation and they, back in the day, allowed residents to be the physicians on the helicopter in your second year of residency. And you can moonlight for 50 bucks an hour, and I moonlit as much as I possibly could which helped me really hone my skills as an emergency medicine provider or critical care provider and that kind of helped me. I loved that role. I love the ER. I loved the PICU. So towards the end, I decided on emergency medicine just because that's where my mentors were.

ALICE: And that's really awesome. Where along the way did you realize that you also had an interest in student education or teaching because that seems to have played a really big role in your career as well.

DR. FIELDER: Yeah. Absolutely. It's funny. I always loved to teach and along the lines of emergency medicine. I love to teach procedural skills to residents and to my colleagues, my fellows and . . . I think it was my first year out of Fellowship, my last year Fellowship, I developed a curriculum in emergency medicine pediatric simulation focused on the skills that are necessary just as an emergency medicine physician so, you know, suturing, abscess drainage, lumbar punctures in infants, bladder caths, and putting IVs in right. So the basic major
ER, sort of, skills that you need to have in the ER and I've developed that my last year of Fellowship.

Somehow that got me into the educator club and one of my mentors asked me if I was interested in being the director of the Pediatric Emergency Medicine sub rotation of the clerkship, of the Pediatric clerkship, and I kind of looked at him like, “I don't know if I'm the best fit for this, you know, I'm really interested in teaching but I don't know if I want, I don't know if I want a role that I have to be accountable to . . .” and it was a little bit scary to imagine being in that role. But he said, “Elaine, you're great with the students. You're nice. They need someone nice. They need someone who's excited about what they're – what you're doing”. And I was like, “alright, that's totally, okay, so I'll apply”.

And I ended up getting this position and that kind of was the initial snowball effect that kind of continued to roll. And so it's funny, every role I've been in I've really been faced with a new challenge as soon as I come into the role, it seems, that it helped me grow into that role. So as the sub rotation director for PEM and within the clerkship, I was immediately met with “okay, you are going to go from 1 week of PEM to two weeks and double the number of students in your subrotation”. And that is – if anybody out there's curriculum, you know bands, you will understand immediately that that's a huge resource, you know your funds, your people, the time invested is a huge amount of resources that that makes.

So I develop this curriculum, I got a grant for $40,000, I funded a simulation curriculum and that again kind of pushed me more into that educator position when the clerkship director at the time left. She took a position up in Oklahoma. The position came open and everyone was like, “you should apply for it”. And again I was like, “what are you talking – you’re crazy! Like there's no way I could do that”. That's just such an impactful role, and I just didn't see myself in that position, but I took people's words and I went for it and I applied and I got the position of clerkship director. And then LCME came and we got cited for 14 different citations, which was an entirely different level of challenge to make me rise to that occasion. 

ALICE: I see. Was there anywhere along the way where you doubted yourself, where you needed mentors to help guide you along this path? Any time where you're feeling like, maybe you didn't belong, maybe you had made the wrong decision?

DR. FIELDER: Oh, yeah. I mean, I think we all have that impostor syndrome for sure and I gave you those two examples of you know, when I took on that first role and then when I took on the clerkship director role. I continued to have those feelings of doubt and “I think they made a mistake. I don't know if they read through my application completely, I just - I don't know if I am right for this”. But every time I was met with students and learners, they were so appreciative of what I was doing. Then it kind of made me think a little bit about “maybe this is what I was meant to do” and it really, that is the glue that sort of kept me together during some times where it would be very easy to sort of become frazzled. My students, my learners, now my residents too, they just come back to me and they remind me that I am in the place exactly where – for me, where God needs me to be, where I would say where I was meant to be at this time. But yeah, there's always that imposter syndrome that kind of creeps in every time you get some accolades, or you get a new position. You just keep thinking there's something wrong with everyone. Then I go back to my learner's and they try to remind me that I'm doing what's needed to be done. 

ALICE: That's awesome. I guess, did you have any role models in your early life that you think pushed you to go into medicine or maybe influenced your inclination towards Pediatrics? Could you have imagined yourself at all in the position you're in today when you started out on this route?

DR. FIELDER: At so many mentors, I think. Along my path there have been people that have almost helped me pivot in time, those periods of self-doubt. There's always a mentor there. There's always someone it's not ever just me, never ever ever. And you know, I'll say that, you know, my mentors in emergency medicine and residency, specifically, really helped me to choose that specialty. You'll go through medical school and look at your faculty or fellows or even residents that you're working with and just have that moment where you're like, “I want to be like him. I want to be that person and I want to be . . .” For me, it was Doctor Stanford in the Arkansas Children's Hospital emergency room when we were doing chest compressions on a patient and I looked up at him and he goes “this is why I do this. This is exactly why I do this. I I want to help my patients” and that was when I knew I wanted to be this, I want to do this. I want to help, I want to make a difference and have an impact.

Dr. Gordon, she who is the Vice Chair of Education, now the Interim Chair of Pediatrics, was my program director at Arkansas Children's Hospital funnily enough, back in the day, and you know, he came here years before I finished my residency and has continued to be a mentor of mine throughout this path. And what I've learned from him, and I can mention so many other mentors, is it's so important to recognize the people in your life that empower you to make decisions. They empower you to make mistakes, and they love you anyway. You know, they support you because if they understand your vision and what you're trying to do, good mentors will be there to fight for you. They'll be there to take the fall if you do something that isn't exactly fantastic. They'll not necessarily take the blame, but they will fight for you and they will give accolades when it's deserved, and will help you get the resources and the everything that you need to get the job done. And that's what all of my mentors have done along the way. There's not a single Mentor who has given me anything specifically, they've had me fight for what I want and they've helped me get the resources to get those grants or to get that position or to get the resources. But that's the other thing about it. They push you they pushed me to stretch myself a little bit further. That's what amazing people do, amazing mentors do.

ALICE: How did you make the decision to come to Houston and Baylor? You said you trained in Arkansas, right? So, how is the transition like to Baylor? What do you find that's unique about Baylor maybe, or different compared to Arkansas?

DR. FIELDER: Yeah, it's funny. My husband Will and I dated for four or five years before we got married, and we never lived in the same state or the same city until we got married. So we had a long-distance relationship for four or five years and you know, I lived in Galveston and he lived in Dallas, and then I moved to Little Rock and he lived in San Antonio, and then he moved to Oklahoma City and then I moved to, you know, I was still in Arkansas and finally when he proposed he was living in Houston. And so I took a gamble. I came down to Texas Children's and I did a rotation my second year of residency in the ER because I knew I wanted to come here. And I said “Will, we are getting married. I am going to live in Houston. I want to do a fellowship. This is where I want to go. And if I don't match then I'm going to get a job as a generalist in the ER or do some other, something else, and then I'll try again”.

But I came down and I did my month rotation in the ER and I loved it. And I loved the faculty and I loved that my training at Arkansas had prepared me to be so autonomous and so hands-on with all of my patients and I knew how to intubate and I knew how to put lines in and I knew all these things that I felt super great about on this rotation. And when I matched because I suicide-matched if you will, I said, “this is where I'm going” and I matched right? So I was very lucky in that regard, but even had I not matched I would have still come here and done some work, you know at Texas Children's or be, you know, I was planning on being a generalist if I hadn't matched but that's how my fate ended up. 

ALICE: So more getting into your time as the clerkship director for Pediatrics. What considerations did you have when you were designing that curriculum? What did you hope that students might have gained from their experiences? And I want to address the same question to the residency program now that you're that director for that.

DR. FIELDER: Yeah. So I mentioned that when I first came on as the sub rotation director that one part of it, that one week of PEM was now going to be two weeks. So that was the initial challenge, that this rotation is going to have twice the number of students in twice the number of weeks and “okay, go!”. So I had to develop this procedural skills curriculum and that helped me get to know a little bit about what the curriculum overall was, right? Easy to stay in my niche that you know, “this is the ER and this is what we should focus on”, but as clerkship director it is “how can we make sure you guys, my students during this eight-week clerkship, have the foundations necessary to help you make a decision about what you want to do with your life?”. And by no means should you be competent in general pediatrics or pediatric emergency medicine at the end of this eight weeks. But you should know and have been exposed to enough pediatrics from the acute side to the general well child checks to some adolescent medicine to you know, neonatology and inpatient. You should know enough about the broad, general pediatrics world to help you make a decision about what to go on to for the rest of your life.

Not only that – and I know EPAs, or entrustable professional activities aren't necessarily part of our curriculum yet. But “what can we teach you and what can we ensure that you guys are entrusted to do by the time you graduate”, right? So that really shaped how the curriculum was developed overall for the clerkship. And so it did mean taking a broader look at general pediatrics and not just focusing on emergency medicine because I can always come back to, “well where they sick or not sick, what would you do, let's talk about triage and what were their . . .” you know, so it needs to be more, okay, let's go back to general pediatric practices that I know that I'm board certified in and talk about the immunization schedule and talk about, you know, late immunizations. And let's talk about the newborn, care of the newborn and I feel fortunate enough to have that knowledge as a PEM provider to know a little bit about everything in peds. That's sort of my job. Right? I think it was the perfect fit but it did help me stretch and realize that it's more than just me and just the ER, that we have to think about all things from the scope of a general pediatrician.

ALICE: In the same line as that question though, you were talking about trying to give students a broad experience of what Pediatrics is like so they can make a decision. What advice do you have for students who are trying to make that decision when they go through different clerkships?

DR. FIELDER: I think the students can be so hard on themselves and feel like they have to master the material by the end of their clerkship. And I do hope that one day we get to more of a competency-based clinical rotation because it's more “are you, do you feel competent or confident enough to assess a child after/at the end of medical school?” You don't have to know the details of how to take care of each individual problem. But if your neighbor came to you and asked you, if you were going to go into neurosurgery or something, “Hey, can you look at my kid?” I need you to understand, I need you to be able to assess if he was sick or not sick. I think students can be so hard on themselves and feel like they have to master all of the minutiae. And of course it's so important for you guys to match and you have to have perfect, you know in-training exams or you know, your shelf exams, you have to have great board scores, and I think they get so bogged down with the details of assessment that they miss the joy of just learning about peds and just learning about assessing and stabilizing patients, you know. I guess to answer your question because I feel like I went on a tangent . . . 

ALICE: No, it was a great answer! General advice like you mentioned, focus on, you know, understanding and appreciating the art of taking care of patients. But also, how do you make that decision eventually, how do you just know that this is right for you and that you want to do this? Any advice on that as well?

DR. FIELDER: Oh, yeah. Yeah, I wish I could give you some great, validated assessment tool or something that you can use. But honestly, it is more about the people that you're working with and knowing your strengths as a person, right? So I'm a big fan of the Clifton Strengths Finder, I don't know if you guys have heard of Strength Finders . . . the Gallup company developed this survey and it's several, it's a few decades old now, but it looks at 34 strengths that you are usually a combination of. And it'll give you your top five strengths, if you take this survey or this assessment, and if you are using your strengths and this is validated, now by data and there's several studies to back this up. But if you're using your strengths you are going to be happier or you're going to love the people that you work with, you're going to love what you do. And if you find yourself going back to a clinical rotation where you're using your strengths and you're empowered to use your strengths you're going to love it.

So I'll give you my top five strengths are, number one, learner. Okay, so no question about that. I love to learn, I listen to podcasts as soon as I get in my ER – I'm sorry, as soon as I get in my car, and I force my learning sometimes on people like “this is a great book. You've got to read it”. My number two is activator. I like to get projects started and off the ground and running. That's why I think I love the ER so much. I love a challenge, I love to get things going. My third is positivity. In peds, I'm using that strength every single day. If you walk around with a frown on in peds, your patients are going to be scared of you. I mean, you know, you just gotta lighten up and you got to put a smile on and you have to work in a team and be positive and so, you know, and then my fourth and fifth are input and relator. So I love to build those relationships with people. So that's just an example of how I can use my strengths every single day in my field. 

And are the people that I'm working with supportive of me using my strengths, right? Are they okay that I'm a learner? Are they okay that I love to, you know, get new information from different people? Are they okay that I'm so positive and a little Pollyanna at times, or do they hate it, right? Because people have differences, right, and that's part of my personality. I think when you go through all of your rotations you will know, when you go home at the end of the day, are you done after like a week like there is no. “Hey I can do this”. Do you feel drained of energy and your emotions are, you know, do you feel awful or do you love the people you work with, love the environment and the energy and want to go back? So that is the best advice I can give is just know yourself, pay attention to those emotions. And take the Clifton Strengths Finder! No stock in the company. I just love it. 

ALICE: Yeah, I think I might, gonna look at it when we get off this call. It sounds . . .

JUAN: You said the “Clifton Strengths Finder”? 

DR. FIELDER: Yeah. 

JUAN: Just to clarify for folks listening, training, and . . .

DR. FIELDER: It’s so funny. I love it so much that, as the program director, and this is my first years as the residency director, I bought a copy for everyone on my leadership team and we're doing some team building around Clifton strengths. So again, there's no, they're probably be like, “what are you paying these people to . . . ?” but I seriously, it is totally a, it's a personal thing. I love it and it's a great way to understand the people on your team and how each of your individual strengths can complement each other. So while I mention I'm an activator, I like to get projects done, I am not an achiever and “achiever” likes to finish projects. I like to start them, but I'm not so much of a finisher all the time. So I need those people in my team to help me finish the things that I get started.

ALICE: Guess this really transitions well into the next question that I was hoping I would ask you, which is what do you think are some qualities that make a great pediatrician? Is it going to be different for every individual? Do you have any thoughts on any general qualities that you think would be a great match for Pediatrics? 

DR. FIELDER: Yeah, I think having that positive nature is a good thing. I think if you’re a pessimist or – and it's okay to be a realist, right? I mean, we need realists in pediatrics too, but I think having an overall ability to look at the big picture and focus on what we're doing well, and for families, and for patients too. And I've seen some very realistic, some people might call them pessimists, but when they walk into a room with a family that has a child who is sick, it's like a new light shines through, right? That realism and the business side of them that's on the other side of the door completely goes away when they walk in because their strengths, which we may not know about, are really highlighted whenever they work with families and when they're focusing on the good in the situation when it can be a very dire situation.

So I think having some sort of empathetic bone, for sure all of us do or we wouldn't be doing this, right? But we have to be able to look at the entire family dynamic, the social situation, the things that may be preventing families from getting the resources that they need, looking at the big picture, being empathetic to every family’s situation and where they're coming from. And then having some positivity I think is always good.

ALICE: Yeah, that's really important. Especially right now, I think, to be able to do that. And I guess now that you’re residency program director, especially since you transitioned quite recently and now there's such a big challenge in the global community . . . how has that been like and how have you tried to work around that and address some of those challenges? 

DR. FIELDER: Well, you know, I always go back to, every time I'm in a new role something new happens, right? So this year has been especially challenging but fortunately for me, I'm not going to know any different and just going to think all the years that come after this winter, so much easier! It's going to just be so, you know, I think that the biggest challenge – and again, this is more of my positivity coming out, but this this situation has brought forward so many opportunities to learn outside of just our normal PowerPoint, 1-hour noon conference lectures that we've had for 25 years, right? This is a brand-new era. I don't think we will ever go back to required noon conference, “death by PowerPoint”. I just don't think we're going to do that. I think this is giving us so many more opportunities to get to know our residents on such a more personal level. To see inside their homes, to see what their kids are doing or what, you know, the names of their pets and to see what life is like outside of those four walls on the third floor of Mark Wallace Tower, you know? And so I think it's been challenging in its own sense in that, you know, we have to meet certain guidelines, ACGME. Make sure that you know, they are very strict about what rotations residents need to complete before they are board eligible for Pediatrics. They are very, you know, very direct on how many hours of learning must be accomplished, you know, within a three-year residency. With the onset of COVID it's a completely different era and so we have had to be very creative in home learning opportunities, in learning to use Zoom and all of the other cool applications that are available to us, and to document that we are making sure that learning is being done, and that those assessments and those evaluations that they need before graduation are still being completed. 

And so while I think, obviously I think what we're all nervous about, is the learning being completed without those in person one-on-one patient bedside opportunities? Yeah, you can still round with your team from home. You can still look at rashes. You can still look at vital signs. You can still hear an assessment and a plan and give your feedback, right? I think there are just so many amazing opportunities to learn from this and I think things will never be the same. I think education as we know it has been flipped on its head and it's never going to be the same. 

ALICE: Yep. There’s really profound change, I think in a lot of ways. I was also curious as to what your opinion is on whether practice has changed for anyone in Pediatrics? I know kids are not the primary population affected by the pandemic, but have you noticed any changes in the way that you diagnose or treat patients?

DR. FIELDER: Yeah, I think that is something I think is another benefit of all of this, or the positive that's going to come out of all of this. Classically in our emergency room, we’ll have 80 patients in the waiting room. In the waiting room alone. Not to mention the 50 beds that we have in our ER that are full. That won't be the same again. I really don't think that that would be the same. I think that telemedicine, thank the Lord, is now to the place that we have needed it and wanted it to be for the last decade, right? So something had to happen for telemedicine to start blooming and this was it. I don't think we'll ever have 80 patients in our waiting room again. I think that families who had limited resources and then limited ability to seek help, to seek medical help or to seek the advice of their physicians came to the ER, right? And they came after work or after their second job, or they came, you know after they finally got someone to help watch their other children for them. This is a beautiful thing that has happened and I think the ability to do telemedicine visits and tell parents, “Hey, I can see your kid in 10 minutes. If you can jump on we’ll set up the appointment online, we’ll have this appointment and I'll see your child and I'll hear about what's going on and I'll be able to see them as well”. And now they don't have to come all the way here and we don't have to worry about them being able to get back home, transportation back home, right? So the cost savings in the long run for families, and for our medical community is going to be tremendous. 

That being said every learner, every resident, and every student still needs to have those one-on-one interactions with patients. And I apologize if you're hearing crying in the background. That's my three-year-old. Can you hear him?

ALICE: It must be hard. I don't know if he usually has more activities to do right now. I have a brother who's at home and he's ready to get back to school and get busy. 

DR. FIELDER: How old is he?

ALICE: He's 10, so been in school for a while.

DR. FIELDER: So either way I think you have to have those one-on-one bedside interactions, but I do think that, you know, the stress of walking into an emergency room or to a clinic where it's just bursting at the seams with patients who probably don't need to be in that crowded environment, you know, waiting for 10 hours to see someone who's going to see them in 15 minutes and send them home – that will no longer be the case, and I'm so glad. So you know thank goodness that insurance companies through all of this are now reimbursing for telemedicine visits and that is just, people have had to rise to the occasion and I think everyone's done that so well. I can only imagine you know, how much better this is going to be when COVID is even over. Again, I don't think we will ever go back to where we were before.

JUAN: I think it's always interesting, if I may interject, that we’re kind of afraid or we're really afraid of what we would lose from telemedicine, you know that patient physician interaction? But I had a phone call, telemedicine, from a VA Doc and I don't feel like I lost anything. It was maybe 15 minutes, I was driving, you know, and in a way it felt that the connection was still there because this physician called me, you know, and we had the same questions, same interaction. And in a way I kind of felt better because of these new methods being put forth in action during this time. So I thought “whoa, this is kind of cool”. I'm being called, you know personally by the physician I was supposed to see, and everything is still being addressed and we’re saving time, we’re being safe. It’s a new era, it's really cool.

DR. FIELDER: I love it, you know and I think that, so – we went through the application process for residents right? For all the senior students around the nation. We had 350 or so applicants that interviewed in person, and now we are inviting them every week to join us on a Xoom conference and we're getting them oriented to the hospital and the policies and procedures in the rotations. You're talking about a several month orientation for these interns that are going to come in in the fall, that they would have never done before, and I feel closer to those – you know, we have like 48 incoming interns in total. I know each and every one of them not just because I knew them from the interview process – and I loved that part of my job this year – but now I get to know them and what's going on in your house like, “who's your spouse and who are your pets?” and you know, and then give them a tour of the ER and do it every single week and play games with them every week, get to know a little bit about they're fun side. And you know that those are things we've never been able to do, never. We crammed intern orientation into ten days before they started and that was it! And if you got it you got it, and if you didn't, well, you're still starting on June 24th.

But now it's just that closeness that you mentioned, that ability to interact – I mean I know you two now as friends and so the next time I see you in person, I'll be like “yeah, what’s going on?”. I mean being in person, I don't think makes that anymore real. And I feel comfortable, you know sitting and talking with you and it's not anxiety-provoking to have someone sitting right in front of you and like fumbling with their papers and stuff like that. I would feel so uncomfortable. But this is so natural in its own sense.

ALICE: I think a lot of students actually are trying to participate somehow in all of this by helping residents get groceries, watch their kids, wash their pets. So these things that you get right now that the teamwork that's being put in, it's never been done before and I think it is banding together the medical community more than ever before. What's your opinion on student volunteerism in general or student participation in the clinics during this time?

DR. FIELDER: You know, I don't know who spearheaded the group that is helping to watch kids and in volunteering for that. I feel like I should know her name but – is it you Alice? No.

JUAN: It's probably a Baylor student for sure. I think I was I was on the email list for that.

DR. FIELDER: Okay, so when I first read through it, you know, I said, I went back to her and I said “I want to do something nice for the residents, right? For the Peds residence. Let me know what kind of response you get from the Peds residence and I want to offer anybody that has a pet or a you know kids or whatever. I want to pay for their like first two sessions or whatever” and she's like “it's free” and I was like, “oh my gosh, you're doing this for free!?”. My mind was blown, I completely missed that and I emailed her back and I was like, “I am just so impressed by your entrepreneurial, you know spirit without the payment, you're doing this from the goodness of your heart and trying to help, you know, people that need it the most” and I just was so impressed that a group of students got together and did this.

And so I think that people are going to start asking on interviews and in the future, what did you do during COVID? What did you do? And I think that those students and all of you guys. I mean the residents, the students, the people at Baylor everybody has just risen to the occasion and I can't imagine a better group of people to work with. I can't imagine a better time to be in medicine even though it seems just daunting and just overwhelming right now for so many. Each one of us wants to give a little bit to our colleagues and to each other and I think the students at Baylor have just been so tremendous. And they've been that way through Harvey and, you know, Hurricane Ike back in the day. I mean, you know, I've been here through a few catastrophes but this one really, I'm just so impressed with what they've been doing.

ALICE: I know a lot of students are really really hoping to get back to the clinics. I think Baylor has suspended rotations until May 26. Do you believe that students are integral to patient care in the hospitals? Would you hope to see students back on the rotations before the end of the pandemic? This is a quite a controversial question, I think, so if you are not willing to answer I completely understand.

DR. FIELDER: I'll say it this way. I think we all serve a purpose, right? When the time is right, and the patients are there . . . right now in Pediatrics, we don't have the patient volume to support a huge number of students. Do I think that it's not a great learning environment? It might not be right now just because we don't have the volume, right? But, could students help with telemedicine. Could they be, you know, seeing patients for a few hours a day in person and then doing telemedicine or some other in the other hours of the day? I think that we all, again, this is a whole new era now, I think we have to be careful with social distancing and making sure that we don't have people there, learners there just for the sake of learning – well not just for the sake of learner, just for the sake of being present because they have to check the box to finish a rotation. I think we need to be very careful about doing that. 

As we sort of ramp back up and more people are coming back to the hospital, it might be a staged approach just like we do with opening restaurants and you know, you know hair salons and stuff, right? I mean that's just going to be a staged approach. Which students, which residents, which learners need to get those hands-on, in-person, patient interactions before they graduate, right? Or before they move on to their sub-I. Or which residents, which students need to complete their sub-I. Those are going to be the ones that are, I would put them first in line before anyone else does. So sub-I’s, maybe even sub-I’s first and then the clerkship students, right? So I think there's learning to be done. I think having anyone there, residents included, on service just for the sake of “you’re assigned to this rotation and you're supposed to be there” is a bad idea.

Are students integral to the functioning of a medical team? Absolutely. You guys keep us on our toes. You know so much more, you are so ingrained into pathophysiology and you remind us again over and over of what we need to learn and what we need to be fresh on. And you pick up on things in patient encounters that nobody else on the team does. Absolutely, I think you’re integral. Would I want you there just for the sake of having you there? No, because I don't want to put you at risk, but I do think we need to have students and residents back on the wards with us as soon as we can.

ALICE: And that wraps up all the questions I have for you today. Thank you so much for your time again. We really loved having you on the show, really grateful that you were able to be here today and I will leave it up to Juan to wrap this up if you're okay, Doctor Fielder.

DR. FIELDER: Thank you so much. So fun.

JUAN: Thank you for being on. I think one really important thing that I, even during these recording sessions I’ll have my pad and my pen and I think one really awesome thing that I could take away, aside from the Clifton Strengths Finder, is said that it's important to have mentors that will empower you and allow you to make mistakes and will fight for you. Super awesome, loved it. I loved having you on. It's been really awesome learning about everything that's happening.

DR. FIELDER: Thanks.

JUAN: Thank you so much.

DR. FIELDER: And I already subscribed on . . . so I am so excited to hear some of the other podcast you guys have put together and I just love what you're doing.

JUAN: Thank you. Thank you so much. 

DR. FIELDER: Thank you.

ALICE: Thank you.

iTunes | Spotify | Google Play | Stitcher | Length: 45 minutes | Published: Jan. 4, 2021

Dr. Zaven Sargsyan tells us all about his life as a hospitalist, residency director and educator to Baylor medical students. We ask him about how he works through complicated cases and how to think through differential diagnoses. He also share what it is like to work in the same place that he went to medical school and how Baylor has changed since he was in school.

Transcript

Erik: This is the Baylor College of Medicine Resonance podcast. I am one of your hosts, Erik Anderson.

Erin: I'm Erin - I'm a writer for this episode.

Eileen: I'm Eileen - I am a writer and sound engineer.

Erin: Today we have the treat of talking to Dr. Zaven Sargsyan. He is an educator and a physician here at Baylor College of Medicine and he actually went to Baylor for med school, so it's really nice to get to talk to him about how things have changed, and how he practices medicine, how that allows him to teach his students better. We wanted to talk to him about his job as a hospitalist. A lot of times when we think about doctors practicing there's like a lot of different ways that doctors are interacting with patients. It could be in the clinic; it could be in kind of the inpatient wards. So, I think hospital medicine is very unique because physicians are just at the bedside with the patient talking to them; usually the patients who are there are admitted. They get a very broad kind of understanding of who this patient is and they're kind of the chief point of contact for these patients.

Eileen: Yeah, so I think the one huge thing about hospitalists is that you said they're the chief point of contact. So, they're kind of like the captain of the team and coordinating between all of the different specialists when you're admitting a patient from the ER who has renal failure and CHF and you're trying to balance how to treat one and treat the other. It really is the hospitalist who kind of comes in and looks at the picture as a bigger whole, and then we'll talk to nephrology and cardiology and what other specialties are needed so that they can all work together - versus other people on the team are just coming at it from sort of a single perspective looking at their piece. 

Erin: I think it's important when we think about the differential diagnosis. We, I feel like, we even as high school college students and pre-meds hear that term and even in med school it's always, ‘what is the differential?’ Like, what are the top three things on your differential and to think about what really is a differential diagnosis. It's not just these three things that are on your head, but it's really thinking through everything that it could possibly be, thinking about the patient as a whole picture, all their body systems together, and then narrowing down and ruling out what it could be.

Eileen: Right, and so an ideal person to do that really is a hospitalist. I think hospitalist is actually fairly new. I could be mistaken on that but in the past, people's primary care physicians would be the admitting physician for their hospital stay and a lot of times primary care physicians now are so busy and have so many patients that they don't really have a chance to work on the wards. So instead of being admitted to a PCP, you get admitted to a hospitalist. So, most people now who are admitted into the hospital will be assigned to a hospitalist and so like you said they can kind of think about all of the different systems - what could this possibly be - and then start narrowing down from there. 
Erik: Yeah definitely and I think Erin and I have had him lecture, and you can definitely see his personality. Like I can just see him being a fantastic doctor and having great bedside manner just because it seems like he's a very caring and empathetic person. And I think that's the kind of person that you need also as a hospitalist because like they're probably going to also be interacting with the patient the most.

Erin: Yeah, I think obviously Dr. Sargsyan's experience as a hospitalist makes him a fantastic teacher just to help med students think about everything that could possibly be going wrong with patients. Even in pre-clinicals when we're just learning from textbooks just to get in the habit of thinking about the patient and everything that the patient represents - all the body systems. Again, and not just, you know, single best answer type things that we're trained usually. 

Eileen: And I think yeah, usually in class it's, you know, what's the one best answer and which answer fits the most you know – a, b, c, or d. But in the real world and in medicine it's important to be able to come up with a broad differential to think of everything it could be, and then equally important to be able to narrow that down and figure out, A) what's most likely and B) what's most dangerous potentially.

Erin: So, yeah just to introduce Dr. Sargsyan he, as I mentioned, went to Baylor College of Medicine for medical school and then went to Massachusetts General Hospital for his residency in internal medicine and then came back after three years, where he practices as a hospitalist at Ben Taub and the VA. Yeah, we're really excited to talk to Zaven Sargsyan today.

[Music] 

Erin: Alrighty, so we are here with Dr. Zaven Sargsyan and we just wanted to ask you to tell us a little bit about yourself first - introduce yourself.

Dr. Sargsyan: Thanks for having me. Introduce myself professionally or personally?

Erin and Eileen: Both, yeah little bit of both.

Dr. Sargsyan: Sure, so I'm from Armenia originally - I spent most of my childhood. And then my family - my parents and my sister - moved to Houston when I was 11, and I’ve been here most of my life since then. I went to high school here, I went to undergrad, and medical school at Baylor. I really enjoyed Houston and becoming a Texan and everything. I'm married - we just had our first kid, uh two and a half months ago. He's doing great and consuming most of our brains and hearts these days in a wonderful way, so that's that. And then work-wise, I do hospital medicine. I work at Ben Taub, the safety net hospital here, and the VA clinically, and then I'm involved with the residency and some stuff at the medical school and really love my job.

Eileen: Great, so I know you said that you went to undergrad in medical school here in Houston and then I believe you went to Mass Gen for residency. So how did you end up back in Houston? Did you always know that you wanted to come back?

Dr. Sargsyan: I did actually. So, it was hard enough for me to decide to even go anywhere just because I loved my experience here at Baylor as a student, and I was also just very grounded here with family and stuff. So, I always kind of knew I’d be back to my personal and professional home.

Erin: So, what's it like to kind of be back where you were in school, and then now you're in attending?

Dr. Sargsyan: It's really cool. It's fun, I mean I think first there's just a sort of an emotional connection to the institution and the experience of all the students and that just feels nice and makes everything um kind of more valent and fun. And then in practical terms it's kind of cool to have some notion of what the experience of the students is like. Even though things have changed, you know, a lot of things kind of stay the same culturally and logistically. So, I feel like I maybe can relate a little bit better than if I was sort of new to the institution.

Erik: I was going to ask - you said some things have changed. Anything that's like striking in particular?

Dr. Sargsyan: In terms of what has changed? No, I mean the curriculum has actually, hasn't undergone a major reform since I was a student here, which wasn't that long ago. I was here from 2007 to 2011. I think a lot of that, you know there's always sort of an ebb and flow of the people at any given institution, so a lot of my attendings I rotated with have retired or moved on and there's sort of a new crop of people. But the students are sort of as I remember them - just great people, really bright people and I would say the sort of core identity of Baylor has stayed true. 

Eileen: If you could go back you know 15 years and you're at the beginning of starting medical school, do you have any advice that you would give yourself as a student at Baylor? 

Dr. Sargsyan: Honestly, I think I was a very happy student, and I don't have a problem with having regrets, but I don't happen to have too many regrets about my sort of MO and choices as a student. I think I would definitely tell myself that you know that everything was gonna work out beautifully and maybe to worry a little bit less. I think that can be applied to every student. I’d probably want to sleep more, and then I would tell my earlier self to read more like fiction and non-medical things. Only like at the very end of medical school and like in the fourth year did I start reading more like I used to, and I realized that was a big way to stay sane and enrich yourself in other ways that I think as a student you sort of have this pressure where like if you're going to read something you want to read your books or notes or whatever, right. But I think there's a lot of benefit to kind of stepping away and staying more broad in your horizons.

Eileen: I think I’m definitely going to steal some of that advice. 

Erin: It's interesting that you talk about that, because I think the curriculum committee and you know LCME in general is trying to promote that. Erik and I right now are on surgery rotation and they're having us do like a narrative medicine aspect in our inter session, and I think just like getting to know your classmates kind of in a different light, and also getting to think about medicine and literature in kind of a different way. You're right, it's all about keeping your horizons broad.

Dr. Sargsyan: That's great to hear and actually I would say that is a big way in which the curriculum and the culture has changed. I think there's a lot more of that in the curriculum as well as in the sort of informal kind of background or hidden curriculum of the students and stuff. A lot more awareness and discussion and learning about, you know, social determinants of health and communication skills and things like that that I think weren't as much a focus when I was a student here. So, it's been a great change, I think. 

Erin: Yeah, so you are kind of a director or associate director I think for IM residency.

Dr. Sargsyan: Yeah, I’m one of the associate program directors.

Erin: Okay, how has that been, getting to decide who gets to be in the program, who doesn’t, like, how do you pick your residents and how do you know who's going to make a good clinician?

Dr. Sargsyan: I mean that's really - so overall the role is something I really enjoy, and I think recruitment is part of the job and selection. But it's not necessarily the most fun part of the job. I think actually mentoring the residents while they're here and thinking about the curriculum and how to help people develop into the best and best prepared clinicians and professionals they can be is the more rewarding part of the job. I think interviewing students and sort of going through the process of selecting, recruiting, is really important too. And it's tough and we do it as a big team. There's a lot of people who both participate in interviewing, advising. I think we're lucky to just have a really great crop of applicants and people who are interested in medicine, in the program, and we really love the residents we end up matching and having the opportunity to work with and train. But it's always, you know, your question about how do you know - it's really tough and I don't think anybody has figured it out. I think a lot of the metrics that people look at don't necessarily reflect the qualities that, you know, for example a patient would love to have in their clinician, right. You try to discern sort of who might best fill that role and also be a good match for your program in particular. But it's always a little bit of guesswork and again you just hope that everybody you interview is going to be more than qualified and whoever ends up matching and showing up is going to be great.

Erik: Well that sort of naturally leads in right to our add-on question.

Erin: You know, with all the hot buzz of Step One now being past fail, I mean that used to be like basically the biggest metric for residencies.

Erik: Or so they told us. I don't know, maybe you can speak to that.

Erin: Legend has it, yeah, how do you feel about the whole pass/fail thing and you know, how do you adjust how to select students?

Eileen: Yeah, because now so many medical schools are pass/fail in their pre-clinical curriculum they've really emphasized to us that Step One is the score that residency directors look at so if you don't have that score how are you thinking that you'll probably adjust?

Erik: Yeah, and just to explain to those who maybe don't know what Step One is too if there's anybody in college or before listening to this. Step One is basically the MCAT of residency, I think that's probably fair to say. It's a test that people generally take after a year and a half or two years and is sort of the culmination of all your pre-clinicals, and has been used as a metric to whether you should get it into a certain specialty. 

Eileen: So, the testing never stops. You got the SAT, you got the MCAT and then Step One which as it implies, is just the first.

Dr. Sargsyan: I think that's a question with a very complicated answer. I'm trying to think about where to even start. I think it's very it's actually very much on students minds I think, and it's been one of the biggest probably, sort of, news and what will be one of the biggest changes in medical education for a long time, believe it or not. So just by way of background. So, as you guys said USMLE step one is, that's the US medical licensing exam, right, step one. And the fact that it's labeled as such implies that there's subsequent steps. So, there's a step two CK - clinical knowledge, which is also a multiple choice knowledge based exam. And then there's a step two clinical skills which is an entirely simulated patient exam, and that one has always been reported as pass/fail. And then step three of the licensing exam series is usually taken during residency. And actually, historically USMLE step one was never meant to be a discriminatory exam to aid in applicant selection for graduate medical education. It was meant to be just a licensing exam for the state licensing boards to say okay, this person is qualified to practice medicine just, you know, along with the other steps. And over time it was sort of evolved to be used in this in this way in you know along a scale and to play, as you guys said, one of the biggest sort of determinants of selection, especially for more competitive specialties. And again, it was never designed to be such an exam and I think when it has been studied there's no convincing evidence that there's a strong correlation between how you perform on step one with your subsequent sort of qualities as a physician, as a colleague. So, it was always problematic for it to be used in that way. Additionally, I think over time we've realized too that the test has created really an undue burden on medical students in terms of the emotional stress, in terms of some of the kind of bias it creates in potentially closing opportunities for certain individuals who don't have as many resources to take the courses or buy the books or allot the time, or whatever it might be. Against individuals who may not be as good as test takers but again are just as good or better as clinicians, communicators, etc. And one sort of personal beef I've always had with it is that it tests the, in my opinion, the least important kind of content of medical school, which is the pre-clinical, the basic sciences rather than the more kind of practical, real life clinical knowledge. Even if you were going to sort of use a knowledge based test to prioritize in that way. So, you know, people including myself spent dozens and hundreds of hours memorizing chemical structures and sort of various details about microbiology and other things that I have since long forgotten. And I actually, this has never been tested but I really think that if you were to take all of the practicing physicians in the US right now and have them take USMLE step one, they would fail it. Which is ironic right it's like the licensing exam and presumably the longer you've been practicing, the more prepared you are to continue to be a doctor, but you would you would fail step one. Whereas I don't think that's true about step two ck. I think most doctors would pass step two ck, but they would fail step one. So again, why is it being used as this sort of discriminatory, most important big test of your life supposedly. I think one of the other challenges is all medical schools, all course directors, periodically and really continually should be reassessing their curriculum, right. Things change, the practice of medicine changes, and you always want to think, how can I better teach my learners, prepare them for their eventual careers in practice. And the fact that this test was such a critical point of achievement for students, it actually shackled medical educators in from focusing on what really matters in preparing the best future physicians. And it informed a lot of the curricula the medical students had to sort of choose and teach to, because if you don't prepare your students to pass step one or really rather to excel at step one, you are limiting their opportunities for postgraduate training. So, in my opinion, from the perspective of someone who just cares about high quality medical education, I feel like a lot of curriculum medical schools have been liberated have been unshackled to actually think about how to best create the best physicians rather than the best step one takers. And I think that that should be great news and that should be celebrated for everyone. Now as a program director, yes, we're facing new challenges. And especially with the problem of overapplication for residency that most specialties have unfortunately suffered from, we just get too many applications to be able to thoroughly review each one and discern the qualities of the applicants beyond objective, easy, number based things. And the step one was used traditionally to screen a lot of applicants and to at least create one kind of filter through which to get started and narrow down the field. But if you take a metric that wasn't that good and get rid of it, it might make your job harder, but maybe it's still a good thing. So even from that perspective I'm actually not sweating it too much. Maybe we'll have to rely on step two more, but hopefully we'll also just take a more holistic approach to reviewing applicants and what they have to offer. So anyway, I think across the board I'm overall optimistic that it's definitely a positive step and that the challenges will be met in turn. Sorry that was a super long answer. 

Eileen: It's so helpful, and as a future applicant for residency, very reassuring to hear. So, speaking of residency have you ever considered doing any sort of sub-specialty within IM and if not, why, and if so, what would it be?

Dr. Sargsyan: In the last 10 years, I've probably seriously wanted to do every internal medicine sub-specialty fellowship, which was a good sign that maybe I shouldn't do any of them and that I'm a generalist at heart. I think I really love my field of general internal medicine and I feel like on a given day sometimes, you know, if it's the content you're interested in of a sub-specialty, right, well then when you have a patient with myocarditis that you that you're taking care of then you're involved with the content of cardiology, right, and you can get to be a cardiologist of sorts in the moment. And then the next day you may have an onslaught of people with respiratory complaints and lung diseases; well then, you're getting to learn and apply your knowledge in that field. So, I just really like the breadth and the fact that you get to constantly be learning and getting better and working with the sub-specialist to collaborate and both take care of that patient on a given day but also to learn from them and be more prepared for the next patient.

Eileen: Yeah, we were actually just talking about how it is that sort of being the generalist gives you that 30,000 foot view that you can see something you might miss if you're only focusing on one specific system or one aspect of the patient.

Dr. Sargsyan: For sure.

Erin: So, you're an academic hospitalist which means you get to work with residents, and students, and maybe even high schoolers, shadowers, the whole totem pole. What is your favorite part about working with medical students and what is your least favorite part, or maybe more frustrating part about working with us? 

Dr. Sargsyan: So many things. I love working with all trainees, but I think it's such a privilege to work with students who just bring a new fresh perspective and haven't been sort of mixed into the into the sausage yet. I mean I think you just get sort of acculturated and indoctrinated into the clinician side of things so quickly that you very much lose touch oftentimes with more experience with the patient experience side of it. I just never cease to be amazed for example how much I learn about medicine every time I have even the smallest or most trivial experience on the patient side either as a patient or a family member or whatever. And I think that that's a perspective that medical students often bring to the to the team. They just, they're often able to empathize with the experience of the patient more than those of us who've been just doing it for longer day in day out on the doctor's side of things. So, I think that that's a great privilege. And then I just, I love learning and I love watching learning happen and it's just, seeing a student get better at a skill on a daily basis literally or to apply something immediately that they learned the hour or the day before. It seems like a simple kind of everyday, mundane thing, right, that learning process but for me it's just really just a joy to observe and to be a part of. So that's just why I like the academic environment in general, but for students that learning curve is even steeper, so I think it's even more sort of drastic, salient version of that process.

Erik: It's good to hear that because I know that there have been times I've felt - you know and I think you probably remember being a medical student - you ask a question that you think is stupid and maybe outside the box, and most of the time it probably is, but maybe there's that one time that like, ‘oh yeah that's actually a good point!’

Dr. Sargsyan: Erik that not the exception. I would say that that happens on almost a daily basis where there's so much dogma in medicine and you just take so many things for granted that aren't necessarily true or don't necessarily make sense. It's just inertia, it's habit right, and yeah. I can't say how often I say the words, ‘you know what, like, that's, I've never thought about that, but that's such a great question. Yeah, I don't know why we do that.’ And those questions come from students not senior residents. 

Eileen: That's really fantastic to hear as a medical student. I'm also curious if there are any particular challenges you have working with us.

Dr. Sargsyan: Challenges, yes, lots. I think teaching in general and including teaching medical students is a very elusive art. and I think if you find it easy all the time, you're probably not paying enough attention. But I think for me, that sort of that intrinsic challenge of the fact that every learner is different, and they start in a different place, and they have sort of different needs and learning styles, and the interaction is so complex in so many ways. I think that challenge is a positive one where it just makes things interesting. It makes a job always, always difficult and always something to aspire to do a little bit better. You know earlier when you asked what are your least favorite things, I think that's a slightly different question and I'm trying to think of something more negative about the experience. And I guess the only thing is level of interest among some senior students who maybe have differentiated themselves into a certain field, and when they're rotating on internal medicine, sometimes they may not realize just how relevant everything is to every other specialty. I think that's the only situation where if I ever get frustrated it's sort of like, wishing I could be better at motivating people to stay engaged even if they think what surrounds them is sort of less relevant to them. But maybe they're right, maybe it isn't.

Erin: Can you just tell us a little bit more about what a day in your life looks like, maybe from academic and also, what you do outside of work - any hobbies, leisurely activities...

Dr. Sargsyan: Sure. My job is such that my days are actually very different from each other. So, oh yeah, I can for example just look at my calendar from yesterday. So, I currently am not on service meaning that I don't have any clinical, any patient care responsibilities, so a lot of what I'm doing is you know sort of academic work, teaching, things like that. So yesterday in the morning I had a one-hour workshop that I led for residents, and then I had a couple of hours off, so I went back home and played with the baby, went for a run. And then in the afternoon I had another lecture, a new conference talk, with the residents, after which we had a residency meeting. And then in the evening had a drink with a colleague and caught up on some academic work and stuff like that. And then this morning I was completely off and this afternoon I’ve had some more classes and meetings and things like that. Tomorrow I don't have anything scheduled at all, so I'm just gonna relax, and then next week though, on Monday, I start with one week straight of working every day in hospital taking care of patients at the VA and the following week is again sort of more flexible, kind of on and off. The week after that I’m working at Ben Taub with residents and students on the wards so it's very variable. Yeah, it's a little bit of kind of clustered more dense duties, and then more flexible time and time off. 

Erik: so that actually brings up a good question of - how is that determined? And I've thought about this with respect to just all the faculty that come and teach us, too. It makes me wonder - do you have a set amount of time that you are supposed to, as an academic physician, do you have to do some duty like whether it's teaching, or whether it's being a program director, or have some part in a curriculum? Or is it kind of up to you to determine?

Dr. Sargsyan: that is really, it's so variable. Yeah, I think the career paths and job descriptions within what may seem like a single descriptor of academic medicine can be just vastly different. So, for example there are Baylor faculty members and fantastic clinicians and educators who see patients. And when they're seeing patients in their clinics or on wards, they often have residents who come and work with them who see patients with them. Sometimes students will rotate through those rotations and they do a lot of teaching in a clinical setting. But that's what they do - they love being doctors, they love being teachers when the learners come to them, and they're exceptionally good at it. But they don’t feel the need nor have any kind of pressure necessarily to go to teach at the medical school or to give extra lectures or to do research or anything like that. And I think that's a very worthwhile calling right, I don't know if you guys agree but that sounds pretty good to me actually, and we need people to do that. There's other people who are more involved at different levels of medical education who, in addition to doing that or instead of doing as much of that, may spend more time giving lectures or participating in certain or well-defined sections of the curriculum. So, for example, one of the things I do at the med school is I am a small group facilitator for the PPS course, which is like the first year kind of introduction to clinical skills course. And that takes up most my Wednesday afternoons and it's kind of a discrete, defined educational role that I really really enjoy, but that I have been given opportunity to do and that I really like but that I don't have to do if I don't want to, you know, I could stop doing it. There's other people who are predominantly more researchers and they may spend 80 of their time and their salary, you know 80 of their salary, is sort of dedicated to protect their time to do research.

Erik: I guess that's sort of my question - is that determined like the year before? And I mean we don't have to obviously get in the specifics of who's going to make more if you work on here and here, but your salary does depend on like if you're spending most of your time doing this thing, then it's going to affect it?

Dr. Sargsyan: Yeah, I mean I would say that most people within an institution and within a practice field like within a specialty - it's not that your salary is determined by how much of what you do. It's that the breakdown of your time is determined by your interest as well as by your demonstration that your time and the institution’s resources are well spent. So, for example if you protected 80 of my time and gave me 80 of my salary to do basic science research, that would not be a good choice because I don't have the right skills to do that and I wouldn't be a productive scientist. 

Erik: Well and I think you'd have to supplement it with your grants. Yeah, but I hear you that's - it's a long way off for most of us but to be thinking about because everybody's asking, ‘oh do you want academic medicine or private practice?’

Erin: I have no idea about that yeah like logistically.

Erik: But that's the thing. None of us really know how any of this stuff works.

Dr. Sargsyan: I think it's, I think that's okay. I think it's good to be asking these questions and to have a general sense of the lay of the land. But I think it's hard enough to, you know most people go to medical school because their primary goal is to become a physician. And that's a hard enough task and a worthy enough calling to really focus 99% of your effort and energy and time on doing that as well as you possibly can. And you can explore some extra interests whether it's teaching or scholarship or leadership, administrative work, health policy, whatever it might be, and potentially with an eye of having incorporating that into part of your career. But it won't be at all “too late” for you to work on those interests and skills at a later time. So yeah, I don't think you have to have figured out exactly what you want to be doing 10 years from now when you're a medical student. That's just my opinion. 

Eileen: I think it's really interesting. I hadn't necessarily considered how different the skill set is for someone who is teaching in clinic kind of on the job versus someone who's teaching in a lecture hall versus someone who's doing kind of a hybrid of both, which is maybe more like what PPS is. Can you talk a little bit about how you have to adjust your teaching style for each of those different settings?

Dr. Sargsyan: Yeah, you definitely do. I think it's, they are different skills. There are some principles that overlap and apply to all of them, but giving an auditorium lecture is so different from teaching a small group interactive session, from teaching in the simulation lab, from teaching in front of a patient. You have to realize that those are different skill sets and different performances and considerations and everything and be reflective about the components and the determinants of your quality as a teacher in each of those settings. And that's why like if you do - the Baylor faculty here have a wonderful program that’s called a Master Teacher Fellowship program. It's a two-year kind of longitudinal curriculum that a lot of faculty take advantage of and as part of that there's discrete sessions - there's workshops about how to refine your large group presentation skills. And then there might be a different session about how to teach at the bedside, there might be a different session about small group teaching, and yeah, the conversation is very different in each of those.

Eileen: I think it's also challenging in medicine because there's not always necessarily one right answer. On the test there usually is a “best answer” but in life it's not always that way. So, we were wondering if you could tell us a little bit about how you teach your students to sort of walk through the process of figuring out what's going on and a little bit about what a differential diagnosis is.

Dr. Sargsyan: Man, so first, before talking about differential diagnosis, I just want to say a few words about diagnosis, period. And this may be obvious, but diagnosis is at least half of what you do as a doctor, what at least internal medicine, that's our core task, that's our core procedure, right. Because the body breaks in a million different ways but the symptoms or the abnormalities that each of those illness entities, each of those diseases causes, a lot of times is the same. Like you could have a million reasons why you're short of breath and people don't walk in through the hospital door or the clinic door and say, ‘doctor I have hemophagocytic lymphohistiocytosis,’ they like walk in and say like ‘I’ve been tired lately.’ And to go from symptom to diagnosis is an incredibly important and challenging thing, because if you don't know which disease entity is causing the problem then you have nowhere to start to figure out how to make the patient feel better, and live longer, etc. And it's incredibly challenging and the data speaks to that in terms of how common it is to have diagnostic delay, diagnostic error. I think it's a huge part of what doctors and internists think about how to do and how to do better and it's a huge part of the sort of long game curriculum of what you learned to do as a clinician. As a result, I can't give you a very satisfying short answer the rest of the way there. But I mean to speak to differential diagnosis though, that's basically, that is the differential diagnosis - is the list of possible diagnoses, list of possibilities to explain a patient's symptoms or abnormalities, when there is not yet a firm diagnosis. And kind of a key concept there is that there's almost always actually some diagnostic uncertainty even if you think that you've recognized a pattern, that you think you know what's going, on just based on what the patient told you based on the physical examination and labs. There's very often and, statistically you're going to run into this, where you were wrong with that impression, and there was you know a less common disease or something presenting atypically that tricked you and in fact it was something else. So that's why it's always important to construct a differential diagnosis to say okay, what do I think this is most probably, but importantly if it's not that what else could it be. Because if you don't think of those alternate possibilities again, you don't have a good chance of making the correct diagnosis. So, I think in terms of how I like to teach those concepts again is to emphasize the complexity and uncertainty inherent in the process. To always emphasize the importance of creating a differential diagnosis and sort of that kind of paranoid humility that you're bound to be proven wrong on most days. And to try to stay ahead of that and then there's you know a lot of kind of complicated approaches to how to approach the differential diagnosis in terms of creating it. You know, using different systematic approaches, frameworks, schemas, for a given complaint or in general. And to always try to develop your own processes realizing that again it's an extremely complex and lifelong skill to work on.

Erin: Wow, thank you, very well said. So, we know that your wife Dr. Sherman also works with you. Can you talk a little bit about what it's like to work with her? Do you get tired of each other, do you get frustrated?

Dr. Sargsyan: So, the answer to this question would be I'm sure very different. People are different, relationships are different, and then the working relationships are different, too, but we absolutely love it. We actually have like very similar jobs so it's not just that we work in the same place but were we're often on the same ward. We're often in the same meetings and discussions and stuff, for us it's really nice like spending time with each other and we enjoy spending even more time with each other at work. And then I think just the mutual sort of understanding of what our jobs are like as well as just being an ally, as sort of a second opinion. We feel very lucky. Like a lot of the, probably most talks that I give for example, have been like torn apart and rebuilt by Steph like at home, and they're so much better for it. And it's been really nice for us.

Eileen: Do you ever have to sort of set a rule when you're at home that, we're not going to talk about work anymore? 

Dr. Sargsyan: yeah, but I think it also just happens naturally. I think most of the time we enjoy talking about our work. We're very passionate and we don't necessarily get tired of it too much and if we do, we just naturally transition to something else or something else will sort of catch our attention naturally. Maybe it's also, maybe we also don't run into the problem because we don’t, we're not big complainers, so a lot of times when we're talking about work it's in a positive light where we're either debriefing and talking about something good or trying to brainstorm and troubleshoot so we don't tend to kind of get bogged down or get tired of it as much.

Eileen: I think that's kind of the dream to have a job that you love doing and you want to talk about it. You’re interested by it. I'm sure also with a two and a half month old at home you have plenty else to focus on.

Dr. Sargsyan: Exactly right, so that's the kind of thing that like naturally will just take your attention and your priorities and turn it upside down. And so yeah, we do have to be very conscious though if there's a third party, so then we definitely obviously tone it way down from our normal sort of dinner making banter.

Eileen: What do you guys like to do just for fun around Houston?

Dr. Sargsyan: We both like to spend time outside, so we'll run around a neighborhood, walk or run to different coffee shops. We like spending time there, throwing a frisbee, I don't know, we kind of treat the neighborhood park as our personal sort of backyard. Yeah, I like the kind of casual existing-in-the-world scene of Houston. I wish it was a little more terrain-y, a little more mountainous.

Eileen: Yeah, I do wish Houston had a little more nature for us. 

Erin: Well, thank you so much Dr. Sargsyan. It's been an absolute treat getting to talk to you and just hearing about your life and about your journey through medicine. I think it's safe to say that we have a lot to learn from our educators and I think it's always really amazing when the educators include the students in the learning and there's kind of this like lifelong process of learning and growing together in medicine. And I think you really exemplify that and yeah, we're just really thankful to be able to talk to you. 

Dr. Sargsyan: Thanks Erin, Erik, Eileen. Thank you for having me, and this was a lot of fun.

iTunes | Spotify | Google Play | Length: 45 minutes | Published: Dec. 18, 2020

Explore the role of the Baylor Transition Medicine Clinic for providing care for patients with IDD: exploring the challenges, marking current progress, and discussing the future of IDD. Join us on this episode to learn from Dr. John Berens on how to better care for patients with IDD as they transition from pediatric to adult medicine.

Transcript

[Intro melody into roundtable discussion.]

Juan Carlos: For our listeners out there that have noticed a change in quality of our audio. We do want to small disclaimer that we are recording this from a closet.

Apoorva: Yes. My closet.

Juan Carlos: hashtag covid times.

Apoorva: Laughs.

Juan Carlos: But the show must go on and we have a really awesome episode for you guys today. And uhh…

Apoorva: We hope you enjoy it!

Juan Carlos: Yeah, but before that we have a few things to talk about – And we are here, uhh, with the Baylor College of Medicine Resonance podcast with your host Juan Carlos Ramirez.

Apoorva: And I’m your other host, Apporva Thatavarty.

Juan Carlos: Cool! And today we are going to talk about transition medicine clinic and care for intellectual disability patients. Apoorva, take it away.

Apoorva: Laughs. Okay, so, uhh, today we are going to be talking to faculty member at Baylor Dr. John Berens and you know, we're going to be discussing taking care of patients with IDD or Intellectual and Developmental Disorders and the vulnerabilities that these patients face while navigating the medical system, but I thought Juan Carlos that you know, like before we got started maybe we would like to discuss some terms and terminologies.

Juan Carlos: Yeah! It's important especially if we're hearing this for the first time. Umm, it's definitely good to know so we can follow along.

Apoorva: Yeah, and just so that you know, we can we can know who exactly were talking about right? It's like what does it mean to be an individual that has an intellectual or developmental Disorder? So, I guess let's get started. Right? So, let's start off by defining what intellectual and developmental disorders are per the CDC. They Define it as – I'm just quoting them – developmental disabilities are defined as a group of conditions due to an impairment and physical learning language or behavioral areas. These conditions begin during the developmental period, may impact day-to-day function, and usually lasts throughout a person's lifetime. So essentially what that means is these diseases run a large gamut of disorders that are really grouped by system. So, you can have disorders that are you know, like little buckets that catch nervous system metabolic disorders, degenerative disorders, and so on and so forth. ..and you know, like essentially as the definition said these conditions are diagnosed, you know, as these patients are children and so and it typically persist throughout their life. So, to kind of dig in a little further, the I portion of IDD is intellectual disabilities. So basically, intellectual disabilities are, you know, a bucket among the developmental disabilities. So, if you imagine like a large umbrella being developmental disorders intellectual disabilities is something their count like falls under it. So, for example, let's think about Cerebral Palsy. Cerebral palsy is a developmental disorder, but it can manifest on a huge spectrum of symptoms and severity. That's basically because cerebral palsy is describing a phenotype or a presentation of a disease, not exactly what the disease is or the disorder is, rather. Some of the patients may present with muscle weakness tightness or problems with controlling their muscles and you know; these patients might need some special equipment to assist with mobility. On the other end of the spectrum you're going to have patients that are going to need lifelong care, including help with like, daily activities like using and maybe using a feeding tube. This developmental, you know this developmental disorder may or may not be associated with an intellectual disability or intellectual, umm, impairment. So that's essentially what I mean by, you know some a bucket with an under a larger umbrella.

Juan Carlos: Gotcha.

Apoorva: So, you know Juan Carlos when you think about the word intelligence or intellect, what do you think about?

Juan Carlos: Chuckles.

Apoorva: Okay, I know I put you right on the spot. So I'm gonna, I'm gonna answer that question for you, maybe. Do you have any answer for that question?

Juan Carlos: Oh, yeah. I just think of what everyone else kind of kind of makes you don't like book smart, uhh, is this person quote unquote smart.

Apoorva: Yeah! Yeah, so, you know like typically that is what we think of we think of IQ, right? We think of how a person is doing in school. Are they able to go to school but intellectual disability really kind of goes way beyond that it really what they really are kind of define is adaptive skills. So what do I mean about the mean by that basically and the ability of an individual to interpret social skills, or to be able to go to the grocery store or just to be able to communicate that “hey I'm feeling really angry today”, so just communicate one's feelings. So it goes way beyond what we would naturally characterize those intelligence. It's not just book smarts.

Juan Carlos: The organism as a whole.

Apoorva: Truly is. All right. So, you know IDD, basically, what I've been telling you until this point is that IDD captures a really large subset of disorders, which basically means the patients that are going to be having these disorders or super diverse they’re unique and they're wonderful in their own ways. So, you know, you're probably wondering Juan Carlos, you know, “Wow! Apoorva, you totally blew my mind today”, you know, like this definition, insane, never heard of it before am I right?

Juan Carlos: This is true.

Apoorva: Okay, so, you know little ol’ me back when I was you know of incoming ms1 really had no idea either, you know, and so prior to medical school. I had like this little teeny tiny experience working with patients with developmental disorders. But it was really when I came to Baylor College of Medicine and we went through the social determinants of Health curriculum that happens right during ms1 orientation. So, before we even start the curriculum for medical school, we learn about how our patients are impacted by health issues or health systemic problems that are not related to their health and it was during this, you know program that we had a seminar by Dr. Berens that truly enlightened me as to –

Juan Carlos: Ta-ta-da (melody).

Apoorva: --what you know, care for patients with IDD is truly like and just hearing him talk about that Summit, during that seminar kind of inspired me to pursue this topic for a podcast today.

Juan Carlos: Yeah, and it's just, I guess made me aware for sure that there are other challenges and especially when, during their critical periods of going from a child or an adolescent to adult and for us is really seen the dawn as challenging but I think of the therapist and transition positions would argue otherwise.

Apoorva: Yes, absolutely. Umm. So yeah, I mean, I really hope that you enjoyed this podcast today because we'll be digging a little deeper into what it means to be a physician that takes care of this vulnerable population and you know, what are some basic things that you know, as students, we can learn to implement so that our patients feel more comfortable with us in the future.

Juan Carlos: Yep!

Apoorva: So, enjoy!

Juan Carlos: And without further Ado. Thank you for that wonderful introduction. Uh, let's learn about transition IDD, its challenges, and talk to Dr. Berens. Let's go to the interview.

Apoorva: Let's get this started.

Juan Carlos: Cool.

[Interlude melody into interview.]

Apoorva: Hi. Dr. Berens. How are you doing today?

Dr. Berens: I'm good. How are you guys?

Apoorva: Doing okay. Doing okay.

Juan Carlos: Doing alright. Difficult podcast, uhh, covid times. We’re getting through it but, uh, we’re very happy to have you on. Welcome!

Dr. Berens: Really happy to be here. Thanks for having me guys.

Apoorva: Thanks for taking the time to be here. We’re so appreciative. Okay. So, to kind of get us started, we just wanted you to tell us a little bit about yourself to our listeners.

Dr. Berens: Perfect. So, my name is John Berens. I'm a physician here at Baylor. I actually grew up in Nebraska.

Apoorva: Nice!

Dr. Berens: And then found my way down to Houston when I went to Rice for college and loved the city, stuck around, went to med school here – Baylor – and then I did my Med-Peds training – so, combination of Internal Medicine and Pediatrics. I did that over on the east coast in Philadelphia, but just missed Houston so much so found myself back down here. Took a job a couple years ago at the Transition Medicine Clinic, which I know we’ll talk a little bit more about here. Other than medicine: I like to cook. I like to do music, try to stay busy outside of work as much as possible.

Apoorva: Awesome! Well, you gave me a really great segue into our next question, which is actually, you know, you mentioned this transition clinic. Can you tell us a little bit more about it and how you kind of became involved in that? And, what exactly is your role is in that facility?

Dr. Berens: Right. Well, the transition medicine clinic I'll tell you a little bit about first. So, it was founded in 2005 or so by Dr. Cynthia Peacock and the initial idea behind it and its namesake was really to be a bridge for individuals who are transitioning out of the Pediatric world into the adult world. Uh, particularly those who had childhood onset conditions. Um. It was found out pretty quickly that that transition. There's really nowhere to go for a lot of individuals and so quickly the clinic pivoted to be more of a medical home. And that's what it is today. It's a medical home, it’s primary care, but the people we take care of at this point are pretty much exclusively adults who have intellectual and developmental disabilities, which I know you guys talked a bit about in your introduction. The question as to how I came to be here, um, in short, I guess I came at this whole group of people, um, in a very fun way. I spent four summers during college, and a little bit of time before that, working at a camp taking care of and just having fun with, in a recreational way, children with special needs and just really had a passion just being with and just caring for that population. And so, when I got to medical school, I heard a talk, actually by Dr. Peacock, about her job in this clinic and about Med-Peds, and how this all kind of ties together, and I knew instantly like that was what I wanted to do and here I am about 10 years later actually working in the clinic taking care of people now more in the clinical side, but really enjoying it. So my job here is mostly clinical but there is still plenty of time to do some projects on the side interact with students and there's a definitely a role of teaching, as we often have learners in our clinic, so it's a great place to be.

Apoorva: So, you mentioned this before, but you were throwing around this word ‘Med-Peds.’ For the listeners that don't necessarily know what that is, would you mind telling us a little bit about that?

Dr. Berens: Yeah, of course. Can never talk enough about Med-Peds. So, Internal Medicine Pediatrics combined residency training is a four-year training program. There's about 80 programs plus or minus around the country, as opposed to Pediatrics or Internal Medicine training if you did those individually, they're each three years. So you're kind of squishing it down almost double majoring in a way, into a four-year chunk. And then with that training you can do a whole host of things either on either side or a lot of times people will combine their skills. Even if they're caring for like in my case, I'm caring for only adults, but I'm really using a lot of the skills and knowledge that I gained on the Pediatric side.

Apoorva: Wonderful! Thank you for clarifying that.

Dr. Berens: Of course.

Apoorva: All right, so as developmental disorders or disorders that you know, Pediatric patients, they're diagnosed for children. What are some of the challenges patients face when transitioning to adult care? Because you mentioned the transition Clinic is really like a home for adult patients that have IDD.

Dr. Berens: There's a lot of challenges. I think first, even before we add the layer of the developmental disabilities. Just take a moment. Remember what it was like to be 18, 19, 20, maybe some of you are closer to those ages than me. But remember it's not an easy time. You're just starting to discover a lot more of your independence. You're trying to figure out what you want to do with your life. You're thinking about a lot of really big questions and a very kind of open road. So that's a tough period. When you add on all the extra layers that come with chronic illness that come with disability, there's a lot more considerations at play when we really think about just the medical side of the Healthcare System side of things. Think about it from all the different perspectives of the people involved. So, if you're a pediatrician you may have cared for this individual for their entire life 18, 20 years, and you're supposed to then say goodbye and trust that the doctors who are going to be receiving them will have the right know-how and somehow be able to do the same level of care and get to know the individual the same way. And then if you're in the internist side, you're saying “Oh my gosh, how am I supposed to review 18 years’ worth of records and get to know this family and this patient maybe with a condition that I don't have a whole lot of knowledge about” because you know up until a few decades ago the lot of these conditions, you know that we may be thinking about the life expectancy was is such that a lot of the individuals didn't survive into adulthood and that's changed a lot. So, there's a lot of barriers at play here from a lot of different angles. And of course, we're not even talking about the healthcare system at large, right? The healthcare system was not necessarily built with this issue in mind and for example, a lot of things change around this period that have nothing to do with health per se. So, insurance coverage changes, for example, a lot of the individuals. I see have Medicaid Insurance in the qualify for that based on their disability and then they re-qualify for adult Medicaid, but those two things are not equivalent. There are a lot of services and things that are covered in the Pediatric world that are not covered in the adult world. So then you have all these layers of all these changing losing Services all these things are happening all at once and it's a very difficult period so it's not a surprise when you start looking at the outcomes and really regardless of how you look at outcomes, if you look at just the experience for these individuals or their families, if you look at Health outcomes, for example, type 1 diabetes, you can look at like a an A1C as a marker of Disease Control or if you look at it just from Health Care spending for looking at dollars spent on care hospitalizations pretty much from every standpoint, the outcomes are not good when you're looking at this really vulnerable period. So, it's not a surprise that this is tough.

Apoorva: Yeah, wow. There are so many other considerations. I just remember when I was 16 and my mom said “Alright, time to go see an adult doctor” and I was like “But wait! My pediatrician!” So, I can only imagine just how much more challenging that is when navigating systemic insurance, you know, just going from Medicare to Medicaid transitioning through that. So, what are some resources that are perhaps present to help patients that are kind of navigating this and going through this vulnerable period themselves or patient’s families for that matter?

Dr. Berens: So, it depends on what level you're looking at, I think on a local level it's important to know what's happening, what options are available and here in Houston, I mean, our Clinic is one of those options, especially for individuals who have intellectual disability or who may have especially complex Health Care needs and require a lot of Specialists, Medical Technology, things like that. So, knowing about those clinics or specific doctors, who might specialize in this area, I think that's important in itself, but there aren't enough clinics like this across the country to address this need and I don't know if there ever will be because we require a lot of Med-Peds trained doctors really, all focusing on this. So, I think it's important regardless of what's available to know some resources that really everyone can use and incorporate into their practices. And this spans people who are pediatricians, adult doctors only as well as this area of medicine that span those so Med-Peds is one. Family Medicine is certainly another one. So this really affects a lot of healthcare professionals if you think about this issue. Now in terms of what resources might be available for the doctor out there or the doctor in training out there who doesn't know the first thing about health care transition or how to make it as good as we know how, a good place to start that I would recommend is gottransition.org and Got Transition is basically a repository of resources and in it, you can target it towards your audience if you’re a pediatrician or an individual who's transitioning, you're an internist, whatever. And the resources talk about the best-known approach that we have right now to Health Care transition, which isn’t perfect, I mean, this is a budding area of research. So, this isn't like there's a bunch of randomized controlled trials saying that this is the gold standard but with that being said, we’ve got to start somewhere and there is some evidence that these practices do seem to improve various outcomes.

Apoorva: Wonderful. I'm glad that they're, you know, like when I am in that future position there might be somewhere that I can go to, you know, appropriately take care of my patients in need. So, thank you for telling us.

Dr. Berens: Exactly, and I think it's good to know because it should empower all of us, you know, this isn't just the job of people who this is their entire world, right? It's not just my job. It's really all of our jobs because it's such a widespread universal issue that we all have to pay attention to it and know about it.

Apoorva: Absolutely. Okay. So, to kind of shift gears away from just medicine, in general, I guess my next question is, what are your thoughts on how our viewpoints towards individuals that have disabilities have changed in society over the past several decades? Do you think it has, first of all, like maybe that's a good place to start?

Dr. Berens: Chuckles. Yeah. I mean, I do think it has. First of all, I do want to add the disclaimer that I'm not a disability scholar and I'm not an individual with a disability so I don't want to you know, speak universally on their behalf or pretend to have really deep knowledge of this. But with that being said, I think that there's some general points that are important to know that you know, I've certainly come across on my own learning and on journey in this area. I think the first thing I don't know if this is necessarily change, but I think it's important to start off talking about language just because that's such an important part of our life and I think language carries so much power to it. The one thing that I can say at least that has changed in the last 10 years, is how we identify people with specifically intellectual disabilities. And that's the preferred term now and has been for some time but in 2011 Rosa’s Law was passed, and that made that official, at least on a federal level. So, federal documents, things like that, have that nomenclature intellectual disability. And part of this was stemmed from a really Grassroots efforts from individuals and families and friends who said, you know, that there's some older terminology that is stigmatizing and isn't fair and we don't want to use it anymore. So, if anyone's heard of ‘Spread the word to end the word,’ that's particularly that effort that really got a lot of this started. So, I think you know, that's one way things have definitely changed. Although this is an ongoing issue in terms of how do we label things in a way that's both accurate, but also humane and keeping the individual at heart of it? The other thing that has definitely changed over the last few decades is the setting in which a lot of people with disabilities reside and historically, people with disabilities really lived in institutions – state-sponsored institutions – at talking about the history of our country and that is definitely changed. There's been a big shift both in a legal standpoint as well as resources to really include people back into their community and that inclusion aspect of it that word ‘inclusion,’ I think it's really important to focus on because that's really been a big shift. And so, with that there's been a lot of changes to try to support individuals and families to help them thrive and be able to stay in their communities and preferably in their family homes.

Apoorva: Wonderful. It seems like we're making strides and you know, we're progressing in ways that are positive that are really positive. But what are some areas –

Dr. Berens: I would agree. I'm sorry. Go ahead.

Apoorva: Can you repeat that one more time?

Dr. Berens: Yeah, I was just going to say I agree. We've made some progress. There's definitely a long ways to go. I think that one of the things

Apoorva: That’s actually my next question –

Dr. Berens: Oh, perfect.

Apoorva: You know, we’ve been making all of these strides but where do you think we have room to grow and improve?

Dr. Berens: Well, I think, you know, a specifically addressing people in the medical field and medical trainees. I think almost the philosophy behind it in terms of the framework and how to think about disability is important because the most common framework that I certainly have encountered most of my training and I think is just a general sense out there is the Medical Model of disability, and that's not, I don't want to say it's inappropriate because we're doctors, or Healthcare professionals. And so, we tend to think of things in manner of their pathology and what can we do to fix things right? Like we go into the field to make people feel better and thrive and feel better and fix things. So, it's going to be second nature to some degree to come approach disabilities in a similar way in the sense that how can we make things better for the individual and I don't want to say that that's bad. We should always look to try to optimize function and people's lives as much as we can. But I think that there's a potential pitfall there because when we really focus on the disability and how to quote fix it, then we're basically saying that you need to be fixed as opposed to you’re okay just the way you are and I think the best example of this is, um, you know, think of someone in the deaf community so someone who is born deaf, a lot of those individuals don't see their deafness as a disability. It's just a part of who they are. And so, the idea of quote fixing that aspect of them doesn't make any sense. It's why would I you know, cochlear implant would be a way to quote fixed it but like, why would I do that? I'm fine. The way I was this is where I was born and I'm doing just fine. It doesn't make any sense to intervene on that. Um, and so, the Social Model of disability, which is very much on the other side of things is ask the question: What do we need to do to make our world a place where everyone can thrive and be included and instead of saying how can we fix you or fix your disability? How can we fix the world around you to make sure that your Incorporated in the same way that most of us can't be? And I think the power of that is that it really acknowledges the span of diversity that humanity truly has to offer because if our narrow definition of diversity only includes people who were quote able-bodied or people, um, you know, who don't have disabilities. I think that's a pretty narrow definition and if we include all people who may not walk or talk the same way or even think the same way is that maybe the majority of people, I think it allows us to be more accepting of those elements of diversity. And when we really are accepting of it, it pushes us to say we accept you. How can we include you how can we change things to include you? So, instead of saying we need to you know, get you a cochlear implant so you can hear, we say how can we make sure that you have access to you know, the same things on the TV that the rest of us do? A la closed caption or having a person who's signing in the corner of the TV like they do in some other countries.

Apoorva: Wow, okay. So, inclusion, diversity, giving a person a seat at the table. I love that. That's exactly what we need to move towards, and I think that's a great place to be moving towards.

Juan Carlos: And I think it's also (Clears throat) pretty amazing that that just by changing the language a little bit, it relieves this stigmatizing sort of viewpoint, right? A perspective from it as well.

Dr. Berens: Mhmm.

Juan Carlos: Just by changing it.

Dr. Berens: Definitely. Language carries a lot of power and I think it's important to be mindful of that. Not just specifically the term intellectual disability, but just how we phrase things and think about things in terms of these frameworks of disability.

Apoorva: Yeah, I think we’ve all fallen into the trap of the Medical Model and sometimes have forgotten about the patient and the lives that they live, and who they are as individuals. So, it’s good to put it back into perspective.

Dr. Berens: And we’re biased. I mean, when they're their sickest, when they have their most difficulties, we're not seeing people in general when they're out in their communities thriving living their lives, and doing things that we may not even dream they may be able to do and I think that's you know, that's part of the reason we have that shortcoming.

Apoorva: I agree. Welp, here’s to hoping that, you and I, Juan Carlos, do better when we see our next patient.

Juan Carlos: Yeah, absolutely. I mean, all it takes is being aware and putting into practice over time.

Dr. Berens: Definitely.

Juan Carlos: Spread that by example, you know, lead by example. We’re very fortunate to be receiving this information.

Apoorva: So on the receiving end, Dr. Berens, do you have any tips for us, you know, as medical providers, you know, future doctors, future nurses, future Pas, future, you know, therapist of individuals that, you know, patients that may have IDD? How should we approach that? What are some things that we should do? How do we make sure that they feel comfortable when interacting with us?

Dr. Berens: That's a really good question. And I think that's a good place to start. Even if you're listening to this and you saying to yourself “I don't know the first thing, I've never really had any experience with people with disabilities, like even if I want to be better or do something different like where do I start?” I think this is the way to start to at least know the first things to know when you walk into a room or a clinic or a hospital in you're going to take cre of someone with a disability a lot of –

Apoorva: Or even just at the grocery store –

Dr. Berens:  Right! Right. even out in the world outside of the medical scenario the first thing and these are going to sound pretty obvious, but they're not always straightforward sometimes the first is when I first walk into a room I always address the individual first. It doesn't matter what their story is. It doesn't matter what their abilities are. Even if I know that fact and I don't always know so I always start by addressing the individual and so I walk in and I say “Hey Johnny its good to see you. How are you doing today?” Now if they can have some verbal communication they'll respond to me great. We'll start there even if they can let's say this is an individual who doesn't have verbal communication, you know, they may not respond to me and usually a parent or another caregiver will chime in and say “oh, you know Johnny doesn't talk” I think oh, that's okay Johnny's good to see you today. I'm going to ask you your who are you and then of course make sure I know who I'm talking to. I don't make any assumptions there. But then I ask and I say “well, how does Johnny communicate?” because everyone communicates people who don't talk, people who have a very profound intellectual disability. Everyone has a way to communicate. If you're in pain you cry, you may have facial gestures. You may point, you may blink, you may have an augmented communication device. So, there are some people who have no verbal abilities but they can communicate completely fluently using device, even like an iPad in today's world to communicate.

Apoorva: Oh, wow.

Dr. Berens: So, I don't, I don't know how someone communicates best. So, I ask the people around them and then a lot of times I'll find out ways that they communicate that I can do right there in the office. So, the first thing is just acknowledging that person as the star of the show and making sure you have all the information you need to be able to communicate them to their fullest extent. The second thing is I think I'm a little bit more cognizant of, you can't tell from the podcast, but I'm very tall and I don't like talking down to people on any day of the week, but I'm very much aware of that when I go into a room and if someone's in a wheelchair, I really or even if they're sitting on the table, I really make sure to try to get more on their level and instead of staring down at them. There's a certain power dynamic there and just if you think about it, if you're nervous to come to the doctors and this giant doctor comes in and is staring down at you right? It's a little daunting. So, I think those are maybe really to concrete things and just keeping in mind that a throughout the visit, right? Just because you introduce yourself to the patient doesn't mean you're off the hook really gears much of the encounter you can towards the patient, even if I know, say mom is going to be answering for the patient, I'm still going to be looking towards a patient. I may even word my questions as if I were asking the patient and everyone knows who's going to be answering it's not like there's some mystery there, but it just again, it acknowledges that they're the one that we’re here to talk about today. They're the one who's humanity matters in this scenario because they're the patient and I'm bound to try to care for them, not the people around them. So, I think that's just important to keep in mind both when you first walk in as well as through the whole time you're there.

Aporva: You know, that sounds so simple but yet so profound, you know? Like, talk to the patient and make sure you're communicating with the patient, and the patient is you know, whoever is in the room regardless of their communicability. So –

Dr. Berens: Exactly.

Juan Carlos: It sounds like you’re also employing, like, non-verbal cues and body language and simple gestures to diffuse any sort of discomfort and allow them to be comfortable and have a pleasant experience to share.

Dr. Berens: Yeah. That's that's a really good point Juan Carlos. I think you know, I didn't even really get into the physical exam part of things. But in this really should go for kind of all physical exams, but I think being more explicit about what you're about to do. You might take things a little bit more slowly than you might normally just being really open and clear about your intentions and what you're doing your communication on your side. I think can go, go a long way.

Apoorva: Wonderful. So, we live in pandemic times, so you knew this question was going to come up at some point but how has covid-19 impacted your ability to take care of your patients, you know, like what has changed of the many unexpected surprises?

Dr. Berens: Yeah. I mean, like you said it's unavoidable. There's going to be some kind of impact in pretty much every area of our Lives. I think the good side of things, start positive here, is been the surgence of Telehealth in a way that I think a lot of us were waiting for and have been waiting for to come into mainstream and particularly to be covered by you know, the most common in insurers. People weren't bound to that. I've been doing this for a while because this is a great technology. It's not new technology. The issue is never really been “do we have the pieces in place?” It's really been more “Can we get paid for our care? Because if we can't get paid for our care we can't operate right?” So, we need to find a way to provide care and get reimbursed for that care so we can continue having our doors open or lights on. So, when that changed at the onset of the pandemic, it allowed us as well as doctors across the country to practice care in a way that included Telehealth. So, telephone encounters or video encounters and particularly for our population, the people that we take care of that's been a game-changer: think about, if you know, we have some people who have autism and a severe anxiety or some behavioral issues and have trouble even coming into the office. Now they can have a visit from the comfort of their home or we have people who have a tracheostomy and they're on a ventilator around the clock. Imagine all the work that goes into loading the ventilator and the person on a stretcher into an ambulance just to come to a regular doctor's visit. That's a lot of work and it's not risk-free either. So, being able to still care for those patients in a meaningful way, it has been wonderful and certainly has been good for the families and you know, there's people looking at that experiential data and I think we'll hopefully see that pan out and adjunctive way but subjectively, anecdotally, it's been really great for a lot of people. Though, I guess not so silver lining here is that practicing medicine this way is, as you can imagine, a little bit trickier without being able to lay your hands on people, you know, get all the information you're used to having, we take for granted having at our disposal and making decisions, can definitely make practicing medicine a little bit more challenging at times and just requires some extra thought and you know, sometimes we have to be creative. Sometimes we still need to bring people in the clinic to make sure we're not that we're getting all the right pieces together. So, it's not what that is challenges, but I think, ultimately, we're all hoping that this will stick around in some capacity because I think it provides a really good option and a lot of scenarios that is really patient-centered.

Apoorva: Yeah, I can only imagine how much stress is alleviated from both patients and families to not have to perhaps come into the doctor's office and do everything that comes before hand to do that and I'm sure from the comfort of their home.

Dr. Berens: Hmm.

Apoorva: Wonderful so, you know with covid, social distancing. We've been spending a lot more times at home even with telemedicine going in at sometimes, so what have you been doing to maintain your sanity during these times, Dr. Berens‑?

Dr. Berens: Chuckles. It's a really good question. I've been putting a lot of my efforts into the kitchen.

Apoorva: Wonderful.

Dr. Berens: I already like to cook and so I've focused a lot of my energies on just learning new skills doing some more cooking and the nice thing about that hobby is when you're done you get to enjoy it. Very tangible way as do the people around me. So I think that's been the biggest thing other than that just spending a lot more time with my family and you know, we're not the kind of family who's going out and doing road trips every weekend anyway, so maybe it wasn't as big of a change as it has been for some. Having a young one at home definitely limits the social outings, but it's been really nice just to spend some extra time just together with the family at home. So overall, can't complain. It's you know, we all miss the things that we miss but been staying busy.

Apoorva: Making the best of the circumstances. That sounds wonderful. So, to close out this podcast, you mentioned earlier that this podcast was a great way to get started, you know to learn about the disabled community and to learn about IDD. What are some other resources that our listeners can go to continue their education to become more well-informed and perhaps to get involved?

Dr. Berens: It's, that's a really great question. And I love ending this way because I think it's important to make the point that this issue matters to everyone even if you don't know someone personally who has an intellectual or developmental disability, even if and most people will fall into this bucket, aren't planning on going into a career in this area like myself. You will still encounter individuals in your life and certainly in the practice of medicine who have disabilities. So, it's universal in the way that you can't avoid it nor should you want to but if it's something you won't counter I feel like it should be on us to make sure we're prepared and make sure we know what to do when that moment comes. Unfortunately, as it stands, right now, this isn't something that's really well incorporated into education in the healthcare field, and I don't want to just single out medicine. It’s this way with dentistry. It's this way with kind of everything. It's just this forgotten topic, even though we all come across it at some point. And you know, credits at Baylor because they are starting to incorporate some of this into the curriculum. Certainly, the medical students will be familiar with the Partake curriculum and the disabilities case discussion that came with that. So that's you know, start of an effort to really incorporate this into the education that everyone will come across but with that being said, I think it's important for us to consider whether more experience would be helpful and I would argue that yes, it would be so how can you get more experience? Well, from a clinical standpoint, there are some electives including Life with IDD, which is a clinical elective put together by one of the doctors in our clinic and that's really great place to go. If you want some more firsthand hands-on knowledge that elective includes a lot of time in our clinic as well as some time out in some of those community centers Community Resources we've alluded to this talk. So, you get to see people more in their element in a way that I think we don't typically get to. The other big thing, that even people who are just starting their medical school experience can join in on, is a student group that's called the American Academy of Developmental Medicine and Dentistry or AADMD and that is a student group and expands just beyond medicine, there's dentistry and the PA school and we're looking to expand to other schools throughout the medical center. But this is a group that's really focused on a lot of the issues that we brought up today in terms of educating oneself in terms of advocacy, in terms of just medical knowledge of how to best care for individuals with disabilities of all kinds. So, it's a great organization. And of course, it's also a shameless plug because I'm the faculty liaison for the Baylor students here. So of course, I'm a little biased but I think it's a pretty great and there's a lot of great students who are involved with it. So stay tuned. There should be a talk coming up here in a couple of months. Actually, I think I'll be giving that talk as of now. So, if you want to hear me talk more about some of these topics, I will be there sometime in October.

Apoorva: Awesome. I've been to that talk. Hence why I know you. Hence, why you are at this interview. So, thank you so much for you know, telling us about all these different resources that we can continue our education with and you know, perhaps actually get to know the community bit more personally and interact with that.

Dr. Berens: Of course. And Apoorva, do they, do you guys include my contact info in the info for the show or should I…?

Apoorva: That's a Juan Carlos‑ –

Dr. Berens: Guess I can give an email now.

Juan Carlos: Uh, we could!

Apoorva: We’ll include it.

Dr. Berens: Perfect. Well, look for the show notes. If you want to contact me in terms of you know, just more questions or want to talk more about this these topics or if you want to get more involved with what we do here at our clinic. Please reach out. We are always looking to expand the circle of people who are thinking about these things.

Apoorva: Wonderful. Welp, Dr. Berens, thank you so much for your time. Thank you so much for introducing our audience to the world of development and taking care of patients with IDD and spreading a bit of inclusion and diversity into our community. So, thank you for your time.

Dr. Berens: Absolutely. It's been my pleasure. Thank you so much for being here. And for those of you still listening, thank you. Thank you for thinking about this.

[Outro melody.]

iTunes | Spotify | Stitcher | Google Play | Length: 50 minutes | Published: Dec. 2, 2020

Dr. Lamees Alshaikh discusses her journey from medical school in Saudi Arabia to an MPH in Oklahoma to emergency medicine residency and fellowship training here at Baylor. She describes her personal experience as an international medical graduate, advice she has for aspiring physicians, and her perspective on the pandemic that has turned people's lives upside-down all over the world. 

Transcript

Juan: Welcome to the Baylor College of Medicine Resonance Podcast. I’m one of your hosts, Juan Carlos Ramirez, and the writer for today's episode is joining me, Eileen. 

Eileen: Hi! As Juan said, I'm Eileen. I’m one of the writers and sound engineers here at Resonance, and today for our episode we'll be talking to Dr. Alshaikh, who is currently a fellow here at Baylor College of Medicine, where she also completed her residency after graduating from medical school in Saudi Arabia where she grew up. We wanted to talk to her a little bit about the difference in medical practice in the US versus in Saudi Arabia and what her experience has been like straddling both of those worlds and her plans moving forward. She is an emergency room physician, so we actually had planned this conversation several months ago not realizing that we would be in the midst of a pandemic. So if you will please excuse the audio quality, it's not quite up to our usual standards, but that is a function of doing a zoom interview. So we also wanted to take the chance to ask her about some of the stuff that's going on in the world right now.

Juan: Yeah, it's a dire time for all of us and we just kind of have to make due with what we have, but I think it'll be a great episode. So can we go into some details, like what are we gonna get?

Eileen: Yes, we're also going to talk a little bit about the role that international medical graduates play in our medical system, which has been growing bigger and bigger and bigger. It's interesting, because if you want to be a resident here and you're applying from a school outside of the United States, it's actually significantly harder to match. So in 2019, the match rate for PGY1 for US seniors was 93.9%, but if you're looking at international medical graduates, it falls to 58.8%. So it's essentially twice as hard to match if you're coming from outside the country. Not to mention the fact that you're having to travel for interviews and try and figure out potentially culture differences, and you also have to take all of the same exams, all of the same step exams, which can be a challenge to do if you haven't done it yet. So for example, if you don't realize that you're going to be applying as an international medical graduate, which is the case with Dr. Alshaikh, she had to take Step One after she had already graduated medical school. For those of you who don't know, Step One is much more focused on the basic sciences and pre-clinical curriculum, so to have to take it after a couple years in clinics would be a big challenge. But despite all of the hurdles, the number of international medical graduates has actually been growing. The number has grown by almost 30,000 in the last 10 years, which is a 15% rise and we're disproportionately seeing more doctors who are coming from medical school abroad. We're really lucky to have them here. 98% of international medical graduates speak two or more languages fluently, and so it can be a huge help in patients who have a language barrier or a culture barrier, who feel they might otherwise be intimidated to seek care, to know that they're going to be able to talk to someone or meet with someone who's more familiar with their home culture.

Juan: Yeah, so I guess, does this reflect--like even given all this, you know I hate to kind of even bring it up, but you know political backlash about, you know, having international travelers come to the US Does that--does that really affect it? Do you think that's affected it in any way?

Eileen: I don't know that we have specific data on the difference in numbers between IMGs who have come in, say, the last four years as opposed to the time before that. I can't imagine that it's been especially welcoming, but I think that we are still seeing a significant rise. And it's also interesting to see where those students end up. So for example, about a third of IMGs end up in the South and about a third end up in the Northeast, but only 20% end up in the Midwest, 17% in the West, and then 3% in territories or military bases. I wonder if there is more of a sense of welcoming or comfort to being in the South or the Northeast, or if that's just the way that the residency programs end up shaking out.

Juan: Interesting, may be interesting to see that data. Just kind of how it's changing over time. I mean, those areas kind of makes sense, right? But I think it'll be interesting to get Dr. Alshaikh's viewpoint and her personal opinions and her story.

Eileen: Yeah, it would be really great to talk to her about her own experience and how her perspective coming from Saudi Arabia has shaped what she thinks not only of the American medical system in general, but also the global nature of the pandemic that we're all living through right now. So without further ado, I will go ahead and start our interview with Dr. Alshaikh. I'm going to start off by asking her where she's from and she's going to give us just a little bit of background and then we'll jump into it.

Interview

Dr. Alshaikh: So I was born and raised in Saudi Arabia. I did medical school there and was planning on doing residency back home before there was like a huge detour in my path. I had, we had, an opportunity (my husband and I) of continuing him doing a master's actually in the States and so I saw this as a great opportunity to start the process of applying for residency here. And so I had to do all the requirements, including all the exams and everything, after I completed my medical school. When I came to the US, I completed all the requirements and then did a master's of public health in Oklahoma before going back home for one year and then starting residency in 2016 here at Baylor. It’s been a long long path, but very worth it.

Eileen: What have you noticed some of the major differences between medical school in Saudi Arabia versus being a resident or a fellow here versus the time that you spent living in Oklahoma?

Dr. Alshaikh: Very different experiences honestly. So starting with med school. In Saudi Arabia, they follow the old system where you do a year of general science and then do six years of medical school that includes a year of internship or general training/clinical exposure. Whereas in the US, you guys follow the newer system of doing like the organ-based like rotations and doing all the basic science as well as the clinical rotations pertaining to that specific system. In here, you do--you graduate from high school, you go into undergrad, and then go to medical school, whereas it's straightforward to like medical school if that's what you want to do. With regards to Oklahoma, so it was my first experience in the US. It wasn't much of a cultural shock because honestly a lot of people around the world are exposed to the American culture one way or the other, like watching movies, shows, news, and that sort of thing. But being away from, you know, your comfort zone, being away from your family is actually stressful, but I feel like it prepared me--a good exposure before residency. 

Eileen: What was your husband studying?

Dr. Alshaikh: He did radiation therapy and then did a master's in dosimetry in Oklahoma, and now he's doing a master's in bioinformatics here in Houston. So I followed him to Oklahoma and he followed me to Houston. 

Eileen: Well it all works out, I guess! Did you always know that you wanted to go into medicine? I personally, when I started my undergrad, I did not know that I wanted to do medicine so I always admire people who know right out the gate like that.

Dr. Alshaikh: Yeah, no. It wasn't it wasn't the case with me until I was in my ninth grade actually. Before that, I never thought of medicine. I wasn't one of those who grew up dressing like doctors or aspiring to be doctors honestly, and I'm the first doctor in my family. My dad is a chemical engineer and my mom is a stay-at-home mom, and so it's very far away from our family (the medical field in general). But I started thinking about it after losing some close people to me and I thought it was empowering in a way, you know, to know what you're dealing with and be able to help people. 

Eileen: So then you went to medical school and then came and did a master's in public health and then went back to Saudi Arabia and then came back to the US.

Dr. Alshaikh: Yeah, back and forth.

Eileen: So you are working in emergency medicine and obviously this has been a pretty crazy time for everyone, but I would think especially emergency medicine. We scheduled this interview I think back in February, but we've been planning it since October, so we didn't know that it was going to be a Zoom interview. But I'm just wondering what your experience has been with all of the craziness with COVID working in the ER?

Dr. Alshaikh: So it's definitely a very stressful time for everyone, especially people in the medical field... and people working in the hospital in general, from different services, like all collaborating in providing the service. The emergency medicine clinicians in general and providers are on the front lines, and so it's more stressful to some people… especially those who have, you know, kids at home or elderly. The situation is not easy on anyone, because nobody knows about this virus and it's like, I'm sure, that first experience of pandemic for everyone except those who are like a hundred year old were there during the Spanish flu. And so there is definitely some stress and anxiety going on, on all levels. For me personally, during this time I'm actually having some credentialing with TMB issues, with the fellowship program itself needing renewal. So I'm not working clinically, but I have been working doing things related to ultrasound... so doing scanning shifts and then also involved with the COVID task force for the emergency. And so we've been planning, scheduling daily meetings going over, you know, what things we could do, with the things we could improve, and working with the different teams in order to prepare our ER to face this pandemic. We just recently, like the past week, moved to every other day meeting. But it's been a very heavy work and I'm actually proud of my colleagues, my senior faculty, who have been working hard to prepare us for this. And actually, our ER was one of the first ERs to prepare for the pandemic in the area. Thankfully we weren't hit hard, but we're still being very cautious because we haven't--most of us think we haven't seen our peak yet--but places in New York, Italy and Spain, you see just a horrific scene and the reports we hear from our colleagues there are honestly frightening. Recently, I don't know if you guys had heard the news, but one of our colleagues--emergency physicians--has lost her life due to this pandemic. A lot of people, you know, can work to a certain… extent extent under stress, but eventually it gets to you.

Eileen: So are you planning to stay at Baylor or are you thinking about going elsewhere?

Dr. Alshaikh: I'm staying at Baylor. I'm doing an additional year doing global health and industrial medicine at the same program so it's a combined ultrasound-disaster medicine with global health mission. 

Eileen: Do you know what you want to do after that?

Dr. Alshaikh: After I finished my fellowship, I'm planning on going back. So I'm going back to Saudi. I'll be working at the tertiary center, a cancer center back home, for about three years and then planning on going back to the academic emergency medicine setting. So to a university or educational facility and hopefully incorporating the additional training I got in ultrasound, disaster medicine, and global health, and doing medical missions worldwide in underserved areas. That's the long-term goal, I would say. 

Juan: So you would agree that this crazy time is kind of preparing you for more challenges down the road? 

Dr. Alshaikh: For sure! Yeah, yeah, for sure. I mean it's preparing everyone. Like I don't think the world is going to be the same after COVID honestly. I feel like it has humbled everyone in a way. 

Juan: So, I mean, it's obviously a very challenging time. You said that this time definitely has prepared and it's going to change medicine for the better. What ways do you see personally from your experiences that this is going to prepare us in the future, or maybe just make a better physician or better public health awareness?

Dr. Alshaikh: It shows how it's important to educate the public and use the available media channels in a way to do so. As I said, a lot of people are having some very stressful times, having anxiety and depression, and some people even--like there are people committing suicide because of all of this. And so it just shows how important this part of medicine is, and how it is vital to incorporate the into patient care and the community actually programs in general. 

Juan: And it's gonna be a little frustrating in some sense to, you know, to understand from the point of view of medicine and being in medicine as a practitioner or as a medical student and then to see the public kind of deny the seriousness of these problems. It's just very frustrating, right?

Dr. Alshaikh: Yeah, absolutely, and that's because they're getting conflicting information. So you see, people from the medical field getting the correct information, but then you see some other people who are not specialized in this part of, you know, this aspect of science or knowledge and then they just give advice or share their information as if facts. And we should--we need to differentiate and take the information from those who are specialized rather than, you know, just listening to everyone's input with regards to this. I feel like public health officials in general need to point out this, and also hold those people who spread those kind of, you know, misinformation accountable in a way to stop it from spreading. 

Eileen: Do you think that your degree and your time spent studying public health has affected how you're looking at this epidemic? 

Dr. Alshaikh: It's always important to be proactive, so I feel like sometimes it's too late to implement measures. And what I loved about our program is that they addressed this even before it got to Houston. You know, they started early on, and that's what I feel helped flatten the curve in a way and made us more comfortable, you know, handling a potential, you know, surge if it occurs at some point, we know all the specific details from the very minor to the major details, and so addressing the problem and dealing with the problem early on is manageable, as opposed to addressing it when it's it's too late--like secondary or tertiary prevention prevention. Like we deal with, for example, cancer--breast cancer for example,--or lung cancer. It's super easy to tell someone, you know, to stop or modify the modifiable risk factors--like, for example, tobacco smoking--as opposed to, you know, address the lung cancer when it's stage four. Same thing goes with the pandemic in general and everything in life generally--if you address it early on, it's much easier for you to control it. 

Juan: I guess that's assuming that we have an open mind and listen, right? And that people understand what they're hearing?

Dr. Alshaikh: True. Unfortunately, everybody now has a way of, you know, having their input out in the world and so there's a lot of people talking and much less people listening honestly. And that's why it's not effective with certain groups of the public. And so, I feel like again you have to take the information from those who are specialized, rather than just, you know, from everyone. Because it's just going to confuse you and and you'll get lost. Ironically, today is the first day of their plan of reopening Texas in general and so a lot of us are very concerned about this. It's good that they're doing a gradual reopening process. It's better than, you know, just moving from shutting down to fully open. But we're still--we still think we haven't reached our peak yet. Very important to follow the public health measures implemented in the beginning, which is social listening distancing--minimizing, you know, gatherings as much as possible and maintaining that six feet distance from everyone. And honestly people who are eager to go to, you know, restaurants, salons, movie theaters, malls--I feel like I understand the economical part--aspect of this all, but we're dealing with a bigger problem honestly. It's your life, as well as the lives of everyone else. You might be fit and healthy. You could have someone elderly at home who might be susceptible and may have complications because of this. As you know, a lot of people can have the infection and wouldn't show any symptoms, and so you could easily transmit this infection to others. And that's why we ask people not just to, you know, keep those who are prone to get the complications or die from the from the infection like locked out, rather have the whole community contribute to this--because of the asymptomatic carriers that could transmit the infection to everyone else. And then there were reports of people having significant morbidity and mortality, despite them not having any risk factors. And so don't… I wouldn't ask… wouldn't tell anyone to take it lightly. Even if you think you're young and healthy, you be should be very cautious until we know more about this virus and hopefully develop a vaccine for it. This case fatality rate thankfully is, is less in the US compared to, for example, Italy. I think it--it's around 3, 3.5%. In Italy, it was at some point around 9%, which is very high. And a lot of people are recovering from the virus, but again this overwhelms our health system and  if the cases start increasing significantly... we could be in the same situation as other parts of the world. But thankfully, currently, it seems like we're doing a good job.

Eileen: Is there anything that you've been doing just personally to kind of keep yourself sane? 

Dr. Alshaikh: So the best thing, honestly, that happened to me is that I had--I got a dog a year ago. Not a year even, nine months ago! And she's turned one year old like two days ago. 

Eileen: Happy birthday!

Dr. Alshaikh: Thank you. And it's been honestly very helpful at keeping me sane. I feel like this, as well as maintaining that communication and connection with family and friends via phone/texting does help. I'm an introvert of sorts, so I don't mind, like, staying home if I need to. It's okay. But I know that it must be difficult for some other people who rely much more than us on, you know, on being outside, being outdoors, and engaging more... can be very stressful. But I feel like--just think of the alternatives. Exercising--you could just try to do that inside the house in a way. A lot of programs out there are providing free workouts and there's also some counseling going on through Baylor and other services. And there's the meditation apps, websites. So there's a lot of options and I feel like the community came together in a way to help provide that support. 

Juan: And I think there are other aspects of all of this, right? We were just focused on the virus, of not getting sick, that we didn't really think of social factors, right? And human factors? And I think a while ago, as this started to increase in severity, I would think of the back end, right? I would think of who would be getting the best care. And it was kind of interesting that the CDC released the numbers from New York… those from disadvantaged backgrounds getting less care and I was wondering if--what your thoughts are on that here, and if you think anything similar is maybe happening here? 

Dr. Alshaikh: You bring up a very good point. Health disparities exist, and it's a real thing, and has been researched. In terms of our experience with this specific pandemic, honestly don't have any data to back this up or personal experiences, honestly, just to support that. But I feel like, giving that we're practicing in a county hospital has been a good thing for us, a fortunate thing, honestly. We really don't close our doors in the face of anyone. We accept everyone and treat everyone, thankfully. ERs in general are governed by EMTALA in general, and so they don't really use anyone who seeks care. They have to stabilize before they transfer, if the transfer is needed. But other services, I can imagine this could be potentially stressful if the physicians host war, you know, to provide care for those who need it... go against the hospitals they work for because the patient doesn't have, you know, what it takes to pay for the care required, or they come from an unfortunate background, or are being judged because, for example, they have some certain aspects to their prior visits. And so they have--people have those preconceived notions that this patient, “Oh he's probably just an alcohol consumer” or “He's done that” or “He did drugs.” And so we don't really provide that same of care because we don't believe him in a way, but I feel that's probably not that common, at least in the--our county hospital. And I feel like a lot I work alongs alongside great physicians, honestly, who try their their best to pay attention to those kind of things. And one of our physicians actually brought up this as a research topic: of looking at racial disparities with regards to COVID. But because we don't have big patient population yet, difficult to look at this at this research topic in particular. But yeah, they do exist unfortunately. 

Eileen: I'm afraid that I don't know terribly much about it, but could you talk a little bit about how the health system works in Saudi Arabia and how it might be similar or different to how we approach health here?

Dr. Alshaikh: Yeah, in Saudi Arabia it's a universal health care system and so everybody has the option of seeking the governmental hospitals and have their care for free, actually, which is a good thing for a lot of people. But the only disadvantage is that because everybody is going through that channel, it could slow things a bit, and so people could have appointments in life six months or a year, and the wait times are longer than than other parts of the world, especially the US. But the--there's a private sector as well, so those who can afford it could potentially go through that. And that's the major difference. With regards to the US, when I first came in here, the biggest shocking factor was the high cost of healthcare in the US compared to the Middle East, and the world in general. Like for example, I'm talking about a medication that I--not a medication, a CT actually. I've had a friend who had a CT scan here in the US in an ER. It cost, if I remember correctly, close to fifteen hundred dollars. And my sister required a CT back home and it costs about 250 dollars. And so it's like six times the price. And then there was my--I had a medication that I needed here in the US, and it had to prescribe… to be prescribed. And it costs around like 190 dollars. Back home, it would cost around 12. So there was a significant, significant difference in terms of the cost in general, and I feel that may have led to this disparity seen as well. The other thing was… given that the US is not a universal health care system, those who can't afford care unfortunately won't get it unless they go through like a county hospital or a charity, and it's been frustrating to hear about this and see that. And I feel like the US is great in many ways and could potentially address this, giving that they are leaders in the medical field in many ways--in research, technology, innovation. This is a big problem and I feel like could potentially be solved and hopefully would be in the future.

Eileen: And how do you think that affects your work in a county hospital, in the emergency department in particular? As you mentioned, if someone comes into the emergency department and they're not stable, you can't just send them home. You have to treat everyone. So do you think that you end up seeing people, like you were saying before, who haven't gotten the preventative care and so they end up in a much worse position than they would have been otherwise?

Dr. Alshaikh: Yeah, so it was honestly frustrating to see like a patient that you treated, for example, weeks ago when you told them, you know, you need to get your medications, you need to see your primary care doctor, and then they come back not doing any of the things you told them. And, you know, me being a junior and not very familiar with the health system, I was like, “This patient is not compliant.” But when I talk to them, it turns out they can't afford the medication, or they don't have a primary care doctor, or they don't have transportation to take them to their doctor. And so it's straining in a way on providers, you know. We swore an oath we want to provide care. We want to help our patients, but our hands are tied. There is a certain limit of help you could provide and at some point you feel like--I mean, engaging social workers could help and our social workers are actually excellent at doing so, but again they too can't help with every aspect of the patient's care and their social issues and barriers. And yeah, it does create that frustration. We do our best, at least when we're prescribing medication, to look at the cost and so we try to find the cheapest option with the equivalent effect of medication but on the cheaper side, to take that into account. And as well, we try not to order or over order things that we don't need. And not just to, you know, minimize cost, but also to limit risk associated, for example, with radiation and unnecessary testing. But yeah, it makes us very very keen on thinking of the economical factors in the ER setting, giving that we're dealing with underserved population. But like I said, with the EMTALA, which is the Emergency Medical Treatment and Active Labor Act, it's a good thing for us in the ER setting, because we really don't shut our doors in the face of anyone. And so everybody is welcome to come to the ER, at least get their medical screening exam done. And so I feel like it's a bit less stressful compared to other services who can't provide that, governed by their institutional life guidelines.

Eileen: And how did you end up specifically in emergency medicine? 

Dr. Alshaikh: When I first got into med school, before even, I was interested in GI and endocrinology. 

Eileen: That’s pretty different.

Dr. Alshaikh: Yeah very very different, but because my late grandma--she died due to complications of cirrhosis and diabetes, and so those were the areas that I was interested in. But as I was getting, going through the years and started getting that clinical exposure, did my ENT rotation first and just fell in love with it, with the surgical aspect of it, and was thinking of even doing a subspecialty in allergy and immunology. And then did an ER rotation, I was like “Wow, this is even more fascinating!” I could still keep that wide large knowledge base and still do interventional procedures and intervene on critical patients and save lives, and still could do things related to ENT, in a way. Like I could still, you know, manage critical ENT situations and keep that connection with every other specialty. And so I decided to go with ER due to that specific fact. If I could do two specialties, those would be my two specialties but that would be impossible of course and just crazy hours, like to study for 20 years or so!

Eileen: As a first year medical student who is very interested in emergency medicine, would you recommend going into emergency medicine?

Dr. Alshaikh: Oh for sure. I mean, this pandemic is the biggest example of how important this field is. At the very basic description of it, you're saving lives on a daily basis. You're seeing a very wide range of cases--from very stable bread and butter, like primary care even cases, all the way to critically ill dying patients and everything in between. You see pediatric patient population, you see geriatric patients, you see female--pregnant females, you see other specialties--like surgical and medical specialties. And you deal with those cases, and so I feel like it's keeping that connection with every other specialty. And so, if you are leaning more towards a generalized specialty, emergency medicine is the most generalized specialty, in my point of view. And you could still do procedures, intervene in a way. If you’re like a person who loves to do some kind of surgical or procedural things, then emergency medicine provides that. But it's very rewarding, I would say, if you're a person who loves to see quick results. If you want to do meaningful things and see quick results immediately, then that is provided in an emergency setting. It can be very stressful and very humbling, especially early on in your training, but it's definitely very rewarding and worth it. I think it's one of the most fascinating specialties out there and I never regretted going into it.

Eileen: Do you have any favorite moments working in the ER, either a moment with a patient or with a colleague?

Dr. Alshaikh: I have so many great moments honestly, but in general it’s when--my favorite moments are when I do a procedure and see a significant and a quick result in a way: like significant or sudden pain relief, a change in the critical situation in a better way, or significant improvement. And then I love those shifts when it's very busy and there's a lot of things that you could do that is 180 degrees transforming the patient's condition. Like for example, when in one of our community side, it was a busy shift and we--in addition to the regular cases we're seeing. And one day I had two intubations, placed two central lines in on those patients, had a patient with altered mental status, had to do an LP in addition to the full workup, had an unconscious patient that we had to resuscitate until patient gained consciousness, had a patient with an overdose we had to give narcan, and then put him on a drip and have to intubate him. And then on top of that, we had a patient with an ankle fracture that we had to splint and reduce. And then just the cherry on top, we had a pregnant lady who was in labor. But we didn't deliver her; thankfully, she was stable to go to the labor ward, but it's just the wide range of things that you see. And you're having to be very efficient and flipping from one room and one case to another. And just change that mentality completely and be able to help and contribute in a way. It's just--just very rewarding. Although it's exhausting, but very rewarding. 

Eileen: I don't think there's any other specialty where you get to see all of that in, you know, one one shift. 

Dr. Alshaikh: Basically all specialties of medicine are incorporated into one.

Juan: Sounds like an Oscar-winning drama series.

Dr. Alshaikh: Yeah, it can be crazy. It can be crazy, but there are days where it's like
slow and different--completely different. The whole situation is unpredictable honestly. In the ER, you don't--you never know. And there's always that subtle anxiety deep down inside in every one of us, because we know it could just transform in a matter of seconds. And so we never say
it's too quiet, because it will jinx it. 

Eileen: I worked in an ER for a couple of years and then we called the keyword quiet--you did not say that.

Dr. Alshaikh: Exactly. It does do something, in a way. Maybe I'm superstitious, but I've seen it. Like early on, during my first medical school, going “Oh my gosh it's super quiet.” And then hell just broke and since then I was like, “Oh I learned my lesson.” 

Eileen: Yeah, one thing that was interesting for me working in the ER is I noticed a pattern that a lot of the younger physicians were a lot quicker to pull out the ultrasound machine and to use it for many more things. So I'm wondering if you can tell us a little bit from the perspective of someone who's doing a fellowship in ultrasound, how do you see that changing medicine and emergency medicine moving forward?

Dr. Alshaikh: So ultrasound is great for patient care in general honestly, because it provides a safe and a quick tool, you know, in order to help determine disposition, as well as a safe procedural guidance. For example, for central lines, people used to do them blindly and so they would stick a needle in the neck of a patient or the groin of a patient and hoping that they get into the vein. Of course, knowing the underlying anatomy helps, but there are some patients who have difficult surface anatomy to tell where the vein is. And so bleeding, puncturing the lung… using ultrasound--Juan is just terrified. Don't worry Juan, we're using ultrasound now! It's much safer.

Juan: Just thinking of someone just turning those arteries into swiss cheese. It's just... poking around.

Dr. Alshaikh: It can be--it can be definitely scary, especially if it's like a junior person who's just learning, you know, the skill. But thankfully, with ultrasound, you don't have this problem or it's significantly minimized. You still do honestly, but it's significantly minimized because you could tell what you're going through. You could tell how deep is your needle and what's--how far is it from the pleura or the lung covering and then how far is it from the artery. Because when you’re doing this procedure, you want to go through a vein. You don't want to be puncturing an artery, leading to hemorrhage and hematoma and whatnot. And so you could potentially control this and minimize any complications with this, with these procedures. And then the other thing that I like about ultrasound is that it just gives you--it's affordable, cheap, useful, and safe modality. And so what I mean by that, it doesn't--it doesn't really use any kind of radiation. And so when I'm--I could easily just pull my ultrasound with me and go look at the heart, looking for any fluid around the heart that could be drained. Is the heart pumping or not? I could scan the lung and look for any fluid around the lung, any air around the lungs or any signs of pneumonia, and then I could move down and look at the belly looking for the aorta and any complications related to that. We could also evaluate the pregnancy, ruptured ectopic pregnancy. We could look for any bleeding within that intra-abdominal space or intraperitoneal space. And then we could also look for DVT, or deep venus thrombosis. So these are just things that you could--it could potentially cause the patient to have shock or hypertension--you could easily screen for within a matter of 10 minutes maximum if you're an experienced scanner. And get your answer then and there. Because a lot of patients who are unstable should not be taken to the CT scan. They could decompensate. And ultrasound could provide answers at bedside. It's safe. Like we said, we don't have to scan the patient multiple times every visit for, for example, aortic pathologies. You could do it do an ultrasound and look for that without exposing to exposing them to that extra radiation. And so that's what I like about it. It's the other new thing that we've been trying to practice more with regards to ultrasound, is regional blocks. So that's like a technique that's used by anesthesiologist, but now we're trying to incorporate that into our practice to minimize the use of anesthetics and opioids. And so it's slowly gaining more popularity and being done in the ER setting as well, under ultrasound guidance. 

Juan: What is the advantage of employing the ultrasound for regional blocks?

Dr. Alshaikh: It's the same thing with other procedures. So you’re actually looking through what the needle is puncturing and what you're going through. You don't want to be developing complications like puncturing the nerve. You want to be around that nerve, inject anesthetic around the nerve, and then also making sure that you're doing it in the correct location in order to increase your success rate as well. 

Eileen: So as ultrasound continues to get cheaper and more portable, do you see that playing a role more in global health and disaster medicine, as you're going in to study next year?

Dr. Alshaikh: For sure. Actually, I went to Belize in a medical mission back in--last year, in April actually, and we did an ultrasound training program. We're still working on that. Like a group of us would go every few months in order to help train and reiterate whatever has been taught. And making sure that we cover all different locations of ultrasound. And it's amazing, because in a lot of sites that we've been to, CT scans are not available, period. They have to transfer them one hour away. So imagine having a trauma patient who's unstable and you really don't know what's going on intra-abdominally, and ultrasound provides that in a matter of seconds and minutes. And so it's definitely very applicable, very useful in limited-resource settings. 

Eileen: Yeah, I think it's incredible the number of things that we can do with ultrasound. It's also a little intimidating when you're first starting to learn how to read an ultrasound, because a lot of it looks like grainy, black and white… 

Dr. Alshaikh: The same?

Eileen: Yep!

Dr. Alshaikh: I know. I've been there, but I promise you it will make more sense if you get exposed. So you're welcome, as well as other medical students, you know, to rotate with us. I think it's provided as an elective. And it will make more sense, I promise you. There is some science to that grainy, unclear, black and white picture. But yeah, and you love it once you see how amazing it is and different applications. For example--like the medical students get excited when we do the ocular ultrasound. They're like “I didn't know that we could use it for the eye.” And they actually see the pupil, you know, constricting and dilating and the eye moving and the different parts, even the optic nerve, back like deep behind the eye. So it's fascinating. It's like that--what is it--the vision? The infrared? I forgot the English term. It's like the through and through vision.

Eileen: X-ray vision, like?

Dr. Alshaikh: Maybe. So it provides that. Because for example, I love radiology and I appreciate the ultrasound because you know it showed me that behind the scenes look. Incorrect description, but yeah. Just shows how fascinated I am with this modality.

Eileen: Could you talk a little bit about the teaching that you've done at Baylor, and how that's been part of your medical career?

Dr. Alshaikh: Every shift is an opportunity for you to teach someone, it’s either your juniors, your medical students--whether that's case-based, whether that's ultrasound-related, whether it’s procedural, or critical care management. With regards to ultrasound, we do scanning shifts. So we have been doing those for the past year and we rotate with residents as well as students and other rotators (PAs) and teach them all the core applications of ultrasound in the ER setting. In addition to that, we do have the journal club and video review weekly meeting. We try to do QI where we review our trainees’ ultrasound scans and send them feedback. The medical mission we've done in Belize also was part of the educational aspect. We also look in, you know, at possible opportunities elsewhere, outside of the hospital. I know prior classes had--had taught EMS and other specialties, as well, pediatrics, people from medicine, I believe. And so it's a good opportunity to teach this modality to everyone who is interested. And we consider every opportunity. We were supposed to actually, in April, participate in TCEP to teach at conference, at a conference in Dallas--Fort Worth, I mean. And then we also taught at ACEP, and there was also a surgical conference back at the beginning of the academic year. My colleagues and I, we did ultrasound teaching to groups of those--groups of interested people. So there's a lot of teaching you could do with ultrasound and we look forward to any opportunity provided.

Eileen: This has been such an interesting conversation, and you've answered most of my questions. I think the last thing that I just wanted to ask you about briefly was how you see the role of international medical graduates becoming more common in the US in residency? And what that was like? You mentioned you had to sort of go back and do all of the US requirements after you had already graduated from medical school, and what that process is...

Dr. Alshaikh: It's a big decision to make, honestly. And a lot of IMGs take risks by coming to the US. The process should, in the most ideal situation, should begin early on, like during your first two years of med school in order to try to incorporate your Step One after you do the basic science. And then do the remaining tests after you're done with your clinical rotations. With regards to--you asked about their contribution, is that correct, or their role? So I feel like it depends; it differs. Like certain IMGs plan on staying in the US, and they do contribute great things to the US system and they embrace the American dream. And there are some other IMGs who want to improve their healthcare work--the health system back in their home countries. And I'm in that group. I want to--I want to go back, I want to teach. I want to help improve the system, as well as the med school there in terms of ultrasound and disaster medicine in general. But I still want to have that connection with the US, as well as the rest of the world in global health so yeah...

Eileen: We're very lucky to have you, even just for a few years.

Dr. Alshaikh: Oh thank you so much. I'm lucky to be here. I'm very fortunate. I love Houston, by the way. It feels like my second home. It's hot and humid, like back home, and crowded. And it's just like home.

Eileen: Do you have any advice for either students who are applying to get into medical school or first-year medical students who are kind of at the beginning of their career?

Dr. Alshaikh: Yeah, I do have advice to those who are beginning residency and those who haven't really decided on what specialty they want to do. For those who didn't decide yet, I would advise you to have all the possible exposure you could get--even specialties that you didn't consider at the beginning. Try to get that exposure. You could be surprised. Your true calling might be something very different from what you've got into medicine thinking you're going to be doing, like in my case. So find that and commit to it. And it's definitely a path worth taking. With regards to those who are starting their residency, I'm gonna be realistic. It might be a very stressful time for you guys. And so it's very important to take care of yourselves: your diet, your health--mental and physical health--and maintain that connection with your loved ones. Maintain that support system, even if it's like talking to your parent or your sister or your friend for like just a couple of minutes every few days. It might be difficult, especially in the beginning, but just remember that everybody is going through a stressful time at the beginning of their training during internship year. Everybody--regardless of what they seem or do. Just some people are better at hiding it and some people seem more anxious than others. So know that you're not in this alone, and make sure that you invest in your health. It's very easy to get into a habit of eating fast food, or you know just the snacks or bars or whatnot, but make sure you know you take some kind of supplemental like diet or multivitamin. Fruits, veggies: smoothies are super easy to do. So invest in a smoothie maker or blender. And then the emotional or the emotional aspect of your health is very very important. It's okay to cry. It's okay to feel like you're lost. It's okay to feel that you're going through a lot. I mean personally, I felt like “Oh my gosh, I can't do this; it's just gonna--I'm just gonna fail.” You know, it's a turmoil. There are some ups and downs. We all go through this. Just reach out to those who can help (your mentors) and remember that it's gonna get easier as you go. You either get more resilient or things truly get easier. And just work on your education and knowledge base slowly but surely. Never stop. There was like a nice sign that I saw all over Belize: “Be slow, but keep moving.” So I feel that's good advice, you know. And it also helps sometimes when you--on your day off, to completely disconnect, even for a few hours and just like go for a run, a yoga class, or you know with your pets if you have a pet, or with your loved ones. You know, just try to disconnect completely from the hospital atmosphere. And I promise you it's worth it at the end. But if you feel like--if the stress is just too big of a burden, there are ways of, you know, getting help. And I know that through Baylor they have this mental health support which is very confidential, and there's a lot of you know channels for which you could get help. So just seek those and ask about them if it's not very clear, but don't ignore that aspect of your health.

Eileen: Great, great advice and very inspiring. Well, we're kind of coming up on the hour and I don't want to keep you any longer. Is there anything else that you wanted to say, or pretty much ready to go hang out with your dog?

Dr. Alshaikh: Well thank you so much, guys, for having me. This has been fun. It actually passed very quickly. I didn't feel like we already reached an hour. So thank you so much for having me.

Eileen: Well thank you so much for talking to us. I really enjoyed the conversation a lot.

Juan: Yeah, thank you. Time flies by when you're sharing an inspirational story and motivating others to do better and to stick through these tough times. And we really appreciate you--having you on. And I wish you all the best in the COVID battles, and just know that you have our full support and that you guys are our heroes and we appreciate everything you do.

Dr. Alshaikh: You too, guys. Thank you so much. And I know the medical students have been very active, actually, in procuring PPE for us. So big shout out to you guys. You've been awesome and always ready to help; so we couldn't do this without you. We're all in this together, so… it's gonna pass.

iTunes | Spotify | Stitcher | Google Play | Length: 39 minutes | Published: Nov. 5, 2020

This is the fifth of a five-episode mini-series on Quality Improvement (QI) in Healthcare in collaboration with the Institute for Healthcare Improvement (IHI) student organization. Listen to Dr. Nana Coleman, associate provost for Academic Affairs and Health Systems Science for Baylor College of Medicine, share her journey to becoming a Quality Improvement and Patient Safety champion (QI/PS). In this episode, she will share some of her past and present initiatives as well as her vision for the future of medical student engagement in QI/PS endeavors.

Transcript

[Music] 

Brandon: And we are here! My name is Brandon Garcia, I’m one of the hosts for the Resonance podcast and joining me today is 

Anoosha: My name is Anoosha I am a fourth year medical student at Baylor College of Medicine, and I am heavily involved with the student group of the Institutes of Healthcare Improvement at Baylor which has brought you a couple of fun episodes in collaboration with Resonance to kind of share our love of quality improvement and patient safety. And so this is another episode of that!

Brandon: Awesome so glad to have you here today who do we have with us today Anoosha?

Anoosha: Yeah so today we have one of the most incredible mentors that we've ever had, Dr. Coleman who is here taking some really precious time of her very very busy schedule to be with us. Dr. Coleman has many different roles here at Baylor College of Medicine, she is a pediatric critical care physician, she served as the assistant dean of graduate medical education for the last five years, and she is a quality improvement and patient safety champion throughout the Texas Medical Center.

Brandon: Wow that's so exciting! Thank you so much Dr. Coleman for being with us today. Real quick, you mentioned before we started this session that this is your first day out of the hospital in how long?

Dr. Coleman: Thank you so much for having me Brandon and Anoosha, it's really a pleasure to be here and thanks so much for that kind introduction. So I’ve actually been on service much of the last few weeks ending of June and into early July working in the pediatric ICU and our service lines. It's obviously a very busy time in hospitals overall, and so it's actually nice to have a chance to return to some of the administrative and educational leadership work that i do. But I have to say, being at the bedside always brings a really unique and grounding perspective in trying to think about how and why we do what we do in education to really help as we train students and trainees to become physicians of tomorrow. 

Brandon: Wow

Anoosha: So, Dr. Coleman we mentioned you're heavily involved in medical education from the medical student to the resident to, I’m sure, even the fellow level and you're also a champion for healthcare quality and health systems science. Today in our episode we'd like to focus on your roles in quality improvement health care system science and medical education. And kind of focus there even though you do have many many roles throughout Baylor. We were curious if you could just tell us a little bit about your path to being in these roles of medical education and healthcare quality that you are today.

Dr. Coleman: Sure, thank you for that really thoughtful question. So when I think back formally to when this journey started, it was actually when I myself was in training. I as a medical student had quite a bit of interest in teamwork and how teams work together to help to make things better for patients. And even at that time in medical school, a lot of the work that I did was in the community and thinking about how what we did even as students would help our adult and pediatric patients have better health outcomes. As i transitioned into training, interestingly, I was in my residency in New York City there was obviously really a lot of work that we were doing just given the population that we served in Washington Heights and a really multicultural diverse community. There was really an opportunity to engage in work that helped us to think about what, at the time, we probably weren't calling social determinants of health and thinking about it from a health equity point of view, but really in the spirit of community pediatrics. As i transitioned into my fellowship I knew that critical care was the field that I loved for a couple of reasons. One, I appreciated the challenge of it. I also appreciated the fact that so much of the work was team based. And again just given the nature of the acuity and the breadth and depth of clinical diseases that we treat in that field, that there would be an opportunity to again think about how health and health outcomes could be impacted by thoughtful care and attention to some of the non-clinical aspects including quality and safety. As I was in my fellowship I had really great mentorship from someone who actually continues to be my mentor today, we just were in touch last week, and really had the opportunity to begin to delve into this work in a more formal way through my fellowship research project which looked at the impact of team and leadership training on patient outcomes particularly for scenarios that were infrequently encountered but high acuity when they were kind of like the ICU. As part of that work, I had the opportunity to be trained in a national program called TEAMSTEPSS which is now pretty ubiquitous, but at the time I was trained at one of only five centers in the country, that was really looking at how that program which focuses on teamwork strategies to mitigate patient safety outcomes, how that program could be integrated into their clinical work. So, from there it really took off. I realized that while team and leadership development were very critically important to health outcomes, really being able to thoughtfully and strategically make inquiry around what can we do to improve the outcome for our patients through a structured process and through a way that was intentional and team based and outcomes driven, would really be the key to helping the patients that I cared the most about. And so, I undertook a number of initiatives to really grow in my knowledge and my skills and training around the issues of quality and safety. Soon after I entered my faculty career, I had a lot of really great opportunities that I’m really thankful for that helped me to acquire a lot of on-the-job experience. I was a Director of Quality and Safety for pediatric critical care division in New York City at a large academic center that really honed my training around building a quality and safety program. How do you do morbidity and mortality in a way that doesn't feel staid and threatening and intimidating? How do you incorporate families as partners in quality and safety? How do you balance the needs of health equity in resource constrained settings? And so, in that work initially for the division and then ultimately for the department that really gave me a good foundation. And so, from there we transitioned to the Houston area and as you've shared I’ve been really grateful and just really excited about the work that I've had the privilege of doing here at Baylor College of Medicine over the past six or so years. 

Anoosha: Dr. Coleman so many of those things that you've outlined could be entire episodes on their own! It's amazing how succinctly you've summarized all of these incredible projects and roles you've had in the past as a champion of quality improvement and patient safety. Thank you so much for sharing that with us.

Dr. Coleman: Certainly, thank you. 

Brandon: So, you shared a bit of about the things you've done in the past, what currently is your primary focus in terms of quality improvement?

Dr. Coleman: Certainly, great question. So in the last five years, as Anoosha mentioned, I have worked with our office of graduate medical education which of course is the office that oversees the training of our almost 1500 residents and fellows here at Baylor College of Medicine across our major affiliates in a number of different specialties. And so, there is a program by the ACGME which is the council that accredits all, or many I should say, of our programs that is called the CLEAR program, clinical learning environment review program. The CLEAR program started through the ACGME in 2012 as a means through which a couple of key priorities could be accomplished. Number one, patients and families were saying it's not enough to have a doctor who understands how to do the procedure, how to do the operation, how to get the history and physical, but we need physicians who are prepared to discuss, address, interpret, and devise solutions for the challenges that we face in health care which more often than not are not just technical and clinical, but rather systems based. And so, the program really became an opportunity for clinical training to be reconsidered. What do I mean by that? So the clinical learning environment is really just that - where do trainees acquire their experience and exposure to patients and health systems? But recognizing that in the course of their clinical training, previously there was not enough emphasis nor really collaboration between affiliates or learning environments and the school or academic center that was actually sponsoring the training program. So through CLEAR, a dialogue began. A dialogue around six core areas: quality improvement/healthcare disparity, patient safety, professionalism, wellness, supervision, transitions of care - and I think that's the six, yes! And so through that work that i have been engaged in over these past five years, I've had the opportunity to partner with members of our academic institution our affiliate sites to really help operationalize and lead a collaborative network across our sites such that when trainees are going to each of these hospitals, they have a common lexicon or vernacular around the importance of quality and safety in their work, a common understanding of why transitions of care matter, common understanding around supervision, and what their role and responsibility is in that context for their patients, and really trying to elevate our collective and shared understanding around these core principles. And so in the past five years, I had the opportunity to lead that program and it was really one of the most foundational exciting and really wonderful journeys that I've been able to take professionally. Very very grateful for that opportunity. More recently, I’ve actually transitioned into another role which actually will help me to continue to do some of this work through the office of the provost in an Associate Provost role and really focusing not only on academic affairs but also Health System Science which, many people are familiar with that term, but for those who may be less so, really defines the broad scope of competencies really across the continuum of medical education that pertain to quality, safety, teamwork, health equity, partnership with families and patients to help prepare us to really be even more effective physicians. And so, I'm excited to have the opportunity to continue work in that area. 

Brandon: So, correct me if I'm wrong. It sounds like a big focus of what you've been doing with this systems approach that you keep mentioning is helping physicians realize that it's not just about recognizing symptoms of a disease and diagnosing it, but also understanding like maybe like the social economic impacts of the disease and in the other aspects of care besides just sitting in the doctor's office that can help the patient. Is that kind of what you're talking about like educating physicians in that area?

Dr. Coleman: I think you've surmised that beautifully Brandon because in reality what you've said is so true. I think we typically as physicians have traditionally measured our effectiveness by what happens to our patients in terms of their outcomes and their numbers and their mortality or their morbidities, but what I think we've been called to do as clinicians in recent years, which I think is really important, is to consider our own accountability in that process. So, what roles do we need to take on to help advance the best interest of our patients? But then also, how do we need to educate differently really from the very beginning all the way through training all the way through our continuing medical education and our long-term careers so that we recognize that quality and safety isn't an add-on, but it's just like clinical medicine. It's just what we do. And so, that concept of Health System Science which really bridges the continuum evaluates individual roles and responsibilities in achieving high quality care and safe quality care for our patients, but also making sure that we understand that systems are part of that and how do we interface with systems to make sure that we have the best possible outcomes. And so yes, I think that new professional identity around what are the other factors? What's my understanding of my role? What are the impacts of social determinants? What are the impacts of areas of implicit bias? How do those factors, for example, impact the ultimate quality and safety of the care that we deliver to our patients?

Brandon: Okay that that makes a lot of sense um, and I actually really like that because I mean especially where I'm at in my training, I'm still my pre-clinicals, you know which is all the book work it's oftentimes boiling it down to - okay patient comes in, they have shortness of breath, they have you know x y and z symptoms, what's their diagnosis? It's relieving to know that eventually you get to the point where you're talking about you know well, where did this person come from? What do they really have in terms of access to care? Like do they have a community support? Do they have social work? Do they have all these other things that can help them? Because giving them a prescription isn't necessarily going to help them fight the disease without other things in place that could benefit them.

Anoosha: And Dr. Coleman we're so lucky to have someone who is so knowledgeable, experienced, but more importantly so passionate about sort of building this intrinsic motivation in learners to work in some of these very important qualities of physicians as well. So it's incredible to know that someone like yourself is so passionate about helping us become the physicians that our patients deserve and really need. So thank you so much for your work. And I'm curious a little bit more about some of the projects that you had done in your role within graduate medical education with the residents at Baylor. Would you mind sharing some examples of how you worked through the ACGME?

Dr. Coleman: Certainly, so one of the things that I just wanted to reflect on was the point that you both shared just a few moments ago as to the passion. And I think that shared passion that all of us have that's what keeps us going. I know that when I was in my pre-clinical years, yes it was fine to do anatomy, and micro, and biochem, but at the end of the day that looking ahead to being connected with the patients was what kind of kept us all going and invigorated. So in the same way, I think of that for training and thinking of how do we alight that interest in our learners so that even through the sometimes drudgery and the challenges that training can bring, that there's still that passion in that interest. And so, I think of some of the areas in which we have had great collaboration with our trainees actually with our students. So one of the areas that I just want to highlight, and honestly express profound gratitude for, is this opportunity is the chance that I was given to serve as the director of the annual Baylor College of Medicine Quality and Safety Conference beginning in October of 2018. That conference really was incepted by and led brilliantly by a core of student leaders from the IHI student interest group and I have to say when I walked into that role, I could not have found a more collaborative, professional, supportive and just really committed and dedicated team led by students for this conference. In the last year or so we have added in some of our resident leaders in quality and safety to partner with the students and the other professionals who comprise the planning committee. And I share that really as an example of a success story the conference is in its seventh year this year. It was postponed due to the ongoing health pandemic, but will be convened next spring. But that being said, we had almost a third more abstracts this year 30 more abstracts than we've had in previous years. The quality just keeps getting better and better, and this is an activity that is not only regional but also now national and brings in many of our health system partners to see the quality of work in terms of inquiry and thoughtful QI projects that are being done across the system. Another area that I just really want to extend credit and gratitude for their contributions is through the house staff quality and safety council that started in GME. We started it about five years ago when I came into that role recognizing that although the executive and administrative leaders of the educational programs had a lot of expertise to contribute, that truly our house staff had not only experienced an interest but in many cases individuals who done masters who were real QI/OS gurus who could really contribute both leadership and really their perspectives to advancing your quality and safety work. So that has been also a great collaboration each year. We started a few years ago a clinical learning environment review orientation because previously when folks would orient to our training programs it was more administrative in function, but we recognized that to help prepare our trainees to be on the wards, in the clinics, and the hospitals that it would be important to give them a framework. Not only around how to do QI projects, but also how do you actually ask questions - and we've all heard of the smart aim - that have the potential for generating solutions that can actually really make a difference. And so, I was able to work with a great team of faculty as well as resident and fellow physicians to deliver that orientation over several iterations in the past few years. And then also just thinking about Texas Children's Hospital where I’m based clinically as a pediatric intensivist, thinking about their very strong QI fellows college that has been a great way to contribute as a core group coach to again help our physicians that are already choosing careers in academic medicine to be able to make quality improvement part of their academic portfolio with the right skills and foundations. And so, those are just some of the areas where I've had a chance to witness firsthand the strength, the quality, and the real interest around quality and safety at the organization. And that's really just for starters. There are a number of people doing great work across the continuum UME, GME, and CME to really bring learners and faculty together around common areas of interest in this discipline and field. 

Brandon: That's amazing! So with this conference, with your role in bringing educators and students and clinicians together, what do you think would be probably the most exciting change that you've been able to see as a result of this kind of work? Has there been anything recently like that?

Dr. Coleman: That's a great question. I think the successes often are small but measurable. So, I remember when I first started in this role a few years ago. CLEAR and that concept was unfamiliar to everyone. No one knew what CLEAR was, why it mattered, but I think back to the results of some of our recent ACGME CLEAR site visits at some of our local affiliates. And to hear the unsolicited purely anonymous responses from our resident and fellow physicians and faculty surrounding their experiences in quality and safety - be it do they feel that they are acquiring training that helps them to be able to make better choices for their patients? Do they get performance metrics that guide their professional development? Do they now receive greater feedback and feel better prepared and trained to participate in root cause analyses and other critical event reviews? Do our learners and trainees feel that they are better equipped to give quality and effective handoffs? Do they better understand their roles for supervision do they understand professionalism expectations and how to execute areas where our patients are really asking for them to be present and to be their advocate? Are they able to recognize the impact of wellness on health outcomes and how they can deliver care safely? All of those are small but collectively, what I think of, really wonderful wins that have been collaborative in nature but that have helped really to achieve our first foundational goal really making this a dialogue that was normative for us in our community. And so, I have great appreciation and gratitude for the privilege of having been able to be a part of that journey over the past few years here at Baylor. 

Brandon: That's awesome! And you know it doesn't have to be landmark sweeping changes. It's just like you said the small things that collectively come together can make a huge difference. And it's cool to hear these kind of stories and hear about what's going on to actually make a real difference.

Dr. Coleman: I just can't say enough about the great collaborations, which I think that's probably the real success story. Because at every affiliate every site within programs specifically, we can name and show it - that would be its podcast on its own as you said! So much great work that's being done that we can really showcase. And so, just thinking about where we have evolved from our culture thinking about some of those concepts that ability to have driven change collaboratively and together, I think is probably the most meaningful and sustainable impact of the work we've done to date.

Anoosha: I wanted to kind of maybe ask a little bit more about your involvement with the medical students. You talked about the conference that we have been able to work together for in the past couple of years. In your opinion, is the appropriate time to start learning about quality improvement and patient safety is that in medical school? And how does starting there help make you a more successful and efficient resident, fellow, faculty etc.

Dr. Coleman: That's a terrific question Anoosha. Thank you for sharing that, thanks for your kind words. It really is a team effort, and it really does take a village. Because one person's ideas and vision can't move forward and make a change if we don't all come together. And so, that for me is really one of the greatest joys of this work being able to help connect people and bring them together. I think with regard to your question - but when should this start - the earlier the better. Why do I say that? One, I and one of the things that again just thinking about how medical education has evolved even just from when I was in medical school to even now as faculty, I think that one overall medical education is realizing that at the point where we begin to integrate some of these principles in residency and fellowship, it's a little too late. It's hard to indoctrinate people into a way of thinking when they're already even under more stress than they may have been under in medical school, they're beginning training, they're on the wards. And it almost represents a missed opportunity if we wait until then. The ideal would be for every patient and for every intern reporting on their patient to come in the door and go through the systems or problems based analysis of what's going on with their patient and then at the end to also note not only well this is our plan, these are the x-rays, these are the labs, these are the studies, but also to think about what can we or what have we not done to help optimize this patient's chance of leaving the hospital or returning to clinic with a good or safe outcome. I think medical school is the right place to begin a lot of this work for many reasons. One because I think as many of us were coming into medical school we come in with an energy and altruism a vision that is pretty unbridled at least at the beginning. And I think the openness and the reciprocity to new concepts and ideas is there. Number two, we now have evidence that actually suggests through be it the AAMC core competencies in QI/PS and other such health systems science work that actually demonstrates that when core principles like this are introduced earlier in the continuum of medical education and training that it's more likely to be sustained throughout. And so, when it becomes a journey that one takes in terms of sequential and progressive competency acquisition as opposed to an add-on here you go quality and safety year one year and three, we come back to it but it's just something that's woven into the fabric. Much like we know that for every presentation there's an assessment and a plan, if we begin to help teach students even at that early phase and cultivate their interest at that early phase as this is just what we do for our patients, I think it has the opportunity to be a lot more meaningful such that by the time students are coming into residency and fellowship they already have a framework. They're better able to integrate into the medical team. They're better able to integrate into the health system because they're not learning a new language, but they already knew the language before coming in.

Anoosha: That is incredible perspective Dr. Coleman thank you so much for that. And just to expand a little bit more, so understanding that there are many possible ways for medical students to get this kind of education, you know ranging from IHI’s Basic Certificate and Quality improvement, Baylor itself has pre-clinical courses that have worked in some QI/PS principles, we have electives, and you're a part of building up many of those projects for you and me as well. This is maybe more of a vision board question, but what in your opinion is an ideal way for medical students to kind of attain this knowledge and have it become sort of a part of them?

Dr. Coleman: First of all, I have to say I love the term vision board. I like that vision board question. I probably need to get one as well. So in terms of vision, that's one of the things I'm actually very excited to have the chance to spend more time thinking about and working with others on in the in the next phase of my career. But a few things that kind of come to mind so first of all, I think many of the programs that you've already outlined are absolutely the right first second and third fourth steps. Why do i say? That you have courses you have interest groups and you have incredible student leaders such as yourselves who even just thinking of something like this mini-series, thinking of the quality of the work that you're doing already brings a level of interest, excitement, prestige, and respect for this as a discipline. I think an important second step or next step as part of that vision is mentorship. I think mentorship is very critical because it not only helps to spark interest but it also helps to really support individuals in their own professional journeys. And so, I think mentorship and having formal mentorships between students and trainees who are interested in QI and safety as a future career and have interest in Health System Science is very key. I think the third piece is really thinking about engaging patients and families. That has long been an area of real interest of mine, one because of the work that I do in the ICU. We're so connected with our patients and our families, one because it's pediatric medicine and two because the heaviness and the weight of what we're doing in a critical care environment really requires I think that not only are we working with families but recognizing that families and patients are the center of the team. At least that's the model that I like to use, and that we all support them. I think recognizing that and giving students and early trainees the opportunity to really prioritize those connections and recognizing the value that patients can bring to the care process is really critical. And so, as I continue to develop my vision board, I am really excited to hear from all of you. Because in many ways, there are things that I can see, but there are many things I cannot see. And so, that's where I think creating forums for openness and thought and dialogue as well as action is really critical to helping to move the work forward. Recognizing from not only what educational leaders and administrators have seen and believe but recognizing from all of you what are the gaps that you perceive when you're on the awards, when you are working pre-clinically, what do you feel is the gap? What do you feel that you as training physicians no matter where you're training no matter what field you're choosing what do you believe would help you to be the kind of position you want to be in the future?

Anoosha: Thank you for that Dr. Coleman. I think so far, we've really covered a wide breadth of what we were hoping to talk about in this episode, from your previous roles and how you got here to your roles in medical education and your passions for furthering the development at Baylor College of Medicine of this kind of work with trainees. And thank you so much again for everything you're doing for the college. Is there anything else that you'd like to share maybe some words of inspiration, or any other projects that you're very passionate about that you think medical students and you know even incoming pre-medical students to Baylor to residents and you know all of Resonance podcast audience that you think could be good for them to hear?

Dr. Coleman: Sure, so first of all I just want to say thank you thanks for the opportunity to be here today but thank you to the colleagues, partners, supporters, and champions who are doing this very very fine work in so many different ways. This is one organization where I've been where I really feel that there is a collective interest commitment and passion to quality safety Health System Science as a whole. There are so many areas of light, so many areas of excitement innovation that are ongoing. And so, I just want to compliment and thank those individuals that have been true partners with me in helping to advance the work. I could not be more excited to be in a community like this where there's so much fervor and excitement around this area. I think in terms of preparing individuals who not only want to pursue quality and safety as a career but recognize its basic importance, I think if I had to say one thing I would say take a moment in every interaction to realize the propensity for improving the outcome of the person for whom you're carrying through processes systems and individuals. And what do I mean by that? No matter the outcome good, bad, or ugly, or somewhere in between, I always believe there's something that we could do if not better at least differently. I think as physicians and trainees and students and members of the clinical and medical community and our bioscience and biomedical community and beyond, we are comfortable with inquiry. But I think we have to be even more comfortable with inquiry and self-reflection to think about even if this went swimmingly well and just perfectly, what could I have done differently or better or could our team have done differently or better for this patient. Because it doesn't always go perfectly or swimmingly because it's human life and thus unpredictable. I think being in a habit of so doing and realizing that is normative, then when the bad things happen not only do you have a potential action plan, not only can you be more proactive in terms of risk mitigation and management, but it also becomes okay and feel psychologically safe to have the dialogue and the conversation around what could we have done differently. Because that dialogue is something that happens all the time. I think as systems grow and teams evolve and individuals develop, I think that concept of open honest authentic discussion really with integrity and mutual respect, that is what helps teams to work well. The best teams and the best organizations with regard to quality and safety are consistent, and they have a culture where it's okay to recognize that we're not perfect because none of us ever will be. It's okay to recognize that sometimes the outcome is not what we want, but rather if the outcome is not what we want, how can we get closer to what we're all hoping to achieve with the next patient or the next experience. And so, I think instilling that through role modeling, leadership, mentorship, culture advancement, all of those areas together I think can really help to elevate our community of individuals who really are passionate about and committed to these really important ideals in medicine.

Anoosha: It truly is so inspiring to hear you speak of these sorts of visions. And I'm just so excited to continue in my own journey hearing here after hearing you talk about your own and all of that. So wonderful, well I don't think i have any more questions for now for this episode at least. There's plenty of things I would love to ask Dr. Coleman's advice about.

Dr. Coleman: Well this has been a real pleasure. I have really been grateful for the opportunities that all of you have given to me to really connect with all of you. Be it through being part of your courses, the conference, the councils, it's really been honestly a joy. I appreciate the opportunity to serve in so many different capacities, but I have to say that being able to work with all of you it is energizing, it's insightful, it's humbling, it just brings me a lot of joy. And so, I wish you could see the smile on my face as to how excited I am that this interview came together, but more importantly just to see the success of all of your work. I just, I'm available, I'm here to support your endeavors and just really thank you for letting me connect with all of you it's been a real pleasure.

Anoosha: Thank you, we're so lucky to have you Dr. Coleman.

Dr. Coleman: Thank you so much take good care bye-bye.   

iTunes | Spotify | Stitcher | Google Play | Length: 43 minutes | Published: Oct. 29, 2020

This is the fourth of a five-episode mini-series on Quality Improvement (QI) in Healthcare in collaboration with the Institute for Healthcare Improvement (IHI) student organization. In this episode, we interview two prior QI chiefs about their position and duties in the Baylor College of Medicine affiliate hospitals and graduate medical education for residents! Come listen to their experience, learn about what the day-to-day activities of a QI chief may look like and how the COVID-19 pandemic has impacted their roles.

Transcript

Erik Anderson: All right, and we are here. My name is Erik Anderson and this is the Residence podcast. We're doing a bit of a special mini series here on quality improvement specifically in the health care field. And we're working with the student org at Baylor College of Medicine, the Institute for Health Care Improvement. And I'm going to let our student representative Jinna take it away. So, Jinna, you want to introduce yourself and the faculty?

Jinna Chu: Yeah, hi. My name is Jinna and I'm a current MS3 at Baylor. So today we have two invited guests with us. First we have Dr. Cai. She's the current chief resident for quality improvement at Baylor. And we also have Dr. Nowalk, and he was a former chief resident for QI and currently a hospitalist at the VA at Baylor.

Dr. Nathan Nowalk: Good to be here. 

Dr. Cecilia Cai: Hi, everyone. I'm happy to be here as well.

Jinna Chu: So I guess we can just go ahead and start asking some questions. Our first question that we had for you all was how did you become interested in QI?

Dr. Cecilia Cai: I can start. So I actually became interested while I was a medical student at Baylor. Some of my friends were in the IHI chapter, and they introduced me to the concept of QI. And I thought that was really cool that we can improve the care that patients receive and their safety as well. Actually, as a medical student, I did a research elective with Dr. Naik at the VA. He's one of the QI experts at Baylor and I was really interested in it afterwards, and then continued that interest in residency and learned more about QI through our residency curriculum.

Jinna Chu: Ok, that's very cool. What about you, Dr. Nowalk?

Dr. Nathan Nowalk: Ok, so I actually came about a little differently. I didn't discover QI really until the second year of residency. My medical school didn't have as much of an emphasis on QI and patient safety. I think that's changed since I graduated as it has changed across many universities and medical schools.

Dr. Nathan Nowalk: So for me, I didn't find it really until that second year when we do our internal medicine QI curriculum. And in doing that, and having already done some research in some other areas, I felt like this was an area that I was very interested in. It spoke to me quite well. 

Erik Anderson: So I just have a quick question – just in your perspectives. What is, and for those of us who might not be completely in tune with this, what is quality improvement pertaining to health care?

Dr. Cecilia Cai: I can talk about that. So quality improvement is improving the existing operations and processes in the hospital to improve the quality of the care that patients receive and what we call the value of the care they receive. So not only that outcomes are good, but that it is the most cost efficient for the patient as well. And there's also a big emphasis on patient safety as well. So providing the best, safe care for the patients. So it's a little bit different than research because research usually has randomized control groups or something. In research you're trying to innovate something new and quality improvement is not always innovating new things – although sometimes you can create new processes. But it is a lot about improving existing processes.

Erik Anderson: Gotcha. But do you generally do it… I mean, you brought up the research sort of example… Do you try to do it kind of one variable at a time, or is it more just you isolate a few things that need to be changed at once and make the change and then sort of see how, I imagine, you have outcomes that you're measuring?

Dr. Cecilia Cai: Right. Yeah, I think you bring up a good point. And often people get confused between QI and research. So yes, you're right. Doing research, you kind of isolate different variables. You prioritize one thing at a time. For QI, you can actually do multiple things at once depending on what you think is the most impactful. And it's an ongoing improvement. We do what we call different cycles of improvement. So it is just kind of ongoing, and you test the change and you continuously see the results at the same time. So research has a more defined start and ending point, but QI is kind of a continuous process of change. I think Dr. Nowalk can also speak about this, too.

Dr. Nathan Nowalk: Yeah. So I think your description was really, really well said. I'll also add that it can occur outside of the hospital. So really in any health care or any health care setting, really. It's about recognizing the quality gap that we see between what we intend to do or maybe what the evidence tells us based on this research you're referring to in the clinical research, basic science research – all these other areas. But yet we're not seeing done in our patients care, whether that's the patient in front of us in that small area, that micro level or on a macro scale. And it does have lots of overlap into other areas of research. I think of health services research as a big one, HSR, that you see quite a bit of people who have their foot in QI and also in health services research. I think that when it comes to QI, you're right, it is very much a continual process. It doesn't have really an end point. However, you can define some endpoints and still publish and still contribute to the literature. There's obviously gigantic areas of literature within quality improvement and it is considered an academic arena by all means. Every major conference has got some form of QI submission opportunity. And every journal, usually even very high impact journals, has some form for QI. Some are completely devoted to QI. So still a very academic area.

Erik Anderson: I see. Thank you.

Jinna Chu: So, Dr. Cai, you're currently the QI chief. And Dr. Nowalk, you are a former QI chief. Why did you all apply for it and what was the process?

Dr. Cecilia Cai: I can start first. So to become QI chief. This is a position offered through the national VA system, and there's some clinical sites across the country that have this position. So not all residences have this position. It has to be affiliated with the VA. It's paid by the national VA office. So for us at Baylor, we can apply to become QI chief within internal medicine as a second year resident. It's usually during the spring of second year – the application process. I applied because I thought it was a great opportunity to learn more about advanced QI techniques. And as Dr. Nowalk mentioned earlier, there are more advanced QI methods that are more research related. And so I wanted to learn more about that and how to apply it to my clinical practice in the future. And also wanted to have an experience to be a leader in the hospital and within the residency. And basically, there's a process of application. They ask for your CV, references, the personal statement of why you want to be a QI chief, and then you go on several interviews.

Erik Anderson: So this is QI pertaining to the VA specifically, or is it more generally like where you are working?

Dr. Cecilia Cai: Yeah, that's correct. So our position specifically, the chief resident quality and patient safety is a position offered through the National VA Center for Patient Safety. It's actually a national program, and we have a set national curriculum that actually goes with it. So there's an educational component as well as like a practical component where we do our QI project.

Erik Anderson: Oh, wow. 

Dr. Nathan Nowalk: Yeah. So I think just from discussing it at different interviews for fellowship, which is really where I found different versions of the chief medical resident. There is more and more push within chief medical residents to have a QI designation or some recognition of quality improvement within their curriculum. And often they will have a chief medical resident take on that title of, you know, there's an ambulatory chief and there's also a QI chief and there's this hospital's chief. So although it's not VA funded, as Cecilia and I were part of a program that's definitely the most long-lasting. Actually, I think this is the eighth year technically at Baylor. This is the eighth year that we've had a QI chief that's funded by the VA. The program itself is a little bit older than that, although our Houston VA is one of the largest and one of the earliest ones to have this position. There's other versions of this at other residencies that aren't VA funded by the VA's Office of Academic Affiliations. This was originally started by the V.A. National Center for Patient Safety and Dartmouth Institute – the whole national curriculum Cecilia was mentioning. And it has expanded into other specialties. So you could do QI chief within your general surgery residency now and your psychiatry, your radiology, anaesthesia – they all could do QI chief years, or as part of their training, and be funded through the VA. And I think now there's 66 internal medicine QI chiefs as of last year across about 60 centers. So it's definitely a national program, and it's recognized by many residencies because of it.

Dr. Cecilia Cai: Yeah, I think they're actually expanding it to more than one hundred residents next year. 

Erik Anderson: Oh, wow.

Jinna Chu: Oh, wow, that's awesome. So what role does the QI chief have for graduate medical education or residency?

Dr. Cecilia Cai: I think they play a major role within the GME community. So every residency is required to have a QI curriculum for the residents. So no matter what residency it is, whether it's internal medicine, surgery, radiology, the Accreditation Council for GME, the ACGME, basically requires all residents to complete QI training and patient safety training doing their residency. And so the QI chief at Baylor, in our internal medicine program, we teach the residents about QI and patient safety. We are in charge of their curriculum. We're also mentoring them for their own QI projects. And we kind of help them along the way for their projects. And we also, at the same time, advocate for the residents at the different hospital levels or different things that come up.

Jinna Chu: Oh, that's really cool. Do y’all support residents that are doing QI projects at the VA or it’s at any of the hospitals here at Baylor?

Dr. Cecilia Cai: At any of the hospitals.

Erik Anderson: Ok, I was wondering because you say a QI year but this year you just mean that is the amount of time that you're the QI chief and doing the curriculum, but it's integrated with whatever year of residency you are in. It's not an extra year, correct?

Dr. Cecilia Cai: Oh, that's correct. Yes. So our QI chief year is an extra year after residency, but the QI curriculum itself is for the residents throughout their residency, specifically during their second year. They have their QI curriculum.

Erik Anderson: Oh, the QI chief is an extra year after your residency finishes. Gotcha.

Jinna Chu: And is this QI curriculum standardized across the nation?

Dr. Cecilia Cai: No, it's not. No, Dr. Nowalk, you may know more about that.

Dr. Nathan Nowalk: Sure. Yeah. So I think if you're talking about the VA affiliated QI position, by OAA, the VA Office of Academic Affiliation, then that absolutely does have some standardization to it. As Cecilia was mentioning earlier, there is a curriculum that's nationalized that we are following. We do monthly meetings, actually twice monthly, where we're actually learning QI ourselves and we're sharing these online lectures with other QI chiefs at other VAs. However, the idea of a QI chief is really not standardized. And in fact, even the VA version, they like to keep it as open as possible, really to not box you in and allow you that freedom to take what you want with the position. And as I said earlier, you'll have QI chiefs in anesthesia, mental health, surgery, and other areas. So they really don't want you to be too closed in as far as, like you said, standardization. But we'll all receive like a certain amount of training that's expected with it. 

Jinna Chu: Ok, very cool.

Dr. Cecilia Cai: And Jinna, I don't know if that answer your question, but the residents’ QI curriculum is also not standardized across the nation. There are some basic requirements that the residency has to meet. So a lot of the QI curriculum and residency addresses those objectives. But it is depending on the residency programs themselves. And they also actually use a lot of IHI materials that are online to plan for those curricula.

Jinna Chu: Hmm. Ok.

Dr. Nathan Nowalk: Yeah, I agree. IHI is probably the most widely used, I think, because it's such a smaller form of QI modality that I think can be easily disseminated and practiced to within your residency. Some of the other modalities are long term courses and things like that. That would require a lot of commitment. But I think the QI curriculum could be easily developed off the Institute for Healthcare Improvement Model for Improvement. So, yeah, to second what Cecilia said, I think that this QI curricula across the different residences are open and the ACGME wants to keep it that way also. So that that's the fun part. Like if we made it so that every resident had to see a certain number of patients of a certain type. “You must see so many pneumoniae to graduate”, then you may not get that flexibility that comes with working in different health care systems. And the same is true of QI. They want to allow us to take advantage of what makes our resident unique, so the curricula are all open as well.

Jinna Chu: Ok, that's awesome. So have y’all seen any changes in your role with the covid-19 pandemic that's going on currently?

Dr. Cecilia Cai: There's definitely been a lot of changes for me as a current QI chief. I still have some clinical duty as an attending at the VA, so I round with the residents. But the rest of my time I'm working more remotely at home now just because they try to not have nonclinical people at the hospital. So when I'm at home, I’m working from home. I'm attending different hospital meetings that are all online now on. On zoom. Lots of zoom meetings. I do a lot of emails with leaders about anything that comes up.  Any issues, they want me to help with. I coordinate with the residency about the different resident projects that were delayed or they need to be presented. So I coordinate with the residency for the different resident project as well.

Erik Anderson: Actually, so that kind of answers the question that I had of what the year as QI chief kind of looks like in terms of how much clinical work are you doing, alongside I guess, your responsibilities as the chief. What's your time breakdown between nonclinical and clinical responsibilities?

Dr. Cecilia Cai: I think that's a great question. So we actually wear a lot of hats. So clinical is only a small part of what we do. As for the national VA CRQS requirement for us, we just do eight weeks of inpatient clinical work. So during that period I round as a normal attending at the hospital with the resident team. I also can moonlight, meaning take on extra clinical shifts at other hospitals. So I do some moonlighting at Ben Taub as well. So that's extra clinical work. But other than that, I'm also an educator. So we do the educational curriculum, as we talked about, for the residents. We do different educational conferences for the residents as well. I'm also helping with administrative stuff in the hospital, so I attend different hospital administrative leadership meetings for the different hospital committees, for patient safety, or for what we call inpatient discharge committee. There's many hospital committee meetings that I go to. At the same time, I'm also doing my own QI projects, and I'm also a learner as well. As Nathan talked about, we have the national VA QI curriculum that we attend. We have monthly meetings for those educational sessions. And at the same time, trying to apply what I learned to my own QI projects, because that's more like research/QI projects.

Dr. Nathan Nowalk: Yeah, so I agree with Cecilia. Just to summarize, you could be an educator of both medical students, allied health students and residents. You are a researcher, conducting QI projects and contributing to literature, if you will. And then you're a learner yourself, going through a curricula and then encouraged to continue learning even outside of the curricula that the VA gives you. And then you're a clinician, even still in whatever. You know if you’re internal medicine, in our case, it would be quite a few weeks of wards. I think my year we did eight. I believe Cecilia did eight as well. So that's a fun experience, obviously. And then you're also an administrator contributing to committees and the day to day that goes on at the VA.

Jinna Chu: And can you tell us about some of the QI projects or any innovations that you've had to implement because of COVID-19?

Dr. Cecilia Cai: I can talk first. Though, I help with several different QI initiatives during the COVID-19 pandemic that’s happened. One of the major things I worked on was kind of improving the discharge processes for COVID patients, or patients who are still having their COVID test pending at discharge. So I work with different hospitals, the primary care doctors, nurses, case managers, social workers, I.T. people. And we all kind of created a comprehensive follow up plan for these patients at the VA when they're ready to get discharged. It's been working well so far, so I was happy to help contribute with that. I know Nathan has been on the COVID task force, so he is definitely more in tune with all of the COVID projects at the VA, so I’ll let him talk.

Dr. Nathan Nowalk: Yes, I wouldn't say I was more in tune. I thought your work on the discharge side was really, really impeccable. It was a huge part of a very gigantic question mark for our hospitals group in an outpatient setting. So she was huge in working with our IT specialists, and working on getting appropriate discharge criteria fulfilled, and making sure that these COVID patients were leaving safely, and that their tests and so on were followed up. From my perspective, I was working, as you mentioned, on the COVID task force, which was a multidisciplinary task force. I was the hospital's representative for it at the Houston VA. The other representatives were of the nursing, the pharmacy, et cetera, and then some other ICU leadership, some other physicians –  many other physicians also on there as well. But I was representing hospitalists and as mentioned earlier, that experience as an administrator - leading other committees or participating in other committees - really does benefit you when you enter as a faculty in terms of continuing such administrative work. And that's kind of what I was doing with the COVID task force. I personally am interested in pulmonary critical care. I’ll be going into fellowship for pulmonary critical care at the University of Chicago this summer. And so for me it was a really nice overlap between my clinical interest and also my QI interests. So the task force was fantastic. The two biggest projects I was directly involved in, although I kind of have my hands in a few things, the two biggest were by far redefining how we safely do rapid responses and how we safely do a code blues with all the new PPE and everything, and making sure that our staff of every type - whether it be trainee on the ACGME side or our nursing, et cetera, anesthesia, everybody - is prepared for protecting ourselves and that we can still continue to deliver very good care in these rapid responses and code blues despite the concern for covid. So that was really my probably biggest project of the COVID experience. So it's really part of the covid preparedness, if you will. 

Erik Anderson: That's all very interesting, and it was making me think. I know we talked about endpoints, maybe, it might be a semantic thing, but I'm just wondering about, like, what are the criteria that you're choosing to determine? Like, if your plans are successful? For example, Dr. Cai with your discharge summaries for figuring out, like, we're going to implement this so that we're discharging everybody safely. Do you have to, I imagine, you have to come up with something to measure that by – or maybe I'm getting caught up on the research again.

Dr. Cecilia Cai: No, no, that's great. Actually, in QI we use something called measurers

Erik Anderson: Okay, so it was a semantic thing.

Dr. Cecilia Cai: Yeah, yeah we do. We do use measures, and there's different types of measures that you use in your QI projects. So, for example, what we use process measures for is to measure whether the process is actually working. Like are people actually doing the things we asked them to do? What is a percentage of the time that patients are people are actually doing this process correctly? So for example, for our discharge improvement, we measure that by whether -  people are one part of a process - is that when providers are discharging a patient, they have to call the hospital physician assistant to make sure that the physician assistant knows his patient is getting discharge, so she can record it on a follow up master document. So one way we track that is to see when these patients are discharged, are they really calling this person? Is that person really tracking everyone who has COVID who was discharged? And is that person actually documenting these patients’ information and calling on the patient afterwards for a follow up? So that's one process measure that we have. The other type of measures are called outcome measures. So whether… so, that's kind of the final result of what you say of QI projects, whether your QI project has actually changed the outcome that you wanted to change. And for us, sometimes our QI project, it is a little bit hard to define a good outcome measure. And for us, we were thinking we could try to see if the discharge improvement process can decrease readmission or decrease ER visits for these patients. And so that's something we're looking at - a long term outcome improvement.

Dr. Nathan Nowalk: Yeah, So just to piggyback that, when you talk about like measures and points and outcomes, I think we start to mix up the idea of what is research and what is QI.  just to kind of clarify one last time. It still very much follows the beginning, middle, and end within a  QI project. I think the difference between what we're doing in the quality improvement world versus what is being done at the bench or what is being done in clinical research is that whatever we're implementing, or hoping to achieve, is not going to stop right there. It's a continuum. It's going to stay alive in this dynamic system, and you're going to continue to be able to hone it. And our stop, middle, and end points, and all these kinds of things are really just to define a single cycle of change. And so you can still comment on the effect of that cycle of change. And these measures, as Cecilia mentioned, are actually very, very important to define very clearly. Specifically up front, we use something called SMART Aim statement to define these within the model for improvement for IHI. So it does have to be quite specific. And if you've ever heard of things like catheter-associated UTI rates or our rates of this type of infection - things like that - those rates are usually different measures that Medicare or Medicaid are following that are very much QI measures that we try to impact. So there's definitely still an end point to this.

Erik Anderson: Right, right. And can you speak to some of the end points in the projects you discuss or sorry, some of the measures, the outcome measures, I should say?

Dr. Nathan Nowalk: Yeah, some of the measures we would be looking at because our project was really focused on taking something we're already doing that is already very well founded within the literature, in terms of its effect and what it does for the patient - rapid responses, in terms of slowing the clinical deterioration for patients; and then obviously ACLS Code Blue Rescue. So for us, there really wasn't as much of a clinical outcome or even a measure up front other than the adoption of this. We wanted to make sure that this was being adopted. And so for my project, it was much more focusing on an area of quality improvement, which there's multiple areas. But the one I'm very engaged in is implementation sciences. So that's very much focused on how do we get something adopted? How does a group of people accept that? Because there's a large adoption curve in terms of how people take on a new initiative. And so for me, it was the implementation sciences aspect. And so our measures were really more focused on the adoption rate, the performance rate in terms of people having showing compliance or adherence to these new protocols, and then eliminating barriers that were keeping them from achieving 100 percent of following that standard operating procedure. So it wasn't as strong of measures as I would say. And Cecilia’s project, which was a more traditional QI project, this was much more on implementation side where we were taking something that we know we should be doing, but just editing it so that it would stay safe in the time of covid.

Erik Anderson: I see.  Very important, because if the data isn't being implemented, if it's not good data in the first place, and - or you know what I mean, like the if the endpoints aren't good because people aren’t implementing them - how can you interpret anything?

Dr. Nathan Nowalk: Yeah, And this is how I love QI. And this goes back to implementation science, because I think you'll you'll read something in the New England Journal and you'll say, wow, you know, that is a great drug. Why don't we use that drug here? How do we do that? And then you find out that the reason that that study was so successful is because it was so controlled, and it was a very specific population, and it may not actually apply to the patient in front of you, though your patient might actually benefit from it. But we haven't really implemented it, even though it may still be part of the guidelines. And so that's where we start getting into evidence-based therapies, inequality gap. And that's really where a lot of QI can occur, is trying to bring these evidence-based, what we call research-founded approaches, and data to the patient. And so a lot of that is implementation science. And I think that that's a big part of what we're doing in QI is closing the quality gap.

Dr. Cecilia Cai: Yeah, I just want to echo what Nathan said, because I think that's a great point, that we have so much great research already, evidence-based guidelines, but there's still a gap between what we know is ideal evidence-based care and what's actually implemented in real life. As you guys know there are so many challenges in the real hospital setting with operational difficulties and many different things. And that's where the QI implementation science, when it comes in to try to address that gap with what we know that patients should receive and what they actually receive. So to bring that up to standards.

Erik Anderson: It's sort of, I don't know, it’s more, I guess, an existential question. I guess, as a doctor, because guidelines are so important like you were saying. And I think probably we do live in a time where these are being implemented more, and certainly being studied, whether the implementation is happening more than ever before. Is there any talk in QI about sort of I guess you could call it like the… I don't want to call it downside, but there is, I think, something that people lose when they work too much from algorithms and they don't think as much about like… ok,  every patient is their own patient. So you have to sort of juggle the algorithm or the guidelines, if you will, is what I mean, versus this is a unique person and might not fit as precisely into these discrete guidelines.

Dr. Nathan Nowalk: So I'll I'll jump on that real quick. So really, the Institute of Medicine, which is who first started making QI really something we need to pay attention to in America, the IOM, they came out with six aims for improvement as part of a quality improvement in trying to define what would be quality care. And so they defined it as STEEP which stands for safe, timely, effective or efficient and equitable. And then the last is P, which is patient centered. So you definitely don't want to just come out with standardized approaches that work for large groups of people but don't impact the patient in front of you. So we do want to leave as much room for clinicians to continue practicing a patient centered care, but we just want the system to help them achieve those goals.

Erik Anderson: Gotcha.

Dr. Cecilia Cai: And I agree that the patient centered approach will always be there. But the goal of some kind of standardization of procedures is to… For example, a checklist that has been shown to really improve a lot of adverse outcomes for surgery and for many other procedures. And that's the way that we all know that as humans, we all are bound to make mistakes. And so really the standardization of procedures is to kind of help prevent those preventable human errors. And so it's not to make us like robots, but to help us do the work. 

Erik Anderson: Right, right.

Dr. Nathan Nowalk: Many of these evidence-based modalities, you know, they apply for a large percentage of the population. That's why they're guidelines. But we really want the clinician to recognize the guidelines and then say, yeah, but this patient's different. I'm acknowledging this landmark trial study, guideline, whatever; but this patient's different. There are going to be patients who just don't fit into the study.

Erik Anderson: Yeah, that was my big question. So I don't know if you want to do some of the extra ones or if whatever.

Jinna Chu: Well, those are definitely some very cool projects. And it's something that I was actually wondering is how did you identify those issues, or did you think of them before they even occurred?

Dr. Cecilia Cai: That's a great question, Jinna. So I think one thing that's really cool about being in QI is that if you see a problem, you can address it or you can initiate the efforts to start addressing those problems. So for me, when I work as an attending on the wards in March, that was when we first started seeing COVID cases in Houston. And I kind of noticed that for my patient who had COVID, who was getting discharge, that I wasn't sure when he was getting proper follow ups. And I just wanted to make sure that he's staying safe at home after he leaves the hospital. And that's when I brought up the issue with some of the other hospitals. And they had similar concerns. And that was kind of when we altogether decided, “oh, we should start a team to address this problem”, to make sure that these patients are all get proper follow ups. 

Dr. Nathan Nowalk: Absolutely. 

Dr. Cecilia Cai: So definitely kind of on the job learning and identify issues. And it feels really good to be able to do something about it, versus sometimes a lot of times with research, it just takes a lot of time to plan to implement. But QI is really about implementing fast, rapid changes and to see those taking effect.

Dr. Nathan Nowalk: Yeah, I really love Cecilia’s answer because many of our projects do originate with the original operator or leader of the project, and I think that - not to get too existential here - but not to go into other areas. But I do think there is overlap. And I might add, my QI chief from last year, June Pickett, she had a nice way of putting it where you really do start to feel that QI is giving you the toolkit of skills and modalities to impact the world around you and feel like less of a product of that world. And so you kind of have a heightened sense of agency. And with that, you do feel that you can make the change you wish or expect of your patient. If you feel like, why aren't we doing this? This looks as we should be doing this or that. That's because someone probably hasn't come and close that quality gap. And you can do that now because you have been trained and you know how to do it in your environment, the people you need to know, and to lead that project. So I think it even goes into burnout. When we talk about some of the biggest reasons physicians burn out, they often say that they just feel like they're a product of their system and they're not really able to mend it or fix things or eliminate redundancy and adjust their system around them. And I think quality improvement really does give you that toolkit you need to do so. So for me, it's like my own personal antidote to burnout, because I do feel like I can make change happen on a regular basis.

Erik Anderson: Well, that's interesting because that was actually one of the reasons I asked my question, because, I mean, you know, I haven't had nearly as much clinical experience as I think any of you guys on the call. But in my limited amount, it does make you feel like, “OK, so I just need to memorize these guidelines and then, you know, do this process.” But you're saying that maybe that's the thing, like you were saying, to keep in mind is that you can change something if you feel like it's needs to be changed.

Dr. Nathan Nowalk: Yeah. The pendulum could shift so far that we become very bound to, you know, these things that maybe were originally designed with a good intent, like she's mentioned checklists to these types of things. But if they stop working, meaning those measures that we originally used to describe them, and show their effect have become ineffectual. We do actually de-implement in those cases. We start pulling back and readdress the change because it is a very dynamic system. So you're not bound to anything. And the idea of a QI researcher or leader is really not to put everybody in a box and make them follow certain measures and complete certain checkboxes. These kinds of things as an administrator sometimes gets blamed for it. It's not that bureaucratic, I guess, is what I'm trying to say. We actually do encourage the creativity and we want to make the system as good as possible for the patients and the providers. And so you may see a study come across that says how to improve wellness in your residency. Well, that's great. This worked at Ohio State University. Now, how do we implement it here? Well, that's quality improvement, right? That's taking somebody else's research and wellness. And they're now learning how to implement it in your system effectively because their environment was probably different. So that's QI affecting medical education, QI affecting wellness. It can really go outside of the clinical arena as well.

Erik Anderson: Are there many projects - I guess, going back on the COVID project topic - that are targeting sort of quality improvement with telemedicine? Seeing how, I mean, this has become probably a bigger aspect of clinical medicine and maybe had been before.

Dr. Cecilia Cai: Yeah, you hit the nail on the head. There are many different actually telemedicine QI projects going on right now. And actually our VA received a grant recently to improve the telemedicine services at our VA. I think it's through Dr Naik and one of the endocrinologist who applied for the grant and received it already. But there's also talks about improving the telemedicine visits for cancer patients in the heme-onc department. And nationally at the VA. They're trying to improve their telemedicine services, increase their capacity, just because we're relying on that a lot more heavily now. Definitely, yes.

Dr. Nathan Nowalk: I think it's a gigantic area of future health services research. There was already a gigantic trend towards that. Like if you had said that COVID had happened two decades ago. Think of how different our world would be. We would be able to connect on Facebook and do telemedicine at the same level we are able to. So we were in some ways very empowered already by our current tools. But there is going to be a huge paradigm shift going forward towards more telemedicine. And the important thing is that we have health care or health services researchers are already looking at making sure this is effectual, that it is a good change, and that outcomes are still appropriate. We're not like having any quality gaps. And then with that, you start building and more and more quality improvement in terms of how do we continue honing the system and making it more equitable and effective.

Erik Anderson: Wow. And very interesting.

Jinna Chu: Yeah. I love how y’all make QI just sound so empowering and that's honestly why I also really am interested in QI. Do y’all have any tips for medical students that are transitioning into residency where they can maybe try to focus on QI?

Dr. Cecilia Cai: For sure. I think it is very exciting field. There is more focus on QI positions and QI research, I would say over the last decade. Definitely hospitals are paying more attention to QI now as well as residency. As we said, it is a residency requirement. So for any medical students who are transitioning to residency, I would say may first be a good intern, where your clinical skills are at the same time, just keep your eyes open for any type of system issues, patient safety issues that you that you see that keeps reoccuring. And just take note of that. And speak to your chief resident, speak to your program directors and your mentors, and see if there's any way for you to get involved at the hospital level to make a change or to make a QI project so that you can improve some of the deficiencies or problems that you see. And people are very well and open to doing these QI projects. Especially the hospital leaders love it if you try to implement a process that will improve the hospital care. So definitely just keep your eyes open and talk to mentors, try to find QI mentors, clinicians who do QI or have a QI background, and they can definitely direct you to what you can do to help out and to learn more about.

Dr. Nathan Nowalk: Yeah, I would completely agree with what Cecilia said, especially about finding the mentors, which can be a hard part. But I think reaching out actually to the QI Chiefs is a good first step, knowing that this position now exists after hearing this podcast. So I think that whoever the Chiefs are at your residency, I think, can connect you with people who are inclined or engaged in QI. I will also say that we often have students who come to me and say, “you know, I already have an MBA, already have an MPH”; and there's a huge overlap. And these other masters and in fields of public health and business and management, and they already have a lot of these modalities. They were actually exposed to some of this quality improvement training earlier. And it's really just about then connecting you to the project, if you will, the opportunity. And maybe you haven't had enough clinical experience or really exposed to lecture halls. You don't have the clinical experience to say, why aren't we using this drug and heart failure? That's a pretty advanced question to probably ask that, you know, we'd expect more of our residents. So I think what you could then start looking at it, again, talking to people like QI chiefs in different departments that are interested in QI. Like there are a number of different departments at every university medical school. But in addition to that, you could first decide if you want to be inpatient or outpatient, if you want your surgery or medicine. Like some of these big, gigantic questions every medical student faces, and then start just kind of narrowing it down into an area you want to do your work in. And maybe you originally wanted do clinical research in that area where now you can start to look at it as “are there any quality issues that you guys are trying to solve within your department that you think the assistance of a medical student could help or early intern resident could help in terms of fixing?” That's really how QI can be looked at as like fixers. And so I think that that's another area to find these projects. Many times they're assigned to us, like we mentioned earlier, how a lot of it initiates within us and our own personal frustrations. But often you get assigned a project and you at first maybe don't feel as passionate about it. But over time, you start to realize there was incredible need here and you're really glad that you had opportunities to fix it.

Jinna Chu: Well, thank y’all. Thanks for taking the time to do this interview. I really appreciate it. 

Erik Anderson: Yeah, thank you. 

Jinna Chu: There are some really great thought out answers, so thank yous.

Dr. Cecilia Cai: Awesome. This was fun. Alright, thanks.

Dr. Nathan Nowalk: Yeah. Thanks again, guys.

iTunes | Spotify | Stitcher | Google Play | Length: 32 minutes | Published: Oct. 21, 2020

This is the third of a five-episode mini-series on Quality Improvement (QI) in Healthcare in collaboration with the Institute for Healthcare Improvement (IHI) student organization. In this episode, we talk with pediatric anesthesiologist Dr. Lauren Lobaugh, discuss how she became interested in the field of patient safety and how anesthesiologists have been at the forefront of safe medication administration. We also discuss the scope of medication errors in modern medicine and how students, clinicians and patients can prevent these errors.

Transcript

Music

Erik: And we're here this is the Baylor College of Medicine Resonance Podcast, I am your host Erik Anderson, and I'm sitting here with somebody, do you want to introduce yourself?

Brice: Yeah my name is Brice Thomas, a third year medical student, happy to be here.

Erik: And I should say virtually sitting here due to COVID.

Brice: Yes yeah that's what we do these days.

Erik: Yeah, so this is part of our IHI mini-series, which at this point I believe you've probably heard a few episodes and had a little bit of introduction. So Brice is going to just tell us a little bit more about the episode before we just jump right into it.

Brice: Sounds good, so this interview is about medication error. This is a topic that's not really discussed until something goes wrong unfortunately. So from errors in prescribing and dosing to errors in actual administration, medication errors are more common than you'd think. We have Dr. Lauren Lobaugh, a pediatric anesthesiologist, myself, and Brandon Garcia talk about why these errors occur and what steps we can take to reduce them.

Erik: Yeah no it's a great talk too, I've…you know we've already shot it already so I don't know if that mystique is gone now. But it's, yeah, I'm excited.

Brice: Yeah, so yeah Dr. Lauren Lobaugh, she's a board-certified pediatric anesthesiologist and an assistant professor of anesthesiology at BCM and Texas Children's Hospital. She completed medical school at UT Houston, residency in anesthesiology at Georgetown, and pediatric anesthesiology fellowship at Children’s Hospital of Philadelphia. She first got involved in quality and safety during her residency as part of wake up safe, an initiative sponsored by the society for pediatric anesthesia that focuses on improving outcomes and quality improvement education. She completed a faculty fellowship in Quality and Safety at TCH in 2016 and earned a master's in healthcare quality and patient safety at the Johns Hopkins School of Public Health in 2019. She currently works with the Institute for Safe Medication Practices on an FDA-sponsored safety assessment tool. She also has a busy personal life with two sons at home. In addition to her clinical duties she's involved in the BCM Chapter 4 IHI, including leading courses like Skills and Advanced Topics in Patient Safety and QI.

Erik: That's great, okay well so without further ado, here's the interview.

Dr. Lobaugh: Anesthesia definitely draws, I think, the type A I'll say control freaks… some it's a range of that, but yes.

Brice: People who love the container store, maybe? 

Dr. Lobaugh: Yeah and for those of you who have yet to come. When you come on to TCH to rotate over and see us, the pediatric anesthesiologists it's even a little bit more intense. Especially when you're dealing with the neonates the small babies, my OCD factor goes through the roof when i have a small baby compared to when I have a 15 year old, per se. 

Brice: Yeah, I love these, like, standard standardization solutions you're talking about, because it seems like common sense to me. You know, like, they may not be easy to implement necessarily, but they're pretty simple solutions that I bet would have pretty large effects and really help patient care. 

Dr. Lobaugh: Yeah, I think they're…it's somewhat controversial. But there is a talk or a push to standardize a lot of things in medicine. If you're talking about like the ER, how we treat people that come in with sepsis, you know, they fit this algorithm. If they meet x, y, and z, they go down this pathway and I think it's nice to have those checks and balances. It's not taking away the ability of the physician to make clinical decisions, but it's ensuring that there are safety nets to catch those things. Because sometimes you don't go around down the right path. You're starting to look for zebras when it really is just a horse. I don't know if I said that correctly, but…

Brandon: No, you did. Sometimes people would say well what if it's a donkey?

Brice: Right 

Brandon: But no that's the phrase. 

Brice: A giraffe. 

Brandon: Yeah

Brice: Do you think other specialties could learn lessons from anesthesia in the way that they do things?

Dr. Lobaugh: Umm yes, but I mean again I think anesthesia is so unique. I think that each specialty has to figure out what works for them. Yeah, you know, like the example in the ER. The ER has found tremendous ways to catch those, you know, very severe, acute needs versus something, you know, when you're triaging patients… How do you know who needs attention right now? Versus someone who really can wait several hours if you're swamped. And they've learned those lessons through experience and I think that kind of plays into the culture. I think it's important when you're looking at, you know, these problems, are you assessing performance? Do you have the data? Do you have a way to report problems? Does your department want to know what's wrong? So if your department doesn't really want to know what the problems are that's really hard to fix it, right? So you should have systems for reporting these and be able to evaluate them in a unbiased manner.  

Brice: Right and if you feel like you're going to be punished, then no one's going to report. 

Dr. Lobaugh: Correct. I mean the problem with I think… So you have quality improvement where you're improving the process, but in general this is safety events and reporting errors, right? And I think the problem with reporting errors is people either don't see that it's a value. Why am I going to take the time to fill out this very long complicated report if nothing ever happens about it? Or they don't want to be stigmatized and I think that it's important to try to diminish that kind of culture of shame and blame, which I think there's been a lot of attention to it. But it still persists. 

Brice: Yeah, absolutely. I'm sure it depends on the institution that you're at. 

Dr. Lobaugh: Absolutely 

Brice: Hopefully you're at a good one.  

Dr. Lobaugh: So when you guys start looking at programs, I think programs that, you know… If someone tells you it's malignant, ask why! 

Brice: There’s something there. 

Dr. Lobaugh: Figure out, you know, what kind of environment… I think at his stage where you guys are at you should have a program that holds you accountable and responsible for someone's life, because that's what you guys are going to be handed. But you also want one that is fair and can look at a problem or error and figure out is it negligence? Do you need to have some kind of remediation? Or is it… If you guys google and I don't know if you guys have had this in any of your QI safety things… like Annie's story, which is about…

Brice: I think I’ve heard that yeah..

Dr. Lobaugh: A nurse in Georgetown that kept checking a patient's blood sugar and it was telling her error, too high. So she kept treating it, because that's what the glucometer was telling her. And the patient ended up critical, having an RT or rapid response and sent to the ICU. And when they checked it in the ICU, it was critically low, not critically high. But she… and she was put on leave and punished and when they actually went back and investigated it, they looked at the human factors of it. And it was the machine that failed her not that she failed the patient. 

Brice: Right 

Dr. Lobaugh: So I think it's important that you find a culture that promotes that. 

Brice: Yeah 

Brandon: So that's actually something that I was thinking of when you're talking about reporting. And things like that… What generally is the course of action when someone, like, discovers a medical error? Like what… I guess maybe you could talk about, like, what generally happens? And then maybe if you could explain what you think should happen?

Dr. Lobaugh: So I think it depends on the severity. So in anesthesia, the first question I would ask is does
it cause harm. And what level of harm. There are… if you look at a lot of the literature, there are levels of harm. Is it that the error just caused psychological distress? Did you have to give additional treatment but not sustained, temporary harm? So we call temporary harm for let's say an event… cardiac arrest. If you're doing chest compressions, that's the potential for temporary harm, right? Does it cause permanent harm? Did you cause a paresthesia that's persistent? And then there's death. And depending on where you are on that spectrum I think depends on your approach. One of the areas is disclosure. To tell the family, do not tell the family? So I'm all for disclosure…

Brice: It’s usually the best thing to do 

Dr. Lobaugh: I think it's very important. Honesty is the best policy. You may not get the answer you want. So I made a medication error when I was a fellow. I did math in my head, which you should not do in pediatrics with a baby. You should always verify and we just… The drug I gave was Toradol, but I gave double the dose. And so the patient was fine. We verified with risk management. I reached out to the pharmacists and talked about the doses. We kept the patient overnight. We checked extra labs. The worst part of it and the most… The baby was fine. The most unsatisfying part was the disclosure. The parents were livid. They were… they did not accept it. They asked to speak to our division chief. They wanted the hospital patient safety officer. The baby was fine and went home and didn't have any sequelae, which I'm very grateful for that. They continued to call the hospital for six months saying what are we going to do about it? And that's a horrible feeling, right? And I think that that has persisted in my mind as a memory that disclosure is important, but it's not really going to be gratifying. You're not going to feel good after you do it. But it doesn't mean that it's not the right thing to do. 

Brice: Right, that's amazing. Yeah, you did the right thing but…

Dr. Lobaugh: And I'm grateful that I didn't cause harm, because the psychological effects on me as a young provider, as a trainee if it had caused harm would probably have been much more significant. But thankfully, the baby was okay. But the disclosure wasn't… They were unwilling to accept that. 

Brandon: Right and I guess at that point you have to be really glad that you're at an institution that can back you up and that's…

Dr. Lobaugh: Correct

Brandon: We understand that this was an issue, but fortunately we don't have any ill consequences.

Dr. Lobaugh: Absolutely 

Brice: Yeah and it's not the individual. Yeah, it's not their fault necessarily. It’s…

Dr. Lobaugh: There are multiple factors that play into that and I mean I've had trainees since then make similar errors and I think that it's very important… and I teach them is that verifying and having an extra safety mechanism to check yourself is very critical. So the anesthesiologist, the resident, whoever's in the room giving the medications to the patient under anesthesia does go unchecked. But there have been things put in place to help that. So one is the electronic medical record. So I tell my trainees, unless it's an emergency, you should always verify the dose that you're going to be giving on the computer. So we have an electronic anesthesia record. You can put in the dose with the patient's weight and make sure that it verifies before you give it. And I think that it's important to do that step, because you can do math in your head sometimes - but not all the time. 

Brice: Yeah, just take the extra step

Brandon: Along with that we've talked a lot about different things that hospitals are doing and, of course, in medical training. Do you think there's any value in talking about medication errors and providing education towards the public in general. Like, what's being done in that area?

Dr. Lobaugh: So I think that it's… that is like a huge task.  

Brandon: Yeah 

Dr. Lobaugh: But what you can… To break that down a little bit, it's patient education of medication and medication safety. I think that it's important that you take the time to educate patients and figure out what their competency is. For example, we have a very diverse population at all these hospitals. We're in Houston, Texas, the melting pot of the world, right? There are very different levels of literacy and understanding about medicine, medical care, medications. I think it's very important that when you're sending a patient home with medications, for example, they understand what the steps are. One drug being Tylenol, right? In kids were giving Tylenol a lot for post-operative pain. If patients don't understand or their families. Obviously parents are giving it… don't understand the schedule they can become confused and give the medication too little, too infrequently, having two big of spaces and then the kid’s really uncomfortable or too frequently and then you have a Tylenol overdose and that's not good either,  right? And so I think that there is an element of medication safety that you need to look at is the understanding and the ability to recall or give the medication. Because they're actually, they're going home and delivering this medication without your direct supervision, right? So they need to… you need to have faith that they can do it correctly. 

Brice: Yeah 

Dr. Lobaugh: Because medications, even Tylenol can be not benign, right? Motrin cannot be benign. 

Brice: Right 

Dr. Lobaugh: If used incorrectly.  

Brice: It always comes back to communication.

Dr. Lobaugh: Correct 

Brice: What do you think clinicians, your everyday general internist or just any clinician - what can they do to help reduce medication errors in their practice?

Dr. Lobaugh: I think they have to look at what their own local environment is like and what are the issues that they have. So one thing that we focused on in anesthesia is high risk medications, so infusions and then some of the medications I talked about. But that might not be applicable to someone who is practicing in rural Texas. 

Brice: Right 

Dr. Lobaugh: Or even in a metropolitan clinic here in Houston. They're going to focus much more on blood pressure medications and knowing the dosages of that and so I think that comes back to culture and the ability to have data and understand what the problem really is. Because if you try to implement the wrong solution or you try to implement a solution that's too big for your local environment, that doesn't work if you don't have the resources. So if you have a tiny clinic and there's, you know, three doctors and two MAs and you're trying to do this big time consuming assessment for every patient to reduce these errors, that's not really going to work. If the internist is supposed to see 30 patients in a day, right? So you have to have the right… You have to identify the right problem and have it be the right environment. You have to make sure you have the tools for success, so that can be leadership. You can make sure you have all the stakeholders, so in that clinic if you don't ask the MAs what their view is, you could have this brilliant idea and then they're like ‘wait a minute that doesn't work with how we do patient flow or patient care’ and it's not going to work. 

Brice: Right 

Dr. Lobaugh: So you have to bring everyone to the table and that's a huge part of implementing and designing these solutions. 

Brandon: So does technology play a role in kind of helping that, because you're talking about, like, having all these lengthy, different, like… there's an option where you could sit down and say ‘Okay, well we're going to review every patient today and make sure we did it right,’ but then we were also talking about earlier about Epic… About how, you know, there's lots of stuff that pops up and it's more click to drag versus writing and stuff like that. How do you feel technology comes into helping reduce medical error? 

Dr. Lobaugh: So there is technology used as a delivery mechanism. So in my world in anesthesia, we have automated pumps and there are Codonics, like I said is the labeling machine. There is also not out on the market, but there's been talk or the development of a product that has a barcode and measures the… it knows the dose of the medicine you're giving and it measures when it's delivered as a safety mechanism. So there's all these things that help you deliver medication. There is the electronic medical record that's supposed to be helping you prescribe correctly. So when you guys are on the wards now let's say you want to start an insulin infusion. So there's an automated order set that comes up. So that order set was likely developed a long time ago, because people were making significant errors in how they did it and it eliminates the wrong dose or the wrong delivery, the wrong concentration. And it allows all of that to be safety checked in a much more streamlined way in terms of ordering. It also allows for documenting. There's so many technologies. The answer to everything, right? One of my mentors says that every single QI problem is solved by technology and informatics. 

Brice: Oh, interesting. 

Dr. Lobaugh: So if you are a data person, an informatics person, your ability to affect quality is tremendous. Your potential. So I am actually involved a lot with The Society for Technology in Anesthesia, not because I know anything. I can hardly run an excel sheet, but because I know that my colleagues in that field are what I need to successfully drive quality forward.  

Brandon: Gotcha, I'm gonna put that on a plaque. Every issue with QI can be solved by technology and
Informatics. 

Dr. Lobaugh: Correct

Brice: I love it. Put it on a throw pillow, yeah. 

Brandon: There you go. One of those ones that you can slide up and down 

Dr. Lobaugh: I mean even data… So we need to get away from subjective data in medicine and be able to pull from Epic. Pull from these systems discrete data points, so you can learn and it should be an easy… I want to know I had seven patients today. I want to know what were their PACU pain scores on arrival. What were they 15 minutes after arrival. What were they on time of discharge and then I can compare that to all my colleagues. I have 90 colleagues in my department and say so you… And it's not the blame game, but your patients frequently have higher post-operative pain and poor pain control in the recovery room compared to the majority of our providers. What do you think you could do differently? Because how else can I be better? This is the practice of anesthesia, the practice of medicine. You should be able to get feedback of what you can do to improve in a non-punitive way and we all want to be better providers. And by having that feedback, that data allows you to grow, because whether you're five years out of training, 10 years or you're 20 years out the… You know, you still should want to improve. If you think you're done improving, then you should get out of medicine. 

Brandon: Right 

Brice: And you would think with the EMR that that would be seamless to get that information, but I know it's not, right? 

Dr. Lobaugh: So if you guys come over to TCH, there is an ENT doctor, her name is Carla Giannoni and she is kind of an Epic guru and at TCH. And she loves to say ‘garbage in, garbage out.’ So if you've read a lot of the charts now that you're on the wards, how many times do you see people cut and paste a note? And it's not accurate. It says the patient's 10 years old and you're like ‘well, they're really 12 now,’ has notes from someone that has nothing to do with why they're here today and it can often be misleading. And then people follow what that says.  

Brice: Cut and paste that, yeah.  

Dr. Lobaugh: Correct 

Brice: And there's templates that, you know, say that you did a physical exam thing that you didn't actually do… 

Dr. Lobaugh: and so I think that the EMR could definitely be better and I think that it is unfortunate that we are not at a point where Epic can collaborate with other hospitals. I mean my Epic shouldn't be drastically different from the Epic at CHOP or at CHLA or at Denver Kids. They should all be able to function together, so that you can collaborate. So that you can compare and that doesn't really exist, right?

Brandon: Yeah, well I mean that's terrifying, because, you know, some people out there think that once you can centralize that information, then you know, you can be tracked and recorded and all that stuff and we… I don't know if we're ready as a society yet to allow that to happen. 

Dr. Lobaugh: So protecting patient information is very important, but you also need to have systems. So if you went and sought care let's say at St. Luke's and had a surgery where you had a difficult airway and you had to be fiber optically intubated. And then you show up let's say at Ben Taub after a horrible car accident. And I'm on call and I have to come down. If I pull up your record and I don't have access to that, I'm going to go in and, you know, I got to treat your airway. It would be better if I knew that before I start to address your airway, right? Because I could have called for all of those things. You know, same thing. Let's say you have a terrible adverse reaction to… I don't know what drugs…

Brice: Penicillin 

Dr. Lobaugh: You have anaphylaxis. Well if you were cared for at, you know, x hospital and it's all over the chart there, but now you're showing up in my hospital emergency, it'd be nice to know that, right? Because you may not have family with you. I may not know that, right? So that's where I think collaboration of data and streamlining data would be helpful.  

Brice: Yeah, again it's kind of a simple common sense solution, but you need those stakeholders and everyone to be on board and recognize that it's an issue.

Brandon: And education so the general public understands that you're not trying to harvest every last detail about them. 

Dr. Lobaugh: You also need Epic to be a little bit more sharing, yeah. 

Brice: I guess it's a private company, so, yeah, they can do whatever they want. 

Dr. Lobaugh: Correct, it's like Apple. 

Brice: Yeah, kind of on that topic. I was curious about this… Is there, like, a safety score for hospitals or for physicians? Is that something that's coming on the horizon?

Dr. Lobaugh: I think it's probably definitely coming. So with CMS and Medicaid, Medicare. There is scoring. There is a lot of the outcomes disclosed particularly in the adult world. The kids world is not as up-to-date, but that is a blessing and a curse, right? Because how is that scoring decided? So you guys will start to hear a lot of this. So if your score is based on satisfaction, patient satisfaction. What does that satisfaction mean? Does it mean that you gave a bad score because every day the resident woke you up at six am to do your vitals when you were in the ICU? Is that really fair? 

Brandon: No way 

Dr. Lobaugh: I mean you can try to be nice and quiet at 6am, but the way a hospital works it's important for you to get those vitals so that then when you're rounding as a team you can address the problems, you can get the consults, and you can start the medication so that it's not 4pm and the patient still hasn't had those needs addressed. So that's why you get woken up at 6am for those things, right? The patient doesn't necessarily understand that.

Brandon: Right 

Dr. Lobaugh: The same… Let's say you come in for a terrible car accident. You're angry, you know, you've lost a limb. You got a car accident, you know, whatever the circumstances are. Do you think you're going to say that you had a good experience, right? 

Brandon: Probably not. 

Dr. Lobaugh: Probably not. Yeah, so that's not necessarily fair. If you Brandon Garcia, the ER doctor have done everything possible and saved this kid's life, if they're like ‘no, dissatisfied.’ So that's one of the fears about the scores, and I think that you just have to be careful in how you go forward with that. 

Brice: Yeah, hospitals are not set up to, you know, provide guest satisfaction as we... 

Brandon: Well, we're not hotels. 

Brice: Yeah, I used to be in the hotel business. It’s all about guest satisfaction. 

Dr. Lobaugh: You know that there's a lot of consulting like TCH has Disney Consulting, so it is about the patient experience and you want to make patients feel like their needs are met, like their voice is heard, like they're part of the decision and the process. But there are some things that are out of your hands and a factor of health care. I will say the one thing that scores have done. Particularly in adult setting, you know, they focused on scores with, for example, heart surgeries that came out… I don't even remember the date of that and it showed that maybe you shouldn't be getting your triple bypass surgery at a hospital that does a lower number of these cases compared to a hospital that does greater than 5000 cases. You know, I’m making up those numbers, because I don't recall the actual numbers. But I think that that is one thing that has been looked at… should hospitals that don't meet a threshold of a particular type of surgery, a particular type of procedure or service line be allowed to perform those and I think that's a good question to ask. I mean if you're shopping around for a hospital to have your transplant surgery, are you gonna go to one that does a couple kidney transplants a year? Are you gonna go to one that's, you know, outperforming and having really good quality outcomes doing 50-60 kidney transplants a year?

Brice: Yeah, does the patient have the right to know, you know, how good their doctor is? I would say ‘probably.’ 

Dr. Lobaugh: So that's where I think scoring is a definitely tool that can be used in a positive way.

Brice: Awesome, well I think we've learned a lot here. Is there anything else you would like to share about your work?

Dr. Lobaugh: You know, I think that the thing that I reiterate is you can get involved in QI a little bit or a whole lot. You don't have to dive in like I've got myself so entrenched in this. You can just have a problem and propose a solution and go with it. And I think you can take on a small project, whether you're in internal medicine or radiology or ER and contribute in that way. And I think that with some basic understanding of the steps and tools you can succeed. Or if you want to run a hospital one day I think that more power to you. I would say definitely try to get the training and experience, but physician leadership is so important in how hospitals are run in my opinion. I think we need more people involved in setting the priorities and determining what are the goals and priorities of a hospital. 

Brice: How do students and residents get involved in that kind of thing? Patient safety and leadership in the hospital?

Dr. Lobaugh: I think that, you know, you have to be eager. You have to pursue sometimes in a nagging capacity. You know, start out with the basic courses. There's a lot of I think younger junior faculty, you know, Molly like I said. I use her as an example Horstman at the VA, myself. And ask for opportunities. It's depending on what's going on, that can be very challenging for us to find opportunities out of nowhere, but if you're persistent I think that you can get experiences. And just you're not going to have a groundbreaking, you know, published study coming necessarily out of medical school, but you could get your feet wet. Get a little bit of experience and then when you're in residency say, ‘Hey, you know, could I do this project when I'm on this rotation?’ And, you know, ‘How do you think I can be supported in that?’ Get involved in that and then it grows from there. So I think persistence is probably the biggest thing. 

Brandon: There you go. Persistence. I used to always get told persistence beats resistance, so I love it when people talk about that. 

Brice: That’s what it's all about. Do you have anything else?

Brandon: No, I'm just really glad you were able to come and chat with us today I feel like I've personally learned a lot, so again I'm just super glad you're willing to come onto the podcast and chat with us for a little bit. I can't wait to get this out, so other people can hear some of the things you have to talk about. 

Dr. Lobaugh: Thanks for having me, I'm just glad I didn't have this baby before.

Brice: I know it really worked out. 

Brandon: When are you due if you don't mind me asking? 

Dr. Lobaugh: So I'm not due till the end of July but I'm actually out of the OR right now, because the baby is trying to come too early. So if you…I was telling Brice the students that were in my Intro class a couple years ago, I had just had my son, my first son and I was like… had all the lectures lined up and I was gonna teach on, I think some date in June… kind of around this time. I was like, it doesn't matter the baby's not gonna be due for several more weeks, I’ll be fine. And then my son came five weeks early, so history is repeating itself with the second boy. 

Brandon: Eager to get here. 

Dr. Lobaugh: Boys

Brice: Hopefully you have some good OB colleagues to get you through.   

Dr. Lobaugh: Yes, being at Texas Children's is a very good place 

Brice: For sure. 

Brandon: All right, well thank you so much and if that is all I’m gonna hit the stop button. 

Music

iTunes | Spotify | Stitcher | Length: 34 minutes | Published: Oct. 14, 2020

This is the second of a five-episode mini-series on Quality Improvement (QI) in Healthcare in collaboration with the Institute for Healthcare Improvement (IHI) student organization. In this episode, we talk with Dr. Lauren Lobaugh, a pediatric anesthesiologist, and discuss how she became interested in the field of patient safety and how anesthesiologists have been at the forefront of safe medication administration. We also discuss the scope of medication errors in modern medicine and how students, clinicians, and patients can prevent these errors.

Transcript

Music 

Erik: And we're here this is the Baylor College of Medicine Resonance Podcast, I am your host Erik Anderson, and I'm sitting here with somebody, do you want to introduce yourself?

Brice: Yeah my name is Brice Thomas, a third year medical student, happy to be here.

Erik: And I should say virtually sitting here due to COVID.

Brice: Yes yeah that's what we do these days.

Erik: Yeah, so this is part of our IHI mini-series, which at this point I believe you've probably heard a few episodes and had a little bit of introduction. So Brice is going to just tell us a little bit more about the episode before we just jump right into it. 

Brice: Sounds good, so this interview is about medication error. This is a topic that's not really discussed until something goes wrong unfortunately. So from errors in prescribing and dosing to errors in actual administration, medication errors are more common than you'd think. We have Dr. Lauren Lobaugh, a pediatric anesthesiologist, myself, and Brandon Garcia talk about why these errors occur and what steps we can take to reduce them.

Erik: Yeah no it's a great talk too, I've…you know we've already shot it already so I don't know if that mystique is gone now. But it's, yeah, I'm excited.

Brice: Yeah, so yeah Dr. Lauren Lobaugh, she's a board-certified pediatric anesthesiologist and an assistant professor of anesthesiology at BCM and Texas Children's Hospital. She completed medical school at UT Houston, residency in anesthesiology at Georgetown, and pediatric anesthesiology fellowship at Children’s Hospital of Philadelphia. She first got involved in quality and safety during her residency as part of wake up safe, an initiative sponsored by the society for pediatric anesthesia that focuses on improving outcomes and quality improvement education. She completed a faculty fellowship in Quality and Safety at TCH in 2016 and earned a master's in healthcare quality and patient safety at the Johns Hopkins School of Public Health in 2019. She currently works with the Institute for Safe Medication Practices on an FDA-sponsored safety assessment tool. She also has a busy personal life with two sons at home. In addition to her clinical duties she's involved in the BCM Chapter 4 IHI, including leading courses like Skills and Advanced Topics in Patient Safety and QI.

Erik: That's great, okay well so without further ado, here's the interview.

[Music]

Brice: All right, welcome. I’m Brice Thomas, a second year medical student currently interested in internal medicine. We're excited to continue our quality improvement mini series today with our guest Dr. Lauren Lobaugh, a pediatric anesthesiologist and expert on medication error. Welcome to the show.

Dr. Lobaugh: Thank you. I don't know if I'd call myself expert, but I do have some knowledge around the topic for sure. 

Brice: Nice, you definitely know more than us and our listeners probably so.. 

Brandon: You were talking to us a little bit about your background. You said you went to McGovern. 

Dr. Lobaugh: Well, it wasn't McGovern then but now let's call it McGovern - I went across the street for medical school. I'm from Houston and then I went to Georgetown in D.C. for my residency in anesthesia and that's where I kind of first got involved in quality improvement and patient safety and I don't know how many years ago that was. We don't need to count that far back and I’m not really that old. But I can't count that far back. They all kind of blend together after a while…and I got involved through my residency. And then as well as there was a regional quality improvement patient safety program through Medstar Health, which was the bigger organization I was in. And I kind of just as they say ‘drank the Kool-Aid’ and I continued on my interest in quality improvement patient safety at CHOP, so I did my clinical fellowship in Philadelphia and pediatric anesthesia there and I really got involved with an initiative out of the Society for Pediatric Anesthesia which is called Wake up Safe. And its an initiative focused on improving outcomes in pediatric anesthesia and education of the members at large. And then from there, you know, what do you do after fellowship, you got to find a job. So I wanted to come back to Houston and I got a faculty fellowship in quality improvement while being a part-time pediatric anesthesiologist at TCH, so it was kind of a hybrid year for me. And then I always felt like that wasn't enough. Peter Pronovos is a big person in quality and patient safety that came out of Hopkins, very famous gentleman and he said in a conference I went to in residency once that if you want to lead or be an expert in this field you really need to have the backbone or the foundation, so I applied for my master's at Hopkins and got accepted to um it was all online program. And so I was able to complete my master's in healthcare quality and patient safety. The following year after my fellowship, I found out I was pregnant two weeks after I started the masters.

Brice: Oh wow 

Dr. Lobaugh: So that was really poor timing but it never really works, right?

Brandon: I don't think there's any like convenient time for anything in life. 

Dr. Lobaugh: Correct. So I continued through that while working full-time and I was able to finish that this last December so now I have my master's. 

Brandon: That's awesome. 

Brice: Nice, congratulations. 

Dr. Lobaugh: And as I've so I've been an attending for almost four years now and I'm involved at the department. I am in charge of our policies and procedures in our department as well as an associate chair for our quality improvement committee and then I'm involved still nationally in Wake Up Safe and have gotten a lot of amazing opportunities to continue that. I was telling Brice earlier today I was on a conference call. I'm on an expert panel for a medication safety assessment tool that the FDA is sponsoring through the Institute for Safe Medication Practices. It's called ISMP, but so that's how I spent my afternoon. 

Brice: Very cool and you're heavily involved too in the medical school advising members of our chapter for IHI, the Institute for Healthcare Improvement and also teaching courses, right? 

Dr. Lobaugh: So I got involved in IHI um by submitting work when I first came on at TCH and when I was there I went internationally to London to one of their conferences. They're amazing and one of the people there asked me if I did anything with the school, Baylor School of Medicine and their IHI program and I said I didn't. So when I came back I was able to get involved and actually kind of was handed over the the courses that I'm now course director. So I am the course director for the Intro to Quality Improvement and then Advanced Topics. And with the help of a lot of your fellow students particularly Anoosha, I've been able to kind of change that course around so that it's tailored to what you guys want and bring in some really great lecturers that I've never even gotten to work with from Ben Taub, from the VA, Molly Horstman is someone who comes to mind who's very involved in education at the VA. I think Dr. Coleman is going to give you guys your wrap up who is very high up in quality improvement in the Baylor system and has a very important leadership role and I think her lecture is always very well received. 

Brandon: That's awesome. 

Brice: Nice

Brandon: It sounds like you have a very impressive record and background in QI what would you say is your passion or your goal in your participation with quality improvement and patient safety? Like what do you personally want to make sure happens? 

Dr. Lobaugh: So I think it stems from when you guys…looking back when I was in y'all's shoes in medical school. You start to get your, you know, experience on the wards, and it's frustrating when you're like, why does it take me an hour to contact someone about a simple question or why are there so many different ways to get to the same answer? Or, you know, or just all the frustrations that you see whether it's delays in care or having orders not done correctly. And you know when I first started residency I'll tell you we were on paper charts, so that was a whole other problem. I think that electronic records have helped but they're a problem in itself and so you're going to see these issues. And you can either be a person that says ‘I can't do anything about it’ or you can get involved and try to be part of the solution. And I think that's kind of fitting for how I take on things. And I've always wanted to see if I can help make it better. The personal part is I am in pediatrics, I’m also a mom and so I so I always feel like I want to make health care for children and their families the best possible experience - what I would want for my own child. And so if I can find solutions to make it better then, you know, kids don't have to be… experience medication errors or medical errors in general and I think that's a, you know, very lofty goal , but I think it's important to strive for. 

Brandon: Definitely. 

Brice: Yeah, I feel like the stakes in pediatrics especially are just so high or at least I had that feeling on my pediatric rotation. You know, you just want to do everything right. You don't want to…

Dr. Lobaugh: Kids make you nervous?

Brice: Yeah, yeah, you know and parents too! You know? So what I'm hearing from you is that, you know, there are these systemic kind of issues and you can either say like ‘oh well this is just this is a system, i can't do anything about this’ or you know, ‘I can investigate what's going on and try to come up with with the solution.’

Dr. Lobaugh: Yeah and I think it's important that you may not be able to solve the problems of Baylor College of Medicine or Ben Taub or Texas Children's as a whole, but you can, you can propose solutions and try to implement them in a smaller scale. In a ward, in a clinic, in the OR, you know I think the important thing is to start very small and see how your success is and if you're successful then you can grow and spread it. People often try to take off these, you know, big bites.

Brice: Yeah, change the world.

Dr. Lobaugh: Change the world and it's disheartening, so I’ve learned through a lot of failures that if you start small it's a little more achievable. 

Brice: For sure. So I'll call you a medication error expert. What are medication errors? What's kind of the , because I know in my reading for this it doesn't necessarily mean that the patient was harmed it could just be, you know, yeah it could be another event yeah or a near miss. 

Dr. Lobaugh: I think that that you have to… So medication errors are a small piece. So if you take a step back at the big picture, there's medical errors in general. And you will all experience them in some form or another. I think we have addressed some of these and so they happen less frequently. But still you can get misdiagnoses, you can get wrong-sided surgeries, falls, burns, pressure ulcers, transfusion reactions, or I should say improper transfusions, mistaken identity, and then you have medication errors. And I think medication errors definitely have got a lot of attention, but the big thing is… So how many years ago? 1999, how many years ago was that?

Brandon: That would be 21. 

Dr. Lobaugh: So 21 years ago, do you know what happened in 1999? It's very quoted there was a report that came out. 

Brice: To Err Is Human? 

Dr. Lobaugh: Correct, okay so To Err Is Human came out and that was like huge. People were aghast, because in it… It said that medical errors and I want to make sure I specified medical errors were the sixth leading cause of death. 

Brice: Right 

Dr. Lobaugh: And people were like that's impossible, but really in the two decades since then we've learned that was grossly underestimated. 

Brice: Right, because the reporting is not there. 

Dr. Lobaugh: The reporting is atrocious and that's a huge problem we have in quality improvement, in healthcare and what it really is more like is the third cause, which is what…

Brice: Wow 

Dr. Lobaugh: I think the literature is a little bit more delayed. We're looking at like 10 year old literature now but it's causing the third cause of death behind heart disease and cancer, which is astounding. 

Brice: Right 

Dr. Lobaugh: So then you have medication errors. Basically, medication errors can be a variety of things associated. They don't necessarily have to cause harm. 

Brice: Okay 

Dr. Lobaugh: The thing that I think is crazy is there are some reports when you look up like the statistics of medication errors that the harm or the the ‘after care’ from after a medication is quoted upwards of 40 billion dollars a year…

Brice: Wow 

Dr. Lobaugh: in expense. 

Brice: Wow 

Brandon: That's the that's how much it costs to make 

Brice: Like just the side effects?

Dr. Lobaugh: So that's how much they believe the care, patient care required or needed after medication errors totals.

Brandon: Okay, okay, so like I said before… I’m very new to QI and to medication error. It's like they've talked about them in medical school and honestly after having been a med student for a little bit I can totally see how that could happen. Because medicine is an ever-changing area and it takes a lot of brain power to keep up, so I can understand. You said that… There was two things you were talking about with medication errors itself. One was that it was the sixth leading cause of death, but under reported. I wanted to ask, what is the rate like currently from your understanding of medical error? And what is the underlying reason for why it was so underreported? Is there like a fear or stigma regarding, like, making mistakes? Like what would you say is the underlying cause of that under reporting?

Dr. Lobaugh: So to clarify, medical error was considered the sixth leading cause of death 20 years ago when that first report came out - the IOM report. Now it's considered to be the third leading cause of death.

Brandon: Is that because of more error or more reporting?

Dr. Lobaugh: More reporting… A better understanding, because from the 90’s on…the past 20 years, quality improvement went from being a very novel concept to now much more commonplace. You guys have it as part of your education in medical school. You're exposed to it in residency. There are whole parts of the administrative aspects of hospitals focused on quality and patient safety that weren't there 20 years ago. So I think that there is much more reporting, so it's considered to be the third leading cause of death. However, to ask for a rate, that's like impossible to quantify. There are studies that try to look at that, but I think that there is a stigma with reporting. There is worry about shame and blame, which is a huge culture problem in a lot of hospitals. And then there's also not knowing you committed an error… If let's say there's no significant harm to the patient, do you know that you made an error? Perhaps you made an error of omission. You forgot to give an antibiotic. Do you know that you did that? Can you, you know… how does that get checked? And so I think a lot of stuff goes under reported. And in medication errors there are lots of steps along the way. So I’m an anesthesiologist, so we'll get to kind of what it's like to be in that role in medication errors later. But in general, you want to write a medicine for your patient , right? You're on the wards. You order it. So you put in the order. It's a… now you guys probably order it in  Epic, you're not really writing orders. But then that order is transcribed, it's dispensed, it's administered, it's documented and then it's monitored. So each of those steps along the way all have the potential for a medication error. The most common is the prescribing. And that's where physicians, mid-levels, people who have prescribing powers or abilities can be the most vulnerable. You can do the wrong medication, you can do the wrong route, the wrong dose, the wrong frequency and it's really hard to keep up. How many times, you know, are new drugs coming out? Or new dosages? You have to tailor it. In my world in peds, you then have to put in weight based…

Brice: Right 

Dr. Lobaugh: …and apply that to it, so I think there's lots of opportunity for error. 

Brice: I just wanted to like reiterate the scope of this kind of issue, you know, it's huge! I was reading that 1.3 million injuries per year occur because of medication errors and even one death per day in the U.S. I think that was the FDA that said that. 

Dr. Lobaugh: Yeah, I mean I think that that is unknown. There are other things I was looking at. Some of the kind of the current papers that have come out as of this year and one of them said 7,000 to 9,000 people die every year. So I think that deaths are very trackable… 

Brice: Yeah

Dr. Lobaugh: …because you need to if someone dies… they do an investigation. There has to be a cause of death and so I think those numbers potentially could be a more reliable factor. But we just don't know with the medication errors for sure. 

Brice: How do you think we reduce these errors? What are… what are some ways we can do that?

Dr. Lobaugh: So I think that the biggest thing is to focus on systemic issues and the fact that the system is failing the providers and the patients. It's wrong to label it as the providers are failing their patients. And that's one thing I think is most crucial if you're interested in quality improvement is to remember that you are human and you… making errors, you know, The Swiss Cheese Model… human factors. There's a huge study in just human factors in these errors and so I think it's important that we demand systems-based solutions for these problems. 

Brice: Yeah 

Dr. Lobaugh: So there's a lot of different areas you can focus on. One is in medication errors, patient information. So do you guys know what a red rule is? 

Brandon: I do not, so I'd love for you to tell me. 

Dr. Lobaugh: So a ‘red rule’ is something that a hospital abides by that cannot be broken. It is a rule that if you do not follow, the potential consequence is termination. So one of the big red rules is using patient identifiers. So you should use two patient identifiers when administering your medicine or verifying a patient. So I can't just say this is Brandon Garcia, he's here for surgery today. I have to say ‘this is Brandon Garcia, your date of birth is 6/10/1990 and this is your MRN.’ So those are two identifiers that are exclusive to you. Because if right next to you in the next bed is Brandon Garcia, what if I just said the name and I didn't do those other identifiers? I could have the wrong Brandon Garcia. So red rules are a big thing. They can be dangerous, because it's an absolute, right? So if you don't want to have something that needs exceptions, but red rules are one way… Also, another thing that you guys probably participate in a lot is updating current medications. So when you're admitting patients on the ward, probably one of the first things they ask is did you get a current med list?

Brice: Yeah, med rec. 

Dr. Lobaugh: Medical rec. You want to reconcile the med list, because you want to know what that patient is taking so you can avoid errors there. In pediatrics, it can be standardizing the weight and height, which has already been done but that was one thing… So in the U.S., you're taught pounds, right? And feet? But really in medicine, that's not how we practice. We practice in kilograms or grams and meters or centimeters. So making sure you have that, but there's also, you know, there's so many other aspects… There's drug information, making sure you are identifying high alert medications. So depending on where you've done your rotations on the wards so far… I mean, there's some pretty potent, dangerous drugs. You can get your hands on heparin, insulin, lidocaine, potassium chloride. Two years ago and I don't even know how these things occur, but I had a resident who asked for some potassium and the pharmacy sent him a vial of 40 milliequivalents of concentrated potassium chloride! Well, if you give that to a patient…

Brice: Yeah 

Dr. Lobaugh: They're not going to be around for much longer! So knowing what medications are very dangerous I think is important. There's also communication, so a lot of errors all come back to communication lapses. In communication, handwriting used to be a problem, but now it's the electronic medical record. Most of the time when you guys are ordering drugs, you type in the name, right? And it pops up with a variety of options for that drug, but handwriting isn't so much a problem as it was…

Brice: Yeah and in your world too it's even more complicated as far as how to address these errors, because it's unique for you. Because you're the one ordering the medication or you don't even order it. You just, you know, take it out, you're drawing it up, you're actually administering it. 

Dr. Lobaugh: So I consider the operating room to be one of the most dangerous places for medication errors, because anesthesiologists are the only providers that go unchecked. So we prescribe, we prepare, we administer, we document, we monitor. All those steps that I described earlier…

Brice: Yeah 

Dr. Lobaugh: …are all done by a single person. Maybe there's a resident or a nurse anesthetist involved, but for the most part they're going unchecked. Whereas, if you order a med on the floor, you put in the order and then what happens?

Brice: Yeah, about five different people look at it. There might be an alert that says ‘oh, this is contraindicated.’ You know, all sorts of things. 

Dr. Lobaugh: You go through pharmacy, then pharmacy sends it out. Verifies it, sends it out. The nurse
checks it oftentimes. The nurses have a double check. So there's a lot more people involved that can catch an error than during the delivery of anesthesia, so that that's definitely a uniqueness. 

Brandon: So why is it that anesthesiologists have all that power with little checks?

Dr. Lobaugh: Because that's the art of anesthesia. I mean you've got to think about when… For example, let's say you have a patient that presents to the ER and their sugar is 300. You're gonna correct that sugar over a long period of time, right? You're gonna admit them, you're gonna get their IV in, you're gonna put the order in, they're gonna send you the insulin, you maybe give them a small dose or start them on infusion and then check periodically. You put that same patient in the OR, you're going to have different… you're going to have different timelines or a different approach. It's much more dynamic. A better example is blood pressure. So you have a patient that comes in with a blood pressure of 200 systolic and 110 diastolic. Let's just throw that one out. So that's an emergent situation, right? And an adult and a kid very emergent, right? So you want to address that, but you don't want to bottom them out, so you're going to give them… if they're eating, maybe give them IV medicine, maybe start him on an oral medicine and kind of watch him over a period of time. For me if I'm in the OR and all sudden that happens in a patient that was previously stable, I'm going to give a medicine that acts over minutes not hours, so it's just very different. I don't have the luxury of the time to go through all those steps. If I had to wait for pharma… so if I have a patient that has that blood pressure and I'm doing an aneurysm clipping and I’m waiting for pharmacy to verify it and then pharmacy to send it and then someone else to check it that patient could…

Brandon: Die. Yeah, so it's about… At that point you're just trying to prioritize, do you want the checks or do you want to be able to get something done in a fast manner?

Dr. Lobaugh: And it's just that it's what the specialty is. So the art of anesthesia is very dynamic you become a specialist in pharmacology and physiology and delivery of these medications. So it is a unique situation. 

Brice: Yeah, for sure, for sure. 

Dr. Lobaugh: But it's also scary, because if you're going unchecked, you might not know that you did something wrong. 

Brice: Yeah and I love what you said before about, you know, we are human as doctors and future doctors. And, you know, we feel sometimes like we have to be perfect, but we're not. We do make mistakes So as anesthesiologists, how do we try to reduce those mistakes?

Dr. Lobaugh: So there have been a lot of focus on safety in the OR and I think that anesthesia providers,  anesthesiologists like to tout themselves as champions of patient safety. We have the Anesthesia Patient Safety Foundation and we feel like we were ahead of a lot of other specialties in terms of focusing on this.  And I say ‘we,’ I mean people that came way before me and they've looked at things at improving safety. So around medications particularly. So there's labeling. So if you guys step into an OR these days, there are machines that color code and label the drugs. That didn't used to happen. There has been a lot of focus on trying to eliminate look-alike medicines. So epinephrine and ephedrine can look like the same thing in the vial, but they're have very different. They're both going to affect cardiovascular system, but differently, right? And so you want to make sure you try to either separate out medicines that can be look-alike or change the packaging. There's also been focus on the organization. So you guys are going to come into contact with many different doctors. Everyone has a personality, right? Just kind of like if we could go into all of your bedrooms, some of you are clean, some of you are not so clean. Some of you have probably sandwiches and cold pizza slices in your room that I don't even want to know about. 

Brice: Right, yeah. Episode of Hoarders maybe. 

Brandon: I do have to admit. One, I am not as clean as I thought, as my wife has let me know over the past few months. Two, it's an organized chaos like it's one of those things where she's like ‘Brandon, where is…’ and she'll name something. I'll be like ‘Oh, it's in the second drawer on the left nightstand underneath blah blah blah blah blah. It's right there.’ And she's like ‘what!’ And you find it. Like, it makes sense to me. 

Dr. Lobaugh: So I would never want to… if you were an anesthesiologist, I would never want to take over your room from you, because your workspace or your anesthesia workspace where we prepare our drugs is probably not organized. Some people are very particular and I… there's been focus on that, whether we should make that mandatory. Seattle Children's is focused on that and having a standardized drug tray, but meaning your emergency drugs go in the right top hand corner. Your antibiotics go in the bottom , you know, right square and they have it all marked out. And the thought is… does that eliminate error? Because let's say you have a very important meeting. You're my colleague, I need to give you a break so you can go to your meeting, which happens routinely in anesthesia because of the way it works in the operating room. And so I'm giving you a break for your meeting. You've already started the case. It's an important case. If I walk in there and you've got syringes places and it's not organized and tidy and let's say the patient goes into cardiac arrest, I'm going to grab what's familiar, right? I'm going to turn around and feel like I should be able to grab x drug from this spot. Well, if you're not organized or sloppy or messy or whatever you've done… or haven't labeled things correctly, I'm gonna grab something. Let's say you had… feel like the kid… they're having ischemia. And you're kind of stretching my knowledge, because I haven't taken care of an adult in a very long time… But let's say they have ischemia and you want to give them a narcotic and I reach and grab that narcotic and I’m like oh great it should be 10 mics per… I'm just making up a dose, because that's a pediatric dose. But I push it all, but really that was a hundred per. But you didn't label it - that's a problem, right?

Brandon: Oh, yeah absolutely and I am 100% there with you. Like I think there's like pros and cons to the whole thing. Like that's a massive probe, being able to have it standardized and be able to say no matter who walks into the room that x is where x is supposed to be. Y is supposed to be where y is supposed to be. I also know and this is probably a reason why I won't end up being an anesthesiologist, I know that that it's hard for me to maintain like that kind of level organization at all times. Not saying I'm not organized in my own way. It's just my brain doesn't always work that way, so I'm one of those people that

I’m always customizing things the way that makes sense in my head and you're right that would make it extremely difficult for someone to come in…

Dr. Lobaugh: and hand off.

Brandon: And yeah for me to hand off what I’m doing to someone else to go handle another thing. So maybe anesthesia is not for me, but what you're saying is definitely making sense -  the fact that like if we have something standard like that it makes it a lot easier to know what's going on and to prevent errors in the operating room or wherever you might be. 

Music

iTunes | Google Play | Spotify | Stitcher | Length: 25 minutes | Published: Oct. 5, 2020

This is the first of a five-episode mini-series on Quality Improvement (QI) in Healthcare in collaboration with the Institute for Healthcare Improvement (IHI) student organization. The episode features the student leaders of the IHI Baylor College of Medicine chapter who introduce the organization, explain some of their group’s activities and give a brief overview of what QI in healthcare is and why it’s so important.

Transcript

[Music]  

Erik: And we're here. This is the Baylor College of Medicine Resonance podcast, I am your host Erik Anderson and I’m here with some other people if you want to introduce yourself.

Adam: Hello I’m Adam Floyd I’m an MS3 here at Baylor College Medicine.

Jinna: Hi I’m Jinna, a current MS4 at Baylor.

Parth: Hi I’m Parth, I’m currently a researcher student at Baylor, I guess I’m technically a second year.

Raj: Hi everyone my name is roger eddie, I'm a third year medical student.

Erik: Cool, and thanks to you all for being here. So to give a quick introduction, everybody that just introduced themselves as part of the Baylor College of Medicine student org: The Institute for Healthcare Improvement (IHI). And we have in collaboration with them, we're about to bring you a mini-series on quality improvement in medicine. We're going to have a lot of great speakers that you know we'll talk about later, but we're going to just kind of do a real quick introductory episode on what healthcare improvement is and quality improvement and a little bit about what the org is. So Adam, do you want to take it away?

Adam: Sure thing. So first up we just wanted to explain a little bit about what IHI is to that end. Raj what is nationwide IHI?

Raj: Sure Adam, that's a big question but I’ll give it a shot. So the IHI, or the Institute for Healthcare Improvement is a national non-profit advocacy education organization dedicated to quality improvement, patient safety, and high value or value-based care. Or since we love acronyms so much in medicine healthcare: QIPS and HVC or VBC. Their vision is that everyone has the best care and health possible and their mission is to improve health and health care worldwide. A lot of the work is focused on improving patient population health outcomes while also reducing medical overuse, waste, and cost, which we often see go hand in hand organizationally. IHI started officially in 1991, although its efforts started as grant funded programs in the late 1980s. One of the key people involved in IHI was their founding president and CEO um Donald Berwick who is a pediatrician, public health expert, and health policy expert, and as well as a health care administrator over at Harvard. He’s kind of been the main leader of this organization's vision. One of the main aspects of IHI that is really relevant to medical students or health professional students is that they have something called the open school, which is a collection of over 30 online courses on various topics in a lot of these areas that we talked about. A lot of which comes from the intersection of biomedicine healthcare with the management sciences and industrial engineering. Focusing on efficiency and process improvement and aspects like that, that are not necessarily strictly the clinical and basic sciences that we learn in our health professions curriculums typically. Finishing that they also run a series of lectures and webinars, courses, podcasts, resources. They publish reports and white papers, they hold several conferences throughout the year um they have some certifications that people can add to their CV and all that in these areas to really gain education and improve their expertise. Two aspects that I really like about the IHI personally are that one, they're really interprofessional and interdisciplinary. So they're all about that teamwork and collaboration, e.g. how we can use our collective knowledge and expertise and resources to really improve health care worldwide. And the second aspect is that worldwide component actually. Even though they do a lot of work in the U.S. they also have a global focus. For example one of their big meetings every year is actually an Africa forum where they focus on improving healthcare across the continent there and improving health systems collaboratively governments. So there are a lot of really cool aspects of IHI I think are really interesting for health professional students.

Adam: That's awesome, thanks Raj. And I mean to go off of that you know very detailed explanation, very good explanation, we also have an IHI branch here at BCM. The BCM IHI Open School, I believe you mentioned. So IHI here at Baylor is kind of a one stop shop organization for all things quality improvement and patient safety. Our mission here at BCM is to educate students about the importance of quality improvement patient safety, equip students with tools and skills in QI and NPS in their future careers, and engage students in improving health outcomes. So really IHI at Baylor includes members with a variety of specialty and research interests but it's all tied together by a desire to make measurable improvements in health care. Our activities here range from workshops to electives to mentorship and research initiatives. Even to the organization of a yearly research conference. So, like Erik mentioned, the Resonance podcast team has been gracious enough to help us put on this quality improvement mini-series. Really this is a way to showcase the quality improvement work being done here at Baylor College of Medicine, kind of advertise opportunities to students on the part of you know great faculty and residents who are you know doing big things in quality improvement and patient safety. A little bit about what quality improvement and patient safety are—patient safety is just reducing or preventing harm to patients, quality improvement is just systemic improvements that lead to measurable improvement in healthcare delivery often measured in terms of efficiency, reproducibility, value, etc. QI work is done here by students, residents, faculty, all in a variety of different specialties, with different research interests, with different backgrounds they all want to improve healthcare. 

Erik: Adam can I jump in real quick?

Adam: Yeah please comment.

Erik: As somebody, you know that's not in the org that's just had a little bit of quality improvement classes, you know experience at Baylor, it really is kind of a foundational thing for our profession. As you were saying it's like it's already sort of built into our code of do no harm and trying to basically maximize that, that I don't know, axiom if I want to sound pretentious. You know that that core belief and fundamental belief for us as a profession. So it's really important, and so I think it's great that you guys like,  we have a student org that's sort of around to try to teach students how to basically be better doctors. How can we how can we improve everything, and then yeah you can basically apply that to anything, as a lot of the faculty talk about in the interviews.

Adam: Yeah and one of the great things about QI is that quality improvement work is one of the quickest ways to make a tangible change as a medical student. So most of us are familiar with you know bench research or clinical research. I know you're doing your PhD right now and that's a you know four or five, six year process. A lot of QI projects can be done really in you know weeks to months where you just you go in you see kind of a need you make a small you know one small discrete change and then you measure what happens. And so you know even as a MS1 or MS2 you can go ahead and get started with that pretty quickly. And yeah, at this point I wanted to kick it over to Parth who's going to talk about maybe why we're doing this series and who we are going to be talking to and that kind of thing.

Parth: Yeah so like Adam said as an organization we're kind of committed to spreading the word on and getting people involved in quality improvement and patient safety research, and just generally knowing about like education. But we're doing this series to give a platform to and kind of shine a spotlight on Texas Medical Center (TMC) faculty that are currently engaged in quality improvement and patient safety research you know. I found that when I came to med school I myself didn't really know much about quality improvement or patient safety. I knew what bench research was, I kind of knew what clinical research was, but even then not really. And I didn't know at all about you know the IHI or the QIPS movement or anything like that. And so we're hoping that by doing this series and by finding you know actual researchers who are doing research in the space and who are making great strides in this space. And giving them a platform and spreading the word on their research we can you know sort of get more students like, you know, everyone on this zoom call here into QIPS research.

Adam: I think that's what we all want, thanks Parth. Yeah and you know to that end IHI here at BCM is loosely organized into more or less four pillars as we call them colloquially. So those for us are: Mentorship, research, community engagement, and education. So to that end I just wanted to have each vice president of each pillar introduce themselves and talk a little bit about what they do and we'll go from there. So first off Jinna if you want to talk about mentorship.

Jinna: Okay so I’m VP of the mentorship pillar and so what I do is try to connect faculty and new members residents along with upperclassmen with lower classmen or just students that are new to our IHI organization. And so with these relationships the goal is to be able to have guidance in quality improvement and learn about new projects that are going on or finding a niche in QI.

Adam: That's awesome, that's awesome. And I know you've helped out you know a lot of younger students including myself find you know mentors within the QI world and so thank you for that. So the next pillar would be research and Parth has been working on a really great kind of research matching program. So Parth if you could speak both to your pillar and then to that program that would be great. 

Parth: Yeah so I'll start with the general pillar first. So I guess kind of as I alluded to before there's a lot of great QIPS research happening at um the TMC, I mean we're the world's largest medical center, and so we just have a lot of medical care being delivered which gives us the opportunity to study a lot of delivery of medical care. And so most of that research is not being done by students, it's being done by MDs, by PhDs, and I guess Erik some of it I’m sure MD/PhDs as well as you know a whole host of other degree holders and then researchers. But most of it isn't being done by students, and so first of all we want to kind of give more students the opportunity to get involved in this kind of research and to do that as a pillar we kind of try to scope out and see what research is being done and then we try to make students aware of it. We try to give some of it a platform and to that end like Adam mentioned we host a yearly QI TMC conference where researchers can go and present their work. And lastly we're in the process of setting up I guess a research matching system, that's what we're operationally calling it for now. But basically what we want to do is we want to reach out to faculty and kind of ask them, hey what projects are you working on and would you like or would you be willing to have students come in and help you with these projects. Then we want to take that list of projects we found and reach out to students and say, hey are you guys interested in this space and if you are would you be interested in getting involved in any of these research projects that we've found that are currently happening. And through this we well, first of all we hope to get more people involved in and thinking about QIPS research, but kind of secondly we just hope to take a lot of the kind of chance out of finding a good research venture and how to find a good research project. I mean I think so many of these sorts of processes are you know kind of probabilistic where you might end up being like a really good researcher or you might be really interested in research but unless you just kind of happen to find the right mentor with the, or the right pi with the right project at the right time, you might not be able to end up doing any research. And that's hard if you kind of come to Baylor without any connections you know if you're not from the area for example. And so we're hoping that we can all kind of you know come together, we've been at the school for two, three or four years now, we're hoping we can kind of come together and put our heads together and help create a project or a program to take some of the chance and the guesswork out of finding a research venture. 

Adam: That's awesome Parth, yeah I really resonate with what you're saying about kind of taking the chance aspect out of finding research projects. I think us as medical students and you know even all the way up to the you know residents, fellow, faculty level can speak to the fact that it can be hard to find a good research project sometimes even though you have you know an abundance or willingness and you have the skills. So thank you for that. Next I wanted to kick it over to our vice president of community engagement Raj Reddy and see what he had to say both about community engagement and some new initiatives he's been heading up during COVID times and recently.

Raj: Sure thanks Adam, so hi everyone my name is Raj I’m the new vice president of community engagement for IHI chapter at Baylor. So actually this isn't a completely new venture for us and we haven't really had a community engagement portion of our chapter before so this is kind of a really novel experiment they're trying to do. But essentially this is kind of our venture into public health quality improvement, which essentially has a lot of the same principles as regular quality improvement that we think about, but deals more specifically with kind of the social determinants of health and how they affect our patients health care and access to care. As well as kind of the additional component of being especially resource strapped in the public health field and really having to use resources and personnel wisely to ensure that we're serving our population the best. And so essentially we've been trying to with this role we've been trying to take a lot of things we've been doing in our IHI chapter but really go out into the community and really try to improve the actual health of our patients in the Houston and Harris county communities. And so essentially that involves working with a lot of our publicly funded community agencies as well as our charitable nonprofits that really fund, for example clinics or health education or other initiatives like that, for patients here in Houston and Harris county. And so actually our work in this area is kind of derived from the IHI national recover hope campaign which ran for a couple years but ended officially this previous year although the work is still ongoing, but specifically focused on substance use disorders and reducing the prevalence, as well as the disparities and the negative outcomes we're seeing with those issues over the last several years, specifically in the opioid crisis but not exclusively opioids and also the full range of substance disorders. And so with that program we actually under our previous presidents started a seminar on motivational interviewing with a focus on using that technique for substance use disorders with patients. And kind of from that seminar, which we're still conducting as a chapter today, we've kind of branched into this whole area of community engagement and how it can really bring again, how we can really bring a lot of those QIPS HVC techniques into the community arena. So in this area I do have some overlap with the research pillar under parth as well as our education pillar under Anje, and which you can ties back into our folk library perspective on QI work because a lot of QI efforts whether they're at an individual hospital or clinic or across an entire health system still involve a research component. We still need to collect data, analyze it, and see whether or not it's working and then revise our plan if necessary. And that's basically the essentials of a PDSI cycle that we do at IHI and QI all the time. And so that's one component, but also the education pillars like I mentioned before, we're still considering our MI, motivation interviewing, seminar we're also seeing other areas that might be particularly underserved or neglected in in current health professions curriculum. Like, for example end of life care, how to fill out an advanced directive, how to fill out a psychiatric advance directive for patients with serious mental illness. Those sort of aspects that still have a very clear connection to improving health care outcomes but may not be in our traditional curriculum already.

Adam: Well thanks Raj I really appreciate that. As someone who's been to the motivational interviewing workshop a couple times at this point I can attest to the fact that it's served me, well you know on the wards. It's just good overall information to have as both a you know medical student and a human being, and i'm excited to see what we continue to do with the community engagement wing of IHI. So next I want to talk about our pillar of education. My name is Adam Floyd and I'm one of the co-presidents of IHI and I’m standing in for Anje Batra who's our VP of education, he wasn't able to be here today. But just briefly about our education wing, Raj already mentioned the motivational interviewing workshop, we do have several workshops that are aimed at really all levels of medical students’ education. We have motivational interviewing, plan do study act cycles, root cause analysis, handoffs, process mappings, and several others. Additionally, we do have several electives, both pre-clinical and clinical electives. Most of these, both the electives and the workshops are you know interactive. They have a practical component and we try to leave attendees with action items that they can use you know either on the wards or in life in the near future. One thing I wanted to talk about, we kind of brought up what is our most important or maybe our most useful workshop for an MS1, and in my opinion I think that might be motivational interviewing. Though I'm a huge fan of all our workshops, motivational interviewing because as an MS1 I so often found it difficult to have conversations with patients about substance abuse or weight loss or really any of those touchy topics where you're trying to lead a patient into, you know a direction that you know is evidence-based and will improve their health care. So motivational interviewing gives you a set of tools to do that. Another question I wanted to bring up, or another statement I guess, is what is the most useful on rotations, or what's a workshop that you've used on rotations? And for me that would be the handoff workshop. So handoffs are kind of transferring care from one provider to another, and we do have a handoff workshop where we work on doing that in an evidence-based fashion, and under that framework I’ve, on wards several times caught little details that later helped me with my differential or patient management that I would not have otherwise caught. So like I said we do have those workshops. We have several electives and then as Parth mentioned we have a QI research conference every year where we have about 90 researchers come in really from all over Texas to present their QI work, and so I think that's a great opportunity for medical students both to network and to you know show off the great work they've been doing over the course of the year. So those would be our four pillars like I said, mentorship, research, community engagement, and education. So thank you so much to the VPs for talking briefly about each of those.

Erik: Yeah, no that was great, especially again as like I said somebody that doesn't know quite as much about all this as obviously all you do, the mini-series in general helped me learn a lot about this and all the workshops you just talked about. I mean it really does serve as a great resource to just better yourself generally as a physician, or a physician in training, because they're all just skills that you're going to need to be really good at. Handing off, you need to be really good at handing a patient off because like you said a lot of errors can happen there, so it's great. 

Adam: Yeah, yeah definitely and you kind of you kind of touched on it earlier that all of us come into medical school wanting to you know follow the Hippocratic oath wanting to prevent error, wanting to provide benefit, that kind of thing, and quality improvement is just kind of intrinsic in that. So one thing Anoosha, my co-president, likes to say is that we're all interested in QI, some of us just don't know it by that name yet. And so i'm a big fan of QI work here at Baylor.

Erik: Definitely yeah it's like you can apply it to anything, just it seems to me, and correct me if I'm wrong, it's just a way of thinking about something. Like breaking it down into a discreet amount of steps and then deciding like, is this where the error is happening, and if not..or if yes then we need to improve something here.

Adam: Exactly and that, what you just mentioned, that is our process mapping workshop. That's what we do. So yeah there are you know a variety of tools, it's kind of like learning to use Microsoft word or Excel or some kind of you know statistical analysis software. We all know kind of what we want to do we're just looking to give people the tools to you know kind of codify that and write it up and make it a discrete project.

Erik: That's great, well thank you so much everybody for talking about the org and kind of all the details. It's a great mini-series so I'm excited we're gonna tee it off now.

Adam: Thank you so much Erik for the opportunity, for giving us this platform. We're big fans of the podcast and what you're doing so thank you for that.

Erik: Without further ado here we go 

[Music]  

iTunes | Google Play | Spotify | Stitcher | Length: 43 minutes | Published: Aug. 19, 2020

The founding team of HTX CovidSitters tells us about the journey to establish a platform for students to help front-line workers during the COVID-19 pandemic. We talk about its conception, evolution, and challenges along the way. 

Transcript

Brandon: Oh it's recording okay oh we're here I'm Brandon Garcia one of your host today this is the Resonance podcast. We're doing a very special episode of CovidSitters, and along with me I have:

Anoosha: Hi guys my name is Anoosha, I'm a third-year medical student at Baylor and I'm going to be the co-host for this episode.

Leia: Hi I'm Leia Tarbox, I am a second year PA student at Baylor College of Medicine.

Hannah: Hi my name is Hannah Mayer I'm also a third-year medical student at Baylor, and I am a COVID sitter.

Katie: Hey guys I'm Katie Naegar I'm a second year here at Baylor and I am helping out with the CovidTutors.

Sophie: Hi guys! I'm Sophie. I'm a third-year medical student at Baylor College of Medicine. I'm the founder for the e-Cards for Seniors program as part of uh HTX CovidSitters.

Brandon: And I am extremely excited to be talking to you guys about CovidSitters. We had an earlier episode with Anoosha, and that went super great with her, and Madhushree and Aanchal. They were awesome, so I'm super excited to hear what you guys had to say right now.

Anoosha: Yeah that's awesome, so let's kind of get started. Leia would you mind sharing with us like what is HTX CovidSitters?

Leia: Yes so you've already heard from Aanchal and Madhushree with the previous podcast but CovidSitters is students that are supporting health care workers during this COVID-19 pandemic. So it started out small, and now has gotten to this wonderful big volunteer group of almost 150 volunteers helping 40 health care families. So we're trying to support Houston by helping manage their households and offering tutoring services and child care services. So we know that schools have closed and there's been increased work demands on health care workers and with social distancing has been tough to find childcare and just health household management for our providers.

Anoosha: That's awesome Leia. And can you tell us, what's your role specifically?

Leia: So I'm part of the exec board that reaches out to students and helps manage and connect health care providers with students. And like it was said, I'm a PA student so I’m able to kind of reach interdisciplinary-wise in Baylor College of Medicine 

Brandon: Wow how quickly were you guys able to get up and running and helping these people?

Leia: it was actually pretty quick. I was very impressed. It came as a brainchild from some of our wonderful med students, and with help from a program up north we were able to have a good blueprint for getting it started down here. So there was a similar program in the Twin Cities, and they had a meeting with us and gave us all of their work that they had already done including a Google Form that students and healthcare providers could fill out that helps us to match students and healthcare providers.

Anoosha: That's awesome Leia! So we know that the program started as kind of household help and dog sitting dog walking, household management type services, but we have expanded over time can you talk about some of the other services that we offer too?

Leia: Yeah absolutely and I know some of the other people in this podcast will do a better job talking about it! Yeah like you said, we did dog walking errands and grocery shopping on top of childcare but it is now expanded to tutoring services as well as providing e-cards for seniors who are trapped in their nursing homes and don't really have family that are able to come visit.

Anoosha: That's really great I'm hoping we can hear from one of the volunteers
themselves to talk about their experiences. Hannah are you are you with us can you talk about what it's like to be a CovidSitters volunteer?

Hannah: Hi sure I think that being a COVID Sitter for me definitely started with when we did get pulled out of clinics you know all of us are one of the want to be helping people and right when the state home order hit, my half uncle had actually been really struggling because he's a four year old and he and his wife were having to work from home and he was just talking to me about how hard it was to work for home with a four year old, and so then the CovidSitters, you know, I saw post online about it and I signed up because I thought that, you know, I just know why and I you can tell how helpful it can really be to households and so for me he that looks like in Houston I've been hired with a family and I am in a pod with four other volunteers and we take care of a two-year-old together which is super fun. He is a jewel way to hang out with and definitely keeps us on our toes. And it really allows both of his parents who are physicians to do their daily activities whether that's go to clinic or you know do research or see patients whatever it is it allows them to do that knowing that you know their son is at home hanging out and someone that's not them is watching.

Brandon: Yeah I was gonna ask that are you guys actually physically go into people's homes in providing this care or is there some way of doing it like contactless how does that look?

Hannah: I mean unfortunately kids are you can't really be contactless. They definitely need supervision in a place that's safe for them. And a lot of times too with these kids, you know their schedule has been incredibly disruptive. And we know that kids can thrive having a schedule they get to follow every day, knowing what to expect, and so for kids this is just as challenging of a time as it is for their parent counterparts. So I believe the majority of situations, the student volunteers are going to houses and doing childcare within that house. And that's I think one of the thoughts behind having these pods where you know it's the same students just going to this one house our household, so that we're not kind of exposing extra people to you know new environments and stuff like that. 

Brandon: Yeah how do you guys are sure that you're not like passing along the virus or anything like that? You said you go to the same house repeatedly are there any like guidelines you guys follow outside of that to make sure that you stay safe particularly? What do you all do there?

Hannah: I wouldn't say that there is any kind of overarching you know thought process besides just use your common sense. So that means that you should be doing all the social distancing measures that everyone else is taking when you're not at your CovidSitters house that means washing your hands when you get there, when you leave. That means you know wearing a mask if you leave the house, and it means that you're just you have to be extra thoughtful because you know that not only your actions impact yourself, but they're going to impact the family that you're also taking care of. 

Brandon: Yeah I imagine that that kind of has to weigh on you a little bit. And I reason I asked, I have a three-year-old myself, and I would love in fact I do love any moment that he gets to spend talking to his grandma or his Grammy and those moments are very precious. I just want to let you know like from a parent's standpoint like this what you guys are doing is absolutely amazing. And I can't imagine the amount of sacrifice and time it takes for you guys on like an emotional level to stay safe for yourself and for these families and to that take the time out of your day. Because I am sure that your lives even though you're out of clinic has not really slowed down because you're still preparing to become a physician.

Hannah: Thanks I mean I think one of the really fun things about this is that you do kind of see that impact. For instance, the family that I was working with, our kid’s main babysitter was his grandma before this kind of all started, but you know she's older she had other health problems and you know that's a situation where the parents were concerned that since they were still a little more active as essential workers they were really nervous that she was going to get sick. And so in that way, I think CovidSitters was really able to help this particular family kind of bridge the gap and get to a place where they could keep everyone in their family kind of as safe as possible.

Brandon: Awesome and like how long at a time are you guys there? Are you there the whole day or just for a couple hours?

Hannah: You know the twos are really a fun time because kids are really pushing boundaries, so that's just a whole other time to really be focused on them. But it does mean that we really did two shifts a day most of the time and they would need childcare anywhere from probably
six to eight or nine hours. And so I normally went for either three and a half two and a half three and a half or four and a half hours I like going in the mornings because that's just what I like to do. And then there was always an afternoon shift, and normally you know he would take a nap at some point in the afternoon and we were just kind of be there to tide over between when his parents were doing the online the telemedicine or you know having to go to clinic for the afternoon. We would just be there for continuity.

Brandon: I think this is this is really cool did you guys run into any problems we initially set out, and maybe you don't answer this or maybe someone else can but was there any concerns with like child care and things like that? Because I know like teachers and daycares and things like that they have some rules and regulations that to make sure they follow in terms of child care. Was that ever a concern or is that something that the organization is gonna have to worry about in the future as this continues? That was just something that popped in my mind.

Leia: I can answer that if you want.

Brandon: Oh yeah yeah.

Leia: So there's this is Leia by the way. There's always going to be complications like that, I mean we all work in health care so we know not everything is black and white. The wonderful thing is that because people work in health care or because you've been students and you know that things can mess up everyone has been really flexible and understanding. It was nice because all of us are in a graduate program, and so we've had background checks we've had our BLS cards and we are more comfortable with caring for children if they were to get hurt as well too. So although things aren't perfect, those were nice added bonuses to being students for the safety aspect there. And then yeah, as well as the pods, it was difficult because some parents were concerned about having pods of students, but being able to do pods helped our students not get burnt out and also helped us keep our students safe. We did try to pair roommates together for the same household. So on top of keeping the same people going the same house every day, it was also people that live in the same home traveling to the same home. So while everything wasn't perfect, we did our best to make sure everything was safe for everyone involved, but also not too time-consuming.

Brandon: Wow that's actually really smart. I didn't think about that. That's a good move on y'all's part to minimize the exposure there.

Anoosha: Yeah and Leia while have you, where do you guys see the rest of CovidSitters going? Do you guys have like a timeline of that?

Leia: Good question. I don't think anyone knows the timeline of COVID-19 as a disease. I think that we will have to continue to be flexible with how this moves forward. A lot of us students are actually starting back on clinicals May 26, myself included. So that makes it difficult too, and we won't have volunteers anymore. The positive thing is that a lot of our first-year medical students and PA students volunteers. Some of them are doing online classes, so things are being done through video. And that might help us, as well as some amazing undergraduate students and people from other programs around the city who have been volunteering to help. So again, not entirely sure what this looks like moving forward, but we do have some good support and some excited people in our community - not just grad students from BCM.

Anoosha: That is so cool well Hannah and Leia thank you guys so much for all of that kind of insight. I feel like we all have a much better understanding of what it's like to be a volunteer and kind of what it was like to kind of sift through the challenges and work through that too from the sort of administrative side.

Leia: Yeah absolutely thanks for having us!

Anoosha: For sure! Hey Brandon would you like to hear about the CovidTutors program?

Brandon: Would I like to hear about the CovidTutors program? Absolutely!

Anoosha: That's awesome! So hey maybe I'll jump in myself and kind of talk about this one. So we heard from Hannah, Leia, Madhushree, and Aanchal already, those were some of the people who are really instrumental in getting CovidSitters kind of up and running. Early March, when I saw their posts, I kind of got thinking because something I was involved with in college was tutoring or mentoring high school kid. And I was just kind of thinking during this time, kids like Hannah mentioned their schedules are getting disrupted they're not able to go to school having to transition to online curriculum, not to mention all the work that the teachers are suddenly very quickly and rapidly transition everything online so have them thought what if we kind of partnered with CovidSitters to add a little branch that we call CovidTutors. So what CovidTutors is a virtual tutoring service that is a socially distancing approved way to tutoring K through 12 students. And so basically we have a very similar volunteer pool to the CovidSitters to begin with but students can specifically sign up for tutoring anything from kind of grade school social studies and ESL courses all the way to AP physics and calculus. So we have like a we have a wide breadth of really awesome volunteers that are all grad students so a lot of them have taken sort of the entire range of grade school classes, and so everyone was quite happy to help with that as well.

Brandon: I think this is awesome. I actually have a cousin who's a freshman in high school who basically, as her mother put it, they went on spring break and then never came back and it's been tremendously hard. I think this is awesome but, how did you guys like get the ball rolling there?  Where did you find students to teach, how does that look? 

Anoosha: Yeah, for sure, so our recruitment process for volunteers was kind of similar to how we recruited volunteers for CovidSitters. We kind of advertised through our own group Facebook pages, Leia and other people helped us reach out to PA students, nursing students, dental students, grad students at Rice University, to kind of gain that interest. And man those sign ups, like they filled up quick. We have so many volunteers. We have more volunteers than we have placed. Which is incredible. 

Brandon: So what you're saying is you really would like some more people to tutor. 

Anoosha: Yeah, I think so. What we did to recruit students...now this is difficult because we have students who tutor, and the students who are tutored.  

Brandon: So the tutored and the tutors.

Anoosha: yeah, that's a good way to put it.

Brandon: The tutorees.

Anoosha: The tutorees. We also went about recruiting by sending out emails to listservs just for as far as we could really. Whether that was our own kind of physician leadership that we'd come in contact with through our clinical rotations or just, you know, other contexts that we've made whether nursing or administrative and just ask them to send the email far and wide because our goal was to just try to try to reach as many kiddos as we could to be able to tutor. So that's how we kind of did the recruitment.

Brandon:  And how many students or tutorees are you tutoring each week now?

Anoosha: Ooh that's a good question. I don't know if I have a good number for you. I'd have to go back and check about that.

Brandon: Oh that's okay.  I was just wondering if you could give me, like a ballpark. Is it two to three people per week?  Or 500?

Anoosha: Not 500 per week.  I would say we probably do maybe like 10-15 sessions a week.

Brandon: Oh wow.

Anoosha: And it's a similar process and we'll get to hear from one of our awesome tutors soon as well, Katie.  But it's a similar process where we have a couple of students, maybe two or three that are assigned to a particular family just to be able to switch off. And sometimes, you know, if a tutoree or the tutored kids want, you know, help with French and math, then maybe we have a grad student who, you know, took French and is comfortable tutoring that and another one who is, you know, is like up to date with their geometry and is more, kind of, happy to help with that. So we try to pair the interests with, kind of like, the expertise of the volunteers.

Brandon: That’s awesome.  Have you guys reached out, maybe, to the school systems around or anything like that to see if they had students that they knew would need help?

Anoosha: Yeah, so that is something we had tried to do with, kind of, limited success.  We’re still kind of working on figuring out the right channels of who to reach out to within a school system or a school district just to get through that kind of avenue as well.  We know finals are kind of coming up so we imagine there could be students that could maybe desire some tutoring.

Brandon: Oh absolutely.  And is it just K through 12, or have you guys branched out to any, like, college students or anything?  

Anoosha: Yeah, right now we kind of focused in on K through 12 because that was something that we knew we would be able to, you know, most of our grad student volunteers would be able to help with most of the subjects of K through 12 as opposed to maybe some of the more specific courses in college, but it's definitely an avenue that we could pursue if we find a need.

Brandon:  Yeah, I was just wondering.  I love this concept of tutoring because there's just, especially, when you're forced to go online like this it just doesn't work for some people. Um I've spent a lot of time in the last six months trying to figure out how I learn and I'm definitely one of those people that just can't sit and read, which is what a lot of these things happen with online. So I think the fact that you guys are coming in tutoring and stuff like that I think that's a wonderful opportunity to help people continue to learn. Are these sessions online like how are y'all coordinating the actual, like, tutoring sessions themselves?

Anoosha: Yeah that's awesome, and I think I'm going to punt this question over to our awesome volunteer tutor, Katie.

Katie: Yeah so hey guys. Most of the sessions that we host are our online sessions and each of them look a little different because each day in the life of an online student I'm sure is a little different. So kind of similar to the way that CovidSitters is set up there's about two or three of us in a group that are serving one student that is a need of tutoring, and we get to go back and teach ourselves in ninth grade for our tutoring. So we have a couple different subjects. We have physics,  we have algebra, we have some Spanish, some SAT vocab, all the good stuff from ninth grade that we get to go over and I probably tutor about two or three days a week for about an hour or two.  And it's been a ton of fun. I just start off by asking, you know, like what classes did you have today? What did you learn at school today? How long did you go to school today? What work do you have? What can we go over? And it's provided a very intimate look at how different these students lives are now that they've moved online, and how different their education is, and how different the resources that I have to teach themselves this material and  to learn this material really look like. And I know personally I've gotten a lot of gratitude both from my student and from my family of how helpful this tutoring has really been, and how necessary it's been for them, and how difficult the transition was so it's been really great, to kind of get to see that up close and to be a part of that and you know to get a refresher on SAT vocab is never a bad thing. 

Brandon: Amen to that. Yeah, well, I'm just going to say if you're as half a good of a SAT tutor as you were, as like, an Anatomy Pinky Pinner, these kids are in really good hands.

Katie: Aw, thank you. 

Brandon: Yeah shout-out to you and all the other former pinky pinners for helping out us all through Anatomy.

Katie:  I would say I was really lucky that this existed because teaching is something that I am very passionate about, that I really love and enjoy. So this really doesn't seem like I'm sacrificing a moment of my time to do this, it just is another opportunity for me to get to do something really cool and something I really enjoy. I don't even think I saw it for a second when I saw Anoosha’s post about volunteers, I think I just immediately signed up and then bombarded her with questions on how I can help and what we can do too to get this project up and going because I just thought it was awesome. I thought it was such a cool idea and it's very clear from the people I've interacted with just how impactful it really can be to some of these students lives just to have someone walk through this transition with them and spend an hour or two a day going over some vocab words.

Brandon:  And that's, that is amazing. That honestly warms my heart as someone who has struggled with school in the past. Who's also been a tutor in the past, to know that there's people like you and Hannah and all the other volunteers who have this heart and compassion towards people. I think that's something, I think, maybe we could all agree is like at the heart of medicine and caring for people. So really, thank you for sharing those insights.

Katie:  Yeah, of course. I'm happy I get to do it.

Anoosha:  Yeah, that was awesome, Katie. Thank you so much. Do you have any other, kind of, thoughts you want to share or any favorite memories from tutoring you want to share?

Katie: Oh, I think I definitely have a favorite memory. A few weeks into tutoring my student and I  always, like kind of, started off you know he had to, like, figure out how to interact with me. He was always a little shy. Kind of had to pull some teeth to get some answers out of him and then probably a week or two in, you could just tell he started to get more and more comfortable, and we got to joke around a little bit more. We had to mix up some tutors, some people's schedules didn't work out and so we added some new tutors and I was explaining to him that another one of my friends was going to get to tutor him the next day and he just looked at me and he's like, “Oh I want you to tutor, like I want to see you tomorrow”. And it was just, like, the most heartwarming moment to see that like personally you can influence someone's life that way. I thought was just like all the justification you need.

Anoosha: That is super heartwarming.

Brandon: Yeah.

Anoosha: Mm-hmm. 

Katie: And of course he loves the other two tutors too. He came back the next day and he was like, “they were awesome!”  It was just a really cool moment.

Anoosha: That’s great, Katie.  Well hey, thank you so much for joining us today and sharing your really thoughtful and heartwarming insights about all this.  Brandon, do you want to talk to Sophie about the e-cards program? 

Brandon: Do I? Hey Sophie! Tell me about the e-cards program.

Sophie: Yeah, sure! Um so, the e-Cards for Seniors program actually came about because I was working on a research project about how older adults in our community were adapting to the pandemic. And, at the time, CovidSitters was already doing so much to help the community with household and the tutoring program, but I felt like we were neglecting a huge part of the older adult population, especially those like Leia mentioned who are in nursing homes, and they were no longer allowed to have visitors. So, we wanted older adults to know that we were still thinking about them during this time, so um I reached out to Madhushree and Aanchal, and we came up with the e-Cards for Seniors program as a safe way to bring older adults some joy and hope um during this time. Um so our volunteers um what would happen is they get like a PowerPoint template from us, and they can do like a personalized message for the resident. They can include some Sudoku or crossword puzzles on the card. Um some people included like a self-care bingo that the older adults can do throughout the week. Um some people have also included like their own artwork in the card. And so once they finish making the card, they usually send it back to me as a PDF. And then every Friday, I send a batch of cards um as an email to the nursing home coordinator, and then they print it out and distribute it to their residents.

Brandon: Wow. So what's uh, what's been the feedback so far from people that have received these cards?

Sophie: Yeah so, so far uh we’ve had pretty good feedback from the nursing home coordinators. Um they say that our cards are really cute and that the older adults have really enjoyed getting cards. I feel like when you're um an elderly, and you get mail, like they always get super excited, and it's wonderful to hear how just like one card can really brighten their entire day. And so, I think that really warms my heart knowing that even one card can make a big impact um to someone during this time. Um and so far, we've delivered over 300 cards, and I think um next Friday will probably be the last batch of cards that we'll be sending um since we have to restart clinic on May 26, but um so far uh our recipients have included residents from St. Dominic Village, Colonial Oaks on Braeswood, um residents from Bayou Manor, and Holly Hall.

Anoosha: That's awesome! So, it's really like kind of a local thing too, like really kind of um sending the cards to places where we see everyday, and uh I wonder and I hope that you know people will kind of notice them more from now on after, now that they've heard the names and kind of understand that who the people are and kind of have a relationship with.

Sophie: Yeah, yeah. I think we definitely started out local cause actually initially like our initial idea was to actually hand-deliver the cards, which is why we looked for nursing homes or senior centers within uh like the TMC area. But then, when I was discussing it with Madhushree and Aanchal, they said that a couple you know like um the virus can be left on cards for x number of days, like we don't really know what their protocol is. And I think just for you know um safety measures, we that's why we decided to transition into like the e-Cards thing, but we still uh decided to send it to the nursing homes that we had already like reached out to.

Brandon: Okay, um do you guys, is it just one e-Card that you send to a resident, or has there been any kind of like dog-dialogue or more of a longish term relationship develop with any residents?

Sophie: Yeah so, funny you mention that because (laughter), so e-Cards for seniors had like a some multiple versions, but like uh one of the things that we had initially talked about was actually doing FaceTime with the residents. Um that was our initial idea, but we ran into logistical issues because not every senior had like a phone or a capability to do FaceTime overtime, and um that a lot of the older adults were also getting a lot of scam calls, so it wasn't safe for them to do that. Um, but we did want to do like FaceTime as like a continuous thing, uh but with e-Cards like so far right now, we've only been able to send like one card to every senior. It hasn't been really like a back and forth thing because the resident hasn't really seen who we are, and I think it’s hard to establish that sort of connection and trust when you haven't actually met the person. Uh, but I think for me, what I would like to see come out of this program is like hopefully when Covid is over, we can transition this to something like an “Adopt-a-Grandparent” kind of deal where our volunteers can send an e-card to the resident that they were paired with every month. So then, they would be able to establish a more long-term relationship um and then hopeful-hopefully keep this going on even when Covid is over.

Brandon: Yeah, that would be awesome, and I think we're gonna want to talk a little bit more about that with everyone in here in just a moment um, but tell me a little bit more about what the volunteers do, how do they help um get this word out to the seniors who are in need?

Sophie: Mhm, so um maybe I- I'm usually the one in charge of reaching out to the senior home coordinator um, so all of the information is more centralized, but if anybody had like knows of a place that they want to you know help or send cards to, then they can just um let me know um and then I'll reach out to see how many residents they have at the center. Um and then when our volunteers sign up, they say how many cards they're able to make, and then I pair them with the number of residents that they can make cards for. So, our volunteers I guess they don't really have to do any of like the logistical stuff. I think it takes a lot of time already to make a very personalized card, and I think our volunteers put in a lot of time and effort to make it really great for the seniors, so I try to take up more of the boring logistical tasks in terms of like reaching out and coordinating, and our volunteers is mainly just like the creative side of the card.

Brandon: When you say personalized, what do you mean? Like do they actually get to know a little bit more about these residents and find stuff that's more meaningful to them? Like what goes into those cards?

Sophie: So some senior centers um, they were able to give me like the first name of the resident. Some people were um didn't want to share that information, so for the ones that did share like the first name of the resident, then the card would be specifically addressed to that resident. And in the card, we would kind of talk about ourselves you know sharing that um you know we're a medical student, we're thinking about them, some of our own hobbies like what are we doing during the quarantine...Some people have said that you know they've been really enjoying spending time with their cats, and they've included personal photos of their cats you know. So not really I guess knowing what the residents are doing at this time, but sharing with them like what we're doing during this time um kind of how we're dealing with the pandemic and even though it's a hard time that we're still thinking about them and that we hope that this card with the games and photos that we provide can bring some happiness like during this time for them as well.

Anoosha: That seems like a really neat way to you know make sure that we're respecting privacy but also kind of giving a little bit of a personal real touch from our end too. That's great Sophie.

Sophie: Yeah.

Brandon: Yeah, I think that's really cool. I mean cause it would be I mean theoretically it'd be super easy for someone to make just a generic card and then send that out to everybody, but the fact that you put a personal touch to it and you have volunteers that take the time to let these people into their lives even if they don't maybe aren't there maybe they're not able to learn everything about the person they're connecting with, I think that that speaks volumes to the humanity aspect of it - the fact that like you said that you know we're real students, real people who actually have a real care for other people. 

Sophie: Yeah uh.

Brandon: Yeah, and I think that's an awesome way to do it.

Sophie: Yeah, you’re totally right! And I think um like some of the coordinators have even told me that you know after all of this is over like we would love if your volunteers could come over and play pi-bingo or do arts and crafts with our residents and maybe even meet you know meet your resident in person. And I thought that that was such a nice gesture because I think it really kind of like you mentioned, it kind of closes the loop and offers that sort of continuity with our program. So, I think um I would really encourage my volunteers who've made cards when all of this is over, it would be nice for us to go to um the senior center and the nursing home and do a little something for them in person.

Brandon: Yeah, that would be amazing.

Anoosha: Well, Brandon it sounds like we've heard from a lot of really great, kind of, student-bred outreach organizations today and some great volunteers who had some awesome stories to share as well.

Brandon: Yeah this has been awesome. I'm really grateful that you were able to reach out and bring these people in the podcast because I cannot stress this enough that this is absolutely amazing. I mean honestly you could have all, could have just gone home, sat around, playing Animal Crossing and just kind of waited this out, but instead you found ways to help and reach out to the community. And I think that speaks to the to the integrity and caliber of students in the healthcare professions. I know we asked Katie this question about what was your favorite part of this whole process, but I want to, kind of, open that up to everyone.  I kind of want to hear more about what has been the most amazing part of this or what you learned.   

Hannah: Hi it's Hannah. I can share one of my most memorable moments from the CovidSitters. So obviously there are a couple of us that are in the same pod and one of my favorite things to do everyday would always be to ask the two-year-old that I was babysitting, “Who are you excited to see this afternoon? Who do you think is coming?” And he, I mean, he's two, but at the end of the day he actually knew all of our names. He would ask who's coming next.  He would ask, you know, do I get to see my friends you know “so-and-so” today. And one of the funniest moments was when he kept asking when he was gonna see “Puff” and I was like okay he's two, is “puff” the name of his dragon or like the name of, like, one of his toys? I was really confused and it turns out his mom was telling me that he had renamed one of the CovidSitters that would come and see him, “Puff” because they had such a good time together. And so I just always thought that was so hilarious the sitter's name had nothing, wasn't even close to Puff, but it was just sweet that, you know, even after only, yeah this was pretty early on in our time there, he would get excited really to hear about who was coming next and which one of his friends was gonna come. And for someone, you know, when I first showed up on the first day he was like not interested in why I was there or who I was, and by the end it was just comforting to see that maybe we had brought like a little bit of normalcy back into his life. So that was probably one of my favorite memories.

Anoosha: That’s awesome, Hannah.  That’s a really cute one.

Brandon: Absolutely.  On that note, can anyone talk about the role that the faculty at Baylor has had in supporting this?  I mean, we’ve all seen emails from different faculty members about this, but how has Baylor been able to help facilitate this initiative.  

Anoosha: That’s a great question. Yeah, we’ve had some really good support from our Student Affairs deans who, kind of, were with us every step of the process to get the program approved through the appropriate channels whether that be, kind of, you know, making sure we have legal considerations figured out or, you know, even getting the word out themselves to their faculty and staff in their departments.  So they’ve been really instrumental in, kind of, making these programs possible.  Definitely.  And faculty themselves have been quite supportive.  

Katie: Yeah, I helped Anoosha a little bit reaching out to some doctors that I knew in the community or at different hospitals to just try to help spread the word.  And every single time I was met with a really enthusiastic like, “Yeah!  Can I share this on a Facebook page of every female physician in Houston?” Like, “Yeah, can I share this with all of the TCH departments?”  Like, everyone was so, like, appreciative and so onboard and so supportive.  I even had one residency director offer to provide pay for a couple of sessions for all her residents and a gift for them working during this time.  And then she came back and she was like, “Oh my God, I just realized this is all volunteer-based.” 

Brandon:  That’s really cool.  The reason I ask is one of the groups that we plan, we hope to catch with this podcast are people who are considering Baylor for medical school, graduate school, or any other of the healthcare professions. And I think this is just an amazing opportunity to show 1) just how awesome students are here, and 2) how awesome faculty are with backing us up with this kind of thing.  And you guys maybe can have a different opinion, or add a little bit to this, but I think it’s times like this that show why Baylor is such an awesome institution. 

Anoosha: 100% agree.  Just a huge shout out to all of our speakers who joined us today for the podcast.  Leia, one of the executive board members of CovidSitters, Hannah, one CovidTutors of our awesome CovidSitters volunteers, Katie, one of our awesome CovidTutors volunteers, and Sophie, the founder of our ecards program.  We really appreciate, like, having the chance to talk to you guys and hear a little bit more about, kind of, the personal side of things, and you know, what you’ve gotten out of it.  And it really means a lot to be able to hear that from you guys and for you to share that with us.  So thank you so much for joining.

Brandon: Yeah, absolutely.  Thank you, guys.  I really appreciate y’all taking the time to come talk with us today and for sharing your amazing stories.

Leia: Thanks for having us!

[Music]

iTunes | Google Play | Spotify | Stitcher | Length: 30:38 minutes | Published: Aug. 5, 2020

The founding team of HTX CovidSitters tells us about the journey to establish a platform for students to help front-line workers during the COVID-19 pandemic. We talk about its conception, evolution, and challenges along the way. 

Transcript

Brandon: And we are here. This is one of your hosts Brandon Garcia. I’m joined today with our guest host Anoosha Moturu.

Anoosha Moturu: Hey guys

Brandon: As well as two of the founders of HTX CovidSitters. We have Madhushree Zope and Aanchal Thadani. How are you guys today

Aanchal: Great how are you?

Brandon: Doing great as good as one can be stuck in a closet. So today we're going to be talking about this wonderful organization you guys have started here helping out, from what I understand, health care professionals and all kinds of people throughout the Houston community. Is that correct?

Aanchal: Yeah, we are looking to serve every person who works in a clinic or hospital setting and some of our branches also go beyond that.

Brandon: That's so awesome. I just can't explain how excited I am to hear you guys talk about this. I think it's an amazing thing that y'all are doing. But before we get into that I was wondering if everyone would be able to give an opportunity to maybe introduce themselves, talk a little bit about maybe their background, and what inspired y'all to get involved in this way. So let's go ahead and start with Anoosha.

Anoosha: Yeah hey guys my name is Anoosha I'm a third year medical student at Baylor College of Medicine and yeah I'm here to help kind of facilitate our understanding of this awesome organization today.

Brandon: Thank you and Madhushree.

Madhushree: Hi this is Madhushree, I'm also a third year medical student at Baylor so Anoosha is one of my wonderful classmates and she's also part of our CovidSitters' admin team. I initially heard about CovidSitters through Minnesota which is kind of how all of this started, but I guess we'll get into that a little bit later

Brandon: Okay and Aanchal?

Aanchal: Hey I'm Aanchal. I'm a first year medical student at Baylor College of Medicine, so I'm very grateful to have wonderful third-years around me to help Madhushree and me through this process. I originally started it with the help of Madhushree and my team. I think that mostly because we were looking for a way to really lend a hand with all that's going on, but I'm sure we'll get into more of that I think as we move forward.

Brandon: Yeah absolutely and again thank you guys for taking the time to sit down and chat with us today. I guess without further ado Anoosha take it away let's see what they've got to say 

Anoosha: Yeah for sure, so today we're going to kind of focus on how you even kind of started this awesome community service initiative. So we’ll kind of start with some info about that. So how did you come up with this idea to start CovidSitters in the first place?

Madhushre: So we initially started off as just an excel sheet which Aanchal started. I think she can talk a little bit more about how she got the idea to start the spreadsheet, and we'll go from there.

Aanchal: Honestly, it was through listening to, well I guess watching, people talk on Twitter - mostly our teachers and our professors at Baylor - speaking about some of the challenges that they were facing while having to work so hard during this this particular and very strange time that we're in, and I was also watching some peers from around the country lend a hand in various ways. And this excel sheet was simply a way of perhaps gathering resources so that residents and doctors could look to it and perhaps reach out to students that way. Yeah it was supposed to be something that was very simple and somewhat quick.

Anoosha: That's awesome! So this Excel spreadsheet, is that how you kind of went about reaching out to volunteers from Baylor College of Medicine? And were there any other schools or places that you reached out to for volunteers?

Aanchal: In its very early stages it was just simply something that was sent out through groupMes and reached our peers that way. And it was quite popular in its first very few days a lot of our classmates and our peers were excited to join. But it was somewhat limited to Baylor because it was quite ad hoc. It was more ad hoc than what we have and nothing was really streamlined.

Madhushree: Yeah and I think going off of that, there is always this initial sentiment of at least the medical student community within Baylor wanting to help out our mentors and faculty who were working very hard on the frontlines of this pandemic which is kind of where the idea for the spreadsheet came along. And then I wanted to kind of generalize this sentiment that students were having all across the country towards the Greater Houston community which is why we kind of upgraded our platform to the website that we have today.

Brandon: That's awesome! Hey, quick question I forgot we should ask this but what do you guys actually do? I know it's called CovidSitters, do you do babysitting? What is it that y'all do?

Aanchal: Well we can walk through the evolution!

Brandon: Oh wow this evolved over time? Okay so would you start with?

Madhushree: So initially it was just household support which included everything from child care services to pet Sitting and errands like pharmacy runs, grocery runs, meal runs things like that and I think that's initially what the spreadsheet was based off of as well. Is that right Aanchal?

Aanchal: Yeah yeah, so it was intended just to be a place where providers could come and look for help for mostly their children was with the initial thought that I had.

Brandon: Mm-hmm and what what did it involve?

Madhushree: Since that initial thought, we've had a lot of classmates and colleagues from institutions across the Texas Medical Center want to join in on the effort and each of them have brought their own ideas as to how to grow our organization to address different needs within the Houston community. So I guess specifically speaking we've added our K through 12 online tutoring branch which Anoosha actually co-founded. She's kind of been the lead for that service arm and she's done a phenomenal job of kind of bringing together the K through 12 the community throughout Houston and trying to help them with the online transition to school that they're seeing. And then a third branch that we recently started with another classmate through Baylor College of Medicine was the E-Cards for Seniors Program. And this one was mainly born out of the concern that senior citizens who are currently living in assisted living facilities or nursing homes have been increasingly impacted by the quarantine and social distancing as they can't have as many volunteers in like contacts with the outside world as they're normally used to. So one of our wonderful classmates decided to start sending e-cards to residents living throughout the nursing homes of Houston. So that's also something that's taken off in recent days.

Brandon: Wow. 

Anoosha: Sure, and I think we'll probably definitely hear more about that in our next episode as well. So thank you for that awesome overview, but stay tuned for more details!

Brandon: Oh absolutely. Wow, I was excited before, but now I'm just like “this is awesome.” I mean honestly, hats off to you guys for this amazing work they all started and it's branched out into something huge and amazing

Madhushree: Yeah we didn't anticipate that it was going to be so interdisciplinary and involved, but it's really been humbling to see everyone come together with the same mission in mind.

Anoosha: Awesome so let's jump into figuring out like how you reached out to other volunteers from different schools and how having volunteers from different schools kind of helped you spread the initiative even further.

Madhushree: So when I was initially forming the I guess admin team for our group I reached out to Aanchal because she was the person who had set up the spreadsheet and we kind of collaborated from there. And I guess being at an MS3, I had a lot of contacts throughout between preclinical and clinical years and various other organizations that I’ve been involved in. So I had networks with the other schools in the area. And going into it the idea of course was to kind of spread this throughout the city of Houston, and with that in mind, we both recognized the need for a diverse volunteer base and then based off of that we started recruiting PA students into our admin team, as well as dental students, and then students from the School of Public Health at UT. So each of them kind of brought their own networks into this which is how we were able to quickly spread the word between all these different communities.

Aanchal: And it was really quite special to see how excited everybody was to be involved and to contribute to this particular project and they sort of brought their own energy, and their own ideas to what we were doing. So it really just felt like the whole of our community was coming together to help make this happen.

Brandon: Yeah, what other institutions are involved? Like what is the scope of this when you say that we've got a widespread community help?

Aanchal: So in terms of a volunteer base it is quite wide. I mean everything from UH law school, to McGovern students, to Rice Ph.D. students, we in fact also have a few a few volunteers who actually don't go to school in Houston, but I'd imagine are from the area and have returned because of the situation that we are now facing, and who are looking to volunteer in their home communities. And that is also similarly special to see 

Brandon: Wow 

Anoosha: That's awesome. So you guys did a lot of work to spread the word and gather volunteers from all over the Houston area. That's so cool to hear. How did you guys go about spreading the word to those in need?

Aanchal: This is where I think that social media and some of our established networks as classes and as schools came in hand. So once we were able to build an admin team that was that was fairly diverse and lucky enough to have some upperclassmen, Madhushree helping me and helping us out and had their own contacts, that we were able to by social media and word-of-mouth and through email really just have it be dispersed. And also I think what helped was when people heard about what we were doing, they were very excited and supportive and they did their bit to help us spread the word as well, so it was sort of this - there's a little bit of a wildfire effect through the community that we're trying to serve.

Madhushree: Yeah and to complement what Aanchal was saying, a lot of it was also based off of just cold emailing admin and faculty and residents in the different hospitals and health care systems throughout Houston. They were just very receptive to our platform and a lot of them were like yeah we'll send this to you know our higher-ups and we'll put it in our newsletters and disseminate it to the entire hospital system. So that was very kind of them to do and very special for us to be a part of 

Aanchal: And then that sort of same line, I think that we were lucky enough to receive some local media attention very early on, fairly early on in our in our endeavors, and so I think that was also quite instrumental in helping us reach some the wider community area in Houston.

Brandon: Yeah, I think Anoosha said something like you guys have been on TV. You've interviewed with like three or four different TV stations. Is that true? 

Madhushree: Yeah, we have been on local and national news outlets at this point and it's just been very interesting to see how our platform has spread kind of outside of the the borders of Houston and Anoosha can talk a little bit more about this in the next episode, but we're definitely also seeing needs from different states which we're trying to work on addressing at the moment. So the media has definitely been helpful in terms of making people aware that we're out here and you know trying to help.

Brandon: Right and y'all obviously reached the with being on the Resonance podcast. So forget CNN the Resonance is where it's at. Just kidding I don't know. I mean wow, that is, to see this blow up in like - how long have you all been doing this? Because I think I remember seeing an excel file like March maybe?

Aanchal:  Yeah, so the excel file went up about the first or second week of March, I would say between the first and second week of March, and then it wasn't until March 23 that we were able to get the website up and so it's been, I think - I'm trying to do math in my head right now - two-ish or three-ish month.

Brandon: And how many volunteers do you have? 

Madhushree: So right now, we're working with upwards of one-hundred and eighty volunteers, which is pretty amazing. 

Brandon: Yeah, that is fantastic. Yeah, I mean I've worked with nonprofits and stuff in the past. That was a big part of my undergrad, and to see this kind of growth in this short of time is absolutely phenomenal and I think that's just like has to do with the fact that this is: one, an amazing need that you guys have found a fill; and two, just the you've found tons of people that are willing to step forth to take the time to help out. This is just mind-boggling how awesome it is. 

Aanchal:  For sure, and it's also a testament to the community that we are part of because I think it's fair to say that it started off as me and Madhushree. But right now we have a large team of admin staff, and an even larger team of volunteers, and everyone really is here doing their bit, and is excited to do their bit, and that really does say something.

Anoosha: That's awesome, guys. It's super inspiring to hear how much success the program has had, and how you guys have really helped it kind of blossom and grow. But I'm sure it was not easy at all. Can you guys talk to just some of the challenges involved in getting this program set up and running?

Madhushree: Yeah, I think one of the main challenges early on was figuring out how to go from an Excel spreadsheet to a full-fledged website platform. In hindsight, it's pretty amazing that we were able to make that turnaround happen.

Aanchal:  In a weekend. 

Madhushree: Yeah, it was basically a weekend where we kind of pulled everything together, got the team together and had everyone like ready to go in terms of assigning volunteers to their shifts. So that was one of the earlier challenges - just like learning how to navigate the technical side of things and the admin side of things, but once that had been up and going it kind of flowed pretty fluidly and we've kind of just changed as the situation requires. 

Aanchal: I think just to add to what Madhuri was saying, that there were some particular challenges with making this a little bit more established and streamlined than simply a Google spreadsheet. Part of that was thinking about some of those potential legal implications and working with some fantastic peers and mentors at Baylor who helped us navigate that space, as well and make sure that we were doing the best that we could to ensure that our program, and our volunteers, and our families were safe. And working through some of those thought exercises as we move forward.

Madhushree: Yeah, and sorry tacking on to that as well - Well, I think pretty early on after we had launched our website on March 23, I believe, the stay at home order went out for Houston. We were kind of frantically in talks with admin and mentors from different institutions to figure out what that meant for volunteers and our families that needed our volunteers. But everyone was very supportive, very helpful and helped us navigate the legalese and behind the scenes to make sure that everyone could volunteer without getting in trouble, so to speak.

Anoosha: That's awesome. Can you guys talk a little bit about, so during this time we've had kind of like constantly changing and updating kind of guidelines and recommendations that we should all follow as a community. Has that affected the volunteering at all? And if it has, how did you guys kind of adapt to those changes?

Madhushree: So I think the major changes that we've seen, at least from a Houston perspective, aside from the stay at home order which was put into effect pretty early on, they've been more focused like travel restrictions and we kind of addressed that and are in the contracts that we provide for our volunteers, the informal contracts as well as the forms that are on our website in terms of the specifications and guidelines as to where they can have traveled and what the quarantine time should be like if they are planning on volunteering after travel. So that's something that we kind of have to stay on top of with the news and the Health Department advisories as they come out. So that's I guess going off of that also a lot of our teammates that have come on to the admin team since the beginning of this initiative have also brought remote volunteering opportunities with them, which has also been like another way of addressing this whole quarantine and social distancing situation.

Brandon: So on the topic, you mentioned the fact that there's an issue like a concern about quarantine yourselves and how that might impact like returning to school with y'all going back to clinics here in the next couple weeks. How has that impacted you guys? Have you had to dial back some of your more like in-person style stuff or like what what's going on in that sense?

Aanchal: So we had spoken to again some admin and mentors at Baylor and some other institutions regarding how best to move forward with that. Because we did have to keep in mind one, the safety of our volunteers the safety of our family, but also just making sure that we were being responsible with how we were moving forward, and also making sure that we don't abruptly take away any needed help from the people that we were serving. But we were making sure to give them enough time to make adjustments and sort of work their schedules out. Speaking with some admin at Baylor, we were able to understand that we should be careful with new assignments because of the time constraints, but also that if our volunteers, and we hope that you know according to the contract in they must be taking care of their social distancing and adhering to proper guidelines outside of their volunteer shift, that they should be okay with returning back to clinics on time while keeping both them and our family safe. However, now sort of crunch time. It's May 17 and a lot of  our volunteer base is returning back to school and clinics in less than ten days and so sort of now is when we're really starting to work with our families and decide sort of how to move forward. One of the thoughts right now is perhaps reaching out to current families and asking them if they would be okay with having undergraduate students volunteer with them and help them with their needs. Because right now our volunteer base is made almost entirely of graduate students, but if they do continue to have needs we do want to make sure that we do whatever we can to make you know to help them with what they need. So right now it's about working with our current families and seeing sort of where they stand and what their needs are, and how we can both keep them safe and meet those needs.

Anoosha: Sounds like a lot of really great communication, and you know constantly adapting to change - bending like the reed. 

Madhushree: That seems to be the name of the game for everything these days.

Anoosha: Yeah

Brandon: If you had to pick one thing, what would you say was the most significant challenge of putting this all together? 

Madhushree: Just one thing?

Brandon: We could go into other things. But I just wanted to see what is, like if you were to think about it - what was the most significant thing? Because I know for starting the podcast, the biggest thing for us was like one, figuring out the right channels and two, finding a way to make the model sustainable. Because, I imagine the first thing they said to us was like - what are you gonna do when you get busy? Because that's the life of a medical student and Eric and I both are kinda like, “duh we'll figure that out.” 

Madhushree: I think within the first week or two, one of the main concerns that I kept having and that kind of honestly me up at night was, you know are we like are we doing right by our volunteers? Are we doing right by our families? Are we keeping everyone safe and making sure that we're not like contributing to the spread of this pandemic? I think a lot of addressing those concerns has been kind of just going back and forth between healthcare faculty as well as healthcare departments in the area and just figuring out like the safest most responsible way to continue to provide our services, which really are essential, in the sense that you know health care workers need family support when they're being called on in the hospitals to such an extent over the course of like these past two or three months. So I think that was one of my major worries going into this and kind of has been throughout but it's been getting better I guess. 

Brandon: What about you, Aanchal?

Aanchal: I fully agree with Missouri. I think that we have had, between her and I, many conversations about that one particular topic and making sure that we are being responsible as we move forward. I think that like with any organization and any initiative we also face some troubles with basic troubleshooting and how to make sure that we're able to how quick turnarounds and meet our familys’ needs in time. You know health care worker schedules are constantly changing. Medical students and other graduate students are busy. So there have definitely been many times where we have had hours of turnaround between when we have a request and when we need people's requests filles. I think that the support for that comes from having a fantastic admin team who have really just been on call and been excited to help with any of these situations that come up. I think that's just sort of obstacle just stuff that we face on the regular and we've just gotten better and better and more efficient at handling them as time has passed. 

Brandon: Awesome. Now on the flip side, what do you guys think would be the single best part of this experience for each of you?

Aanchal: The best part for me is getting to know and getting to work with such amazing peers across the medical field. Just so you and our listeners know that I have met Madhuri once in person for a grand total of maybe a half hour. I have never met anybody else on our admin team and so these are all brand new friends that I have gotten to make over this really difficult time and gotten to work with in a really intimate space and build something that we can all really be proud of. And just extending that to our greater volunteer base I know for a fact that the connections and the bonds that they build with their mentors as they work with them in their homes, and with their peers as they work together to fill the needs of their mentors are definitely going to be quite prominent as they move forward in their educational career. So I think that the relationship that we've been able to build as we sort of model this from ground up have been really quite special. 

Madhushree:  Yeah and I think I'm speaking as an MS3, so just for a little bit of context when I was a first-year medical student in the fall semester, it was actually when Harvey happened and we experienced some shutdowns and disruptions within our medical curriculum because of all the aftermath of the hurricane. So I think back then thinking of like what the medical students role was in a community response, it was very much me kind of just following leadership from our upperclassmen and our faculty at the time. And now as an MS 3 it's been nice to see it's been nice to see the growth of my class between Harvey and now. I think going off of that it's just been very amazing and phenomenal to see how all of my classmates have come together with such passion and such initiative to start new branches with CovidSitters, and they kind of really just take the lead and go off on their own. It's just been a very humbling growth journey amongst peers. 

Anoosha: That's awesome, Madhushree. Yeah I haven't thought about that. Framing it with when we entered Medical School during the time of Harvey, it was like right as we'd started, to now. You kind of hit the nail on the head. That's awesome. I'm glad you set it in that way.

Madhushree: Yeah, and I'm sure you probably can attest to this in some degree but it's been really nice to see ourselves grow as like medical professionals, and kind of increase our capacity in giving back and contributing to the Houston community.

Branson: Yeah, I just I just don't echo and say that this is absolutely fantastic and I am so glad that y'all set this up and gave so many people the opportunity to get out and serve. I think that's one of the beautiful things about this situation we're in, which is mind you very terrible. I don't know if there's anyone on the planet that maybe feels like they like this, I don't know, I for sure don't. But it's awesome to be able to see that there's some good coming out of being stuck at  home having to deal with this awful pandemic and having literally everything sidelined. So thank you guys so much for taking the time to start this program and to help people out. And then also thank you for taking the time to come talk with us. 

Aanchal: Thank you for having us. 

Madhushree: Thank you for being part of our community, helping us spread the word. 

Anoosha: Yeah is there any like one message or several messages even that you guys want to share with the Resonance podcast audience?

Madhushree: I guess just as like good note to end on I just really want to say like a true heartfelt thank you to really everyone involved with CovidSitters - everyone from the admin team, all the volunteers who really are the backbone of our organization, and all of the health care workers who have willingly let us enter their homes and families and have established meaningful connections with us. 

Aanchal: And all the faculty that helped us get started and move forward.

Madhushree: Definitely. 

Brandon: Well, awesome guys. Thank you so much for being here today.

Aanchal: Thank you. 

[Music]

iTunes | Google Play | Spotify | Stitcher | Length: 37 minutes | Published: May 6, 2020

Dr. Ellen Friedman discusses what it is like to be an otolaryngologist and the director of Baylor's center for professionalism as well as some projects that the center has created, like the "Threads Among Us."

Transcript

Erik: Here we are.

Karl: We are here.

Erik: This is the Baylor College of Medicine Resonance podcast. I am one of your hosts, Erik Anderson.

Juan Carlos: I'm another host Juan Carlos Ramirez.

Karl: And I am Karl Lundin, I am the writer for this episode.

Erik: Before we get into today's episode on professionalism with Dr. Friedman I just figured we should introduce Mr. Juan, umm, who will be, you'll be hearing a lot more from him in the second season as we kind of rotate through the leadership position, because so the podcast as you guys all know is a student-run podcast and so basically every year we're gonna have new people cycling in and so Juan's starting to, umm, kind of getting more involved and will be on most of the episodes in the second season as I will fade out in a way.

Karl: What Erik is trying to say is he's being pushed out.

All: (Laughing out loud).

Erik: Yeah.

Karl: Juan has seized the reins of power. With iron fists.

Erik: Yes.

Karl: Yeah, I support, I support you.

Erik: Yeah, no. It’s true. Well, we all know that Karl.

Karl: So there’s gonna be some changes around here.

Erik: Yeah. So yeah. So anyways, without further ado though, Karl if you want to tell us about professionalism.

Karl: Yeah and I know professionalism is one of those topics where we probably have heard a lot about it in med school more like “Oh, professionalism. Yeah, I know what that is,” and to certain extent you do but today we're gonna kind of get into I think a very different perspective on Professionalism, more as like a state of mind or an outlook than a specific set of rules but before we do that let's go ahead and get into the specific definition of professionalism officially so according to the American Board of Medical Specialties medical professionalism is and I quote “a belief system in which group members declare to each other and the public the shared competency standards and ethical values they promise to uphold in their work and what the public and individual patients can and should expect for medical professionals…,” it's a lot!

Juan Carlos: I think I caught according to the American Board of Medical Specialties.

Karl: Yeah, you know I think that's good enough for our purposes today. I mean, it is important to have this official definition of professionalism, right? But today we're gonna really get into more like, what does professionalism look like? How do we bring professionalism into our interactions with others? And it's gonna be a lot less about like “do this, don't do that, do this don't do that!” and more about how you treat people what your attitude towards people is, like the example we get into Dr. Friedman, I remember for example is, let's say you're in the OR and this nurse is being really, surgeon is, excuse me, being really snippy with you or like, just kind of grumpy you could be like “Oh, this guy's just a jerk. Surgeons are just jerks. I hate surgeons.” Right? Or you could think “Oh, I don't know what's going on in this guy's day.” Maybe, or he had something rough happen, you know? And so, we need to have like, that understanding compassion and kind of bring that to the workplace, and that's kind of what we get into. You were gonna say?

Erik: I was gonna say empathy, right?

Karl: Yeah, empathy. Empathy. Exactly.

Erik: Yeah, no it's true and I think as we were outlining this episode as we do with all of them, before we do the interview, I certainly focus more on writing this roundtable about sort of the cut-and-dry of here's the definition of professionalism, here's what each ethical standard of, uhh, that the specialties hold themselves to, and then as we interviewed her I was like, oh wow! Well, this is a lot more relatable and makes a lot more sense. It's just the golden rule, right? Treat others as you want to be treated and Juan I believe you have, uhh, some experience with professionalism in a different vein – is that correct?

Juan Carlos: Yes, certainly. So, umm, I spent a nearly a decade in the military and uhh, whether you're in the Regular Army or in Special Operations, professionalism goes way beyond, you know, showing up in the right uniform at the right time in the right place, but the professionalism is really how you treat others and how you present yourself to others through your actions. It's good to, to build cohesion this way, right? Umm, most people want to be treated in the same professional manner, so I think it's kind of a really good initiative that Baylor is kind of spearheading this effort to, to you know? Grow, not just in the medical field in medical knowledge but how you, how do you become a real professional? How do you treat people right? Right? And so, this is amazing. I look forward to the, to the actual episode and uhh, how to become better physicians by being better professionals.

Erik: Yeah, and well, and I think actually the definition of a professional, as we were told on like the first few days of medical school, is that you have just a core set of values, so like, you take the Hippocratic oath and you have the beneficence, and non-malefeasance and all that stuff that everybody in the profession holds and abides by. It makes sense, and you would want that in your physician or your lawyer or any other profession that you can think of or you know, your military.

Karl: Well, like Juan was pointing out, is kind of like, umm, anytime you're working with other people, you all want to be treated with a certain amount of respect, right? And the more people feel respected, the more people feel appreciated, the more they feel part of a cohesive team, and the better you can do in general, right? And so, in healthcare, umm, that means the attitude you have towards the patient, the attitude you have towards the other doctors, the nurses, the person who, umm, cleans the floors, right? You have that certain attitude towards them of respect, of empathy – that's gonna make everybody cohesive as a team and make everybody do a better job, which is ultimately improving people's health and improving their lives, right?

Erik: Mm-hmm.

Karl: And Dr. Friedman has actually taken over for Baylor's new center of professionalism. She's the director. It's actually a new initiative here at Baylor. Very few medical schools are doing this right now, so we're kind of cutting edge and their real like, whole plan, is to, kind of, show us how to be professionals like, help demonstrate how to be professionals. So, we're gonna talk to her today about a number of projects they have going on. We're gonna talk about a project they have called the “Threads Among Us,” which really focuses on how we can take these concepts and kind of, incorporate them, not just in our interactions with patients or interactions with you know fellow doctors, but with everybody here and we're also gonna talk about some other projects they have going on like the, uhh, pop Awards which is a kind of positive thing that we can use to highlight people. So it's gonna be a great conversation and I think it's gonna give people really new kind of outlook and a different kind of take on what professionalism is and it, for me, it makes it very clear like, what this should look like in my daily practice, umm, not just in medicine but in every area of life. So, it's gonna be great, I think.

Erik: Yeah, no. Definitely, so I guess without further ado we'll get into the interview. Dr. Friedman, who is an Otolaryngologist, got her Bachelor of Science from Boston University, her MD from Albert Einstein College of Medicine, and completed advanced training at Montefiore Hospital and Medical Center, George Washington University affiliate hospitals, and Harvard Medical School affiliate hospitals.

Karl: Yeah, so let's talk to Dr. Friedman.

Juan Carlos: Right on.

Interview

Karl: Well thank you very much for joining us today Dr. Friedman. Umm, to start off I was wondering if you could just tell us a little bit about yourself, your career, what's your day like as an otolaryngologist.

Dr. Friedman: Well, thank you so much for inviting me I'm really excited that you've started this podcast and I wish you great luck and I hope it's quite popular. So, I have been an otolaryngologist for a very long time and I enjoy it thoroughly. It's a field that I'd love to recommend to the students to investigate because it's a beautiful balance of medical and surgical options: you can treat males, females, adults, children – there's a lot of variety within the field and it, I've been doing it for many, many years and I continue to love it. I think most of the people who go into Otolaryngology are kind and very lovely colleagues, so it's made a beautiful career. Okay, that's great. Do you spend a lot of your time in practice still? I know you have some administrative duties - so what's the division there I guess.

Dr. Friedman: Right. For many years, I was the chairman of the division of pediatric otolaryngology at Texas Children's Hospital over 20 years and about six years ago I stepped down to take the position of being the director of the Center for professionalism here at Baylor. Now I do a very limited amount of clinical work. I work clinically one day a week. Uhh, in a month, I have three operating days and two clinic days when there are five, five weeks in a month, and it's a great balance and it's been a really exciting and positive mood because it's been invigorating to think about new topics in our, or maybe even old topics but in a new way.

Karl: Oh, okay. That's very interesting. Thank you. So, you mentioned you are the director for the center of professionalism here at Baylor. I was wondering if you could tell us a little bit about the center, of what you guys do, and what you're all about.

Dr. Friedman: Yes. the Center for professionalism was actually the dot idea of Dr. Klottman and when he was recruited here it was one of the top priorities in his recruitment package because he had created one at Mount Sinai and felt it was one of his most proud accomplishments there. So, he was highly motivated to start one here and I am the first director of that Center. The center has two major missions one is to elevate and support professionalism throughout the campus from students to the highest faculty within the clinical sciences as well as the basic scientists and that's the, the wonderful role and the other role is to identify and remediate lapses in professionalism in a clear, consistent, and predictable and fair manner. So, those are the two missions and it's been a very exciting and challenging position.

Karl: What was the formal process like before the Center for Professionalism for dealing for professionalism issues and that sort of thing?

Dr. Friedman: Yes. That's a great question. I think it was done in a very, umm, inconsistent way, and even today, I wouldn't say we've totally harnessed the topic but I think it was very inconsistent and frequently not transparent, and so, this has been a very positive move towards trying to change the culture and to improve the culture towards a culture of greater patient safety and greater collegiality among community.

Karl: Okay, so it sounds like may use a bit more of an ‘ad hoc’ system before. We're trying to just make things standardized – uniform.

Dr. Friedman: Right. And, and to make sure that it's fair to everybody involved. That, that's really my personal goal – that I want it to be consistent, you know? I think there has been a suspicion that higher up people don't have, get treated the same way that either students or assistant professors would be treated and I really pride myself on having a very consistent approach and it may be a little bit more awkward when you're talking to someone higher up but everyone gets the exact same approach and I'm confident of that.

Karl: So, I guess along that line, what does professionalism mean in a medical context? What would that look like?

Dr. Friedman: Yes. Actually, almost every talk I give I start with that because I think there's a wide perception of what professionalism means and the type of definition that I like to use is that professionalism in medicine is a collection of behaviors such as altruism, compassion, integrity, striving for excellence. That builds trust for relationships between patients and physicians, and physicians and their colleagues.

Karl: Okay, so it's kind of really about a framework we use to make sure that we can trust each other and we can work well together to accomplish things.

Dr. Friedman: Exactly. I think, for patients, when you have a trustful relationship, there will be compliance with your recommendations, there'll be an open real conversation, you'll, everyone benefits. Patient safety benefits. Patient outcomes benefit, and when you work well with your colleagues you'll also maximize your efficiencies, your effectiveness, and it's just a much more pleasant work environment. So, there, there's a lot to be saying for professionalism.

Karl: Yeah, I mean, it's a lot harder to get burnt out if you have that kind of trust in the good relationships.

Dr. Friedman: Absolutely. Not, not only with burnout, which is a whole separate podcast I'm sure, but in terms of, of communication skills and professionalism there are numerous very large and significant studies that show that the vast majority of medical errors as well as malpractice litigation are not due to lack of expertise, lack of medical knowledge, or lack a poor technique but it's due to poor communication and poor professionalism by far. So, it's really, professionalism has really risen in terms of national interests because it is linked to so many downstream problems.

Karl: Okay. That's very interesting and that, kind of, does remind me of the project you guys did recently called ‘The Threads Among Us,’ and how it kind of helped highlight how professionalism, at least to me when I saw it, was maybe not always all the things we think of when we think of professionalism but it's a much, kind of, broader sort of thing. So, I wonder if you could tell us a bit about that project and everything.

Dr. Friedman: Yes. My – my collaborator with that was Dr. Jordan Shapiro. He is currently a fellow in adult medicine GI but he also has training in pediatrics and before he even came to Baylor he had contacted me with an interest in professionalism and, a personal peeve of mine is a lot of the inter-professional disrespect and in civilities and I really wanted to do a project that would work towards increasing empathy among our co-workers and as a surgeon myself, I have frequently heard the pediatricians who think that surgeons are idiots with knives, and surgeons think that pediatricians can't make a decision, and the OBGYN people don't like the urologist, and – I mean, you could stack it up, but there's nobody who's immune from it and it's so counterproductive, and the truth is that medicine is so complicated today, no one can do it on their own. I mean, we all have to rely on each other and when you badmouth a colleague, the likelihood that you're going to have a wonderful outcome is significantly diminished. In fact, that was one of the issues that would came up in the student survey – that they actually felt moral distress when they would hear people on a service bad-mouthing other people on other services or consultants, and it's something that I have seen many, many times for many, many years, and for example, in the doctor’s lounge, where groups of residents or attendings – believe me, the attendings are just as guilty – will sit and make fun of someone else who's had a complication or someone else who didn't seem to understand the underlying clinical issue, and I find that very distressing because the truth is, we all have areas of expertise and you know being able to rely on each other and have confidence in each other is really critical, and one of the things that I really love about Baylor is we have so many great people here and to undermine each other is really, umm, distressing.

Karl: Yeah. I mean, kind of what struck me about it when I saw the project is, seems like professionalism is almost, uh, we're talking about a mindset, right? – Having a certain kind of gratitude for the situation, for the people you have to work with, for the opportunities you've been given, having a certain kind of graciousness in the way you approach others, and thinking like “Well, you know, so-and-so is taking a little time to call me back, but maybe they're busy.” Maybe, you know, giving people the benefit of the doubt – that sort of thing. It's very important.

Dr. Friedman: Wow. You really got it. Yes! That's exactly the message. The idea is that, I also would use the term empathy for each other, you know, because, you know, I think if we could all give each other a little bit of a break, I think that sometimes, um, you just, either from a past experience or from, or even just a rumor about someone else's behavior or someone else's experience with someone, you prejudge them and you jump off and are already annoyed before you've even given them a chance, and I guess another point that I hope that, that we discuss in the workshop following that video, is that, you know, everybody has their own back life and they may have personal issues on it, and everybody can't be a hundred percent their best self every single day because there are issues that come up, and in the video I'm happy that you've seen it, you know. It shows that when people are driving in they sometimes they – they have traffic for an hour and a half before they get here! Then they have to park their car, and these things kind of stack up, and you can start your day already frustrated and annoyed. So, I think it's really a great reminder to try to step back, you know, take some breaths and really be gracious. I think you really described exactly – exactly what we were hoping a participant in the workshop would feel.

Erik: …and you briefly mentioned a student survey. Um, we know what you're talking about but for those of us that are listening that might not know, would you be able to explain that?

Dr. Friedman: Well, every year Baylor College of Medicine, as well as every medical school around the country, gives students – graduating students, as well as students in each of the years – a survey to get their impression of their education, the learning environment, basically, I think it's called a learning environment climate study, and we look at that information and take it very seriously. I – I guess, I'm glad you asked me that because I think the students think we just collected and gave it a toss or something, but the truth is, we actually pour over it because we want you to be the best physicians and the best end product as possible, and we want to make you have a very positive experience while you're at Baylor. So, we take all of that information, which is giving totally confidentially, and we analyze it, and we look for steps, specific tangible steps, that we can do to address the concerns.

Karl: Just delving into some of the theory or the concepts that kind of underlie the threads among us and then just kind of the work you guys do in the professionalism Center: Is there any, if we could talk about a few concepts, so could you tell us a little bit about social contagion theory? I guess, we already talked about but the importance of gratitude, and then also on the ‘Ladder of Inference,’ kind of what these things are and what they mean.

Dr. Friedman: Sure. So, um, the way the workshop work goes with the threads among us is that there is a seven-minute video and then we have a discussion with a workshop, and it's a – It's available online both the video as well as the workshop, and in the workshop, we speak about three different principles that we hope are illustrated well in the video. The first is the social contagion theory, and that is how we basically show how there are social networks and every part of our lives – things that we don't, we're not even aware of. For example, there are studies that show if a friend of a friend of a friend of yours smoked cigarettes it's more likely, statistically, that you'll smoke cigarettes, and there are a number of different behaviors where there is this interwoven network that shows connectivity, basically, among large social groups, and we use that example to show how someone who has, is in a bad mood affects everyone that they come in contact with, and I think the thing that I like about the way we use the social contagion factor is in the discussion aspect, is that we always think about people who affect us but the idea is to remember that your attitude affects others, so you are a vector also. So, we talked about example, if we first asked people in small groups to think about individuals who can suck the energy out of a room, and I think everybody can think about a work situation where you see that you're partnered with someone, you're assigned to work with someone, and you know, it's going to be an unpleasant situation, it's going to be aggravating because they just are so negative, they’re so, maybe depressed but basically the negativity – it just can suck the life out of you and then there are also individuals where, you know, you're part paired up with them – not really even your personal friend – but they always lighten the day and they roll with whatever happens, they're flexible and they're positive, and you know you're going to have a good day, and so we get those – those individuals in our mind and then we go to realize that we also have the ability to either suck the life out of a room or to elevate it, and I think it's a very powerful exercise when you do it because some people honestly get this “aha, like, yeah, you know, I – I probably am doing that too,” and it might be even the first time they think about themselves sending out the vibes. They only have thought about receiving the vibe so, that's the social contagion theory. The ‘Ladder of Inference’ is a little bit more complicated to think about but, the Ladder of Influence is sort of the explanation behind a knee-jerk reaction, where instantaneously, you – you flip in your brain from a very neutral occurrence that you observe to maybe a negative interpretation, and it is a way how you can make instantaneous bad decisions and bad judgments. So, it's a little bit like when you're driving – driving, and a person in a fancy Lexus cuts you off and you say “Ugh, those guys are jerks!” You know? And the next time you see someone in a Lexus, you're already ready for the, to honk at them, and I think that happens to all of us, and I think that's one of the ways with stereotyping that even whole fields medicine gets stereotypes where you, when you already are talking to a surgeon you think they're going to be jerks or you when you're talking to the pathologist you think they can't decide or whatever group, and the idea of the activity that we do with the Ladder of Inference is to first of all make you aware of it because it's so quick you're not even aware of it when it's happening, and trying to get, let you get in touch with how this happens and to remind you that when you get a gut feeling that is kind of, maybe out of proportion to the actual occurrence, that you can step back, take a deep breath – literally, take a deep breath and say to yourself “Is this out of proportion to what's actually happening here?” and give your brain a chance to, sort of, recalibrate because, um, it's not that easy to do but, the truth is, that when you make these – these gut reactions with the knee-jerk reaction, it can be based on a perception that's completely out of whack with reality and so, I think that – that's a very helpful approach, and in the workshop we try to discuss the tools to get off of the ladder before you jump to a decision that will move you towards a bad action or bad decision.

Karl: Yeah. So, I guess, to me, that kind of reminds me about – you use the traffic example – sometimes, when somebody will cut me off or something in traffic, I'll feel that anger coming up, then I'll say to myself “Well, I don't know what's going on in their day. Maybe something happened. Maybe they are rushing off because they've got somebody sick in the hospital, the loved one or something. No, I don't know.”

Dr. Friedman: It's so hard to do that but you're so right, and I, and the thing is, especially when you're driving in the medical area I think there are a lot of people who are distraught, you know. They're – they're going to see a very ill family member or maybe they have someone in the car. I mean, I'm not mother Teresa and I'm not able to think that at every moment of every day but, the truth is, there are a lot of distraught people driving around here and I really do try to give everybody a little bit of a break. I wanted to say that the last concept in the ‘Threads Among Us,’ is the idea about gratitude, and I know we touched on it a little bit but, the truth is, that I think that we could all benefit with a little bit more appreciation. I know that when you do something wrong you usually get the feedback, right? But, when you do something right, people act sometimes like it's expected or it wasn't even enough or one thing or another, and I think, um, that the truth is, that, in fact, has even been studied by sociologists – that the impact of gratitude is very profound, not only on the recipient who recieves the gratitude but on the person who gives the gratitude, and we try to demonstrate that and give an interactive activity involved with that in the workshop because there's so many people in the chain that we work with and the threads that connect us, actually, and in a patient encounter, and during our day, who get very little positive feedback, you know? I always think about the unit Secretaries, you know? And I'll come into my clinic and I'll see a family yelling at the unit secretary about their having a long wait and they go on, and on, and on, and on, and then when I see them in the room they say “Oh, Dr. Friedman, how are you? Tell me how, what's new with your son, and they're so charming because, I guess, they feel that they're entitled to take it out on the unit secretary and so, I think it's really helpful to express appreciation for everyone who helps you during the day, and it makes a big difference and it makes you have a better day.

Erik: Well, on that note, um, because that sounds like a technique to, kind of, like help combat maybe the social contagion theory.

Dr. Friedman: Yeah. Very much.

Erik: So, when you were talking about it, it was making me wonder at the workshops. I think you had said you – you'll offer up some techniques, um, and like, mindfulness kind of comes to mind to, I don't know – do you ever talk about that with people or really, just any technique to like just kind of come back into yourself and, and, and foster that empathy that you're talking about.

Dr. Friedman: Well, that's the goal of the entire workshop: is to foster empathy. In fact, we try to. We talked about incivilities but, in terms of, that's a negative term, and so we try to frame it in terms of developing empathy for others with mindfulness and kindness, basically, and uh so, those are exactly the goals of this project.

Karl: That's good, and I think it is good for us to point out, like, this topic of professionalism, we often think of it in the context of what you shouldn't do, right? But, equally, and even maybe more important component, is what you should do. Like, the attitude you should have, the minds that you should have, um, and I think it's very good that we have initiatives we're trying to do that. Um, we were talking before the podcast about a new initiative you guys are doing to, kind of, provide some positive incentive for people to demonstrate excellent behavior, so…

Dr. Friedman: Yes. We're really proud of the P.O.P Award, and I hope that you've heard of it. It stands for the ‘Power of Professionalism’ and it's an award that is unique in terms of awards within the Baylor system. We already have professionalism awards for, sort of, lifetime achievements – let's senior people, very senior faculty people win once a year but, the P.O.P Award is totally different because it can be peer-nominated and it can be, it's given on a rolling basis. We can give multiple awards on the same day, and all you have to do is see someone and it can be given to, for anyone, from a medical student to a senior person, to support staff, who you think has done something special. So, the idea is, it shouldn't be really just baseline kindness but something unusual something – something that, you, really impresses you, and then you have to write one to two paragraphs describing the action and submit it to the Center for professionalism. We have a committee that reads them and – and then you can win the award, and the great thing about, there, so, I think there are a lot of great things about it but, one is that it shows appreciation and for positive behavior so, it draws your attention away from the lists of people who have delayed charts or have, or come late to clinic, or start the O.R. late, and it focuses on positive behavior. Plus, we have a little ceremony where we give the award and we usually do it at Grand Rounds so, there's a large audience and I think it inspires the audience because it makes you feel like “Hmph, that's attainable.” Sometimes you think about professionalism as, as you mentioned, that there's so many different ideas of what constitutes professionalism and you think of it as some kind of a unreachable goal but during the ceremony you see you and one of your peers gets it and you also hear the specific actions because we read the actual nomination at the ceremony and then you get a very valuable prize you get this P.O.P lapel pin as well as a box of microwave popcorn, and two tickets to the movie theater, and I have to tell you that as, as simple as this approach has been, some of the recipients have cried when at the ceremony. Many of the students get standing ovations. I mean, it has really been a very powerful, in my opinion, and a powerful innovation and actually, just yesterday, a colleague from UT came because she wants to copy the P.O.P Award there, which I was – I was gratified that she wants to do it but I, I, I think it's another example of appreciative appreciation in the role of appreciation and I think having a more positive work climate, it was better for everyone and – and, you know? We actually surveyed the recipients of the P.O.P Award, and one of the comments I thought was so telling, it said “It shows that the things that some people aren't counting actually matter,” and you know, I think Einstein has a quote about that, that you know, you can think sometimes the things that – um...

Karl: “Not everything that matters can be counted, and not everything that can be counted – ”

Dr. Friedman:  “ – matters!”

Erik: He’s a physicist.

Dr. Friedman: Oh. Well, there you go!

(All laugh.)

Dr. Friedman: Well, I'm certainly not a physicist.

Erik: Me neither.

(Dr. Friedman laughs.)

Karl: I am not either, so…

Dr. Friedman: No, but isn't that a great quote? Because it seems to be, in fact, that's exactly what – what professionalism is about: it's not so easy to measure, it's not so easy to, you know, make little check marks, you know, to – to get points or anything but it's this general culture and it's your behavior, it's your mind, I think you use the term mindset, and it really is a mindset it's – it's recognizing that you want to be kind and, I mean, I believe that everyone got into this because they want to help people, I mean, as corny as that sounds ,and as a cliché that everyone used during their medical school interviews. I actually think everybody means it, and I think that our, my goal, is to make it easier to the best of my limited ability to let people continue to keep that goal in their heart because there are a lot of discouraging distractors in our environment and so, I think keeping professionalism foremost in your mind is extremely helpful.

Karl: That sounds very good. So, I guess to close, I figure we take a, kind of, broader scope view and just ask you over your career. How have you, kind of, seen attitudes and ideas, and even awareness, towards professionalism change?

Dr. Friedman: Hmm. Well, I've actually have always really cared about professionalism and I think that you know there have always been examples of people with poor professionalism and so I don't think this new, this new focus on professionalism is actually new, I mean, I, I, I think, as a beginning medical student, I remember seeing things that I would say “I am never gonna do that,” you know? You know what I mean? So, I'm not sure that, that so much has changed I, I, also I guess, I'd like to say a word about millennial learners, you know, that's what people talk about a lot and I am, and I think there are differences in the mental outlook and the approach to life between the old days which weren't, aren't really the good old days but the old days, and the current millennial mindset but, something that kind of annoys me is when people say “Oh, the Millennials are like precious little snowflakes,” you know? “They have to have everything perfect” but, you know, the truth is, I think we're all precious little snowflakes. I'm not kidding. I think that the faculty, when they get negative feedback or what we call constructive input, they take, they take it very personally and they take it very seriously so, I, I guess, I, that's something that I – I'm not that fond of the this characterization of the Millennials as being perfect little precious little snowflakes that can't handle any adversity because I, I don't think it's true and I definitely don't think that the Millennials don't care or aren't hard-working or any of those things that you sometimes hear or see written about Millennials because actually I've been quite impressed. That, that's not the case.

Karl: Okay.

Erik: Well, I was going to ask. So, do you feel like, uh, well there's any, any mentality that we have is obviously thanks to the quote as you said older generation, the Boomers, the Gen-X, so we are who we are because of great teachers, um, and…

Dr. Friedman: That's it. That's a really good point. Then, I have read some of the things about Millennials. They say, you know, they're your children, so you know, so I mean, I think we own it, so I mean, where we should own it so, I'm agreeing with you completely.

Erik: But I was, I was going to ask, uh, do you feel, I mean it's hard to quantify, and you can't quantify it but, you feel like, what is a change maybe that you've seen between just now and as you said the old days? If you can just think of one example.

Dr. Friedman: I'm I have a very vivid – well, I don't know if this is the kind of type of category you're thinking about but for me the biggest thing is the commercialization of medicine. You know, my entire career I, and maybe I am a little, little wacky but, honestly, I never thought about the financial aspect. I mean, I knew you had to earn money. I knew you had to pay rent, you have to pay for utilities, you have to pay for your staff, I mean, I wasn't lying to all of that but it was a very insignificant consideration in my part and I was always proud that I tried to make the best decision for every patient every single day, and I believe that we are still doing that but there is so much emphasis on rvu production and those elements and efficiency but not just efficiencies to make patient care faster, or more but, merely to increase output these things are, I find personally discouraging and so I, I wish that there would be a way to mitigate some of that. I mean, I certainly recognize that the reality is, you know, whatever they say no margin no mission but I want to make sure that we don't have a profit above people, you know? So, to use two clichés.

Erik: And you feel like that is more acute now than it was maybe when you were training or?

Dr. Friedman: Oh, absolutely. Absolutely, and I mean, you know when I don't feel, I'm not a scholar on medical economics or medical policy so maybe I don't understand all of the ramifications but, I can say, as a practicing clinician, for a long time, I was oblivious to it. Now, probably being totally oblivious isn't the right approach, you know, you're, because you can't manage resources effectively and thoughtfully so, I mean, I think that there have been benefits to having more of an awakening about the economic impact of the practice of medicine but I think that it has shifted perhaps overboard and that I think that the majority of people in the workforce honestly are caring, compassionate, empathetic, professional people, and I feel that talking about the technical money aspects is sort of a disappointment.

Karl: I can see that, and I guess, um, kind of, to tie it all back together: the thing that kind of protects you from that is keeping this attitude of what am I as a professional, right? What's a medical professional? What's the profession about? It's about people. It's about taking care of the patient, right? And so, hopefully if you kind of keep that in mind and you keep your professionalism, that will always be your first priority.

Dr. Friedman: And that is exactly it. You know, what I say is that professionalism is really our life raft because if you hold on to that, you know, you won't get off track because, you know, especially if you surround yourself – which I strongly against – that surround yourself with negative, cynical people, um, you're going to be discouraged but the truth is, this is a very beautiful career and, um, when you don't, you think back at night you say, you don't say to yourself “Oh, I made 10 more RV use today.” No, you've said yourself wow that kid is reading more books because I talked to him about a certain author and during my clinic visit or you know any of the incredible and interchanges we have with colleagues or with patients and families and that's what really does bring you joy and I, I mean I'm sure listening to this it sounds perhaps too flowery or something but the truth is, I didn't get joy out of that and I, I do hold on to that and, and, and I have plenty of bad days or unfortunate interactions but the idea is to hang on to your professionalism. I think you've capsulized it very well.

Karl: Thank you. That was a very beautiful way to end it. Thank you for your time Dr. Friedman.

Erik: Yeah, thank you so much.

Dr. Friedman: Thank you so much and thanks again for this, um, creating this podcast. I think it's going to be a very impactful opportunity.

Outro

Jennifer: Alright. That's it for now. We'd like to thank everyone out there who took the time to listen to this episode of the podcast. Special thanks to Eric and Carl for writing that episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor Communications department for helping with the production and the website and thank you again to Dr. Freedman for taking the time to be interviewed by us. We hope everyone enjoyed it and we hope you tune in again soon. Goodbye for now. [Music]

iTunes | Google Play | Spotify | Stitcher | Length: 34 minutes | Published: April 22, 2020

Dr. Melanie Samuel discusses her research on neuron mapping and her experience advocating for scientific funding from the government.

Transcript

Erik: And we’re here.

Brandon: We are here.

Jenny: We’re here.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your Hosts, Erick Anderson.

Brandon: And I am another host, Brandon Garcia.

Jenny: And I am, you guessed it, another host, Jennifer Deger

Brandon: Whoa

Erik: Wow. And we are as I said, the Baylor College of Medicine Resonance Podcast. Today we are going to be Talking with Dr. Melanie Samuel about her work on Neurotal mapping using the retina as a model system as well as some of her work advocating for scientific research.

Jenny: Yeah, so I gathered some information about her research in her lab and one of the things that came to my mind was the saying or the question can you teach an old dog new tricks?

Brandon: People go to college all the time in the 40’s and 50’s and change career paths and things like that so there has to be some way to learn and generate new skill sets.

Jenny: Yeah otherwise we would stop learning when we were, ya know, 20 and that would be really bad for medical school. So, I think the answer is yes, if those dogs are neurons and Dr. Samuel’s lab looks at that how neurons choose new synaptic partners and how they wire up with each other. Ya know, why would they choose one neuron verses another neuron is kind of a big mystery right now. So, as Erik said she is using a mouse retina as the model to look at that because the retina if you, ya know, look at one of those diagrams that has so many layers in it it’s pretty uh…

Brandon: It’s like an ogre

Jenny: Yeah like an ogre with the onion yeah.

Erik: Or a parfait.

Jenny: She of course when she looks at synaptic mapping, she’s also looking at aging and why do we kinda ya know you can still learn into old age but obviously it slows down a lot. So, it’s like why does this happen why do neurons kind of slow down a little bit the older that we get? And I also read an interesting paper by Samuel Etal that kind explains or proposes a hypothesis for why our visual acuity might decline as we age aside from, you know, glaucoma and macular degeneration and all those things and cataracts plenty of things can go wrong but she found that retinal neurons exhibited age related quantitative alterations but they’re qualitative features were largely preserved which is interesting so quantitative alterations include like the areas of dendritic and axonal arbors so stuff that you can actually count and assign a number to. And the qualitative features which were largely preserved were like the molecular identity and the laminar specificity of the neurons. So, it’s pretty interesting when you think about how we age is not as simple as we might think. At least in the retina.

Erik: Yeah. Well and she also does some interesting work on, as already said, of getting more scientific funding kind of promoting that.

Brandon: Oh yeah, her advocacy work is very interesting just talking with her and talking with other scientists there is definitely a movement of idea of that in order for science to become better funded and more of a forefront in society, scientists have to figure out a way to talk about it and Dr. Samuel has definitely taken that to heart she works with The Society of Neuroscience to do these things called Capitol Hill Days. She’ll talk about this in the episode to scope and scale but basically they try to do everything they can to help our representatives at Capitol Hill and Washington DC really get to know what scientific funding is and they’ve had some success some pretty good success that she talks about that I’m really, really impressed with and I think it’s a good idea and something that we need to understand as listeners and people who are wanting to get into the sciences that talking to other people about science and helping them find a way to understand it is key to helping us move science forward.

Erik: Yeah and she also had a pretty I think very important point that she made that for anybody going into research is that the writing aspect is incredibly important for that people, myself included, don’t realize how much writing is a factor for becoming like a PI or ya know doing any sort of scientific research and I think that’s another important point that she makes.

Brandon: Oh yeah, I mean we can talk about it all day about how like television shows show scientists being all test tubes and lab coats but really, it’s a lot a lot a lot of writing.

Jenny: You have to constantly persuade people. You have to persuade them to ya know fund your research. You have to persuade them to publish your paper and yeah to do that you need some pretty good rhetorical skills.

Erik: Well and so that’s a good lead into our introduction and our interview with Dr. Samuel. So, Dr. Samuel received a Bachelor’s of Science and Art from the University of Idaho majoring in both Biochemistry and Microbiology as well as English so on the back of that writing comment she’s got a strong background in English. And so, she went on to do her PhD at the Washington University School of Medicine in St. Louis Missouri and she did Postdoctoral training at Harvard and so she is now here at Baylor College of Medicine and we’re really excited to talk with her. Here is our interview with Dr. Samuel.

Interview

Brandon: Dr. Samuel thank you so much for being with us today and thank you for being with us today and being on our podcast. Before we get started with some of the questions, do you mind telling us a little bit about yourself and how your research interests have evolved over time.

Dr. Samuel: Sure. So, first thanks very much for having me. I think this is really great and I’m really thrilled to be here. Let’s see so I started in research as an undergraduate as many scientists I grew up in Idaho, actually in the foothills around Boise. So, I went to the University of Idaho where I started research as a major in microbiology and English actually and worked in a virology lab. I really became fascinated by how a virus that has as little as 5 proteins can make people sick. And so I studied that question for a number of years including how viruses evolved to cause disease first choosing a bacteria phage and then moving to human centric viruses. So, I carried that interest forward into graduate school. I went to the University of Washing in St. Louis and I worked with a person named Mike Diamond who was really a forefront of studying how West Nile virus, you may remember that it was a virus that emerged in the US in the early 2000’s, and so that’s perfect timing for us because we were really interesting in understanding how the virus can spread, how it can cause disease and one of the unique features of West Nile virus and other members of that family is that it can infect the nervous system. So, I really got fascinated with the question of how viruses can have different tropism, the ability to effect different neurons in the brain, and that was one of the key things that I studied as a graduate student and the different path ways that are involved with fighting off viruses and neurons. So then as I graduated I had the choice to kind of stay in virology and stay in immunology or switch to neuroscience and for a number of reasons that I’m happy to talk about I decided to switch to neuroscience and really go and try to understand the nervous system more fundamentally and get some training in that so for my post doc I worked with Josh Hanes at Harvard to study different aspects of neuron survival and the context of disease and aging with the idea that at this phase of my career I could kind of bring back those fundamental interests in immunology and virology and my now background in neuroscience.

Jenny: Cool. So why did you switch to neuroscience?

Dr. Samuel: Yeah, so I think there were like three driving forces. One was that I felt with all of my training up to that point had been probably about ten years that I had been working in virology and I had a pretty good understanding of the way those types of experiments were done but I didn’t really understand the nervous system or really how to study it very well. So, one was just to kind of increase my skill set and kind of develop a unique way of perhaps thinking about the nervous system infection and disease and the other is that I feel that nervous system is one of the last remaining kind of biologic frontiers. Right? I think that if we understand our nervous system, we will understand ourselves and what makes us human. So, it was partly kind of looking towards the future and what are the big unsolved problems that face us.

Brandon: When you made that jump, were you nervous like how did you feel about that?

Dr. Samuel: Yeah, it’s always a little scary when you switch fields and I think yeah that’s true for everybody. On the other hand there is a lot of power I think in trying to get a diverse training set and you do have to accept a lot of responsibility for obviously for coming up to speed and in a new field but it’s really fun and it exposes you to a whole other realm of clients and people and ideas that I hadn’t been exposed to before.

Erik: Did you get any pushback?

Dr. Samuel: Yes and no. I mean one of that, just as you guys are training in medical school, one of the things about sort of scientific training is that you learn how to think like a scientist and it doesn’t often matter so much exactly what problem you’re focused on but rather kind of developing the skills to understand how to think about it, identify important problems and then go after them. So, if you have sort of a training in that, although you need some background information, you can apply those skills to almost any field. And actually, a lot of people switch areas throughout their careers. It’s not that uncommon.  

Brandon: Oh okay. I didn’t realize that. I kinda thought you get started in one field and you kinda stay there.

Jenny: You just have to pick one when you’re like 20.

Dr. Samuel: Yeah. You can. Yeah but ya know often things change. Right? The science may change. You may think you’re a neuroscience and then have a really cool discovery in liver that you just can’t ignore, and you need to go then after it. So, you have to be adaptable and flexible and the funding landscape changes and so sometimes you have to be responsive to that.

Jenny: Dose your virology background help at all in neuroscience?

Dr. Samuel: Yeah, I think so. Ya know, there is practical ways so often we use viruses as tools to visualize neurons, to see their structure by enabling them to express things like green florescent protein and then you can light up the neuron and really see it and better understand it. But also, kind of in thinking about how different neurons may become more resilient or susceptible to disease that idea was planted in my mind through my work in virology.

Jenny: Cool.

Brandon: Wow, that’s awesome. So you, correct me if I’m wrong, you do research looking at synaptic wiring and you use the retina as a model, correct?

Dr. Samuel: Mhmm, that’s right. Yep.

Brandon: What are the advantages and disadvantages of using that optical system for synaptic wiring in the brain?

Dr. Samuel: Yeah, so one of the really interesting things about neuroscience is that we are still in our infancy in understanding how the brain works and what the fundamental units are that allow it to work and those are neurons and their synapses. So, in the retina we have fifty plus years of research trying to understand what these neuron-types are and how they’re connected together so we have a really solid base of information that we can work from. The brain is still in its’ early days of trying to understand that, so we don’t really know very much about the individual neuron types that reside there and even less about the ways in which they wire up. So that makes it really hard to study synaptic wiring questions if you don’t understand sort of the fundamental organization because you can’t tell if it’s different or the same and kind of different manipulations or disease states. And the retina we have this understanding, so it becomes a lot easier to tell if things are going wrong or going right. The other advantage of it is that it’s laminated or layered, kind of like a ham sandwich. So, there is neuron, synapsis, neuron, synapsis and so because you have that ordering if instead of looking like a ham sandwich it starts to look like a bagel or some other food group you know something is wrong with it. So, there is kind of that basic organization that allows you to readily tell if things are okay and developed correctly or if things are not okay. So that is helpful too.

Jenny: How do you practically study the retina? It’s so thin and delicate I feel like it would be really challenging.

Dr. Samuel: Yeah, so you develop fine motor skills.

Jenny: Yeah.

Dr. Samuel: That’s key and ya know really as a neural structure having it be accessible through the eye is really helpful because the brain is protected by the skull. So, when you’re doing experiments it can be quite hard to access and manipulate and the retina, because it’s outside the skull, but still part of the CNS you can directly manipulate cells much more easily so that’s quite helpful. And having it be thin is actually an advantage because you can look all the way through it and see all the neurons and you’re not as affected by kind of things that can diffuse the signal or make it hard to visualize deep into the brain, for example.

Jenny: Cool. It still sounds challenging.

Dr. Samuel: Come to the lab. You can help us dissect some retina.

Jenny: See it in real life. So, our next question is how does synaptic wiring change in the brain over time?

Dr. Samuel: Yeah, that’s a great question. So, first of all, I think it’s important to say this is an area of active investigation, so we don’t have all the answers. In fact, we have very few of the answers. What we do know is that in many types of neural diseases including normal aging, disease free aging, synapses are among the first structures to kind of become degraded as we get older and that’s because we are very precisely ordered structures and very small and often very far from the cell body of the neuron so it takes a lot of effort for the neuron to maintain them and so those are some of the reasons that we think they are susceptible. And so that’s one of the reasons that we’ve focused our work on synapses because changes at the structures seem to be common among a lot of different types of neurologic disease and neurologic insults.

Jenny: Okay. Does your lab do specifically Alzheimer’s research or other neurodegenerative diseases?

Dr. Samuel: Yeah, so we do. We do both basic development, how do these cells know the partners to wire up with and make those decisions correctly during development and then how do those connections go awry and we have a various number of models that we use to study that. One is Alzheimer’s and we’ve also looked at other types of diseases including epilepsy, ETC. So, we really think about the retina as a window into the brain and kind of an approachable part of the brain.

Jenny: So, as we get older do those connections kind of become more faulty or it gets harder to make those connections?

Dr. Samuel: Yeah, so it’s quite interesting in some work I did starting as a Postdoc what we found was that there are particular neurons and their synapses that were more susceptible to aging. So, some neurons seem to be okay and others undergo dramatic remodeling and kind of make synapses where they shouldn’t be and lose other synapses. So, we’re very curious as to what protects some neurons and what makes other neurons susceptible. So that’s an area of active investigation in the lab.

Jenny: Cool. Is there any regional difference? Like does our hippocampus degenerate faster or anything like that?

Dr. Samuel: Yes. So, in the brain there are certain areas that are more suspectable to disease including things like the hippocampus and one of the theories is that because that area involved in learning and memory is that it needs to be continually synaptically plastic. That means that it has to have the ability to change even in adulthood. So, one of the theories is that that plasticity is what makes some of those areas more vulnerable. In the retina we see that photo receptors, rods particularly, their night vision cells are acutely susceptible to age related changes. They don’t die but instead they undergo the synaptic remodeling events at least in our animal models.

Brandon: So, I’m sorry you just said that like different parts of the brain are different amounts of plastic. Can you elaborate a little bit more just on that aspect? I think that’s kind of fascinating. That’s not something I’ve heard a lot about.

Dr. Samuel: Yeah, so I should say that this is not my area of expertise but I’m happy to chat a bit about it. So, the leading theory about memory and memory formation is that it involves structural changes to our neurons. So, when you make a memory you have to have something that physically changes in your brain to have that memory stay there and so that you can recall it. And it’s thought that a lot of this encoding happens at the level of synapsis these connections between neurons and that plasticity refers to the synapsis sort of change and remodel. So there is this idea that when we are young we have this period time called the critical period where we are really good at learning and we can learn languages and kind of cram a bunch of information to our brains but as we get older that critical period ends and we become less able to kind of learn languages as well and things like that. But we still have the ability in some part of our brain to kind of encode memories and learn in that way. Obviously because you guys are a medical school you are adults, but you still have to learn lots of information. So there are certain parts of the brain that participate in that and one of them is the hippocampus.

Brandon: Oh wow. Thank you.

Erik: So, it sounds like barring disease though our brains will keep remodeling throughout our life? Is that true?

Dr. Samuel: So, ya know again this is an area of active investigation so we are still trying to figure out what parts of our brain are really plastic. There are certainly evidence for some level of new neurons born in adults, in particular regions in the brain in our animal models, and there is of course evidence of the ability to form memories but whether or not particular subsets of neurons in different parts in the brain can remain synaptic and plastic, I think we don’t know. In the system that we study, I’ve been surprised that neurons that we thought kind of that had made their final synaptic wiring choice if you manipulate them in particular ways, they can actually become plastic again. So, I’m hopeful that as we understand factors that control neuron stability verses neuron flexibility that we may be able to manipulate them in precise ways to repair the nervous system when we need to.

Erik: So, I wonder then, because you hear a lot if you read a magazine there is a lot of buzz articles about keep your brain healthy and what not.

Brandon: Yeah, the luminosity or other brain apps and stuff like that.

Jenny: Cross word puzzles.

Erik: I mean it’s such an array that we should probably pick one, but I don’t know if there is actually any mechanisms that are known to actually “keep your brain healthy” or is it all a marketing gamma?

Dr. Samuel: Right, so there are very few good controlled studies about the effectiveness of these things. However, it’s never a bad idea to continues to be engaged and mentally active as throughout our life. I think that’s pretty clear that people that continue to work or be mentally actively engaged even as they grow older tend to have a higher cognitive function for longer periods of time. But the mechanisms and whether these apps help, I don’t think we really know.

Erik: Yeah. I understand.

Jenny: So do you think people can change I know it’s more of a philosophical question, given your work with how synaptic wiring changes and if that makes up, ya know, someone’s soul we just wanted to know what you think about that question.

Dr. Samuel: Yeah, so this is very philosophical. Let’s see. I think people change in the sense of perhaps an onion that maybe they reveal more layers of their personality that were maybe there a little bit from the beginning. And certainly, people can change in the sense of maybe variations on a theme like a musical composition will change a little bit and you’ll have a few new notes here and there, but the same kind of tune probably will still be present. I’ve observed that too in mentoring lots of students that sort of. The student hat walks in the door is the person that is there, and they will learn, and they will grow but that fundamental personality traits are kind of they’re solid.

Jenny: They’re set in place.

Dr. Samuel: Yeah, exactly.

Jenny: Yeah, from an early age.

Brandon: So maybe not necessarily you can teach an old dog new tricks, but you can help him with the ones he’s already learned.

Dr. Samuel: Yeah or strengthen the ones that are there but maybe haven’t been brought to the forefront. I think we all have innate capabilities that maybe we are untapped just by virtue of our the way what we’ve been exposed to and what we’ve chosen to do with our lives.

Brandon: That’s awesome. So, we want to switch gears a little bit and talk a little bit about your work and advocacy and outreach in terms of like scientific funding and things like that. First of all, what made you want to take an active role in science, policy and scientific funding?

Dr. Samuel: Yeah, this is a really important question so I’m glad you asked it. I feel that as scientists it’s our job to make sure that the general public knows what it is that we do every day and why it’s so important. If you think about back to the 1600’s and times before there were things like antibiotics what world we lived in and how different it is from all of the medical tools and techniques we have at our disposal all of that was made possible through science and through discovery and I think sometimes we take a lot of that for granted we forget, we forget how lucky we are and how far we have come and it’s scientists and doctors that have brought us there. So, it’s really important that we communicate that, and I think often as scientists we don’t do a good job. We kind of get excited about the details of our work and we forget that those aren’t immediately obvious to the general public and so I really have kind of embraced that idea and taken it to heart and I do whatever I can with things like this and other things to help spread, spread the word about what science and medicine are capable of. In terms of science funding of course nothing can happen without money and this is particularly true with research because it requires and ton of infostructure, a ton of equipment, expensive equipment to even be able to attempt these studies and all of that is funded through the government primarily, although there are some small foundations that help as well, and so it’s our tax dollars at work in funding these studies through a competitive grant process that we go through. We submit, we write grants. Those are our ideas about science, hypothesis and experiments and test them. Those get sent to review panels and the federal government that are composed of peers, other scientists, they get scored and then the top 5%, usually or maybe 10%, get money and the other 90% don’t. So, it’s extremely competitive. Then that money comes to the lab and they use it to accomplish the aims of the grant. If there is no money for science, then grants don’t get funded and the work simply just doesn’t get done. So as a percentage of the budget, the money that goes to what’s called The National Institutes of Health and The National Science Foundation is a very small part of the pie but it’s often one that congress may go to to kind of carve things out of and so it’s really important that scientists are there on Capitol Hill to say, ‘Oh no wait, remember this money is really important otherwise we won’t be able to make these discoveries that have helped increase our lifespan in the last century. So, I routinely go to Capitol Hill to advocate to science funding with our congress people and our senators and generally people are really receptive I mean this is something we can all get behind. This nonpartisan issue. I think we all have family members that have been affected by various diseases and we’ve seen the kind of impact those can have and we’ve also seen the impact of effective medicine and effective understanding of the way these pathways work. So thankfully in the last few years science funding has been maintained and has gone up a bit and these are highly coordinated effects. So, we all go in asking for the same budgetary increase and we have a plan about how what money is needed to continue to fund the research.

Brandon: I do what to know, we’ve talked a lot about this. What do you think we can as students either graduate students, medical students, ya know of the like, anyone who is curious about getting into this field, what can we do to improve awareness and understanding of science?

Dr. Samuel: Yeah, that’s a great question. So, I wanted to say a couple of things. One, for those listeners who are interested in thinking about science as a career and are concerned about this issue of science funding. First of all, I’d be happy to chat with anybody one on one about this. The second thing is what really makes a difference is your ability to write. So for students about there who are thinking about going into science and really wanted to do research, you’re going to need to be able to write well so I would encourage you to hone those skills now, practice early and often, take writing courses, hug your English teachers. I think that’s all really important.

Brandon: Says the English major, right?

Dr. Samuel: I think it’s true. I thank them every day, right?

Brandon: Yeah.

Dr. Samuel: I mean they really made a big impact on my career as a scientist. Okay, to get to your other question about what students can do to raise awareness. There are a couple really, really practical things. One is to get involved in science policy, advocacy and outreach. At Baylor we have a student-lead science policy group that’s really strong and they have initiatives, they invite congress people and senators and people to come to Baylor and tour, they have advocacy efforts to contact senators with particular messages and all those things are really effective. If your senator or congress person hears from you that you care about science that makes a difference and that’s something we all can do as constituents. Write emails, show up in people’s offices, ya know just give them the message that science is important, and we need their support of it. So, we all as citizens have the ability to do that. In terms of particular things, in addition to that, different societies have policy outreach and policy groups so I work a lot with The Society for Neuroscience, I’m the local advocacy leader for that society here in the Houston area and that’s composed of I think at our annual meeting we have over 25,000 neurosciences so it’s a large group of people with a big voice that coordinates Capitol Hill Days so we actually go to Washington DC twice a year at a particular time and they arrange meetings and we go shake hands with the congress people, senators, and talk about what we want to ask them to fund specifically and give our personal stories. So, you can do anything form sending an email to actually going to Washington DC to kind of personally advocate for science and all those things are really powerful but also supper fun. I think it’s important to say that it’s not just a thing to do because we feel like we should but it’s actually really cool and you get to go and see how government works and so that’s really neat.

Brandon: Oh yeah, I would love to go and shake hands with a congressman or a senator or two.

Jenny: I was curious what does that actually look like? Do you go into the capitol and meet with them?

Dr. Samuel: Yep.

Jenny: Or do they set up conference rooms?

Dr. Samuel: Yes. So, the study for neuroscience has a dedicated staff that are involved in science policy and they prearrange all of these meetings.

Jenny: Oh wow.

Dr. Samuel: It’s over 200 meetings with different congress people and senators from representatives all over the voluntary and then…

Jenny: Scheduling nightmare.

Dr. Samuel: Scientists fly in from all the different states and we have delegations from different parts of the country, so I was in the Texas Delegations and we went to the Texas congress people and senators that were available and met with them and then sometimes I’d be in Ohio but that’s okay, ya know, we just kind of bounce around and fill our day with these meetings. So, it’s a good way to kind of put a face and a story behind science.

Jenny: Right. Yeah. Are they usually pretty receptive? The congress men and women that you’ve met?

Dr. Samuel: Generally, yes. Generally. Again, it’s one of those things that, ya know, we all have families and we all have people that we love, and we all want them to be healthy and so it’s something that I think almost everybody and be behind.

Jenny: Have you seen any changes as a result of your work in the capitol?

Dr. Samuel: Yes. So, we’ve had really good success in the past couple of years of getting the budget initiatives of I think a 2 billion dollar increase in the NAH budget is what we targeted last year.

Jenny: Wow.

Dr. Samuel: And that was passed and we are advocating for the same thing this year and so we had a period not that long ago where science funding fell flat and because of inflation basically it was on a downward track and now we are almost back up to where we were and starting to grow so that’s super exciting.

Brandon: That’s awesome. Is there anything that you would change about the process of getting funding or how scientists get money or how it’s allocated in the government?

Dr. Samuel: Yeah, I mean I think we all would have things we wish were a bit different. On the other hand, I think overall the process works really well. It’s very fair overall. Your coleges are quite good at evaluating work. One thing I think is really fun to think about are some new initiatives that aim to fund maybe the scientist rather than the project. So the idea that if you can identify people that are creative and motivated and skilled that maybe it doesn’t matter so much if they’re going to do a particular aim on Alzheimer’s or instead going to tweak that aim and focus on epilepsy and kind of let them have some control over to be able to follow the signs what particular things they apply the money to. So, there are a few initiatives like this. I think they are very powerful because you get to fund more innovative discovery driven work and is sometimes funded by some more traditional grant mechanisms so I think seeing more things like that would be more fun and helpful.

Brandon: You’ve given us a lot of great advice today. Is there anything else that you would like our listeners to know any passing words of advice you’d like to give us to make sure that as we move forward in our careers as physicians and scientists of things we should be aware of or thoughts we should have?

Dr. Samuel: Yeah, I think one thing that’s really important is to identify what drives you and gives you energy and that you’re passionate about. Because often, we get into doing things because maybe our parents thought it was a good idea or because we thought it was the next hot thing to do, we didn’t ya know, higher education seems great. That’s good but I think our motivation for doing these things really needs to be internal and we need to identify within our self what is it about that career or that job that motives you to show up every day. Because that’s what’s going to make the job fun and that’s what’s going to get you through challenges that we all encounter and so I really encourage my trainees to think about that question early in their training and identify that for themselves and write it down and hold onto it and then when you have that day where you’re just like I’m not sure I can do this anymore, pull it out, remind yourself why you’re here and then you’ll be able to kind of move forward with kind of a sense of internal motivation and I think really a sense of happiness. And you know what if it stops being fun then think about other things you might be able to do. I think we only have one life, so we need to be doing things that we love. We have often the gift in this country of making that choice and so we should pursue it.

Brandon: Well think you so much. Again, we really greatly appreciate you coming out and being on the podcast.

Dr. Samuel: Yeah, thank you. This has been really fun.

Jenny: Yeah, thank you.

Erik: Thanks.

Dr. Samuel: Thanks.

Outro

Erik: Alright. That is it for now. We would like to thank everyone out there who took the time to listen to this episode of the podcast. Special thanks to Jennifer and Brandon for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor Communications Department for help with the production and website and thank you again to Dr. Samuel for taking the time to be interviewed by us. We hope everyone enjoyed it and we hope you tune in again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 38 minutes | Published: April 6, 2020

COVID19 is an illness caused by the Coronavirus SARS-Cov2, and this episode offers a summary of some of the information we have about this new virus from the scientific literature. The episode features medical students from Baylor College of Medicine, and contains general background about what the Coronaviruses are, epidemiology and symptoms of COVID19, and some of the current and future treatments.

Transcript

Brandon and Erik: And we're here.

Erik: Oh my goodness, we are here. This is the Baylor College of Medicine resonance podcast I am one of your hosts Erik Anderson.

Brandon: And another host, Brandon Garcia.

Jennifer: I'm Jennifer.

Karl: I'm Karl, I'm another writer.

Dan: I'm Dan, I'm just here.

Erik: Dan is also a writer.

Jennifer: You’re very important.

Erik: So this is a very, I guess, relevant episode that we decided to put out. Kind of on the fly, to do a quick: COVID-19 information, what is the newest in the literature…

Brandon: Coronavirus!

Erik: Yes, the coronavirus, to try to get it to your ears, and kind of point you in the direction if you want to learn more about it. So, we're gonna just kind of go through talking first about a little bit of background. What are the coronaviruses? And then a little bit of epidemiology, pathogenesis, and some of the current treatment options, and maybe some future ones that we'll be seeing.

Brandon: So yeah, basically we're all quarantined just like everyone else right now, can't do much, and we decided we wanted to talk about the Coronavirus and see what we could explain to you guys.

Erik: And before we start, I'd just like to mention something very important. We are medical students. We are not licensed medical personnel, and so everything that we are about to tell you is what we have learned from our research and from our own understanding of everything. But know that if you are feeling like you're having any symptoms, or any sort of like cough or fever, you should call your doctor.

Brandon: Yeah we’re medical students. We know a little bit more than maybe the public because we're in it, but that doesn't mean we should be your ultimate source of understanding what's going on. We definitely encourage you to go through, read the material, we will have it posted so that you can be able to see what it is that we read through, and realize that this is an ongoing situation. Meaning it's constantly changing. Information is going to change and update, and things are going to be different ten months from now than they are right this moment.

Erik: Yeah that's a good point. We're going to make it so that all of our references are available on the website. So, Jenni would you like to start?

Jennifer: Yeah I'm going to talk about the terminology, because Coronavirus, COVID, SARS, can be kind of confusing. But coronavirus is the most general term. So Coronaviruses are just a group of viruses that can cause respiratory disease in humans. And you might have heard of Severe Acute Respiratory Syndrome Coronavirus, or SARS coronavirus. Also called SARS, or also called SARS Cov1. That caused an outbreak in 2002. And then MERS Cov is another kind of Coronavirus that caused an outbreak in 2012. But now we're on to SARS Cov2, and that is what causes COVID19, but now people kind of use the terms interchangeably, so they might use COVID19 to just refer to the virus itself. Or they might just say Coronavirus. So that's what we're dealing with now^2,7.

Brandon: I actually remember as a kid…my family was really big on watching the news. I remember being like, what you said like 2002? So I was like 10 or 11, and I remember them talking about SARS and it being a big deal. So it kind feels like an instance of history repeating itself right now.

Karl: Yeah I think the big distinguishing factor was that the SARS-CoV1 outbreak, the 2002 outbreak, never really got too far outside of Asia, the original site. It spread to a few countries, it spread you know from mainland China to Hong Kong and so on and so forth, but it didn't go worldwide like we're seeing now.

Erik: Yeah and we'll talk a little bit about why that probably is, actually pretty soon.

Jennifer: Yeah so just a little bit about how this virus started from what we think. So patient zero seems to have come from a seafood market in Wuhan. There were 27 cases of a pretty bad viral pneumonia that were reported mostly from one specific market. And this was a market where they sold live poultry, and snakes, and bats. And other kinds of wildlife animals. And when they look at the DNA, or the RNA actually because this is an RNA virus^9,10. When they look at the genetic makeup of this Coronavirus it looks like it's a combination of a bat coronavirus, and it has some snake coronavirus elements as well. So it seems like the wrong bat met up with the wrong snake. Perhaps at this market³.

Erik: And this was in December of 2019 right? Which is how it got the 2019 designation, or the 19 designation.

Brandon: So this is some kind of bat snake thing?

Jennifer: Bat snake thing. But also there's no evidence that COVID19 infects cats or dogs. So for now don't be worried about, you know, your little fluffy companions.

Brandon: I just think it's interesting because from a viral epidemiology standpoint this happens every year with the flu. You know Flu seems to rearrange itself fairly frequently by this interaction between species. And when you have a virus that can jump between multiple species, and this seems to be another case of it. It’s just wrong virus at the wrong time hooking up in a weird kind of snake bat thing.

Karl: I think you are right Brandon, pointing out that with these new zoonotic pathogens—pathogens that have large components of their genetic code that come from animals—it's really like a perfect storm. Because our bodies aren't really used to it or familiar to it so we don't have good defenses for it. Plus, it's not well adapted to us, which means it might be a lot more toxic to us even though that's not really efficient for the transmission of the virus or the bacteria.

Brandon: I think this is important to talk about because it's a key thing to understand that this isn't like a man-made virus. It wasn't something created in the lab or it's not some kind of bioterrorism thing gone wrong. It's just the product of high population density both of animals and humans living together.

Erik: Yeah, and so to move on and talk a little bit about the epidemiology. One of the first big studies that came out February 24th was by the Chinese CDC and they did a study of about 44,000 confirmed COVID19 cases and found a case fatality of 2.3 percent. The case fatality is the number of deaths per confirmed cases^{4, 5, 6, 8}. So 2.3% would be 23 people in a thousand would die if they were infected. And then they also kind of stratified the population that it infected but we'll be talking about that a little bit more later. And very recent a study actually just came out that was looking at this percentage a little bit more closely, and kind of commenting that a lot of these numbers that you might see thrown around for other countries and places are actually difficult to really get a straight answer about. Because it's an ongoing situation. And so you might have a number of confirmed cases, but it takes two to three weeks to know what the outcome was, so that can kind of lead to some skewing. And then also if you're not testing all asymptomatic people, which we're definitely not, that's going to skew the numbers. So, with all that being said another team looked at a smaller cohort and found, trying to account for some of these variables, found that the case fatality rate was really more like 1.8^%7. Which is not to say that it's still not a serious thing, and just to give you some reference influenza has a case fatality of .0024%. So, the point being it's still serious and it's still an issue. One of the reasons why this is causing the pandemic that it is, is it's sort of at this sweet spot of infectious but also still being carried by a lot of asymptomatic people. Whereas SARS had a case fatality rate of like 14 to 15 percent, and that's what people think is why it wasn't able to spread as much because it was too deadly so it couldn't be maintained in the host. And I don't know if you want to talk about the R°? And kind of what that is?

Jennifer: Yeah, so R° is a concept in epidemiology that's supposed to estimate how many people will you give a virus, or you know disease, if you have it. So the R° for this virus is between 2 and 3.5, meaning that if one person is infected with COVID, they will give it to about two or three people on average.

Brandon: In contrast to that Measles is, if one person is infected they're probably gonna’ spread it to nine.

Jennifer: Yeah Measles is super contagious. And then I had the flu in here…

Brandon: I think the flu is like 3 or 5 somewhere in that range.

Jennifer: Really? I thought it was less than COVID, I thought it was 1.

Karl: Seasonal flu I think is maybe slightly over one so it's like really 1.1…1.3, I think typically. It depends on the strain.

Jennifer: Where’s our fact checker?

Brandon: Dan!

Karl: When we're vaccinated I think it's actually less than 1, that's why vaccines are so important. That's the important thing about R°, is that it’s modifiable by our behaviors and actions. Which is the whole point of the flatten the curve.

Jennifer: Yeah, and they think COVID might be a little more contagious than say the flu because there's a longer incubation time. So you could have it and not know for like a week or so, and you're just you know, living your life touching your eye and then touching things at the grocery store, etc., and spreading it to people without knowing it.

Erik:  Yeah and I think that's probably a good transition into the pathogenesis to talk a little bit about how this is spread and a little bit more detail of the molecular physiology.

Karl: You mean it's time to get up close and personal with the Coronavirus?

Erik: One could say that!

Karl: So, Coronavirus is pretty interesting, there's actually a lot of different strains of Coronavirus that have kind of not very close relation to each other. This one obviously is relatively new to the human population. It is a very large single stranded positive sense RNA virus. It's about thirty kilobases, which for an RNA virus is actually on the larger side. The reason it’s called Coronavirus is because it has a crown like appearance when you look at it under the microscope. It basically has these little spikes that stick out of it, which some old-guy way back in the day thought looked like a crown. And then there's a Latin word for crown that's corona like, so they said Coronavirus. The spike proteins on the virus, there's actually two specific types S1 and S2¹¹. The S1 proteins are the ones that are used to usually grab on to your cells to help facilitate infection. And actually it's been talked about the receptor used by those cells is ACEII, which is Angiotensin Converting Enzyme Receptor II. Because there's multiple types of ACE receptors. And it's pretty interesting because that's also target for certain blood pressure medications and things, so that's a physiologically important receptor that it uses to dock on to the cells. There's also another peptide on there in the spikes called the S2 which helps for fusion of the virus into the cells. So, you have those two basic spikes that their whole point is to just get the virus into the cell. Once it's in the cell the virus does its thing, which basically means it hijacks your cells machinery to make a whole bunch of copies of itself, which then it can launch out into your body to spread the infection. Very complex pathogenic mechanism by this virus. It does seem to, more so than other Coronaviruses, really target the respiratory system. We're not sure why. And when we say the respiratory system, we really mean the lower respiratory system. So usually we divide into the upper respiratory system, which you can think of as things above the neck, you know in the neck and the head. And then the lower, which is in the chest, which is the lungs for the most part, that's the big thing for the lower respiratory system. And this is where Coronavirus really likes to attack. So yeah as far as transmission we have different classifications that are official classifications. Right now, we are certain that this is what's called droplet, it has droplet transmission. Which means relatively large droplets of water that come out when you cough, sneeze, spit, can carry the virus a decent distance, probably at least about six feet before falling to the ground. That's the whole social distancing keep six feet away. There is some discussion about whether or not it can stay in the air for longer, which would be considered more like airborne type transmission. That's an ongoing area of research.

Jennifer: But better to assume it's airborne and it not be airborne then assume it's not airborne and it is. So wear masks, you look cool.

Karl: It seems to cause major illness by triggering possibly an overactive immune response. There's a lot of intermediaries involved in this process, we think one important one is Interleukin 6, called IL-6. But there's a lot of other intermediaries. We can get something called a cytokine storm actually happening, where just a whole bunch of immunomodulatory chemicals are released into the body and it causes lots of issues. They haven't gotten a lot of chances yet to see what this thing looks like, what a person's lungs look like in an active infection. But it's interesting there was one case study where two infected patients were incidentally examined in China. They actually were people who went in for lobectomies, to have part of their lungs cut out because they had lung cancer, and they just happened to be infected. And they noticed and they got to look, and it did seem like in both of these patients there was a lot of edema in the lungs, which is basically swelling up. A lot of congestion of the blood vessels, once again is kind of like swelling or filling with fluid. There is what we call exudate filling up the lungs, which is a pretty common thing when you have a process called a pneumonia.

Erik: I was just thinking it's important for us to also make the disclaimer: We are not licensed medical professionals, just to reiterate. We are medical students. So everything that we're telling you right now is what we have found from, you know our literature search of the scientific literature, but if you're feeling any symptoms that you think are alarming then you should call your doctor.

Karl: That's a good point. We talked a little bit about how Coronavirus is spread and transmitted, and what it kind of does in a more scientific or detailed way in the body. But what are the general signs and symptoms that you kind of notice clinically when a person walks into a hospital? Or if you yourself were feeling ill, what should you be looking out for? So there is a wide spectrum of symptoms with this thing, that's one of the things that's tricky about it. As Erik has said, people can be asymptomatic and have no symptoms but still the virus. People can have really mild symptoms. People can have really bad symptoms like organ failure, respiratory failures. So wide spectrum. Of the people that are symptomatic we've noticed, seems like the consensus is starting to form that about 80 percent will have what we call mild symptoms. So these are people that are typically going to be okay if they just stay at home, isolate, make sure they don't spread the disease to other people, and just kind of treat this like a normal bout of the flu. So those people could have lots of symptoms, fever is the most consistent one. So most of people to get coronavirus have some form of fever, how severe the fever is varies but most people with symptoms will have a fever. Next most common symptom is a cough, dry cough, which means there's not usually that much sputum. You can also have things like fatigue, malaise, sinus congestion, or runny nose, a sore throat, body aches, very rarely diarrhea. So you'll kind of just have a lot of general flu-like symptoms with a big focus on cough and fever. That's about 80% of people. Then you have 15% of people, roughly, who are said to have severe illness. And looking around it seems like the agreement with severe illness, mostly what characterizes severe illness, is it does interfere with a person's ability to breathe in some way. So either people have difficulty breathing, or the oxygen saturation in their blood decreases, and that gets us to the 5% of people who have what's called critical illness. And critical illness is defined as people who have either respiratory failure, something called septic shock, or some sort of organ dysfunction or organ failure. And these people are very sick. A lot of these people their lungs just aren't working at all, and the only way we can really keep them going is to stick in something like a ventilator, which breathes for them essentially to try to keep them oxygenated. That's about 5% of people and that is really concerning because that requires a lot of medical equipment, a lot of staff, a lot of attention. And that's what we're really worried about with flattening the curve is trying to make it so fewer people get to that level of illness, which then won't strain our medical system as much. Does that make sense?

Brandon: Yeah.

Erik: Yeah.

Karl: So, usually for people they start the illness with mild symptoms, but for some patients they can start right away with breathing dysfunction. The patients that start right away with problems breathing tend to be people who are older or have pre-existing comorbidities, what we call them. So other conditions in addition to the virus.

Brandon: Like people who have heart problems, people who are supremely overweight, those kind of deals.

Karl: Yeah, yeah. It could be a variety of underlying conditions basically yeah. That's where you do hear about people with like cardiovascular issues or lung issues. For most people though, they have the mild symptoms. For a certain percentage of patients, after about one week, could be more or less, all the sudden they can have a rapid worsening of the illness where they start struggling to breathe. One of the most concerning signs I came across when I was reading they said was once the patient starts having difficulty breathing on their own in any way, or once their oxygen saturation starts to go down in any way, that's when you really need to keep an eye on them. Because that’s when they can take a massive turn for the worse, go into the critical illness state where they can't breathe on their own and that's when you really need to make sure you get on top of that and intubate or ventilate to keep them going alright. As far as making a diagnosis, a lot of this stuff is diagnosed just by doctors clinically, meaning they look at the pattern of symptoms and they say this was like what's going on. Then we confirm by testing for presence of the virus. There are a couple of imaging results that are indicative, but they're not super specific. So when they did CT scans of people's chests they did find signs consistent with pneumonia, because that's ultimately what this illness is, it’s basically a pneumonia. They also in some patients have found ground-glass opacities, which they think are indicative of once again inflammatory changes ongoing in the lung. But really, it's mostly something that we look at your clinical symptoms and then we make a diagnosis based on that. Confirm it with a test for the virus. I would say the big takeaway though is basically that people, once they get into the critical illness state, may require mechanical ventilation for a long time. Even sometimes there have been cases where people will prove for a little bit, and they'll take them off of ventilation, but then they'll deteriorate again and need to be re-ventilated. So it's looking like a lot of people may take two weeks or more on a vent to get them through it, which is why the shortage of vents is a big talking point we have in the modern medical picture. But hopefully we'll have enough of supplies and resources to get through this and hopefully we also have some exciting new treatments coming down the pipeline that will hope to mitigate the illness and make it so not as many people get into that rough of shape. What do you got to say about that Dan?

Daniel: Alright yeah so you've touched upon some of the mainstays of treatment and so we don't really have any real cure right now. There's a lot of medications in trials but right now the recommendation is mainly supportive care, symptom management, and a lot of that is going to be giving respiratory support —oxygen, positive pressure ventilation, and for the cases that do get worse, intubation, mechanical ventilation, and in some cases even something called ECMO, which is extracorporeal membrane oxygenation^17,18. And that's when you take the blood out of the body into a machine that could then exchange carbon dioxide and oxygen so it kind of bypasses the lungs, which in the most severe patients as you mentioned they're so waterlogged essentially that they can't really do anything. And you mentioned something else, which is that a lot of the damage being done to the lungs comes from something called a “cytokine storm” and the immune system response. So back when we had SARS when we had MERS, one way of thinking was, can we control the immune system—can we turn it down so the immune system isn’t damaging their own organs as much, and so they give people glucocorticoids. But after the fact, when they went back and analyzed the data they found out that this really wasn't helping and there was even an association that suggested this may even have been hurting the patients, which is why now with SARS-CoV2/COVID19 they're saying that the recommendation has been to not use glucocorticoids unless there's some other kind of comorbid condition like a COPD exacerbation.

Erik: Hmm, that’s interesting.

Daniel: Something else that's been said is don't use NSAIDs, and that comes from a few case reports pretty early on that said that maybe giving people NSAIDs to control their fevers might have been associated with worse outcomes. But there really has not been any clear data, no real trial showing one way or another whether NSAIDs are good or bad but that hasn't stopped some places from saying “yeah, no NSAIDs, let's be safe, let's stick to something like Tylenol/acetaminophen, which can break fevers and isn't an NSAID. And actually, something that's pretty interesting is in some places you can get Tylenol over the counter, and some places are sold out of it now. So everyone's stocking up on it.

Erik. Hmm. Can you speak to toilet-paper?

All: (laughter)

Erik: (laughing) No, so are there any interesting things on the horizon?

Daniel: Yeah, so you may have seen in the news that there's a lot of drugs entering trials right now and for those of you who are a bit more familiar with the intricacies of the pharma-industry, that might seem a bit quick. Like how can we go from, there's a new virus and then to where we’re trialing a cure in just one or two months? And the answer is this concept called “drug repurposing” or “drug repositioning”. And that's where we think, it's going to take a long time to develop something new, but what if we already have something that's maybe in development, maybe in trials, maybe even approved, and then and it has a mechanism that you know plausibly could work against this new illness, why don't we try that first, why don't we see if something we have in a little toolkit out of our arsenal can be used first. And that's where all these things that are being tested right now come from. They were developed previously for other diseases or other illnesses and they happen to have something about them, something about the mechanism, that says you know maybe we can use it for a COVID. And one of these mechanisms, one of these drugs, that's been getting a lot of press recently works through inhibition of the viral protease. So the viral protease is our enzymes that are made by the virus or encoded by the virus made by the hosts that are involved in processing viral proteins into a more usable form so they're in a central part of the virus's replication cycle. And this is the mechanism of an HIV drug combo, lopinavir-ritonavir, which was used back in the day to treat SARS and MERS, and was one of the first drugs that they tried in China to treat COVID19¹⁵. Unfortunately, this one's already failed a trial but it is still being tested in the WHO’s new trial, it's called SOLIDARITY. And you know what an acronym, you know props to whoever twisted you know ten words to be able to spell that out.

Jennifer: It’s almost as good as that DARTH VADER satellite.

All: (laughing)

Daniel: (laughing) But yeah, it's being tested in combination with other things like interferon-beta, which is something that your cells normally release in response to viral infection to help your cells, your immune system, fight off said viral infection. So, we'll see how those new trials go. And this is also the mechanism that this drug you may have heard of, or even used, called Tamiflu or to use the generic name, Oseltamivir, which has also been used by some hospitals and has also been trialed in some places. Another mechanism that we've got is inhibition of the viral polymerase, which is the viral enzyme that actually will engage with the viral RNA and to strategies here, we've got nucleotide analogs²⁰, which are incorporated into the assembling virus, and then through various means terminate replication, and we also have direct inhibitors of the RNA polymerase. Now the big name here is Remdesivir, which was originally made to treat Ebola virus, and since January it's been used in China, it's be used in Europe, it's been used in the US, in a few patients and in these case reports it's had supposedly some benefit and it's now being trialed, phase III trial in China. And it is also a major part of the SOLIDARITY trial. There's a lot of hope around that drug. Other things in that category, we've got Favipiravir, it's an anti-flu drug used in Asia. It's also had some claimed uses against COVID19 and the interesting thing about this one is that it's already had a very small clinical trial in China where they found that the Favipiravir was effective, but then it turns out that trial has a lot of questions about the way that it was conducted with the etiology, you know which patients were selected, the relevance of the population to the general population¹². So it's something we'll have to really wait for larger, more elegant trials, to really see. And probably the most talked about drug back in February was something called a Chloroquine, along with its close relative, Hydroxychloroquine. These are anti-malarial agents, but they also appear to have some activity against coronaviruses through a mechanism that's not quite fully understood, but it seems to have a lot of multi-access, you know, affect against viruses. They're saying that it might inhibit some of the pH-dependent steps in viral replication, it might prevent viral release through inhibition of autophagy and vesicle formation, it might interfere with surface receptors of the viral particle. And the major thing about Chloroquine is that it's one of the drugs that the China's National Health Commission, that their COVID report recommends. And both Chloroquine and Hydroxychloroquine are not part of the WHO SOLIDARITY trial. Interestingly there's a small French clinical trial that tested Hydroxychloroquine and they found that it's actually very effective in reducing the nasopharyngeal viral load¹⁴. And we mentioned that that's where the virus is going to concentrate and that's you're going to spread the viral droplets. But the viral load was reduced in these hospitalized COVID patients to a level where they were undetectable, so signs of strong potential there.

Karl: Maybe we should add a disclaimer here, these are all like early trials. Just because we think something like Hydroxychloroquine looks promising, you should still go to a doctor, discuss with a doctor, whether or not this is an appropriate therapy for you.

Erik: And I don't think anybody in the US is...

Karl: I think they're starting to try to roll out some trials in New York, nut I've just heard that anecdotally. But I have heard confirmed cases of people going out, seeing things on the shelf in the back of their garage that say “Chloroquine” on it and thinking I'm going to take some of this prophylactically. Do not do that. This is serious medication. You need to have a medical professional supervising you before you do anything like that.

Erik: Yeah, talk about side effects, isn’t it with the Chloroquines you get nightmares?

Daniel: These anti-malarial drugs have terrible side effects, and Hydroxychloroquine is actually the one using the US mainly because it's the less toxic version. Not non-toxic but less toxic. So those were some of the big guns right now, the ones getting the most press and attention but there's a few other strategies that are being considered one of them is using the blood serum, the plasma from recovered patients which should contain antibodies against the SARS-Cov2. And you give that serum to current patients and the idea is the antibodies will then attack the Cov2 in your current patients and help their immune system deal with it. That's the principle of passive immunization that is used a lot in infants and in the immunocompromised.

Erik: You might see “convalescent” is what it is called.

Daniel: Yeah, “convalescent serum” is the official term.

Erik: Yeah, the movie “Outbreak” really explains it quite well.

All: (laughing)

Jennifer: Yeah, that was a cute monkey.

Daniel: Hollywood just has so many of these movies about pandemics.

Karl: Yeah that was a cute monkey I can understand.

Jennifer: I’m glad it was immune.

Daniel: But there's also a large number of biotech companies that are kind of taken that one step further and saying what if we can make a better antibody, one that we can give to patients and kind of prophylactically give to these patients and prevent them from getting this illness. Kind of like a large-scale passive immunization program. And in terms of the timeline we could be seeing those being used around the end of the year. Whereas for active immunization, like what we should think of traditionally as vaccines, the optimistic timeline for them puts them out as being ready next year at the earliest¹⁹.

Karl: Any idea idea when we can expect a vaccine?

Daniel: Yeah, so the NIH has been doing a phase I trial on a possible vaccine that trial should be wrapping up at the end of April. Now a phase I trial is going to be mostly about safety. So is the vaccine safe to give to healthy people, and does that elicit an immune response in healthy people? So it's the very earliest stage and most of the drugs that I mentioned have done this already, like if they skip straight to phase II or phase III.

Karl: Because they're already proven safe because they're being used for other things

Daniel: Yeah, phase II is the kind of efficacy. You go to a small population and you say, does our drug actually do what it's advertised to do. And then phase III is your comparison and it says now, is your drug better than nothing? And it's only really after the phase III when groups like the FDA can say, I give you my approval to sell this drug to market. So some of the strategies that are worth mentioning, of only for the scientific interest, so Australia actually is piloting a massive trial of the BCG vaccine, now that's the childhood TB vaccine that the US doesn't use but many other nations around the world do use. And they’re trialing this in healthcare workers with the rationale that BCG may potentiate the immune response against other infectious diseases^13,16. And there's been some literature in the past showing that this effect might be real. So now they're trying to see if this can be used in any way against COVID19.

Erik: Do they think like heterologous immunity, like it’s ramping up the immune sysm?

Daniel: Something like that!

Karl: That’s a fancy word.

Erik: Thank you.

Daniel: And lastly, this is more related to symptom management than the antiviral effect, but it was also an IL-6 inhibitor out there called Tocilizumab, originally used for treating arthritis, but with IL-6 being an important mediator and the immune system being a cause of damage here they're hoping that using this IL-6 inhibitor can improve or at least ease the disease course for these patients²¹.

Erik: It's also high yield for the boards.

Daniel: Yeah so overall there's a lot of potential for something out of this massive, massive basket to be effective against SARS-CoV2 and COVID19.

Erik: And, do any of you want to talk about the other big thing that we hear about in terms of, I guess it's more prophylactic, of flattening the curve?

Jennifer: Social distancing. Which means...you know, concrete terms instead of buzzwords.

Karl: Hashtag flatten the curve.

Jennifer: Yeah, and like what does that mean.

Karl: Hashtag six feet apart.

Daniel: An ounce of prevention is better than a pound of cure. You don't want to get to the point where your options are supportive management and then hoping to get one of these drugs that hasn't been approved yet, basically an experimental drug treatment.

Jennifer: Yeah, so basically social distancing means, stay at home and only go out for essential things like groceries once a week or if you have to go to a pharmacy. But stay at home as much as you can, is what that means.

Danel: And one more important thing to remember is that some people are going to be asymptomatic, so you may have the illness but you just don’t know it but you can spread it to other people. And it may not be so harmless for other people.

Erik: For the reason that I think Karl mentioned, of if anything, because there are so many asymptomatic cases and mild cases, you might think that it’s going to be fine, but a lot of it is so that we don’t overburden the healthcare system.

Daniel: And especially for young people, there’s a persistent myth in some places that young people are not as vulnerable to this disease or are even protected against the disease and that’s really not true. Young people get the disease, young people die of the disease, there are a lot of young doctors in China, in the US, who have fallen victim to COVID19.

Erik: Yeah. Any other last thoughts?

Jennifer: I don’t think so.

Brandon: No.

Erik: We hope this has been informative. Again, we are medical students, we are not medical doctors, so if you have any symptoms, really just anything that you are concerned about, call your doctor because it’s better to be safe than sorry.

Karl: Yeah, it’s a tough time we’re going through but we just have to be smart and stay together, work together, look out for each other, and we’ll all get through it.

Erik: Alright, signing off.

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Verity, Robert, et al. "Estimates of the severity of coronavirus disease 2019: a model-based analysis." The Lancet Infectious Diseases (2020). https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30243-7/fulltext.

Wang, Yixuan, et al. "Unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (COVID‐19) implicate special control measures." Journal of medical virology (2020). https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.25748.

Wu, Zunyou, and Jennifer M. McGoogan. "Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention." Jama (2020). https://jamanetwork.com/journals/jama/fullarticle/2762130.

Pathogenesis:

Cascella, Marco, et al. "Features, evaluation and treatment coronavirus (COVID-19)." StatPearls [Internet]. StatPearls Publishing, 2020. https://www.ncbi.nlm.nih.gov/books/NBK554776/#_NBK554776_pubdet_.  

Rothan, Hussin A., and Siddappa N. Byrareddy. "The epidemiology and pathogenesis of coronavirus disease (COVID-19) outbreak." Journal of Autoimmunity (2020): 102433. https://www.sciencedirect.com/science/article/pii/S0896841120300469.  

Zhang, Yuan, et al. "A molecular docking model of SARS-CoV S1 protein in complex with its receptor, human ACE2." Computational biology and chemistry 29.3 (2005): 254-257. https://www.ncbi.nlm.nih.gov/pubmed/15979045.  

Treatment:

WITHDRAWN: Cai, Qingxian, et al. "Experimental Treatment with Favipiravir for COVID-19: An Open-Label Control Study." Engineering (2020). https://www.sciencedirect.com/science/article/pii/S2095809920300631. 

Cascella, Marco, et al. "Features, evaluation and treatment coronavirus (COVID-19)." StatPearls [Internet]. StatPearls Publishing, 2020. https://www.ncbi.nlm.nih.gov/books/NBK554776/#_NBK554776_pubdet_.

Gautret, Philippe, et al. "Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial." International Journal of Antimicrobial Agents (2020):105949. https://reader.elsevier.com/reader/sd/pii/S0924857920300996?token=1512E2C8FFF1138B0848EA96B7991D99458462F47E15EA7019E3CFE4EA9D18F0CC69979554EA33FFEF469F74BAFB0E5B.  

Guo, Yan-Rong, et al. "The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak–an update on the status." Military Medical Research 7.1 (2020): 1-10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068984/.  

 Higgins, Julian PT, et al. "Association of BCG, DTP, and measles containing vaccines with childhood mortality: systematic review." bmj 355 (2016): i5170. https://www.bmj.com/content/355/bmj.i5170.

Holshue, Michelle L., et al. "First case of 2019 novel coronavirus in the United States." New England Journal of Medicine (2020). https://www.ncbi.nlm.nih.gov/pubmed/32004427/.  

McIntosh, Kenneth. "Coronavirus disease 2019 (COVID-19)." UpToDate. Hirsch MS, Bloom A (Eds.). Accessed Mar 5 (2020). https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19.

Sandwalk. “Coronavirus Part III. Humankind firing back: Our molecular weaponry against it.” Sandwalk Bioventures. https://www.sandwalkbio.com/post/coronavirus-part-iii-humankind-firing-back-our-molecular-weaponry-against-it.

Sheahan, Timothy P., et al. "An orally bioavailable broad-spectrum antiviral inhibits SARS-CoV-2 and multiple endemic, epidemic and bat coronavirus." bioRxiv (2020). https://www.biorxiv.org/content/10.1101/2020.03.19.997890v1.abstract.  

Usdin, Steve. “Plotting a scientific path to counter COVID-19.” https://www.biocentury.com/article/304521/how-covid-19-response-is-stimulating-global-scientificcollaboration?fbclid=IwAR0Dr4jXTCRMA1CsGXMOkL43FLIDXHYMhTWu5pHS5_dXqfalzfnPdxo6gyo

iTunes | Google Play | Spotify | Stitcher | Length: 28 minutes | Published: April 1, 2020

Dr. Francis Gannon describes how he arrived at his position and specific assignment, how the experience changed him, and the role science plays in helping us to understand and cope with tragic events. 

Transcript

Erik: And we're here. This is the Baylor College of Medicine Resonance Podcast, I am one of your hosts Erik Anderson.

Brandon: And I'm another host Brandon Garcia.

Jennifer: And I'm the head writer for this episode and I'm Jennifer Deger.

Erik: And we're gonna be taking a bit more of a somber tone for this episode because we're going to be talking about the Columbia space shuttle disaster that happened in 2003. And we're gonna be talking with Dr. Francis Gannon who actually performed some of the autopsies for that disaster…and we urge if you have not heard our first episode with Dr. Gannon and want to know more about his journey into medicine and how he got to Baylor, I would urge you to go and listen to the first episode that we did where he discusses his body armor that he helped design, because we're really going to just be talking about Columbia in this episode.

Brandon: Yeah and just for everyone who's listening, we are going to be talking about some sensitive things. We’re going to be getting into the personal feelings and some of the stuff that Dr. Gannon went through and others went through with this disaster. If this is something that's not for you then just go ahead and go to the next episode or take this light, take it easy, just be aware that we are going to be talking about autopsies, we're gonna be talking about death and that could be an issue for some of you listeners out there. We greatly appreciate and honor the people who have given up their lives for space exploration for…all the different ways that that it has benefitted humanity and we've done everything we can to treat this subject with respect because we know just of how devastating it was for their families and for the people that were involved. This is something that's very sensitive and we've done everything that we can to bring this to you in a way that's both honorable and respectable towards the people who are involved.

Erik: But enlightening, we hope you learn something.

Brandon: Yeah, that’s the whole point.

Jennifer: So we'll start this story way before spaceflight came into existence with Leonardo da Vinci who once said “For once you have tasted flight you will walk the earth with eyes turned skyward, for there you have been and there you will long to return”. So we've designed much more advanced methods of flight since da Vinci's time. It started with the Wright brothers in 1903 with their little, you know, basically a paper and wood airplane that could get about twenty feet of ground on the beach. And then not even a century later, not even a hundred years later we put someone on the moon two people on the moon and brought them back safely. It's just insane.

Brandon: Yeah that just goes to show the ingenuity that humans have and the ability that we have to do amazing great things. You think about it like, we have cell phones in our pockets right now all three of us, and… those have more computing power than what they had in 1969 when they sent Neil Armstrong and Buzz Aldrin to the moon.

Jennifer: Yeah it would have taken up a stadium the amount of computing power that is in one phone now, it's just insane, we're just inherently driven to answer the question of what's next. We were like in the trees and then we thought we wanted to go down to the ground and then we looked up to the sky and then the sky was next, and then the moon was next, now Mars is next.

Brandon: But that's not always easy.

Jennifer: Yeah.

Brandon: There's a lot of things that can go wrong, and do go wrong, and have gone wrong for centuries and probably will continue to. That's part of what comes with discoveries, there's that sense of danger and the unknown.

Erik: Yeah, and this unfortunately was not the only disaster, like space shuttle disaster that happened. Am I right about that?

Jennifer: Yeah, there was challenger in 1986 was the other big one, there was one in 1967, and you know of course cosmonauts have not always had an easy time getting out of the Earth's atmosphere or getting back in. But…yeah so, it's amazing that people are willing to leave in a little metal cage basically and shoot through the Earth's atmosphere.

Erik: But yeah, well and what's amazing about Columbia is that for many of us it was in our lifetime whereas some of us weren't alive during the Challenger, which is the last big one.

Brandon: Yeah I was I was actually living in East Texas at the time when Columbia exploded and I actually remember the explosion itself. I was over at a friend's house, me and a couple of buds, and I woke up to the sound of an explosion in the sky, woke up my friends and we ran outside, looked out, and there was the debris flying out all around us. And I remember, you know, the weeks…for weeks afterwards people coming all through, government agencies and stuff like that, to try to recover as much as they could and you know just the kind of hubbub that it generated and all the rumors and stuff like that. It was really terrifying and amazing at the same time.

Jennifer: This story's pretty personal to me because I also remember it, I think I was eight at the time. I lived down near Johnson Space Center and I come from kind of a NASA family I would say. I remember laying flowers at the memorial around Johnson Space Center afterwards and my dad…he actually was one of the astronaut instructors for the astronauts on this flight, so here's an excerpt with him talking about his experience with Columbia.

Daniel Deger Columbia Excerpt

Jennifer: Okay, did you know any of the astronauts on board?

Mr. Deger: Oh yes I did, I knew three of them fairly well. The commander’s name was Rick Husband, and he and I had a common ground that we both were born and raised in Amarillo Texas. So Rick Husband became the astronaut from Amarillo, I was the astronaut wanna, the turned astronaut instructor. Rick and I got along really well together, in fact they named the airport in Amarillo after him. The airport Amarillo is the Rick Husband International Airport named after Rick Husband who was a son of Amarillo.

Jennifer: Yeah, did you train those three astronauts?

Mr. Deger: Yeah three of the astronauts I remember were in my class at some point so I knew you three people when I first heard Columbia went down, there were three people I knew personally that were in the shuttle when it went down. So it was a little bit of an emotional experience shall we say. To know that three of your buddies…

Jennifer: The day of Columbia was there any expectation that something bad would happen or was it just like a complete surprise?

Mr. Deger: A little bit of forewarning, they knew the shuttle has been hit with a piece of foam.

Jennifer: With a piece of what? Oh Foam.

Mr. Deger: Foam, from the tank. They knew it had been hit, they saw getting hit on the television cameras watching the astronauts, they did see a piece of foam fall out off and hit the shuttle. But they had come to the conclusion there was no significant damage to the space shuttle and it would be able to enter okay. But obviously they were mistaken it was obviously in retrospect fatally damaged.

Jennifer: Do you think that was what made the difference? Was the foam hitting it?

Mr. Deger: Oh yeah the foam hitting it is what caused the accident, yeah a piece of foam fell off of the tank, hit the leading edge of the wing of the shuttle and poked a hole in it.

Jennifer: Could you explain like how the hole… the mechanics of how the hole led to the entire spaceship scattering.

Mr. Deger: Well what happened is there's a hole in the wing, and entry is very very hot. If you're in outer space and you enter you have a lot of heat get to deal with. So there was a surface on the leading edge of the wing to protect the wing from the heat, well that surface was damaged…it had a big hole in it. So all of these very hot gases from entry entered the wing and then basically melted the wing off. I mean that's pretty much what happened is the wing melted off from all the heat because they lost that heat shield. Without that heat shield aluminum melts at about 450 degrees and it was up like 3,000 degrees. So the aluminum couldn't survive that hot temperature without the heat shield. With the heat shield aluminum is okay but you take away the heat shield and the hot plasma hits the aluminum directly the aluminum loses the battle and that's what happened. Now after Columbia, every time the space shuttle flew they had a backup shuttle sitting on the launch pad ready to go, so in case the one that was just launched was fatally wounded by foam coming off the tank there was a process in the place at that time, in retrospect, to launch the shuttle and go get the crew off of the crippled shuttle and bring them home. But at the time of Colombia there was no such thing of sitting a shuttle on the launch pad ready to go.

Jennifer: What was it like at NASA after that happened?

Mr. Deger: Oh wow that's hard to describe, obviously a lot of, a great deal of sadness because people knew these astronauts. No we came together as a family, I could put it as NASA came together as a family to support each other and make sure it never happened again.

Back to round table

Erik: Wow that was really interesting

Brandon: Yeah.

Jennifer: Thanks guys. So Dr. Francis Gannon, our guest on this episode, is an osteopathologist at Baylor and he performed the autopsies after the disaster, and for this work he was awarded the meritorious civilian service award. We have the honor of speaking with him now.

Interview

Jennifer: Could you tell us about the path that brought you, you know, to doing the Columbia autopsies after the shuttle disaster.

Dr. Gannon: Sure, while I was at the Armed Forces Institute of Pathology that we had talked about, before unfortunately the Columbia Shuttle exploded on re-entry, and I know that that story is well known. There are books on it, so if your listeners want to read about that and why it happened there was an exhaustive investigation into it. But, at the time what was surprising to many of us was that there were large portions of the astronauts that were recovered for their remains and this was only the second time in history that that had happened. I think in the early 70s there was some cosmonauts that had had this…something similar happen, not in a shuttle. And so, this was one of the first times that we could look at bone, we don't often biopsy astronauts for bone because it's invasive and it's harmful and you can do it through x-ray. So to look at the bone and to look at the nervous system and things like that, myself as a bone pathology perspective and a longtime friend of mine Glenn Sandburg, who is a neuro pathologist, we were both working at the Armed Forces Institute of Pathology and were called by the commander to say to report to the Dover Air Force Base. So the Armed Forces Institute of Pathology is located in Washington DC and the Dover Air Force Base is in Dover Delaware. That is the place where all the remains of people who've died in combat or other places are brought for…to be taken care of. And so the astronauts were brought there and when Glenn and I showed up to say we're here to do…to provide some specialty expertise, we are pathologists, so it was decided that since we were going to look at samples the two of us should do the autopsies, which we did on all of the crew members.

Erik: Is it common for pathologists to do the autopsies? Or does that generally go to another specialty? Or do all specialties…are they…I know like with Semmelweis era right, it sounded like back in the day everybody would do autopsies, is that the case now, or…?

Dr. Gannon: Another really good question. The short answer is autopsies are done by a pathologist now. Now, in olden times physicians would do the autopsy but now there are two types of autopsies. So there are people trained in forensic medicine, which you need to do a fellowship for because it's specialized and they do autopsies of patients who have died of trauma, or not under our physicians care, or suspicious circumstances. The things you see on TV. However the autopsies that I and others like me who have not been forensically trained are patients that have died after long-term illnesses, or things like that. And so a pathologist does the autopsies now.

Jennifer: More for research purposes I guess…was your assignment?

Dr. Gannon: Correct, partially. My original assignment in this case was to look specifically at the bones, but an autopsy…the best way that I try to describe autopsies to others is…it is a clinical investigation, but probably the best result of it is to bring closure to a family. So the best answer that I can give a family after an autopsy is there really was nothing else that could have been done. Because oftentimes when a loved one dies the question is should we have gone with a respirator or should we have done the experimental chemo. And so being able to tell them no you did everything that you could and there really was nothing else that could be done brings healing to people, and that's one of the things I enjoy most about being a physician in general and a pathologist in particular. In doing these autopsies there were a lot of questions about pain and suffering and things like that and we were able to answer that and so that was the successful closure to that.

Erik: Well that actually leads us into our next question. Can you tell us a little bit about some of the thoughts and emotions that you faced while working on this project?

Dr. Gannon: Wow, we had talked about the body armor before and I will tell you I was very proud to do that. It was a very different feeling doing this. I was moved almost to tears even while I was doing the autopsy at their bravery, at the tragedy of the loss, at the dignity and solemnity of the situation, and proud that I could assist in this. And additionally, it was moving in another way, one of the astronauts was Israeli and so there was a rabbi I believe he was a colonel in the Israeli army, or Air Force, unfortunately I can't remember. He was flown over to perform the Orthodox burial rites and so to stand back and witness that was the memory of a lifetime. And so, even in death there was a sharing of our humanity that was very very nice.

Jennifer: Do you think the experience changed you?

Dr. Gannon: It did. I was, yeah young at the time, which we're all guilty of at some point. I think I was in my mid-30s and I just remember thinking that I was part of something that would be in the history books and even though my name…I mean I was part of the official NASA report but I wasn't…that's not why I'm talking about it, but just to be a small cog in this to help future shuttle missions be successful was…really reminded me of why I like doing what I do.

Erik: And I'm curious, given I guess…there's a lot more talk now about space travel with space X, Blue Origin, all of all of those companies are sort of reviving because…you know I'll be just be honest I feel like our generation, I'm a millennial, we sort of missed a lot of the space, like you know the space television, like nobody watched launches or anything like that. But now it's sort of being revived a little bit, but given your experience with Columbia, does that make you now a little bit more hesitant about space travel or even just technological development in general for going and kind of pushing the boundaries? Or do you think it's probably necessary that it should be done?

Dr. Gannon: So I may or may not be the right person to us because if I was told that I could get on a shuttle tomorrow I would be packed and be at the launch early. So I think we should go out and explore, I think there are a number of very real technical issues to overcome. Bone loss is one, radiation is a huge problem. You know, the year and a half to get to Mars, or two years to get to Mars, the amount of exposure of solar radiation you would get…there would likely be malignancies by the time they got there so that alone is enough. But I don't think that should stop us.

Jennifer: So how is there…is there any thought as to how we could prevent bone loss in space beside, I mean everyone knows you see the astronauts on their treadmill and their rowing machines, but are there any like treatments or drugs that you found in your research that might be helpful?

Dr. Gannon: Not that we know of. The treadmills and the armbands and things do provide a little bit. The problem is the effect of gravity on bone, and there is a significant bone loss that occurs within the first few months, which is different from what we used to understand. That it goes up sharply as a spike and then plateaus off, and we haven't developed any drugs to combat that because it's a biophysical issue. So maybe someone in your class or your generation will be able to take that and figure something out.

Jennifer: That would be awesome, especially if we go to Mars.

Erik: Yeah, they understand, I presume they understand the mechanism behind how gravity affects the cell orientation?

Dr. Gannon: Not so far, or if they do I don't know because I'm not heavily involved in that anymore.

Erik: Because I know, I think they…there's research on…because plants obviously have a mechanism to detect gravity and even some bacteria with iron. But yeah that's interesting.

Jennifer: So going back to, you know the Mars mission that might or might not happen in the future. Are you excited about the lunar gateway, they're building like a pit stop by the moon?

Dr. Gannon: Oh no I am. I’ve been following it, and so I'm very excited about that.

Erik: Can you talk about that? I don’t think I’m familiar with that.

Jennifer: Yeah, since it's gonna be hard to just go directly from here to Mars in one trip, they're building it both as you know a refueling stop and everything like that, and to kind of like practice going to Mars I think.

Erik: Oh wow.

Jennifer: I'm also curious what you think about, so there's some debate about whether the crew going to Mars should be all one gender because we have no idea what it would be like to you know, for a fetus to develop in microgravity. So that might be a whole other set of complications that we had no idea what would happen, and you know like hopefully the astronauts would refrain from that but it gets very boring…

Dr. Gannon: On a two-year trip in a confined space, yes. No I…I'm trying to be as delicate as I can but I think there are very real concerns about…I mean science fiction is full of trying to wrestle with that question of, if a child is born in space can they actually come back to earth or an earth-like gravity, or what would that do to the…even the spatial patterning of things like bone morphogenic proteins and you know bone remodeling during puberty. Because you have to have stress across the bones to help that so, that's why often times I mean…we could send someone to Mars today. The technology exists, the rockets exist, the question is how do we get people there and back safely, and I don't know if much of the sort of the lay public understands that it's not a question of the machinery. We have that. It's the human beings.

Jennifer: Yeah I mean the rover has been there for years and years and years so…and he's been fine. Curiosity. So our last question is a little more general it's…we're asking about your perspective on how science helps us cope with disasters like the Challenger disaster in the 80s and the Columbia disaster now. So you obviously had a role in you know looking at the astronauts after and trying to understand what happened but, more in general like, what is your perspective on science helping us with that?

Dr. Gannon: So if I may, if you would accept a refinement to your question I would like to talk about medicine and how it can help just because I can't speak about the others. No I understood your question, but I believe that there are untapped sources in medicine which is why I'm a big believer in a multidisciplinary team to approach a problem. Because you're at least…a lot of thoughts on how do we make astronauts safer or in space you wouldn't…you might not normally think of a pathologist or someone like that because you know, even among other physicians you know pathologists deal with dead bodies and that's a lot of understandably the stereotype because that's the thing that people know most about pathology. But there are you know, endocrinologists and oncologist, I mean all of those problems are going to be in space and so I think bringing smart people together to say, how can we think about how the body's going to react in this harsh environment? Cold, weightless, radiation, a moment away from suffocating from the lack of oxygen, I mean these things we can bring together people now to address that as we move forward. So I'm a big proponent in having…not just talking about how do we keep someone from getting an infection, which is definitely important in space and how to treat it, but how can we get people to survive and back in a homeostatic physiologic way.

Jennifer: Yeah, do you think…do you have your own time estimate for when we'll be able to go to Mars and back safely?

Dr. Gannon: I don't, because it's daunting even to think about overcoming the challenges and that's for some people way smarter than me so…

Jennifer: I think we’re pretty close, what did Trump say like 2026? Or something.

Erik: Correct me if I'm wrong but you received a medal for your work on this as well right?

Dr. Gannon: I did.

Erik: Would you be willing to tell the audience?

Dr. Gannon: Sure. I received the third highest civilian service medal for this. It was recognized as a help to NASA and to this space program as a whole.

Erik: And was there…how was your interaction with I guess the higher-ups during your time there?

Dr. Gannon: Um, what I found was not well received because it essentially said that the paradigm of bone loss that we had all been working on in space was wrong.

Erik: And that was that it doesn't happen, right?

Dr. Gannon: Close, the paradigm at that time was that there was 1% of bone loss for every month in space. Whereas what I found was in the first month there's about a 25% loss. It's not that 25% of your bones go away, it's 25% of your trabecular bone and some of your cortical bone is resorbed and then all of that calcium that's released into the body, at least some of us believe, causes the space sickness and the other things that people get, but then it plateaus off. And so after many many months in space it looks like, you know, after 18 months and you lose 18 percent of your bone by DEXA scanning, it looks like 1 percent a month, but what it is it's acute increased spike. So that was…unfortunately that was not well received, but recently they recognized that that is correct and now it's accepted that that's how bone is lost.

Erik: And I believe issued you an apology?

Dr. Gannon: Yes they sent me a letter saying thank you…you were right essentially.

Jennifer: Yes frame that by your metal.

Dr. Gannon: It is! It’s hanging by that metal.

Jennifer: I mean, I feel like that should be good news for them because then, you know, people can go out in space for longer if there's a plateau rather than, you know, if you're just losing bone linearly while you're out there you can't stay out there very long.

Dr. Gannon: Which goes back to your point that if we could find something to halt that resorption.

Jennifer: So when you come back down, does that resorbed calcium then go back into your bones, or do we know?

Dr. Gannon: Another good question. We don't know, but we do know that after a couple of months of being back on earth, I mean that the bone volume goes back to if not the same then close.

Erik: I think maybe we could close it off by having a moment of silence for the crew members and their family.

<Moment of Silence>

Erik: Thank you so much for your time Dr. Gannon

Dr. Gannon: Thank you, thank you for having me.

Outro

Brandon: Alright, that is it for now, we would like to thank everyone out there who took the time to listen to our episode of the podcast. Special thanks to Jenni for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for your help with the production and website. And thank you again to Dr. Gannon for taking the time to be interviewed by us. We hope again that everyone enjoyed it, and hope you tune in again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 45 minutes | Published: March 18, 2020

Dr. Musher discusses his experience as a clinical researcher, some of his discoveries that he made during his career as an infectious disease doctor and some of his outside interests like music and literature.

Transcript

Erik: And we're here.

Brandon: We are here.

Erik: This is the Baylor College of Medicine Resonance Podcast; I am one of your hosts Erik Anderson.

Brandon: And I'm the other host Brandon Garcia.

Phillip: And I'm Philip Burkhardt, writer for this episode.

Erik: Yeah so today we're going to be talking with Dr. Daniel musher who is an infectious disease doctor and also teaches some of the infectious disease course to the medical students here at Baylor College of Medicine. We're really excited because he's a bit of an institution here so…

Brandon: He's very colorful fellow.

Erik: Yes, and has given us a lot of great clinical pearls about you know how to detect things from syphilis to…

Brandon: Hemophilus, it doesn’t seem like that much of a jump, but it might be.

Erik: And pneumococcus.

Phillip: And every Gram stain in-between. We're excited to talk to him today because we're gonna be looking a little bit about performing research as a clinician, which is one of his big topics he likes to bring up in class, and to start that off we're gonna talk a little bit about the history of kind of what the physician and the relationship to medicine has been kind of in the past and how it still reflects that today a little bit. The physicians in the past where were always kind of learning and trying to seek new knowledge and doing experiments of their own with patients or with what they saw. And we're gonna talk to Dr. Musher on how he's still doing that today.

Erik: Yeah so, I guess to start with do you want to tell us a little bit about maybe some famous physician scientists if you will in history?

Phillip: Yeah, I think my favorite one by far is Dr. Jon Snow famous for his cholera outbreak map and father of Epidemiology. I think he's a really cool story on how that even before germ theory you know he didn't know what was causing this illness and everyone was thinking that this cholera outbreaks in London at the time in the 1850s were due to the bad air and he didn't really have a good microbiology understanding, nobody did on what could be a different answer to that question but he was able to just map out kind of what he saw and realized that it had to be this water the famous one being the Broad Street pump.

Brandon: Like he found like one single source that was the source of all the cholera in the in the city.

Phillip: Yeah for one specific outbreak, yeah he just kind of went around talked to his neighborhood, it happened to the neighborhood he was practicing near, and he has a famous map where he has the little black bars of every case and it all just centers around the pump. And a couple of the pieces of evidence that were very helpful to him were people that were outside of this area but had traveled and used this water and it kind of spurred the idea that illnesses could be from something else and it was just something else other than this bad air, that we know now it sounds really silly but was the predominant, you know, idea at the time and I think an interesting to hear from Dr. Musher is going to be that a lot of times you know we look back on these stories and it seems obvious like bad air you know we know so much better than that now how could they have thought that but there's things that are still being discovered now that you know in a couple years then look pretty obvious and I think it's interesting to hear how people make those realizations to start with I think that's interesting thing.

Erik: Well in a really interesting thing about this too is that it's all before the germ theory was really like yeah Koch and Pasteur and all the doctors in the late 19th century who came up with this yeah.

Phillip: I like to hear from it as kind of like a way to look at things, like a way to notice these discoveries that you know kind of changed the way people think about certain things and I think Dr. Musher himself, just to kind of further plug him, did that with Hemophilus in a way that he kind of discovered that it was an infectious cause of pneumonia when other people weren't looking at that and so I think that's something we're gonna hear from him you know and later in this podcast and I really like to hear about how he approaches these questions.

Erik: Yeah so you want to lead us in?

Phillip: Yeah so you know like we've been talking about; Dr. Musher is with us today he's an infectious disease clinician who works primarily at the VA here in Houston he originally got his medical degree from Columbia University and his residency and fellowship at Tufts University and we're really excited to have him on the podcast today.

Interview

Phillip: All right, today with us we had a Dr. Musher. I'm very happy to have him here so Dr. Musher just to start us off can you describe to us how you came to Baylor and the VA and what your current position is?

Dr. Musher: I was raised in Northeast I almost never been west of the Hudson River and never south of bottom of Manhattan, except to go to museums in DC. The military stationed me in Texas, and I loved the place. The people are so nice especially after having been raised in Manhattan. So I actually met my wife in Laredo Texas went back to Boston for training and since my professor was well known I was offered jobs at a lot of places, but my wife's family was in Texas, mine was in Manhattan, and I didn't think I could afford to teach medicine and raise a family in Manhattan and I loved everything I saw about Texas. Baylor offered me a wonderful job it's been wonderful since the day I arrived in 1971 it's been my only job and I love it and that's why I'm here that's why I've stayed. My specialty is internal medicine, my subspecialty is infectious diseases and a lot of younger folks forget that but we are internal medicine physicians first, and the subspecialty is something that's on well.

Erik: Many of us first years, and really anybody that's come through the Baylor program, will know that you give many lectures for the infectious disease block, we're curious can you tell us a little bit about some of your research.

Dr. Musher: May I first tell you how I selected infectious diseases as a specialty

Erik: Absolutely

Dr. Musher: I love internal medicine and I didn't even think about quote sub-specializing when I was younger. I thought I would practice internal medicine but it did seem to me that if there was some area in which I could have special expertise I would feel more fulfilled as a physician and among the sub-specialties infectious diseases is the broadest because it's not based on a particular organ or organ system, and I think that was actually part of my conscious reason for choosing infectious diseases of specialty. Now when I went to my fellowship, I never planned to do research. I majored in college and medieval studies, I took the briefest number of the shortest number of requisite science courses to be able to apply to medical school, and I did adequately in them just by cramming for exams. But I did love medicine the more I got into medical school the more I loved it and by third and fourth year and by internship I just was totally in love with internal medicine. When I decided I wanted to sub-specialize I picked infectious diseases, for the reason that I told you, I still never planed to do research. Dr. Lewis Weinstein who was one of the two great infectious disease physicians in America the last century offered me a fellowship, and his fellowship program was one year as a chief resident, his chief resident, working personally with him every day and then two years in research and when I arrived he switched it I think he had the feeling that Musher would take that first clinical year and then vanish, so he made me do research the first two years. And at first I thought it was like cooking, and I hate cooking, but what I realized is it's research is though gives you the opportunity to answer clinical questions that are unanswered and I will say that throughout my internship and residency every day I was raising questions and they my fellow residents would comment on it the attendings would tell me that like “Musher why are you asking so many questions”, I said because it's interesting and there's a lot of stuff that's not known so any of the research that I've ever done has been based on clinical problems specifically, and from the very first research that I did you can see the clinical basis for all of it some has been laboratory intense some has been new techniques that are widely used developed by me in the laboratory but they were all to answer clinical problems.

Erik: You make a good point about how you can discover new things that maybe people haven't noticed and specifically you know we know about your work on Hemophilus influenza and I'm curious with your work, I think some papers that you released in the early 1980s, that showed that it was a common cause of pneumonia and older men can you tell us how you notice this trend.

Dr. Musher: I love the question the way to do it is to look at data. So patients are admitted to the VA hospital they have pneumonia, they cough up a good sputum sample and you look under the microscope and you see zillions of little teeny-tiny gram-negative coccobacilli and then the culture plate shows just about pure Hemophilus influenza and the textbook says well Hemophilus influenza doesn't cause pneumonia in adults and I said well but it does I mean here I've got a case here, I've got another case, and here I got another one. So I did for a period of a year look at all the gram stain's of all the patients have been with pneumonia, not every single one, my subsequent research I tried to do every single one for one of the studies I did, but I looked very conscientiously at the Gram stain and the culture results and there were a lot of them that had Hemophilus influenza. Now at the time, this was in late 1970s, I began doing this research the Hemophilus vaccine the little kids had not been introduced and Hemophilus influenza type B was a major cause of disease and little kids but nobody thought it was a cause disease in adults because by adulthood almost everybody had acquired antibody that was reactive against the polyribosyl phosphate capsule of H flu type B, whether by having been exposed to H flu type B or by being exposed to other bacteria that had capsules that reacted immunologically similarly. So adults didn't get the flu type B disease and these Hemophilus when we set about to be typed they were non-typable and quite seriously they were regarded as laboratory contaminants. But I said look they got a pneumonia syndrome, they got inflammatory exudate accumulating in the lungs, what they coughed up reflects what's in the lungs and you look on the glass slide and there's loads of polymorphonuclear leukocytes that's not present in a normal lung, and there were loads of these bacteria and there aren't any other bacteria. So it seems to me that's indicating that those bacteria are causing pneumonia. Well it wasn't so easy I have to, quote, convince people so I decided that I would try to determine whether people who had Hemophilus influenza pneumonia had antibody to their Hemophilus at the time they were admitted and if they didn't did they develop antibody when they got over it. In other words an acute and a convalescent serum. So to do this you've got to go through an institutional review board and a lot of work and a lot of the research I've done it's just because I've got no particular brilliance just a lot of hard work and energy. So I'd identify patients get their permission take their blood, spin down the blood, store away the serum, collect blood from them a few weeks later, save their organism and then look to see the bactericidal effect of serum because antibody to Hemophilus kills Hemophilus because it's a gram-negative organism. And I showed that a lot of them had some minimal or moderate bactericidal activity at the time of admission, but two weeks later their serum just wiped out these organisms so it was a very distinct documentation of emergence of antibody and that is basically the way in which I got the work published. So I showed it was just clinical observation with looking at laboratory results myself and thinking about them, but then the way to get the world to accept it was to develop a laboratory technique and show that antibody did emerge. I also had to learn how to do studies of opsonization in which you exposed the Hemophilus to serum when the patient's just were admitted and then exposed Hemophilus to the serum obtained a few weeks later, and then incubate those Hemophilus with white blood cells and had to radio label them first, it's kind of complicated. You radio label and incubating with white blood cells and you see which ones are taken up by the white blood cells. And the ones exposed to the convalescent serum were taken up very nicely by the white blood cells, and the ones that were exposed only to the acute serum we're not taken up by white blood cells. So I showed antibody in two different ways and that's what made the world accept it.

Erik: And just for people out there who might be unfamiliar but that basically shows because they took it up that shows that the immune cells had been exposed to it prior.

Dr. Musher: it shows that there was not only bacteria present in the lung, but there was an immunologic response to those bacteria proving that they weren't just quote colonizing they were actually getting into the system and the body was making an antibody to them.

Phillip: From just sitting in your lecture you always bring up things that you've worked on almost in every aspect of the field and major discoveries like this that you've made and I think obviously there's other people treating these patients that aren't making these discoveries that you are. So I'm wondering if you could kind of describe to us your mindset on how you approach your day-to-day work with these patients that helped you come up with these questions and these discoveries.

Dr. Musher: Okay how I work with patients is I like take care of patients. I like people I sit and chat with them I visit with them but that doesn't necessarily affect my scientific thinking. I ask how does the disease come about and that's why in my lectures I emphasize pathogenesis. Why is this person getting a disease and somebody else isn't getting a disease? So, I'm as interested in why some people don't get disease as in why some people do get disease. And then I go looking for the differences. I'd also say that it's just having a, just being very curious, curious about things, intellectual curiosity. I'm Jewish and the Jewish religion literally forces you to ask questions. I don't think a lot of people who aren’t Jewish know that. You're forced to ask questions. That Talmud which is that very lengthy series of books written by the rabbi's in the 2nd to the 5th century is not full of answers it's full of disputes and discussions and a lot of questions go unanswered so somebody who takes that stuff seriously, has been raised that way, says oh there's a question and you ask questions and maybe get an answer you may not get an answer.

Erik: That's a very interesting point and actually I think I remember from a previous conversation with you, you in your undergraduate studies were studying an ancient Jewish scholar is that correct?

Dr. Musher: it is, I did medieval studies at Harvard and I was studying Christian theology because that's what was taught and it actually, I was really an expert on St. Augustine, like I was a super expert on St. Augustine. Once when I was a junior the chairman of history at Harvard called and asked me a question about St. Augustine, amazing. But anyway, I came to the end of junior year I had to write an honors thesis and I was gonna write one on Meister Eckhart, the Christian mystic theologian from the 13th century. And one day I said, you know I'm Jewish why should I write on that Christian mystic I'm sure I can find some Jewish mystic to write on, so I did. I don't know, you can eliminate all this from the podcast if you want, my grandfather was a very famous rabbi and professor in the twentieth century. He's the one who first had girls become botanists for they never had been botanists before. He was the first one to found a Jewish Community Center, I mean he had a major influence but he was kind of very non-mystical in his thinking. So I went to visit him at the Jewish Theological Seminary I said grandpa I'm interested in writing honors thesis in college on a Jewish mystic, so he basically laughed cause he's so anti-mystic he says, “but let's ask Abraham Joshua Heschel.” And you guys may be too young to know that name but he was the great mystic Jewish theologian. He's one who marched with Martin Luther King, a very, very big name. He said let's go down the hall and they asked professor Heschel if he's got an idea for you. So Heschel was the one who suggested that I do my honors thesis on Bachya ibn Paquda, who was in fact 10^th to 11^th century Jewish, Judeo-Arabic philosopher with certain mystical tendencies. So yes, I was interested in theology. I think the liberal arts training is a much better discipline to be a good and thoughtful physician then the usual pre-med training. The usual one that's not someone who really loves science and is interested and there's taking science because he or she loves biochemistry or biology or whatever it is, but lots of pre-meds are just taking a certain number of courses so they can get to medical school and I don't think that's any kind of good training at all.

Erik: I mean I'm also partial that I was a music major

Dr. Musher: There you go.

Erik: And I remember taking a class on historical performance practice which is essentially how there nobody really knows the, quote, true way a Bach song is supposed to be played right because there aren't any notations modern notations people sort of just infer them and so you have to think like, well like what is the true way and then you basically get to the point where there is no true way. Nobody really knows what it was in his head and I think you could probably get a lot of parallels to medicine with that in some ways.

Dr. Musher: One of the most important philosophers of history was in the in the 1950s was a British historian / philosopher named Collingwood and he helped to clarify what we all knew. He said you've got to put yourself into the shoes of the person whom you're writing about to see what he possibly was thinking and how he or she might have reacted and why, so if again you can see to questioning what's one of the reasons what's the motivation and that's the same kind of reasoning that applies in medical investigation as well. How do these things come about. How does it happen that this person does this, or this immune system does this, and that immune system does something else, or this organism does one thing and that organism does something else? In class you might remember, although I am absolutely not an expert in virology, herpes one virus and herpes two viruses are almost identical just ever so most minimal differences and they behave biologically differently. The reason still not know I think that's fascinating, if I was a younger guy I think I might take that on as an investigation.

Erik: So, Dr. Musher, why do you like to teach medical students

Dr. Musher: I love teaching medical students because they ask questions that are different and interesting. They haven't yet brainwashed but a medical establishment to accept all the stuff that's in the textbook of medicine, so it's a great experience and I get asked questions at the end of my lectures first of all you've heard me I get asked questions which I don't know the answers but I get asked questions sometimes nobody's ever asked before to my knowledge and they're just fascinating.

Erik: Well I like you always tell us to email you after.

Dr. Musher: Precisely, I get questions by emails and about practicing. And when you talk to patients you get ideas about the way the disease evolves.

Erik: Well I have a historical question that I think we have to ask because we're here at Baylor and I know you're an institution at Baylor now yourself.

Dr. Musher: I've just survived I'm a survivor.

Erik: Did your time at Baylor overlap with Dr. DeBakey?

Musher: My time at Baylor overlapped with Dr. DeBakey and I had a couple of experiences that I'm willing to describe. It was a search committee for a new chief of staff at the VA and Dr. DeBakey was on the search committee. So I got to sit on a committee with Dr. DeBakey and the two final candidates were a surgeon and a psychiatrist and Dr. DeBakey listened to people discuss it and he said, you know a surgeon works in an operating room works with nurses, OR nurses, and residents, and post-op patients. A psychiatrist works with patients and psychiatry wards, but he or she does consultations all over the hospital, works intimately with social workers, and with social support, and with pharmacy, and with all kinds of other issues. So says dr. DeBakey, I think in general a psychiatrist is a better choice to be chief of staff of a hospital than a surgeon. And how do you like that, isn’t that amazing. Subsequently my wife and his wife became friendly, so we were invited to his house a number of times he was a fascinating man, really, really brilliant. He was the one who engineered the separation of Baylor College of Medicine from Baylor University I don't know if you know that

Erik: Familiar with it okay, but don't know details.

Dr. Musher: Well the reason is that Baylor University, because of its religious requirements for students and faculty, was not allowed to accept federal grants and that DeBakey said a medical school can't survive without federal grants so obviously it took a lot of negotiation I'm sure there were a lot of egos that were involved but he did get the medical school to separate from the College of Medicine. The next thing he engineered was incorporating the VA fully into the Baylor teaching system a College of Medicine doesn't have enough money to pay all the salaries for all the faculty it needs but a federal hospital needs to be covered by physicians so he created the idea of a dean's committee in which they were representatives of the VA and in the Baylor College of Medicine and all appointments of physicians at the VA hospital since 1969 have been made by or approved by the deans committee, which means they've been approved by the Baylor College of Medicine and by the VA. So everyone at the VA basically is involved in some way or another in teaching. Now if you think about that, I told you originally I wanted to teach medicine and I did by the time I finished this fellowship of mine I wanted to do research, so I needed an institution that would support me would give me sufficient time to do my teaching and do the research well. The VA was willing to do that under these guidelines, so I was therefore willing to come and be a VA physician. Boston VA didn't have this arrangement and I wouldn't have dreamed staying in Boston to the Boston VA. Houston VA was first class faculty, first class citizens because it was fully integrated as a teaching system that was DeBakey's doing so the guy was obviously a brilliant surgeon who was apparently a very good engineer. Also yeah some of the stuff engineering skills and he also had brilliance and foresight in his administration, yeah so I  think the guy was a super genius he actually was very nice when you met him personally and socially.

Erik: Wow well thank you for sharing that. We're always curious here to hear about the great Dr. DeBakey we see his name all over the place right.

Phillip: I kind of had a question more about staying up to date on current papers and being able to I guess pull back from those later papers as well. How do you in medicine, and being in practice as long as you have, how do you make sure that you're up to date?

Dr. Musher: It's a very good question it's harder, it's much harder, because there's so much more that's known and that does drive people to sub-specialize. I do think it's unfortunate because a lot of folks who are doing subspecialty medicine forget the fact that I emphasize at first we were internal medicine specialists before so specialized. When I graduated medical school the whole textbook of medicine I think was 1,100 pages long with big print and big margins. The infectious disease textbook at the present time is four thousand pages with tiny print no margins whatsoever and it's just incredible. When I started on the faculty I did read 12 or 13 journals regularly I'd sit down at 10 o'clock at night after the kids went to bed and I would either read literature or write manuscripts from 10:00 until 2:00 every morning so I really pushed myself and I deprived myself asleep, because when I'm on vacation I sleep eight hours a night like everybody else, but I just didn't let myself do it. And as an intern and as a resident I read voraciously every night no matter how late it was. I had a resident who inspired me and drove me to do this when I was an intern. First week “Musher would you read last night”, “Dr. Greco I went to bed at two o'clock in the morning how much could I have read”. “Musher you could have gone to bed at 3 o'clock in the morning, what did you read last night”. That guy ferocious, he became the head of medicine at Roosevelt St. Luke's in New York he was really, really good so he got me started on this path, but I read. We were on every other night but we didn't work anywhere near as hard as you guys work when you're on at night because I just covered my patients and the other one other interns patients and not that much happened. Now you're on every fifth night which means you're covering your service and four others so what's all night long. So I was there at Bellevue and you've worked for a few hours and Bellevue had a wonderful library I sit there and I read I remember reading Goodpasture's original article, I think it was American Journal in medical sciences 1919, I'm sure people are pulling out their computers to fact-check me. I remember Harvey Cushing's experiments on increased intracranial pressure and the effects on blood pressure and pulse I think that was nineteen o- four to five it was nineteen o-four to five and that was American Journal of Medical Sciences I read it was something called Hamman-Rich syndrome, which is now really acute onset of interstitial lung disease. It was described by two pathologists at Johns Hopkins, Hamman and Rich. Rich was also the great pathologist to describe TB. I read their articles, I read circulation beginning in volume 1, I just read it 13 years of circulation. I mean every thought was a bit crazy, but I loved it. Then for six months I was in the Bellevue chess service and we were on every third night. This was an unbelievable luxury so I work one night I'd read one night and I'd go out one night I go see Shakespeare productions in Central Park and wintertime I go ice-skating in Central Park. I went to theater movies whatever it was, so I loved my internship and residency. Anyway I did read a lot when I was junior faculty. I read 12 or 13 journals and that was beginning in 71 when I first came to Baylor and I kept up that pace through the early 80s and then I started to reduce the amount of reading because journals that used to publish once a month we're now publishing every two weeks, some of them every one week, that it just wasn't possible wasn't it humanly possible to keep up. And now I read the major medical journals which is Annals of Internal Medicine, New England Journal of Medicine, JAMA, and the major journals in my field which is Clinical Infectious Diseases journal, Infectious Diseases, Lancet Infectious Diseases, and every article they refer to that I'm interested in and I read. I do write a number of sections for Up To Date so I have to stay up-to-date in those. Because I write articles I've got to be reviewing literature all the time. I'm upset I just submitted an article to Lancet Infectious Diseases they wanted only 30 references, I had 50 references. I had beautiful, I had references back to the 1915 I mean oh guys it, gorgeous references. I had to cut them out, it bothered me to cut them out.

Erik: I've never heard of a journal wanting fewer reference, wow.

Dr. Musher: They do. Clinical infectious diseases allows you forty references new English journal of medicine allows you only forty references.

Erik: I wanted to just quickly, you mentioned Bellevue and it's a historic hospital and I think it's important for people at Baylor to know about it because you know I think that's where the ambulatory program originated in America and I guess the world and as you were just quoting like the library that it has because it's been around since I think the smallpox in the 18th century. Can you tell us anything special that you noticed about it or was it just like any other Hospital?

Dr. Musher: Well every hospital has its own culture. Bellevue it's interesting there were three medical schools that each had separate services at Bellevue and NYU service, Columbia had a Columbia division, that's what I was on, Cornell had a Cornell division. Each of us thought that we were better than the others and there was a lot of pride we tried to do very good work. Yeah it wasn't beautifully equipped, it wasn't like Columbia Presbyterian which is where the fancy residents and the fancy patients went, it was just Bellevue. And in those days Bellevue was near the Bowery, which you guys probably don't even know about, but now what is now Soho in Manhattan is so gentrified was slums. And at the foot of the third Avenue L as the elevators subway was where what we would now call homeless people would stay, except it was against the law to be homeless you have to go find somewhere to stay at night, but basically that's where they were and that's who our clientele was. We also had lots of patients from Chinatown, the Lower East Side had large Italian population, large Jewish population, many of these were either immigrants or their parents had been immigrants and brought them as little kids or at most they were born here and raised here but they were first-generation and barely. So there were tremendous diversity of population tremendous diversity of disease. We worked terribly hard there were no politics that's what I loved about Bellevue. At Bellevue there was so damn much work to do you have time to jockey for power or importance you just have to do the work and I did love the work.

Erik: Well that's a good point because it's a public hospital and it was like one of the first public hospitals.

Dr. Musher: Exactly right. Historically it was and it was it was a place where they introduced some of the important good nursing practices and I read a history about it and as you say it began they were the precursors were in the late 1700s I think and then by eighteen, mid 19th century mid 1800s it was really starting to grow into flourish.

Phillip: I feel very lucky to be here at Baylor and have that same sort of public hospital training here at Ben Taub.

Dr. Musher: Oh yeah, Ben Taub is amazing.

Phillip: it's such a good you know resource as a student to be able to see that kind of diversity.

Dr. Musher: Ben Taub gives you exactly that experience. I did round at Ben Taub when I first came my first couple of years I rounded at Ben Taub and I sure did like it, but it was just so disruptive to drive from the VA to drive over here park and drive back.

Erik: the VA has also been helpful in your clinical work because you have like longitudinal population that you see for a long time is that correct.

Dr. Musher: Yeah that’s terribly important yeah and that's actually why, well it's one of the reasons, that the VA provides such extremely good care. I will mention that in addition to by working there, in addition to being a veteran, about 20 years ago I stopped getting health care anywhere else in Houston, I get all my care at the VA as well. I think in general the average ordinary VA patient gets better care than my financially comfortable friends and family do in Houston. So I do like the place and we have a way of following our patients because they come to us and they stay with us and you're absolutely right so if you want to do a longitudinal study you can do it at a VA. At the Ben Taub it's hard because people drop in and drop out, and the same thing with the good private hospitals they may choose to go to St. Luke's this month and they may choose to go to Methodists and then go off to the Mayo Clinic or the God knows where and the records are all scattered about yeah and you can't do those same kinds of studies.

Phillip: Transitioning from clinical practice to more a personal life question you mentioned in your internship years you know were able to go out and see some Shakespeare productions and those kind of things and you just want to share with us how you're able to incorporate the rest of your life.

Erik: Hobbies?

Phillip: Hobbies. That was long-winded, I apologize.

Dr. Musher: No, no, I’m long-winded

Erik: You have a lot of cool stuff to say though its ok.

Dr. Musher: You ask me a short question and get a long answer. I played the violin in high school I was I was good I played but I didn't I practiced but half an hour, 40 minutes a day that's all, but very carefully. I got to college I played more. They made me concert master at the college Orchestra, I played much more. It was one week sophomore year in college I played 40 hours of music, I was really proud of it. I decided in medical school I'm certainly not going to stop and even as an intern and a resident at Bellevue I found a room where I could take my violin and practice on nights I was on call I could practice and I have played several times a week ever since. So whole life I have I play string quartets. Almost every week my son Benjamin, who is really good violist, plays in and we play with we're fortunate we play with some very good professional musicians in town, so music is a very big part of my life.

Phillip: I have to ask, did you raise your son to be a violist so he could accompany you. that seems a little too convenient

Dr. Musher: Important question, I raised him to be a violinist and I kept begging him I said, “Benjamin”, he was a kid, “Benjamin please learn to play the viola”, “dad I'm busy”, cuz he's young he's also a wonderful ballplayer - you wouldn't know that he's an astonishing ballplayer I don't know where the genes came from.

Erik: And a physician, on staff here.

Dr. Musher: He’s an astonishing physician, that’s absolutely true. But anyway, and then he went off to college and he actually sang in college so he was in the Harvard glee club and he was one the acapella groups, he was a musical director of the acapella group, so are my other kids, all my kids did singing, so we didn't even play the violin much in college. But he came home one winter when, I offered him $100 when he was in high school said, “Benjamin I can give a hundred dollars, learn to play the viola.” He came home one Christmas break he says okay dad I'll play the viola he picked up the viola, now he plays the viola so that's kind of how that came about, I raised him to be a violinist. Now my youngest one wanted to play the flute I said Debra you know there are two chairs for a flutist in the orchestra and there are hundreds of young people who want that position. There are eight or ten shares for cellists and the back four of them were never filled so it's true I made her play the cello and she's petite and every time she picked it up she gives me a soulful look like daddy why did you do this to me I wanted to play the flute, but she played the cello and she played in the orchestra high school, she stopped in college. The oldest one played piano, I made her play viola so I did have a string quartet when the kids were growing up.

Phillip: The truth comes out.

Dr. Musher: I play violin, Benjamin played violin, Rebecca played viola, and Debra played cello. We had a little string quartet.

Erik: That amazing.

Dr. Musher: So, and then when they set up the Medical Center orchestra. I played, I was the concert master that from the opening until about five or six years ago and we were rehearsing with the orchestra for one night a week. So I played quartets one night a week and rehearse with the orchestra one night every week. I do love Shakespeare I never miss a Shakespeare play in town I read a lot try to read a novel a week and just don't let myself sleep.

Erik: I think you also mentioned that you take part in a lot of activities with the Jewish community.

Dr. Musher: Oh yeah that's true. All three of my kids I'm pleased to say are what you would say their competent liturgically, that means that they can stand up and lead any service in correct Hebrew with the correct melodies, that's what a professional cantor does, but they're able to do that and they've all done that. They can read from the scrolls which requires a special chant, they can read the profits from the book requires a different chant, they can lead services, and I was able to learn those things as a kid so I passed that along, pass those skills along to my kids, it is true.

Erik: Well thank you so much for your time, we know that you're busy, so we really appreciate you taking the time to come over here.

Dr. Musher: I'm honored to have been asked I thank you very much. I'm not sure what a podcast is, I don't do social media, but if anybody's interested I'm glad they'll be interested. You have to call me you know where to find me.

Phillip: We definitely appreciate all your lectures in infectious disease that we just you know wanted to hear more about you.

Dr. Musher: Thank you very much, I appreciate it.

Outro

Jennifer: Alright that's it for now we'd like to thank everyone who took the time to listen to this episode of the podcast. Special thanks to Philip for writing the episode thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for helping with the production and website and thank you again to Dr. Musher for taking the time to be interviewed by us. we hope everyone enjoyed it and hope you tune in again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 36 minutes | Published: March 4, 2020

Dr. Blumenthal-Barby discusses her personal journey and her career as a medical ethicist, as well as current issues surrounding ethics such as genetics technology.

Transcript

Brandon: And we are here

Erik: And we are here. This is the Baylor College of Medicine Resonance podcast. I am one of your hosts Erik Anderson.

Brandon: And I'm another host Brandon Garcia.

Jason: I'm a writer Jason Shiau.

Erin: And I'm another writer Erin Tang.

Erik: Yeah and so today we're going to be talking with Dr. Blumenthal-Barby about ethics. Jason, Erin you guys want to just take it away.

Jason: Yeah so ethical principle is something that's been part of the medical profession for a really long time ever since Hippocrates with principles like beneficence and non-maleficence and over time the ethical principles that govern medical practice have been refined, and the modern medicine really relies on the foundational principles off of things from people like John Gregory and Thomas Percival from the 18th century.

Brandon: I really feel like there should be like some kind of like stately music playing, can you make sure that happens?

Erik: Yeah 18th century.

Erin: Yeah I think it's crazy that a lot of I mean over all these years a lot of the same ethical principles guide a lot of medical practices both in the US and worldwide. I think we all have a lot of the same core values when it comes to treating patients especially like Jason said with beneficence which is promoting the well-being of others versus non-maleficence which is to do no harm which theoretically sounds similar but are actually like very different in practice I think.

Brandon: I think ethics itself is something that's very interesting because on one hand I feel like it can be kind of intuitive you know when we when we enter into medical school when we start learning about all the different things we are gonna have to do in how we involve patients and stuff like that you start thinking about – I feel like the same person is gonna start thinking oh man like what would it be like if I was in the patient's shoes and I feel like that guides a lot. I don't know I don't know how you guys feel but that kind of guides me and like how I feel about care patient care.

Erik: Well but even that gets tricky because then everybody's different that's the other issue and I think that's something that difficult. We went through the ethics course in the first year and it's like - you think everything's straightforward and then you realize how much gray is out there. In terms of maybe maybe you could really maybe go both ways. And so they teach us I think to it mostly comes down to committees, right? If there's really difficult decisions to be made about, you know, should somebody be continued on life support or something like that – who should make that decision? Pretty interesting

Erin: I agree, I think you know there's never a right answer which is what makes ethics both challenging and very fun. And I think if you look in the news these days there's all kinds of crazy and interesting ethical dilemmas with CRISPR and with genetic testing, 23andme (copyright). Yeah stuff like that. I think it's really interesting to kind of think about what it’s gonna look like in even like five to ten years when a lot of people will have a full kind of family history of, you know, what kind of genetic things they might have, and, you know, bring that to the doctor, and, you know, the craziness that's gonna ensue from that. So I think it's really interesting to think about

Erik: Yeah, who gets that data I think we’re already struggling with that when you get your genome sequenced by 23andme, do they own that data now? And can they do whatever they want with it?

Brandon: I think what's interesting with your talking with like the advancement of technology the fact that like we're on new frontiers. Some of the questions we're having to ask today especially what you just asked with the genome is something that we didn't have to worry about or think about 40-50 years ago that's just didn't exist. So makes me wonder what what kind of ethical things we're gonna have to figure out in the future?

Erin: Yep for sure I think it'll be really interesting to think about, especially with genetics and genetic engineering there are a lot of different possibilities when it comes to in vitro fertilization and all this talk about designer babies. I think it'll be really interesting to talk about all the possibilities that are in store. Maybe not possibilities may be scary kind of outlooks that people have about this kind of stuff.

Brandon: Yeah - you definitely have like either positive or like a dystopian view all this

Erin: Yeah so I think, you know, speaking of which I think the ethics work up that we learned to do use is pretty high yield and we are able to talk to Dr. Blumenthal-Barby.

Jason: Yeah, so today we’re going to talk with Dr. Blumenthal-Barby, who is an associate professor in the department of medical ethics here at Baylor who graduated with an MA from Bowling Green State University in Bowling Green Ohio, and a PhD from Michigan State University in East Lansing, Michigan. And here we have Dr. Blumenthal-Barby.

Interview

Erin: So we are here with Dr. Blumenthal-Barby. Thank you for joining us and if you don't mind, could you tell us a little bit about your journey through academia?

Dr. Blumenthal-Barby: Sure - so I actually started out as a health sciences major. I thought I wanted to be a physician assistant, a physical therapist - something like that, and then when I was in college I was required to take a philosophy class, and I was sort of hooked. It was an introduction to ethics and we were talking about things like cultural relativism and whether ethics is something that is totally relative to particular cultures or there's something more absolute to it. We were talking about sort of, you know, practical debates like abortion and euthanasia, and that just really stood out to me as really interesting and sort of challenging in a way that was different from the science classes that I was taking. And I just found myself really wanting to explore more so I took some more classes, ended up doing a minor in philosophy, and then it was time to graduate and I realized that that meant that I had to choose what to do next and I thought I'll just keep studying this a little bit more I'll go and I'll get a master's in philosophy and I can always apply to PA school or PT school after that. And I did my masters at Bowling Green State University which is the same place I did my undergrad so I just stayed on for two more years and the thing that was nice about that program is that it was an applied philosophy program. And so it was very much concerned with sort of asking philosophical questions that related to the real world, like bioethics for example. And they had a joint program with the Cleveland Clinic in Ohio where you could go and spend a semester at the hospital with their bioethics department. So I got to spend an entire semester shadowing the bioethicists, following them around on cases, going to family meetings with them, going to committee and policy meetings with them, and just really see what it meant to do something like philosophy in the real world. And that's when I decided to go for the full PhD and then I did the the PhD in philosophy focusing on bioethics at Michigan State.

Erin: So what does a PhD in bioethics look like?

Dr. Blumenthal-Barby: Yes so the way that the way that PhD programs in philosophy work is you have to do your general requirements and then you specialize. You specialize in ethics, Bioethics, epistemology, logic, political philosophy – something like that. So you spend your first year or two taking really basic philosophy courses like logic and political philosophy and ancient philosophy and all the things you're sort of expected to know, sort of the basic science of philosophy so to speak. And then you can start taking seminars that are more particular to your area. So I took an entire seminar for example on the difference between causing and allowing which turns out to be a really relevant distinction in medicine, right – the difference between allowing a patient to die and causing a patient's death. That's a really deep philosophical question so we spent an entire seminar trying to really dig into that and address it and understand it and think through it. We spent an entire seminar on the ethics of organ transplantation: so what are some of the ethical questions that are raised: When can we take someone's organs? What does it mean for someone to be dead? How do we know when someone's dead? How do we allocate organs to people in a fair way? How do we think about issues like justice and then once you complete all your classes you get to write a dissertation, so you spend your last four years or so; you're not taking classes anymore and you write a dissertation on a particular topic. And my topic was the topic of ambivalence so this was actually based on a case that I saw during my internship in Cleveland where a patient was really indecisive about whether he wanted to live or not after he had been in an accident and paralyzed from the neck down. So he was really ambivalent – he didn't know what he wanted and that was a really challenging case because in bioethics were always taught to respect patient autonomy, but it wasn't clear to me what it meant to respect someone's autonomy when they themselves didn't really know what they wanted. So that's sort of how the PhD worked in philosophy

Erin: Okay – what made you interested in medical as opposed to other kinds of ethics like, legal ethics?

Dr. Blumenthal-Barby: I think was really the internship at Cleveland Clinic where I could see medicine is something that really is present in almost all of our lives, in one way shape or form at some point. And so just being in the hospital and seeing that this is something that people are faced with these really deep questions about what they should do for themselves in different medical situations. Clinicians are faced with really tough questions about how to navigate with patients through difficult value-laden decisions. And so it struck me as something that was very very fundamental to almost everyone's life this is just thinking about ethical issues that arise in medicine.

Jason: So I guess nowadays how do you interact with healthcare professional professionals?

Dr. Blumenthal-Barby: So in ethics, if you're a bioethicists in a medical school you can do a bunch of different things. You can be a consultant where you go into the hospitals so they call you in for a difficult case and they say help us to work through this case with the patients, the patients’ family, the physicians, and you're sort of in the hospital navigating people through a case those people are called ethics consultants. You can also do research where you are doing work to understand some of the normative issues that are arising in the hospital or in practical care in health policy, and trying to provide people with some research that can help inform how those issues should be addressed. And you can also do education which is to educate current practicing physicians and then the next generation of healthcare providers as well about how to think through ethical dilemmas. So my interaction with healthcare professionals is really primarily at the research and education arms of things. I'm not in the hospital – right now I'm not in the hospital doing the on-call consultation. So I'm primarily act interacting with healthcare providers as research partners and collaborators and then also on the education front.

Jason: Do you have any like struggles when you work with that kind of team with a lot of different backgrounds?

Dr. Blumenthal-Barby: I think that the main struggle with working with a very interdisciplinary team is just that you all come from very different perspectives. So, for example, bioethics is – by its very nature bioethics is a field we which means it's an area where people address similar sorts of questions and issues but it's a field that's made of many different disciplines. So discipline is sort of where do you get your methodological training it can be medicine, it can be law, it can be philosophy, anthropology, social science; so there are many disciplines that make up the field of bioethics. And everyone from their discipline has their particular methodology that you have to kind of learn a little bit in order to converse with them, interact with them, collaborate with them, but at the same time you'll never learn it as well as they do. So for example when I'm talking with my physician collaborators there they are they have medical knowledge that I don't have, and they have to sort of translate that to me in a way that I can understand the basic facts of the case to help them think through the ethical issues. Same thing you know the other way around I have to be able to describe ethical concepts and theories in a way that makes sense and is not too abstract and is practical and applied. If you have somebody on the team who is an anthropologist they need to be able to provide you with on-the-ground sort of view of what does it mean to approach this from an anthropological point of view that's not too abstract or overwhelming. So I think that that is one of the challenges of an interdisciplinary field and interdisciplinary work: is just trying to work across all those different disciplines which can be challenging because they're simply not areas that you're knowledgeable about all the time. And you have to be patient with each other and you also have to be humble and respectful to your team members right I mean you can't ridicule somebody because they don't know X, Y, or Z. That's not a good way to collaborate so, so a good amount of humility I think it was really important.

Jason: I guess off of that, do you do you feel like currently like medical professionals that you've worked with that they have they are adequately trained in making ethical decisions?

Erik: Abstractly – we don’t want to mention any names.

Dr. Blumenthal-Barby: No particular names or institutions. I will say I think that medical schools nowadays – most medical schools have ethics as a required course so students are introduced to the idea that a lot of times when you practice medicine values a part of the decisions that you make. And whenever values are part of the decisions that you make you should pause, give it some thought, give it some reflection, engage patients, engage ethicists – things like that. So I think people are increasingly aware of that fact, which is progress. And people are increasingly trained for some of the kind of basic terms and concepts that you use, like informed consent: what does informed consent mean? How do you know if a patient can make their own decisions? That's the notion of decision-making capacity. How do you deal with pediatric patients and children? What are the norms and the boundaries for decision-making with them? I feel that there is an increasing amount of knowledge about how to deal with some of those basic situations and facts. And I also think that people are increasingly trained at Baylor, for example as you all know, we have a curriculum that trains people to think about ethical dilemmas in a systematic fashion. I think that one of the challenges out there or where I would say that people sometimes have less training or less prepared is when they think about ethics as something that is merely opinion or reflex, or merely following the law because ethics is none of those things it's not just your opinion it's not your knee-jerk reaction or your emotional reaction to how a case should be handled or what is right or wrong, and it's not simply a matter of looking up what the law is. It's really having a systematic way to think through the issues at stake, the pros and the cons on both sides of the debate or on the different courses of action, and come to a reasoned judgement about what to do that's a very thoughtful judgement. So I think that there maybe can be more progress made in that because a lot of times when people think about ethics they think they just need to look up, you know, some professional standard or some law or something like that rather than really giving it, giving it more now more deeper analysis. But I do think that that there's a lot of progress that has been made and that people are prepared to think through ethical dilemmas. I will say that there is also a difference between kind of thinking through an ethical dilemma and then what you actually do. This is I'm sure that you all heard about this a lot the notion of the hidden curriculum. You can you can know what the right thing to do is you should know that you should that a patient needs to give consent. You should know that you know patients need to be treated with respect and not have jokes made about them. But what do you do in a situation where especially as a learner you witness a situation where you don't think that proper consent was obtained or you witness somebody laughing or snickering about a patient? That requires a different step, beyond ethical analysis. That's just really a character step of courage and creating a culture where people feel like they can talk openly about those things, they can talk with other people when they see those things happen. That is something that I think medicine needs to constantly improve on and that in some ways is the harder part than the analysis part.

Erik: Yeah I definitely thought – I mean I know you guys – the cases that you picked in the ethics course were hand-picked because of their difficulty but I was definitely amazed by how just ambiguous that the right decision the quote “right decision” could be and it was a… I hope every case isn't going to be like that.

Dr. Blumenthal-Barby: There are there are some – fortunately there are some what we call consensus cases where it's really obvious what the right thing to do is, but there there are lots of times really tough cases but, you know, people are never alone in thinking through those cases. You've got colleagues you've most hospitals nowadays have an ethics committee and everyone is there to be a support system. I think that's another misconception when people think about ethics I think the ethics police or something like that. I mean in institutions today ethics is really there to help people think through a problem together as part of the team and they should be used. They're a great resource.

Erik: I have a question about that, and forgive me if we were supposed known this because of the course that we took, but you know we learned about the systematic way that you go through an ethical case and then we also learn that that is basically the way that the ethics counsel is going to approach it. So at that point once you've brought it to the ethics counsel and (or committee) and they decide what to do, are you – does that take away the legal, I guess, repercussions off of the doctor, the attending doctor?

Dr. Blumenthal-Barby: Well – let me preface that I'm not a lawyer but that having been said it is always so the ethics committee and ethicists always make recommendations to physicians. So it is always a recommendation that is made to you as a physician. Now obviously just from a process point of view if you go against the recommendation that a lot of people have gotten together to think very hard about, you should probably question yourself, think about that a little bit more. And at the same time you know it's still your action and your responsibility as if we're talking about physicians as is the case with an attending physician, but if you have gone through, you know, your due diligence and gone through a really robust process to have other people help you think through it that probably lends some support from a legal perspective as well.

Erin: I'm curious like working with all these ethical cases on a day to day do you feel like you like when you're just making like everyday decisions that you like have ethics on your mind? I don't understand actually how that works because when I was taking the ethics class like I thought about it all the time. Yeah even when I'm at the grocery store I’d think about ethics. When I was making everyday decisions I feel.

Dr. Blumenthal-Barby: It's a great question well it's even worse - because I'm a philosopher ethicist, but I also work on decision making. And so it's even worse because I study decision making, and so I would say that that makes decision-making much more difficult in my own personal life. I think a great example is, and I hope it's not too sad of a story I feel okay about it now; I probably would have been crying a week ago, but last week I had to make the decision about whether or not to euthanize my 19 year old cat.

Erin: Goodness.

Dr. Blumenthal-Barby: I’m good now but I decided to do it, and it was a really interesting experience to go through making that decision as an ethicist and as someone who has thought a lot about euthanasia, about dying and a good death, and about rights of individual beings, and creatures, and about respect and about suffering; it definitely complicated the situation and the decision-making in ways that I think you know if I wasn't a philosopher ethicist that probably would have been a more straightforward decision. For sure, I mean I'm able fortunately to go grocery shopping.

Erin: I see.

Dr. Blumenthal-Barby: But I see your point.

Erin: Yeah I guess you talked about like some of the things that you work in decision-making capacity. What is your personal area of interest in ethics, and how or why did you like get to that interest?

Dr. Blumenthal-Barby: My specific area of interest I do most of my research on is on the ethics of kind of shaping and manipulating patient decision-making. And I know manipulating is a strong word and I don't mean anything by that or anything bad other than just understanding when you study decision psychology and you study all of the sort of heuristics and shortcuts that people use to make decisions, and I can give you some examples, you start to realize that you can use that knowledge inevitably when you talk with patients and you engage in decision making with patients as you all will, you can sort of use that knowledge to think about how you frame decisions with patients. So for example, we know that people tend to choose what they perceive as the middle-of-the-road option. So, this happens all the time when you're choosing a cable plan, right, they know what plan they want to get you to choose and they make one plan seem really, really cheap and one plan seem really, really expensive, and they know you're gonna choose that middle-of-the-road plan. Maybe you don't need that middle-of-the-road plan; maybe you would have been fine with the cheap plan, but we have this heuristic that we use when we make decisions to go with what feels like middle-of-the-road. So this could translate to decision making with patients that you're presenting options to patients – you have one that seems really aggressive, one that seems very minimal, and one that seems middle-of-the-road. They're going to be biased towards that middle-of-the-road option. We also know that people have a tendency to do what they think other people are doing or other people are choosing. So if you just tell people you know here are your options: most patients in your situation would choose option A. That makes the patient more disposed to choose option A. Just really simple things. One more example when you frame risks to patients, we know that patients are more influenced by – people are more influenced by what's called lost frame rather than gain frame. So you're telling patient about a risk of surgery; if you frame it as the percent chance of mortality they're going to be more afraid and less likely to consent than if you give them the odds of survival, which is the exact same piece of information it's just framed a little bit differently. So I'm interested in, and I could go on because it's this whole field of decision science, decision psychology, behavioral economics, judgment, and decision making, where psychologists are telling us about the ways that people make decisions. And I think that medicine is particularly interesting because we ask people to make decisions all the time. And we ask them to make very high stakes important decisions and then that raises all these ethical questions of: well how should I frame the information? What are the boundaries of using some of those insights during the consent and decision-making processes to shape decisions? This the whole field has gotten the name of nudging. Nudging decision-making engaging in so-called choice architecture. There were some popular books that were published. The book nudge, for example, is a really popular book that talks all about this if you're interested. But that's my main research area.

Erin: do you think it's ethical to nudge people, I guess?

Dr. Blumenthal-Barby: I do; part of the reason that I think that is because I think as I was sort of giving a sense of by my answer I think that nudging to some extent is inevitable because you have to frame information, you have to present, you know you have to decide whether you're going to tell somebody the odds of survival or mortality. You have to decide the order that you're going to present information to people in. You have to decide the tone that you're going to use when you present information. You have to decide when they ask you what would you do or what would other patients do; you have to decide what you're gonna tell them. Are you gonna tell them what all other patients do, what most patients like them do, what you would do, what you think they should do? So I think to some extent it's inevitable, which is why I think – I mean it's a little bit of a tautology that doesn't make it ethical it just makes it inevitable and then the decision, the ethical decision is sort of how to think about how to do that responsibly. So to what end do we nudge people – do we nudge people to do whatever we want them to do because we think it's best? Or to be trying to figure out what's important to them and what their values are and then nudge them to a decision that is most in line with their values. I think that's probably the more ethical approach. And what are the boundaries of it? I mean you can you can imagine that we could, for example, I know a few years ago there was a campaign to get parents to vaccinate their children that put together some pretty horrific videos of what might happen if you don't vaccinate your children. Now that's a nudge and it might be effective but it might also alienate, I don't know it's an empirical question, but it might also alienate parents to having a negative view about the medical establishment, it could further fracture their relationship with their physician if they feel like their physician is being too disrespectful or manipulative or something like that. So I do think that nudging is not only do I think it's epically defensible I think it's in some senses ethically obligatory that we in the medical field; part of our obligation is to protect and promote patients interests and if we understand the psychology of decision making we can use that to do it.

Erik: Are there any ethical dilemmas in particular that you lose sleep over?

Dr. Blumenthal-Barby: I do not lose sleep over very much to be honest, but you know, I would say those sorts of dilemmas that I would lose sleep over are less ethical dilemmas and more tough cases. And this is part of the reason why I've focused actually more on research and education than being over in the hospital doing consulting because I think that when you get in the middle of a really tough case, and it's oftentimes not the analytical dilemma about what's the right thing to do, but it's just dealing with people in a very emotionally difficult and fragile point in their decision-making in a really difficult ethical decision that I think what caused me to lose sleep, definitely. And I remember a couple of cases when I was a graduate student and I was shadowing the consultant that were really, really tough and they did cause me to lose sleep at the time and one was the one that I mentioned that I wrote my dissertation about which was this man who literally for months sort of was just in tears and torn about whether he should live life like this or not and one day he would tell us I don't want to live like this please disconnect the ventilator, and the team would be ready to disconnect the ventilator and then the next day he would say “no no I think I want to live like this”. And everyone felt like they wanted to help him make the right decision, but no one knew what the right decision was and it was incredibly difficult for him, obviously you could tell by his emotional distress of being in tears every day. And it was incredibly difficult for his family who were trying to be supportive of him but didn't know what he wanted. And I also think really tough cases were cases where family members were probably not ready to let go of a family member but people after a lot of thought about the case all came to the conclusion that it was probably best for the family member if they, based on their values and their prognosis, did not continue to have life-sustaining treatment. But the family was having a tough time saying goodbye and those are tough cases because you want to promote kind of what's in the patient's best interest but you also want to be sensitive to human beings who are there family members who are actually in the situation will have to deal with. You know, the emotions that go on days and years after you're not involved in the case anymore. So those were definitely cases where, and I'm sure that all of you have I mean have and will encounter those cases just par for the course as being practitioners in medicine, would definitely caused you to lose sleep.  

Jason: So I guess on the education side, what is your favorite part of teaching students?

Dr. Blumenthal-Barby: Oh, my favorite part of teaching students is just the students. They are I mean you all are so, I think, I mean you're smart but you're also really willing to intellectually challenge yourselves I think. I mean – I'm amazed when I would do the ethics lectures how people would come down afterwards and still have more questions. And I would get emails from people that would, you know, they would ask sort of well “what about this case” or “what about that case”. So it's all the you know the permutations of even just thinking beyond whatever immediate issue we were we were sort of working on; there's an intellectual curiosity there and an energy that is really invigorating, which is part of why I love teaching so much. And I also love that – I think many students especially at Baylor are also so interested in research as well and that's been really rewarding. We have the ethics pathway for our medical students who are interested in furthering their study in scholarship and ethics, and part of that is a research project that they do in their fourth year. And I'll often have students email me in their very first year right when they get here and they'll say I know I want to do the ethics pathway I know I'm interested in research, you know, like can I start and how do I get started and all those sorts of things. So I think just the intellectual energy and curiosity, and the investment are all what make it really, really rewarding to teach and interact with you all.

Jason: Are there any frustrating parts?

Dr. Blumenthal-Barby: No none.

Erin: Really?

Erik: When students invite you on podcast.

Dr. Blumenthal-Barby: Oh no the podcast is amazing I think there should be more of this sort of thing. Frustrating cards – I would say from my particular perspective of teaching ethics, the frustrating part is when students ask me what the right answer is, or what the legal answer is.

Erik: My bad.

Dr. Blumenthal-Barby: That being said, I think ask the legal question, but then like don't let end there. I think that it's just the law gets things really wrong sometimes, right? Or it's silent on things, or something like that. And I also think that to some extent it's, you know, what I would do in a particular situation it's relevant and I should be able to explain why I would do what I would do and that might be insightful for somebody making their own personal decision about what to do. But it's really me so I feel like the question of you know like what should I do based on what you would do is only step one to everyone reaching their own personal decision about what the right thing to do is in a particular circumstance. But those are two very, very minor things. I mean the students are really amazing and I have not – I've been working I've been working at Baylor for 10 years now and I actually was directing the ethics course up until about – for probably five years or something like that and so I got a lot of direct interaction with students and there were very, very few frustrating parts which is great.

Erin: What about frustrating parts of your job in general?

Dr. Blumenthal-Barby: The most frustrating part of my job I think is just more kind of the bureaucratic side of things of, you know, having to kind of comply with certain processes and procedures and systems and things like that, and how much time that takes. But that's all just kind of part of you know trying to be in a responsible culture where everything has to be tracked and recorded and things like that. It's kind of probably like in your world like EMR work or something like that, right? So it's and it's annoying but it's part of the larger picture.

Erin: I was actually pretty curious like with like – a lot of my friends are getting like 23andme testing as like birthday gifts, and like whatever gifts. And I'm just curious like what you feel about the ethics of I guess like big data and genetic testing and how that's gonna affect healthcare in the future.

Dr. Blumenthal-Barby: I think that it is probably going to affect health care significantly in a lot of different ways. I mean imagine that patients are going to be coming to their physicians with the results of these tests and asking their physicians to help them make sense of these results. And so I think that's going to take a lot of time it's going to take a lot of patience. It's also going to take a lot of education. And I think to relate it directly to the work that I do on judgment and decision making, you know when people get an enormous amount of information certain biases kick in. They're gonna focus on –it's hard to deal with complex and large amounts of information, and so people do certain strange things in response to that. They'll focus on a particular thing it's like a focusing effect and they ignore everything else. So I think we're gonna have to be aware of that. People have what's called a curiosity bias where they're just they want data and information for the sake of data and information, and that feeds into the focusing effect. And I think that people are also; another thing that they do is they'll use information as a form of denial: so if they get a lot of information and there's a particular piece of it that's really threatening or concerning, they'll focus on all the other parts. I mean we know this from decision science and I think we'll see this more and more when people have large amounts of information. And then I think we're gonna have to make decisions about how to when we get information where patients are at risk for something that we're significantly worried about how to make that stand out to them. And so this is giving them that information and saying your risk of developing this is 30% and the average risk is 1%. So finding ways; if you just say 30% I don't know what they think of 30% maybe they think that's not that big, especially when you've given them the risk of, you know, a dozen other conditions and there are results and variance for that. So I think actually communication and risk communication and understanding how to do that effectively will also be really, really important. And supporting people's decision-making as they get all of this information. It’s gonna be really challenging, but exciting

Erin: Well thank you so much Dr. Blumenthal-Barby for joining us, and I think we really learned a lot about ethics and ethical decision-making so thank you for joining us.

Dr. Blumenthal-Barby: Thank you all.

Outro

Erik: Alright; that is it for now, we would like to thank everyone out there who took the time to listen to this episode of the podcast. Special thanks to Jason and Erin for writing the episode. thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for helping with the production and the website. And thank you again to Dr. Blumenthal-Barby for taking the time to be interviewed by us. We hope everyone enjoyed it and we hope you tune in again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 37 minutes | Published: Feb. 19, 2020

Dr. Daryl Scott discusses tell us about how he uses genomics to diagnose multifactorial diseases such as autism, as well as rare diseases managed by the Undiagnosed Diseases Network. 

Transcript

Erik: And we are here!

Brandon:  We are here!

Erik: This is the Baylor College of Medicine Resonance Podcast I am one of your hosts, Erik Anderson.

Brandon: … and I'm your other host, Brandon Garcia.

Erik: And, we're going to be talking to Dr. Daryll Scott today, who is a clinical geneticist, and we're going to be talking about clinical genetics. So, Brandon, I believe you were taking the lead on this one, right?

Brandon: Oh yeah absolutely, I'm actually really stoked for this episode because I like Dr. Scott a lot- not that I don't like everyone else we've interviewed- but he's he went to BYU like I did and he's someone I've really clicked with here at Baylor. He's just like you said. He's clinical geneticists, a pediatric geneticist, at Texas Children's Hospital and with Baylor College of Medicine (and we'll read through all of his couldn't his credentials and stuff like that later). He gives us a really good snapshot of what life as a clinical geneticist is like. Which I think is really cool, especially for us who were going into clinics and thinking about residency's and stuff like that. And while he does a really good job explaining that, what I didn't realize is that the field itself is really new. Genetics as a research field has been around for a couple centuries (with people like Gregor Mendel and things like that) but actually applying it to clinic…

Brandon:  yeah as far as like actually adding that to the clinic and trying to use it that's only been around for like 70 years- like 1948 is when they created an American clinical geneticists Association.

Erik: Wow

Brandon: Yeah. So initially, it was something that started out with Pediatrics that has grown over time.

Erik: Why pediatrics?

Brandon: Well I think it's I think it's because a lot of these congenital defects and diseases and stuff like that you see when patients are really young- when they're toddlers, when they're young.  Kid’s parents start seeing something that's not usual and they bring them to the doctor and say “What's going on?” And when we started realizing that we could use genetics as an answer, that's when we started to see clinical genetics. And it just started with Pediatrics because these patients tend to be super young.

Erik: Right

Brandon: Yeah so, the key to the growth of clinical genetics is the same thing that like we've mentioned a dozen times on this podcast already, it's the growth of technology. We've got the internet; we've got computers that can compute massive amounts of the information. Now we've got genomics and the ability to look at the whole sequence of a person, and that's allowed us to just explode the field of clinical genetics.

Erik: Yeah, well, and it's especially fitting to be talking about this at Baylor College of Medicine because of our history with the human genome project as being one of the sequencing centers for that. There's just so many great faculty members who are working on genetics and are leaders in the field probably due to this one thing- we have the infrastructure. And that's an important thing, you need servers to put all this sequencing data on and so it, you know, takes a lot of behind the scenes, I guess you could say, “stuff” that maybe other places don't necessarily have, but we are privileged enough to have available to us here.

Brandon: Yeah speaking of that, we've been in this game (I say we, but the college has been in this game) since 1971, when they decided to add a genetics division to their internal medicine and pediatrics department. Then it became its own department in 1994, which makes it one of the few departments that is actually kind of younger than we are. Then like just like what you said, in 1996 we created the Human Genome Center which became part of the Human Genome Project and we stuck with it we were one of three organizations that stayed with it all the way through to the end and because of that we have that infrastructure (we have the technology, we can rebuild them). I mean we can do genetics.

Erik: And how about funding for this

Brandon: As of 2018, we're the number one ranked department in the U.S. for NIH funding.

Erik: Yeah, that's amazing!

Brandon: Yeah and it's allowed us to do things like create a genetic counseling program

Erik: Yeah

Brandon: As far as a note too, Medical Genetics is great in the fact that it's changed in what it's been able to do over the past couple of decades. We now have the ability to meet with you, meet with patients, and actually be able to tell them a little bit more about what's going on in their lives and why they have whatever they have. Whether it's a defect or a disorder or anything like that. In short, genetics is awesome, and it has allowed us to learn a lot of things.

Erik: Yeah definitely so without further ado we will be talking to Dr. Daryl Scott, as I've already said, and Dr. Scott got his undergraduate at Brigham Young University…

Brandon: Go Cougs!

Erik: …and he completed his MD PhD at the University of Iowa. His residency was in Pediatrics at the University of Utah, and he actually did another residency in clinical genetics here at Baylor College of Medicine. He stayed on as faculty studying congenital diseases, like diaphragmatic hernias and congenital heart defects, so here is our interview with Dr. Scott.

Interview

Brandon: Dr. Scott, thank you so much for coming with us today. I really appreciate you meeting and letting us interview you. To get things started let's go ahead and just talk about your journey. Where did you start, how'd you get into medicine, and how did you end up here at Baylor?

Dr. Scott: That's kind of an interesting question. My pathway into Baylor- pathway into medicine- was not exactly the typical one. I always had an interest in genetics which probably started in seventh grade when my seventh-grade science teacher indicated that we were going to put aside all the regular curriculum and spend an entire week talking about genetics. I was fascinated by the things that he talked about, especially the fact that you could take just even a single letter change could cause an individual to be dramatically different as far as their health goes. And so, from that point forward, I always had in the back of my mind that maybe I would like to be a geneticist, but, at that point or that period of time, there really wasn't a lot of clinical genetics that could be done. And so, I toyed around with thinking about making pharmaceuticals and bacteria and other stuff, but I always had a focus on being a scientist and it was only when I was at my undergraduate university that accidentally walked into the wrong counseling office. Instead of going to the biology office, I walked into the pre-medical/pre-dental office and that is where I found out about a program called the MD Ph.D. program, or the medical scientist training program. I was absolutely overwhelmed that this was exactly what I wanted to be, but I still saw this as a pathway to being a scientist not a doctor and the descriptions said, you know, “You will go to medical school to be a scientist working on human diseases.” I said this would be great, so I called my wife and said “Would you mind if I went to medical school?” and she literally said “Sure, you can do whatever you want” and so I dramatically changed my course and said “Oh, I'm going to go to medical school and be a genetic scientist.” And it was only on my first interview that someone asked me, “So what kind of doctor are you going to be?” I said “I'm not going to be a doctor; I'm going be a genetic scientist. And I'm going to go to med school to know how I'm going to do that.” and they said “Well, isn't that kind of a waste of going to medical school?” And, I had never thought of that. I said, “well how long does it take to be a doctor,” and he said “Well, it will take you a couple more years.” I said, “Well, a couple of more years isn't that big a deal.” And so, then I found out that, well, you go to med school and then there's residency, and then there's fellowship, and all this. Thankfully, my wife only learned about this a little bit by bit, but ultimately that’s how I ended up becoming both a doctor and a scientist. And to tell you the truth, there was no better path for me.

Brandon: Oh, that's awesome! Real quick, where did you go for your training?

Dr. Scott: So I did an MD PhD at the University of Iowa, and then I went to do Pediatrics residency at the University of Utah, and after- that's when I came here to Baylor- I was a clinical genetics resident here at Baylor, and, after my residency, I stayed on in his faculty.

Brandon: Oh, what about your residency made you want to stay here as faculty?

Dr. Scott: By the time you're in residency -or at least at that time- residency was highly focused on research. And so, most of the people who were doing genetics, our clinical genetics residency, wanted to be geneticists, but almost all of us were very interested in doing research as well. And so, in my residency, I already began to work with mouse models trying to understand how human diseases can be modeled in mice, and then finding ways to understand those diseases and perhaps even cure them using these mouse models. By the time I was done with my two years of residency here, we were well on our way to identifying some important things about how the diaphragm works and the genes that cause diaphragmatic hernia, which is a very common problem in in pediatrics, but was not really known to be genetic at that time. And so, from there I looked at many different places, but there was there was no one who had the facilities, and especially the clinical understanding, and contact with clinical patients. There wasn’t anything similar to what we could find at Baylor, and it was just obvious that to stay here would be far better than to move because I would be able to not only pursue my scientific interest but also mesh that with the clinical patients that I was seeing in clinic on a regular basis.

Brandon: Gotcha, I really get that. When I was preparing to come to Baylor, one of the things that really attracted me was the genetics program. And the fact that, here at the Texas Medical Center, we have all kinds of opportunities, and I don't think there's many places else in the world where you can get the kind of work and opportunity that you get here.

Dr. Scott:  One of the things that's very different about Baylor and Genetics, is most places have a division of genetics. In other words, it's part of a clinical department and it shares a very small piece of the medical school. Here we have a genetics department, and so that actually includes, under one umbrella, both researchers and clinicians. And, we also have our own genetics laboratory, so we do genetic tests here. That triad of doctors, physicians, and laboratory individuals all working together is extremely powerful and allows us to move and do things much faster here than perhaps anywhere else I’m aware of.

Erik: Did you see the genetics program and pathway change a lot in your career then? Just, I know that it's changed a lot even in just the past, probably, 15 years and especially with the emphasis on personalized medicine.

Dr. Scott:  Yeah! One of the things that's really made a big difference is the technology that we used when we were first starting out as genetics residents. We would go to clinic and we would diagnose perhaps five percent of the patients that we saw. And so, I would go home on a regular basis and my wife would say “So how was clinic today?” And I would just say “I feel extremely humble because every single patient I saw I could not diagnose it.” That was just because we didn't have the tools to do so. Right now, we have the genetic tools to be able to diagnose perhaps 40 to 50 percent of the kids that we see. The need for clinical Genetics has also gone way up.

Erik: Yeah

Dr. Scott:  And so, we see far more people interested in becoming clinical geneticists with the idea of not just doing research, but also just doing clinical medicine because they will have the tools to be able to help patients. And, we can really significantly help not only individuals, but families with the diagnosis that we make and, in some cases, the treatments that we can offer. That has been probably the biggest change and it's so much nicer to be able to go home and tell my wife that “Yes, actually could diagnose them today.”

Erik: Well, by tools do you mean just the fact that we can sequence a lot more readily? I mean, probably with the human genome sequence and so now we're starting to find more genes that actually correlate with these diseases or…

Dr. Scott:  Yeah, so probably the most important tools that we have are genetic tests. One is called a chromosome microarray analysis. it’s been around for a significant amount of time, but was a huge breakthrough. It basically allowed us to look for big pieces of DNA that are missing, or extra, and that was something we could not do across the entire genome in the past. When we could do that, awesome! We had a whole new area of genomic disorders that we could diagnose and we went again from going, let’s say, from 5% of the patients that we saw we could diagnose to maybe 10 or 15. I mean that may not sound like a big jump, but that's three times more. And all of a sudden, we had that ability/then we were able to do exome sequencing, which allows us to check the letter codes of all 20,000 genes at once and that technology again boosted our ability to diagnose more children. Not only that, we're also finding that same data sometimes gave us clues on brand-new genes and brand-new diseases that have never been described before. That's perhaps one of the things that I enjoy the most. If you said, “Well what would you classify yourself as far as a researcher goes?” More and more [I would say that] I am gene hunter. In other words, we look for new disease genes and we do so across a wide variety of children. I started here looking at diaphragmatic hernia. Then I became interested in heart defects, but now we are able to do this for eye defects, lung abnormalities, autism, developmental delay, intellectual disability, and we can find new genes for all the different types of children I see in clinic.

Brandon: That's awesome! I like that term! Gene hunter- that makes me think of like something like Animal Planet.

Dr. Scott: It's a little bit addicting. I often tell peoples most doctors go to a clinic and they hope they find something they've never seen before and they'll be able to diagnose some child with a rare disorder that they've heard about, but never seen. We go to clinic literally thinking that we might diagnose someone with a disease that has never been described before. Now that sounds a little bit wild, [but] we do this on a regular basis. This is actually quite a project to do one of these. First of all, l we have families that are very interested in trying to identify what is the cause of their child’s medical problems. When we can offer them a possible solution, or a possible answer, to that question they’re very interested in working with us. We then work with a network of doctors all over the world to try to identify more patients that have changes in that same gene. And so, we're very, I guess we'd say, gene-centric, or we look at genes as a way of trying to understand what they are doing and how many patients can they describe, or help us understand. Often, we will gather sometimes three or four, sometimes ten, sometimes dozens of patients that have changes in specific genes and then we see common patterns and that was from those patients. It opens up, again, a brand-new genetic disorder there's not only an answer for all the patients that have been working with us (and their families). But we recognize that as soon as we do so, all the tests that are being done, the world will also change. In other words, now those tests, or the people who read that in the laboratory, will be on alert that that is a disease-causing gene. And so, you have a very fast ripple effect where people are being diagnosed all over the world with that disease, and your understanding more and more about it as each new report comes in.

Brandon:  What do you mean by fast? Are we talking weeks, months, years?

Dr. Scott: So, the fastest we've ever done this was it about eight hours.

Brandon: OH

Dr. Scott: There was a time when I was preparing for clinic, and I typically prepare in the morning, so I come in really early in the morning and I go through all the different patients I'm going to see that day. There was one patient that already had a genetic test result, but the laboratory did not flag it as being the cause of this child's problems because it involved genes that were not known to cause disease. But by looking at animal models for those diseases, I could see that these genes actually played a role in the pathways that might be affected in this child. I went and saw the child in clinic, and noted that he had some very unusual features. Probably the most unusual was that he had super flexible joints. It's unusual we actually have a way of scoring that and this child had the maximum score possible. And so, extremely flexible. After that clinic visit we had already sent out feelers I already sent out feelers that morning to ask if other people had had patients who had deletions- so some pieces were this these genes were missing, or changes in those genes- and when I got back to my office that afternoon there was an email from a physician in England saying that he also had a family that had almost the exact same change that was seen in my patient. I asked him what his family members, or the family members not in that family, had and he said all the same features is my patient including the hyper flexibility that I noted in my child, or my patient. Anyway, I was quite surprised because now we had three patients with the same disorder. Just after that email exchange a person came in and asked if I could take a phone call from another physician (this time in Dallas.) When I talked to her, she had another patient which also had the same type of medical problems and hyper flexibility to the point where he was having a difficult time actually holding a pencil because his fingers were so flexible. And so, literally within eight hours we had four patients on two different continents. All of whom had the same new genetic disorder. And again, that was done in in eight hours.

Erik: Wow

Brandon: Wow okay, so a couple follow-ups on that (because that in and of itself is just fascinating.) First of all, once people have this information, once these families know of this new genetic disorder, what are the next steps for them? Is it just letting them know for future family planning, or is there a treatment option?

Dr. Scott:  So, every gene is going to be different. I wish we had more treatment options that were obvious from the genes that we find. Many of these genes work very early in embryology. And so, they actually make structural changes to the body even before a child is born. So, for example, to find a new gene for a heart defect; it's very unlikely we’re going to be able to treat that child’s heart defect because it's already in play. In other words, all the changes that that gene may have done in heart development have already taken place. There are other genes though- For example, genes that cause problems with nerves which may we may be enabled to prevent or preventive measures. This may be especially true for kids who have neurological deficits that change over time, and others they are born perfectly fine or perhaps have some deficit but then over time they have more and more problems for them- that it may be possible to actually alter or treat them so they can avoid these type of problems. Probably the most common examples of that are metabolic disorders. So, every child that's born in the United States is screened for a certain set of genetic problems that cause metabolic disorders, or a problem with the way the body uses or  breaks down metabolites or like your food or substances that are in your food or perhaps substances that are made by your own body. Children who are missing enzymes that break those things down have problems with accumulation of these products in their tissues. And so, overtime they have more and more problems. Those are sometimes very amenable to dietary changes or sometimes to enzyme therapy where we can give them back the things that they need to break those products down, or we can eliminate them from their diet, and you can have a child who was destined to have major medical problems and you can actually transfer that that child into a position where they should live essentially a normal life (with again these dietary modifications). Other things that are helpful though too, is families do want to know if this is something that might reoccur in a family member. Often people say “Well, we're not going to have any more children, so we're not particularly interested in identifying a genetic cause for our child's medical problems.” But often they don't recognize that even individuals in their family may be carrying something that puts them at risk, or their children at risk, for having other medical problems and so often when we make these diagnoses and end up providing information not only to parents but also to siblings who may be at higher risk.

Erik:  It sounds like when you make these diagnoses though you’re working with a team of physicians. Is that correct, or do they generally come and find you and then you just relay it to the patient?

Dr. Scott: So especially with new disease genes we are working with groups and so almost no one publishes new genes or new diseases by themselves anymore. It's almost always an international or at least a national collaboration between lots of different families and physicians to make that happen. Once the disease is known, well then an individual doctor working anywhere could understand that diagnosis, get the information about the disease, and then give that to the patient. And so, we’re actually, again, just describing these new genes. We can make this possible for anyone in the world to be able to diagnose on a regular basis. I go to different countries to teach about genetics, so I go to Guatemala on a regular basis (I also have gone to Kazakhstan) to teach genetics to doctors there. In each of those places, I see patients that have genetic diagnosis that have been properly made in their home country. Some of those whose use specific genetic tests that they have available and in other cases it's done on a clinical basis but that's always because of the work that's already gone before in describing these diseases and then they can reference that and make those diagnoses. And I recognize that’s happening, of course, all around the world and sometimes in places where genetics is not very strong. And so, when we go, we try to teach doctors how to be even more effective geneticists. In a lot of places that we go, genetics is not really considered a major player in their healthcare system because they don’t realize how big of an impact it's having on the patients that they're seeing.

Erik: So, because we know about, you know, the Human Microbiome Project, and the Human Genome Project, and The Undiagnosed Disease Network. Correct me if I'm wrong, but those are all American based, or is there similar body for the world that sort of allows you to communicate these and maybe get more investigators working together?

Dr. Scott: So, there's many things that are paralleled. So, for example, one of the things is required in order to do research is to be able to have funding of some kind to actually fund that research. So, for example, the Undiagnosed Diseases Network is funded by the National Institutes of Health and it would be an American organization. A lot of times, we have similar bodies that are doing the same thing in other countries. For example, in the European Union or in other countries and scientists from both camps work together. Okay, and I especially enjoy something that was a simple technology, but has proven very powerful. There's a website called GeneMatcher.com. It has a very simple process, or a way of working. You can go into Gene Matcher as a scientist, or a physician, or anyone who has a specific interest and record your interest in a gene. In other words, I see a patient in the clinic who has a change in this gene I think it might be the cause of their medical problems. I can say I'm going to put that gene into Gene Matcher and say I have an interest in that. Gene Matcher then gives back to me all the email addresses of anybody else who’s registered an interest in that gene. And so, immediately I have perhaps the names of a dozen or sometimes fewer. It just depends on people who also potentially hold patients, or work on mouse models, or have learned something important, or have a special interest in this gene. We then can begin to collaborate immediately to say “Well, what are you seeing?” or “What do you see in your patients and does that match with what I see in mine?” Sometimes, there is no match and we quickly realized that we don't understand enough about what this gene is really doing just yet. Other times, the matches are strikingly similar and that allows us to do this. That is a system that can be used and accessed by anyone in the world. And so, we literally get hits from all over the world with the different physicians having patients that may be useful in finding new genes.

Erik:  That's amazing! And the internet, I assume, has probably helped us along, yeah ?

Dr. Scott: It's actually really funny because a lot of the projects I'm doing right now I spend most of my time Googling different terms and identifying patients that may already be published, but they are hidden inside articles. For example, if I can go back into those articles, I can actually find patients that sometimes have already been described, but no one has put all the links together. And so, typically when we put these things together we'll have three or four patients that have been published, but no one has ever really wrapped their minds around the fact that they all have the same pattern and then we add additional patients to that and we have a new disease gene.

Brandon:  Wow that's awesome! So, one of the things we will also really wanted to talk to you about is in one of the classes that you taught us you went into depth a little bit about autism and we've seen a rise in the diagnosis of autism in the past few years, and there's a ton of different ideas and speculations (some more scientific than others), and why we have autism occurring so much in our society. I wanted to get your perspective on what you've seen in the clinic, if there's any kind of genetics involved with autism, and things like that.

Dr. Scott: So, remember how we talked about how genetics has changed over the last let's say 15 years since I became a geneticist? One of the things we see that's just dramatically changed is the type of patient I see in clinic. It used to be that only the patient's I saw in clinic were children with multiple congenital anomalies and others who have many birth defects and (because of that) a doctor suspected they might have a genetic syndrome. That has changed over time, again, because of the techniques we have and the patients I see most often in clinic are now patients that have one of three diagnoses: autism, developmental delay, or intellectual disability. Those three things actually kind of come together. In other words, they're all signs that the brain is either not formed correctly or is not functioning correctly, and we actually find that individual genes often can cause all three of those problems. In other words, some children will be diagnosed with developmental delay while a subset will be diagnosed with autism and some will be having two of the disabilities, or some will have all three.  Well, for a long-time people have thought that maybe autism was not genetic (probably that's because we often saw families where there was only one child that was affected with autism, but they're certainly plenty of families where there are more than that). Many scientists felt that most cases of autism would be multifactorial. In other words, a combination of many different genes and environmental factors perhaps all playing together in one child to give them autism. The shocking thing that we've learned over the last few years is that actually many of those children that have autism have changes in specific genes that are causing that autism. And so, if you take a child who comes in with autism into the clinic, or developmental delay, or intellectual disability. We will probably find the answer in forty percent of kids who come and visit us. In others will actually find a molecular diagnosis for them. I think if you ask people ten years ago if that would be possible, they would have laughed at you, but now it's a reality. The difficulty is that most people do not know that. And so, I go around the state of Texas talking to families and they are shocked to learn that autism is actually genetic (or when I say genetic that doesn't mean the same thing as inherited because sometimes these children have brand-new changes in genes that cause autism), but they're shocked to learn that you could do genetic tests that would actually give you the answer to why that child has that that problem. Sometimes, people also want me to tell them whether because of a genetic test their child has autism. As it turns out, that that doesn't quite work the same way. Autism is actually a diagnosis that's usually made by developmental pediatricians or other people who are trained to be able to diagnose autism. It's a pattern that we see in behavior and language development. And so, our genetic tests again can't tell us whether a child has autism instead it says why is the autism being caused in this child. But yes, we can we have dramatically changed the way we think about and look at children with autism and our ability to help them or their families know the cause.

Brandon: That's amazing! We've talked a lot about genetics, and I imagine a lot of this is implied, as well, in understanding genomics (looking at the entire sequence of the human body). When you when you have a child coming into the clinic and you're making these diagnoses do \you just look at specific genes or do you look at their whole genetic code and then try to find something what do you do there?

Dr. Scott: Yeah, so often when one of the things that we try to teach to our trainees is to try to identify what is the best genetic test to use. There are some diseases where we can walk into the room and we can make a diagnosis just clinically. In other words, I can look at a child and say this child has this disorder. In most cases, especially when we can identify a specific genetic syndrome, there may only be a few genes that cause that syndrome, but they that can range from just one gene to sometimes a dozen or more. And more and more often we're using a combination of identifying single genes then testing those, or testing panels of genes that can cause similar diseases. For example, one of the panels that we use very often is a panel that tests for all known hearing loss genes. It's a very powerful panel. And when we do that, we can identify the great majority of children with hearing loss and can identify the genetic cause. At the same time, we recognize that some kids aren't diagnosed that way, and it could be that they have some type of environmental cause for their hearing loss or maybe their genes that are not known (and certainly there are). But that would be a panel test, and it may test ninety different genes. Other times we go in and there's not enough of a pattern to be able to make a clinical diagnosis, or maybe we don't recognize the pattern. In those particular cases, I don't know what this child has and if I don't know and others around me, when we try to share this information amongst doctors, no one can see the pattern then we go to these genomic tests. Those are the tests I was talking about before- that chromosome microarray analysis (it looks at all the genome for those big pieces that are missing, or extra) Whole exome sequencing or whole genome sequencing is another way of looking across all the genome.  Seeing are there changes in the letter codes these become our go-to tests again when there's one we have to find an answer and the and the clinical exam does not give it to us. This is very powerful because we can use these tests sometimes when a child is very small, sort for even amongst newborns and we may not have seen the full effects of all the changes that are happening. So, for example, in a newborn with a heart defect and maybe some other change, we don't know how their brain will work, or how will they develop, or will they have difficulties. And yet, we can use these wide tests to then identify the genes and then kind of work backwards and saying children with changes in these genes typically have problems with their kidneys or with their development. And then, we can send them to the correct specialist so they can watch their kidneys and make sure that kidney function remains healthy, or we can send them to early therapy so that they can begin to maximize their ability to grow and develop normally. And so, these are going to become very powerful, but it's a mixture and every different patient will need a specific test that's kind of matched to the things that we see in clinic.

Brandon:  Thank you so much. I want to bring this all back around to the first couple of minutes and ask you one last question. You said, that this whole journey started with a seventh-grade teacher that wanted to talk about genetics. My question for you is have you ever followed up with that teacher and told him, or her, just how much of an impact that had on your life and how you've been able to impact medicine in the lives of dozens of others?

Dr. Scott:  So, I haven't personally talked to Mr. Aldridge because that was back in seventh grade and by the time I really was well onto this path we had lost communication. I have gone back to some of the other teachers I had in high school and said “Hey, this is the things that are going on and I thank you for the for the encouragement that I received to do great things.” A lot of times people have dreams and they're told this is impossible. I was blessed with teachers that said “sure you can do these things and this is how you get them done.” And so, I would say yes parents, siblings, all these individuals have been key to me having what I consider a really great life. I appreciate my family. I try to balance all the things that I do, but I think in that balance we can do many great things in many different areas of our life. So, I try not to sacrifice family for my career, I try not to sacrifice what would be good for my career and sacrifice that things would be important for my patients. So, all these things we find a balance and we try very hard to focus on all these things and do the things that are the most important, but I must admit I am very grateful that I am both a scientist and a doctor, and that I get to be that in this particular time when so much is happening. It's a wonderful time to be a clinical geneticist.

Brandon:  All right! Thank you so much!

Erik: Thank you!

Outro

Brandon: All right! That is it, for now. Erik and I would like to thank everyone out there who took the time to listen to this episode of the podcast. Thank you to our faculty advisor, Dr. Poythress for helping us out put everything together.  Thank you to Baylor Communications Department for help with the production and website, and thank you again to Dr. Scott for taking the time to interview with us. We hope everyone enjoyed it and hope you tune in again soon. Goodbye for now

iTunes | Google Play | Spotify | Stitcher | Length: 40:55 | Published: Nov. 27, 2019

Dr. Mary Brandt tells us about her career journey, the unique challenges and rewards of treating children and adolescents, as well as her experience teaching at Baylor College of Medicine

Transcript

Brandon: We are here.

Erik: And we are here.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.

Brandon: I am another host, Brandon Garcia.

Jennifer: I was one of the writers for this episode, Jennifer Deger.

Erin: And I’m another writer, Erin Yang.

Erik: Yeah, and so today we’re going to be talking with Dr. Mary Brandt about some of her work with bariatric surgery in adolescents, children, as well as her experience teaching at Baylor for many years and also how she sees medical education change and many other things. And so today yeah we have Jennifer and Erin who were the writers for this episode are gonna give us a little bit of background about Dr. Brandt.

Jennifer: I think pediatric surgery is kind of unique because your patient population is so vulnerable I mean if you’re any kind of doctor you’re going to have human patients and humans themselves are vulnerable. We’re like, you know, hairless and soft and we don’t have class. We don’t have big teeth. We’re basically just like sitting ducks on this planet waiting for an alien to come and eat us alive. You know?

All: (Laughing uncomfortably).

Jennifer: No exoskeleton!

Brandon: Wow, somebody’s been watching some Sigourney Weaver movies haven’t they?

Jennifer: Yeah. But uh and that’s one of the things that drew me to medicine I think is just the vulnerability—

Brandon: Sigourney Weaver?

Jennifer: Yeah yeah, Sigourney Weaver.

Brandon: Haha, yeah okay.

Erin: I definitely agree with you. I think um just hearing Dr. Brandt talk to us during lecture when she came, she would always talk about um, these like tiny little babies that she’s like holding in her hands.

Jennifer: I know, yeah.

Erin: I mean they’re literally the size of your hand or smaller and she’s working on premature babies and babies with like, I think she focuses on anorectal malformation like when the spinal cord doesn’t develop properly, all kinds of things that she does. And it’s just crazy to see how small they are and how fragile they are.

Jennifer: Yeah ,that would be terrifying in its own way to do surgery on like a premee baby.

Erin. Yeah, yeah. But you said she also does a lot of work with like bariatric surgery too, right, with teenagers and adolescents?

Jennifer: Yeah she was actually on Oprah talking about these teenagers that she helped with their bariatric surgery. I couldn’t find the episode itself but I could find screenshots. And I know she talked about it so I don’t know what the theme was exactly. But I can imagine you know, Oprah was like “we have these teens now who had surgery, but is this a problem?” I’m sure some people would be like you shouldn’t be doing bariatric surgery to teenagers, or some controversy over it or something.

Brandon: Yeah I definitely can understand that being someone who’s been overweight their entire life. Like bariatric surgery scares me but it was something I thought about when I was a teen. It sometimes feels like an options so I’m really interested to see what her take is on that. Because bariatric surgery is life-changing, both in good and in bad ways.

Jennifer: Yeah it’s like a very, um, it kind of cures a lot of other diseases. I actually shadowed a bariatric surgeon when I was in college and all of his patients were so, so grateful to him. Like I’ve never seen patients just worship their doctors the way that they did with him because they had lost you know like, 300 pounds or something ridiculous and their diabetes had gone away, their hypertension had gone away. But he was very on them about taking their vitamins because that’s a big risk because you can get vitamin deficiency and he was like “if you lose your sight because of vitamin deficiency you won’t get it back”, so you have to be proactive and take your vitamins.

Brandon: Everyone should take their vitamins.

Everyone: Yeah.

Brandon: I do want to make one comment though, that if we’re having a guest that was on Oprah does that put us on the same level?

Jennifer: As Oprah?

Erin: I’d like to think so.

Erik: We’re about to open our own network too.

All: (Laughing).

Jennifer: You get a humpback whale!

Brandon: I was going to ask, what is my gift today?

Jennifer: You get a school!

All: (Laughing).

Brandon: You get some schooling, you get a lecture.

Jennifer: Everyone look under their seats.

Erin: Yeah one of the things that Dr. Brandt was really good about when she talked to us was always stressing wellness, you know speaking of vitamins and stuff, just making time to like take care of yourself before thinking about taking care of other people. I think she always encouraged us to have a stop point for studying and go out and exercise and gave us all these recipe ideas, like going to snap kitchen or something. I always found it such a breath of fresh air actually after talking about these crazy surgeries. Just keeping it real, you know

Jennifer: She would like stop ten minutes early and be like wait, but take care of yourself first.

Barndon: she was one of the people that um, when we started medical school last year, that really impressed me to consider the idea of getting help when I needed it which was super helpful this past year when I really was struggling and I got the courage to reach out and ask for help both from professionals and from friends and stuff like that. And I’m really grateful for the wellness course and stuff that she did because it kinda was inspiring to me to get that help that I needed.

Erik: Yeah, I know, so she’s had a big impact on all of us. We’re extremely excited to talk to her.

Erin: So just a little bit of an introduction before we have her on. She is professor of lots of different things. Lots of different departments. But she’s specialized in bariatric surgery and also her surgical focus on younger patients is on biliary atresia, anorectal malformations, gut disorders, and again, bariatric surgery. So she is a PI also, at Texas Children’s Hospital, so she’d definitely got her hand in a lots of jars doing all kinds of stuff from the TMC. And she’s an amazing lecturer at Baylor College of Medicine and we’re super lucky to be able to interact with her.

Erik: Yeah and just a quick note about her background, she did her BA at UT Austin and hook em’, if you will.

Jennifer: What do we hook? Em’.

Erik: So she got her MD at Baylor College of Medicine, did her residency in general surgery at Baylor College of Medicine, and her residency at St. Justine Hospital at the University of Montreal. So yeah we’re very excited to talk to her as Erin said and here’s our interview with Dr. Brandt.

Interview

Jennifer: Hi Dr. Brandt, thanks so much for being here!

Dr. Brandt: I’m happy to be here. Just fresh from the OR. So we were talking a minute ago about Baylor and how people who aren’t here don’t quite understand where it is. And you were saying…

Jennifer: They think Baylor University in Waco.

Dr. Brandt: Periodically when I tell people I work at Baylor, they’ll say “Oh, you guys have a great football team!”

Erin: Yikes

Dr. Brandt: No offense to Baylor in Waco.

All: (Laughing).

Jennifer: I remember when I first got here I had some trouble logging in to some online portal and I found like a tech, and online IT number, but it was for Baylor University so I was on the phone with Baylor University’s tech people for like thirty minutes before we figured out oh you’re at Baylor College of Medicine, not Baylor University.

Dr. Brandt: So you guys know the history, right, about why it’s Baylor?

Erin: They like, got divorced in like the sixties?

Dr. Brandt: Well they wanted to build a medical school And I don’t know all the political issues, I’m sure there were some, but Waco is not the ideal place to build a medical school and so they built it in Dallas. And that’s why the Baylor University Medical Center is there, that’s the other part of that, and then it migrated to Houston. So yeah we're kind of connected by name to a lot of different people.

Jennifer: We are, yeah. So you went to Baylor for medical school?

Dr. Brandt: I did, I absolutely did.

Jennifer: Do you want to tell us where did you go after that in your career journey?

Dr. Brandt: Sure so I went to the University of Texas first of all. What did you guys major in?

Erin: Biochem.

Jennifer: Neuroscience.

Dr. Brandt: I was a Plan II major.

Jennifer: Ooh okay, the real intellectuals.

Dr. Brandt: Hah! I don’t know about that, but it’s a great education and I'm a big proponent of liberal arts for people that are applying to medical school and I do think one of the interesting things about failure and it's always been true is there's a little more diversity in the backgrounds than in a lot of schools. So it wasn't a big deal that I was a liberal arts major. We had a guy that was a merchant marine that had sailed around the world eight times, we had a woman who was a PhD chemist who had worked for McDonald’s. I mean it just went on.

Jennifer: Did you do any gap years?

Dr. Brandt: I didn’t, I went straight in and then after that you know I did my surgery rotation first, and I've told a lot of people this story, to get it out of the way because I was sure I would never be a surgeon, a psychiatrist, or pathologist. And when I trained in surgery there were a lot of reasons to not want to go into a surgery residency but anyway I did my rotation first and day three I thought “Ooooh darn (that's not exactly what I thought), I think I'm supposed to do this.” And then I spent a whole lot of time in medical school trying to find anything else and didn't, so I ended up in surgery. And I stayed at Baylor to do general surgery here. That was with Michael DeBakey as the chief so that was still that era and I was the only woman in the residency for all five years and the third woman who ever finished it.

Erin: How many people were there total in the residency?

Dr. Brandt: We started with 11 in my class and ended with five. It was a pyramidal system, which doesn’t exist anymore.

Erin: Goodness. Okay, so you did residency here?

Dr. Brandt: I did and I did my pediatric surgery training in Montreal. So I speak French because my father was an exchange professor when I was in Middle School and then I went back to France for my freshman year in college to a French University and so I applied to the French speaking Hospital in Montreal because I spoke French. I didn't realize I didn't speak québécois and I also didn't know I didn't speak medical French. But I was working in the French-speaking Hospital St. Justine in Montreal as a fellow for two years. Then I came back here and I've been at Baylor ever since.

Erin: How, I guess besides everything you just talked about, how has Baylor changed since you were here as a med student versus now?

Dr. Brandt: Well I think medicine in general has changed and education and has changed in a lot of aspects. I think there's no question there's a lot more oversight of a lot of things which is good. It does add a different layer of work and I'm gonna say bureaucracy, I don't mean that sound negative, but there's a lot of checks and balances now on what gets done in medicine and in medical education. I'm not going to say it was more freeform because it was incredibly strict when I went, it was just a different kind of strict.

Jennifer: What's it like to teach at the same medical school you attended?

Dr. Brandt: Yeah so I didn't actually start teaching embryology until I'd been back here several years. But you know the first year I walked in and I'm in front of the auditorium that I used to sit in, it was pretty amazing.

Jennifer: Yes that’s really unique! So if you don't mind if we switch to talking a little bit about your specialty in pediatric surgery, what are some of the unique rewards and challenges of operating on such small patients?

Dr. Brandt: Wow. There's a spectrum of things that are really different. I think particularly in a center like Texas Children's where we were really a quaternary center so we get the rarest of the rare things that come in. So we have incredibly complex patients along with the kids in the community we're taking care of. On any given day I and my colleagues can be reconstructing a child that was born without an anus and without an esophagus and then doing a hernia and draining an abscess you know so it's this great balance of really healthy kids and really complex things. To me that reward is extraordinary, to be able to take care of people's lifetimes, instead of just their lives. And to have really long-term relationships. Most of the complex patients you end up staying with and they stay with you over years and years. I actually just had a young lady that came to clinic yesterday to find me who's going to college and she was born with biliary atresia, so without her bile ducts, and I did her original operation when she was a newborn and so I've kept up with her through the years but she and her mom made a special trip to come see me because she's going off to college.

Jennifer: Wow, that’s amazing.

Dr. Brandt: Yeah so I meant, what’s that worth? There’s not a column in the spreadsheet for that.

Jennifer: Do any of your patients want to be a surgeon like you?

Dr. Brandt: Yeah you know there's fair number that end up wanting to go into medicine but I think—I don't know if it's because of me or what they went through. I think a lot of people who will go to medical school have had childhood events where someone helped them. But I think the bigger motivation for people is just to want to help. And so, unlike going into business, which is very noble in and of itself, but the mission of medicine is very different than the mission of business. And there's just a certain group of people who choose that kind of altruistic profession. A calling, for a lot of people, that you don't see in the business world and in some other spheres.

Erik: You mentioned that there was something about surgery that kind of spoke to you when you were talking about doing your rotation in it. What was that?

Dr. Brandt: You know I still look back, you know I don't know. I mean I’ve counseled a lot of students on how to pick your specialty.

Erik: Yeah, that’s why I’m asking

All: (Laughing).

Dr. Brandt: And I think that it's rare to have that moment where you go, “Oh man this is what I'm supposed to do!” Especially when you went into it thinking, “No way!”, right? So you kind of pay more attention to it when you give that hundred and eighty degree flip. I think choosing your specialty in general—you know there's so many factors that do go into it, but I think we sometimes have a mistaken idea that you are always going to have that flash or that recognition and I saw so many students through the years that just put themselves in a corner going, “I’m making the wrong decision,” “what if it's something else,” “I needed to do one more rotation,” “I need to do this.” And I used to tell them that it's really more like dating and getting married emotionally, okay, so all of us recognize that no matter who we end up with for our significant other there's probably hundreds out there that would be just as good for the rest of our life right? So this idea that there's just “the one” is not true in who we date and who we marry and it's also not true in how we pick our specialties. So I've come to believe that, just like a good marriage, it's after you make the commitment that the work starts. And I've often said after I get to know you a little bit, because there's a little bit of a personality difference, assign you something.

Jennifer: You want to assign us?

All: (Laughing).

Dr. Brandt: And you accept it and say that's what I'm gonna do the rest of my life. What you would do is start working to master it and as you master it, you fall in love with it!

Erin: That’s actually so refreshing to hear. I feel like, I don't know about you guys, but I always hear people saying like “oh if you're like this and this, this will be good for you,” or like “if you're like this you definitely shouldn't consider this.”

Dr. Brandt: When people say that it's like okay, and I don't know if you guys are married or not, but all of us when we start dating we’re thinking about who we're gonna spend our lives with, we have a list of in mind right? Sometimes it's our parents’ lists and we're modifying it a little bit but we all have a list. And I will tell you, and you guys can correct me if I'm wrong, I have never met anyone who married the person who had everything on the list.

Jennifer: Yeah have you ever read the book The Course of Love by Alain de Botton?

Dr. Brandt: No.

Jennifer: It’s kind of about that whole concept. Society tells us we're supposed to meet a soulmate and they're gonna be perfect and we're not gonna have problems. But he talks about how it's all about compromise and being okay with being average, otherwise no one would be happy.

Dr. Brandt: Well, I don't think “okay with being average” is the right idea but I think you have to have this craftsman mentality I’ll remember the name of the book in a minute, I have a blog post about, which is this mentality that “I'm gonna take what I'm given…” You know you guide yourself into what's the most likely thing but then you're gonna take what you're given and work at it like a craftsman so that you end up becoming the best spouse or the best pathologist or whatever you know whatever it is because you're just working at it.

Erik: She pointed at me!

All: (Laughing).

Dr. Brandt: Really? You’re thinking about pathology? Cool! Listen but pathology and radiology and PMNR, which have always been sort of underappreciated, undervalued, I don’t know, in the crazy hierarchy that people make about specialties, which I do believe is crazy because I think we have to have that jigsaw puzzle all of them take care human beings, but they're about ready to explode! You know PMNR and radiology when we start doing all of the microchip technology and the incredible computing, and pathology as well, and then it's going to enter an entirely different..it's gonna be an entirely different field!

Erik: Yeah, well what you spoke about also is making me think of how you had your background in the liberal arts. I also had it in the liberal arts and I went through that sort of decision-making of like “what am I meant to do?” When deciding to get into medicine and you're right I mean it's you can maybe make yourself go crazy but you just have to make a decision at some point

Dr. Brandt: Well the other thing is you also have to realize is there are no bad choices. There are no bad choices in medicine. You are not fixing roofs in Houston in the summer. Everything you're doing is making other human beings better.

Jennifer: So I have a more technical question that actually came up in conversation yesterday with my mom. We were talking about you know like omphalocele where a baby is born with its intestines outside of its body. And with other defects also like you said if a baby's born without an esophagus and an anus. How much can you prepare for that by doing ultrasound or other imaging techniques before?

Dr. Brandt: Oh, most of our congenital anomalies can be diagnosed by ultrasound. Prenatal ultrasound or MRI. So it's very rare these days that we have sort of the surprise diagnosis

Jennifer: In what scenario would that happen—if the mother just had no prenatal care?

Dr. Brandt: Poor prenatal care, yeah. And there's a few that are a little harder to diagnose. They're just a little stealthier when it comes through the ultrasound probe. But the big heart defects, things like I'm omphalocele and gastroschisis, the abdominal wall defects, which those two are part of, those you can usually diagnose.

Jennifer: And then is everyone ready in the delivery room to just whisk the baby away to the OR?

Dr. Brandt: Well a lot of them don't get whisked.

Jennifer: Really?

Dr. Brandt: Well there’s maybe a few cardiac things that they really have to do immediately but most of the time when you're transitioning from I kind of believe I'm a fish and now I have to breathe air, right? We don't want to disrupt that thing that happens in those first 24 hours so a lot of these things we just are very deliberate about the timing. It's really only on the TV shows that you run down to the operating room with the baby in your arms.

All: (Laughing)

Erin: I was curious so you do also like bariatric surgery with adolescents?

Dr. Brandt: I started the program here, I've been doing it for 17 years, and really did it as an ethical conundrum as well. So here's kind of the long story: when this first started one of the GI doctors stopped me in the hall and said “Mary you need to learn to do bariatric surgery”. And I responded to him in a way that I can't really repeat on a podcast but the bottom line was you're crazy! And then I started meeting these 500-pound kids that couldn't go to school and were pre-diabetic and having heart failure and just socially miserable and psychologically miserable And you have to start weighing the pros and cons of a big life-changing operation. So I became part of a NIH-funded study with Tom Inge who was at Cincinnati then and is at Denver now, was the head of it. But there were five of us that banded together and these programs started enrolling patients that the NIH paid for us to follow. I think we're now in year 12 and we’re already paid through year 15 for the long-term outcome. Because we didn't completely understand the risks that could happen we assumed that in teenagers it was going to be close to adults, but teenagers are a really special group of human beings, particularly psychologically, but also physiologically. And so we've been able to show that it is safe, that there is a subset of young people that benefit from having this operation early because it has a better chance of reversing the things that have happened like high blood pressure and diabetes and all that, than if you wait till they're adults. And we’re have two New England journal publications out of this and the second one which just came out a month or so ago was the one that really talked about that. So I think it’s such an interesting part of medicine. Bariatric surgery has kind of these two components. There's a part of it that is a little bit like plastic surgery, that is about the way people look. And people paying to look a different way, which is foreign to me I have to be honest. I'm an academic surgeon and I'm a sort of metabolic surgeon so that's not the way I think. But I know it's there. And then there's the other group that really is trying to figure out, so what is causing this obesity epidemic? And what do we do with the really sick patients that need some intervention? And I don't believe and I don't think anyone believes that bariatric surgery is the solution. And I would just assume we figure out socially how to deal with the obesity epidemic that didn't exist thirty years ago, and put bariatric surgeon is almost out of business because it doesn't make sense that in a society where we've gotten this level of obesity, that we’re treating it with surgery. So I certainly feel for myself I have an ethical obligation to also focus on food and nutrition for children and all of the things to do the right thing for their nutrition and prevent the obesity and so I've been very active doing that too.

Erin: Yeah don’t you do the CHEF class?

Dr. Brandt: Yeah so when I was Dean of Student Affairs that was started by a group of students and I was super happy to sponsor it. It's been it's been a real success, it's still ongoing. And actually I'm the faculty advisor for it now.

Jennifer: So I was going to ask—you mentioned it a little bit with the NIH study—does bariatric surgery help the kids long-term and what what's the longest you've followed a patient?

Dr. Brandt: So we’re in twelve years right now, you know if you look at sort of history of the epidemic and the history of the surgery you know it's been interesting. So the lap-band which was the billboard surgery right? Made a lot of money for a lot of people. I predicted when it first came out that it wasn't gonna work because putting a rigid device around the top of the stomach was gonna cause a blockage for the esophagus and cause problems, and guess what? So now nobody's doing bands anymore at all. The bypass has been done, the gastric bypass, for about I think 35 or 40 years, there's probably good data in adults. And we can maybe extrapolate that to adolescence with just some tweaks. The other really big operation that's out there—the gastric sleeve—has only been happening for less than ten years. So we don't know even in adults what happens. And I have some qualms about it just physiologically so it'll be interesting to see what happens what time, whether that pans out to be as effective as the bypass without some major complications.

Jennifer: Right, yeah. I shadowed an adult bariatric surgeon one time and he told me a lot of his patients you know they'll lose the weight very rapidly. They'll lose 300 pounds in like a year but then over time they slowly start to gain it back because they learn how to overeat basically in a way that doesn't overfill their stomach.

Dr. Brandt: Yeah the way the way we set up our program, our kids come in for or came in for about nine months to a year with us, meeting with a psychologist and dietician every month. Because we had to teach them how to eat healthier because these were kids, I mean I still remember having a family that brought a kid into me and I was talking about healthy eating because it was a four year old or something that was really overweight. And the mom said well we eat fruit, he eats Cheetos. And she thought because Cheetos were orange it was a fruit. And there is no parent who wants to do harm to a child. Sometimes it's just an issue of education and an issue of education in our schools for kids that we've been missing out on.

Jennifer: So you appeared on Oprah, we have to ask. What was that like?

Dr. Brandt: Oh you know it was so interesting. She was interviewing three people who had had bariatric surgery as teenagers and I just was along for the ride kind of in there as a possible expert. At one point, I can't remember who was saying what, but it was so outrageous and there were some people from TCH and some of my people that were with me and they started elbowing me like “You’ve got  to say something!” so I did. It was quite an experience it was you know people have said jokingly but maybe not so much in the past when she had this show that there were two ways to change medicine the United States: one was with a New England Journal article and the other was by going on Oprah.

Erin: Did you get to meet her in person?

Dr. Brandt: Just briefly at the end, I got a picture with her.

Jennifer: Did you meet Dr. Oz?

Dr. Brandt: He was in the audience.

Erin: So I wanted to ask more about your talking about being the only female resident in your program. Even now I think surgery is pretty male dominated. Can you comment on how that’s changed or how you feel about that or what it’s been like to be in a male-dominated field?

Dr. Brandt: Well I think Baylor has done a really good job of becoming much more diverse—gender diverse and ethnically diverse in our surgery program. And I think you can tell the difference in how the residents are treated and how they treat each other. I hope socially there's been a change. I'm very worried right now that we're backsliding in the United States on a lot of issues of equality and diversity. And I think it's really very important for those who are in medicine to speak up about that. I certainly use Twitter a lot as a platform. We all hear all this negativity about social media but especially if you get to be a senior person who has a voice and has a reputation and a standing, I almost view it as important for me to speak out. And I encourage people to speak out. I think we've got to all band together to keep from backsliding. And keep it moving forward.

Jennifer: Any advice for female medical students who are thinking about going into surgery?

Dr. Brandt: No different than any other field, I mean honestly I think you know we have issues across the board in our country with pockets of people who express or believe one of the “-isms”. And sometimes I really think they don't see it and I also just did a blog post recently on social location. It's a very important kinds of that we don't talk about very much. But every one of us has a social location. So it's your gender, it's your race, it's your educational background, it's whether you're able or disabled, it's whether you're cis-gendered or not, it's whether you're gay or straight, all of those things make up your social location. And in the United States, in what is a constructed reality, so this isn't saying that this is true—but there's a hierarchy of social location. And in social location in the United States hierarchically at the top is: white, male, cis-gendered, straight, Christian. And here's the thing if you're in those groups you literally can't see the other ones. So my favorite story about this is David Foster Wallace's commencement address called “This is Water.” I don’t know if you guys have ever read it or seen it, you really have to. But in it he tells this little parable of these two young fish that are swimming along and the old fish is coming toward them and swims by them and goes “hey boys how's the water?” and they swim on a little bit and one of them finally says “what's water?” because in the United States if you're in one of the dominant social locations, it’s water right? You don't have a desire to be a sexist if you're male or be a racist if you're white, some people do want but that's a totally different thing. But most the time it's inadvertent because it's the water. And until someone points it out to you, you can't see it. So I think part of our job is to keep pointing it out, you know “did you realize the way I interpreted that?” Or “I heard you say this, did you really mean that?” I talk to men all the time and you know I have several colleagues who are Latinx and if a Latina walks into Grand Rounds she is always aware that she is of Latin descent and she's a woman. If a white guy walks into Grand Rounds that thought’s never in their head, right? So I think we just need to keep talking about it and so my advice to all women going in or anyone who's not in the super dominant social location, is most of the time people are not doing this intentionally. But there are -isms. And so it's our job to call them out when they happen. And if you are able, if you're one of the people that is in a senior level that, you know I feel very strongly as a white senior person at Baylor, if I see any discrimination towards a student of color, it is my job call it out because it should not be the students of color who are having to raise the issue themselves. It should be me and my colleagues so I think that's real important too.

Jennifer: How do you see medical education changing in the next, say 20 to 25 years? And medicine, as well.

Dr. Brandt: Oh my gosh!

Jennifer: It’s a very broad question. This was actually suggested by Dr. Poythress, so thanks Dr. Poythress. He wanted us to ask you that.

Dr. Brandt: (Laughing). Oh, he and I should go out for a cup of coffee. So I think we're in a very big transition right now in the United States more than other countries, where we're gonna have to make some decisions about the business of medicine versus the calling of medicine. And that transition that we're in right now is a hard one. And I think there's potential repercussions if we make the wrong choices as to who's gonna want to go into medicine, who's gonna stay in medicine, what's gonna happen with our burnout rates which are sky-high. I am believing more and more that burnout is not about doing more yoga and eating right. It almost is a moral distress of being in an environment where as a physician who is called to this profession you want to do what's right for your patients. And the institutions we work in absolutely believe that too but there's just different ways of looking at it that sometimes are in conflict. And I think particularly if you look in the private sector in smaller communities, we have a huge number of young adults who are uninsured or underinsured, who are not seeking medical care. And if you're the physician when they walk into your office and you know you can make them better but you can't find a way financially to do it, that creates moral distress. And when that happens over and over and over again I think that's one of the things we need to talk about in terms of burnout.

Erik: We hear about burnout all the time now, do you think burnout was around 30, 40 years ago and it wasn’t talked about as much or do you think fundamentally something, maybe the presence of insurance companies more and more in your daily like prescribing and everything has affected it?

Dr. Brandt: I think there were always some people. I do not think what we have now existed then. I don't. A lot of it was, physicians had much more agency and autonomy. We were much less likely to be part of big, big organizations. And there's something in there, I haven't even sorted out myself, so I don't want that to be misinterpreted, but how medicine is practiced on a day to day basis by physicians has changed. And part of that change I think has definitely contributed to burnout.

Jennifer: Do you think technology at all has played a role in it?

Dr. Brandt. Oh you're gonna get me in the EMR. So if you're on Twitter you have to follow EMR, you have to check out Epic Parody. So when we talk about the electronic medical record which has contributed to burn out—the data is really clear right—we have to remember that it's not in its infancy but we are still very early in the evolution of this EMR. We went from like 12% to 80% of physicians on EMR ten years ago. And that’s when Obama passed the legislation that allowed for the money to be used for, you know that whole thing—I can’t remember the name of the act but I should, there was a sudden burst right. And so we went to the blue screen of dos, which you guys don't even know what that is, but basically if you imagine the very first computers and the interface is off, but it just kept evolving and the latest rendition we have of epic here is much more user-friendly and much better. But there's still a huge burden of clerical work now that physicians are having to do that was not true previously. And that has to be looked at because it's kind of a waste of a lot of education if there's things—that could be offloaded to people who need the jobs and have the skills—but they’re keeping physicians from doing what they're actually trained to do and seeing patients.

Jennifer: I remember that movie Code Black, it was a documentary showing an emergency room in LA, I think the big LA hospital that sees more car accidents than anywhere in the world. But they were showing this waiting room full of people who are super sick, like throwing up into bags, and the physicians are just like having to fill out all this paperwork. It was ridiculous and they were like “oh I got to finish this before I see my next patient.” Like you said a waste of a lot of education.

Dr. Brandt: Well I think you know, big changes that happen this fast create unintended consequences and I think that's where we are is trying to figure out what those unintended consequences are and how to deal with them.

Jennifer: Well if y'all don't have any questions I have one last question for you: why is there no fifth for pharyngeal arch, or is there?

Dr. Brandt: (Laughing). There was in fishes!

Jennifer: There was in fish, fishes.

Dr. Brandt: Yeah, so we have, I don’t know. I don’t know.

All: (Laughing)

Erin: Don’t know where it went.

Dr. Brandt: There's a lot of symmetry that gets to asymmetry as things get developed. That  could be a new t-shirt.

Jennifer: “What happened to the fifth pharyngeal arch?” Well thank you so much for your time, you can go back to saving the world.

Erin: We won’t keep you any longer.

Dr. Brandt: Alright well thanks the opportunity to talk to you guys.

Jennifer: Yeah, of course.

Outro

Brandon: All right, that is it for now, we would like to thank everyone who took the time to listen to this episode of the podcast. Special thanks to Karl for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for help with the production and website and thank you again to Drs. Pillow and Agrawal for taking the time to be interviewed by us. We hope everyone enjoyed it and hope you tune in again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 44:31 | Published: Oct. 16, 2019

Drs. Agrawal and Pillow will discuss how rapid technological innovation has affected medical education, and how institutions are adapting to better instruct tomorrow's physicians.

Transcript

Erik: And we're here.

Brandon: We are here.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.

Brandon: And I am Brandon Garcia, another host.

Karl: And I'm Karl Lundin. I was the writer for this episode.

Erik: Yeah, and so we're gonna be picking up off of our previous episode. This is a two-part series if you will on medical education, and so if you haven't heard the first part, I urge you to go listen to that now. Karl, would you want to give us a little summary of everything?

Karl: Yeah, so basically we just talked to Dr. Tyson Pillow and Dr. Anoop Agrawal about their own experiences here at Baylor College of Medicine. We went over some sort of like education theory, a few educational models they like to use and apply here at Baylor, and also we talked about some exciting things they've been doing sort of conducting courses on this topic of medical education and technology. And now in the second half we're gonna kind of go into some more in-depth discussion on application, on potential changes that some of these technological advances might bring to Baylor or that they would like to see, or just kind of some far-out interesting ideas about how this stuff might alter medical school education in the not-too-distant future. And then we'll also kind of hone in and talk about specialty-specific sort of impacts and also on how this medical technology—I'm sorry medical education technology—is going to impact education at the bedside and not just the classroom.

Erik: Yeah, and I believe we even talked a little bit about AI. Everybody loves that.

Karl: Oh yeah, the buzzword yeah everybody's got to talk about AI right.

Erik: We have to.

Brandon: So I have a question, so they're gonna talk a lot about possible changes to education that reflects technology and stuff like that. Are any of the things they're talking about things that we're actually gonna see happen here at Baylor, or are they more hypothetical?

Karl: I think mostly it's gonna be hypothetical stuff. We will discuss a few things that techniques that they themselves, or that other medical educators here at Baylor are using, right, kind of on their own. But as far as like talking about broad sweeping changes that are gonna be implemented we're not really going to get into that today. And some of the stuff we're gonna even talk about is gonna kind of like far out there into speculation territory, where it's not like it's just you know…there's the disclaimer these are our opinions, not the college's type of thing, right.

Brandon: So it's just stuff that it could happen maybe one day, or it's cool stuff that may happen or would be good ideas, but not official curriculum changes like that. No one needs to be thinking, oh wow the resonance podcast is so…

Erik: Cutting edge.

Brandon: Cutting edge…

Erik: I mean, we are cutting edge.

Karl: We are cutting edge.

Brandon: Well, who knows, maybe we are.

Erik: All right well, so on that note, to get us started with the interview portion to introduce the faculty that will be talking with. Dr. Anoop Agrawal got his BA from the University of Missouri at Kansas City, his MD from the University of Missouri in Kansas City, and came to Houston and did his internship and residency here at Baylor College of Medicine. And is now currently the Internal Medicine and Pediatrics Residency program director.

Karl: And our other guest does not need any introduction if you took our pharmacology class here at Baylor, but I'll introduce him anyways is Dr. Tyson Pillow. Dr. Pillow is a faculty at our emergency medicine department here at Baylor; he's an associate professor. He actually got his BA at Rice University and then also his MD right here at Baylor before doing a residency at the University of Chicago. And he is now working at Baylor like I said as a faculty, and also is the residency program director for our budding emergency medicine department and the medical director for our simulation and standardized patient program. We're very excited to talk to them both.

Interview

Karl: You guys mentioned in our talks before this for the podcast, the possibility of creating a paperless curriculum using materials like the iPad that sort of thing. What would that kind of look like? And how close do you think we already implementing that here at Baylor? What are some things you'd like to see?

Dr. Agrawal: Money?

Dr. Pillow: So, I'm gonna speak for Jared Howell, but I would highly suggest you all get him on the podcast. He has digitized his curriculum. He talks about how one of the first steps is to put the iPad in his faculties hands and get them used to that, get them comfortable with it. And then he also talks about how in transitioning from paper to iPad, specifically iPad but I should say tablet, but in this case iPad that the students…it becomes natural when you start to use it. It gives them the option of using paper if they choose but puts everything…and students take notes on the iPad—on the tablets—students manage their learning through the cloud servers, share through the cloud servers. That actually struck me teaching, helping to teach, pharmacology this year as well the number of students who wanted the slides before class, not because they want the answers but because they want to annotate directly on the slides. It has changed note-taking. And so the other thing I'll throw in is that per Jared, the actual cost is …it's cheaper to buy iPads for everyone than it is to print the thousands of thousands of pages of paper and I all the binders that he had. So he actually says there's a cost savings associated with moving digitally. I think people are uncomfortable with it. I like to…I wish I had done my research to come with the specific references, but you'll see this across the board. Well, I'm researching various things, but one of the very interesting things is, for example, when the stethoscope was first introduced. Apparently, there was a lot of backlash and pushback. Why wouldn't we just put our ear to their chest? What is this stethoscope thing? And then when PowerPoint came through, there's tons of articles when PowerPoint was first developed like, oh this is the devil. Why would we use this thing with these digital images? And what will happen to our 35-millimeter slides and our transparencies? And so you will get pushback and if anything that's probably a good indication you're headed the right direction.

Erik: Yeah, what was that, Kuhn's book about paradigm-shifting?

Dr. Pillow: Absolutely.

Erik: Well, that's a great point and actually kind of building off of a comment that Dr. Agrawal you made earlier. I was wondering, so there's an idea out there as you were alluding to that there's a possible to shift all the basic sciences education in an online format, like you know the likes of Khan Academy, wherein this model students would study independently to take USMLE before entering medical school, and then medical school would just be the clerkship. What are your thoughts on that?

Dr. Agrawal: And again I'm speaking out of turn, and so yeah these are my opinions alone, and they don't represent Baylor College of Medicine or my residency program, it's just …it's nice to have this discussion. Because yes. And there's actually…I hope I'm not breaking any new news here, but there is an active conversation going on at the NBME of making the USMLE pass/fail, step one at least. And you can see there's a slippery slope if that becomes past fail step two will probably become pass/fail. And I get why they 're—I'm sorry I'm going a little bit on tangent— you can kind of figure out the logic of why they're considering this. Because of the undue pressure that's placed on this one exam that could determine your whole career trajectory, and therefore students aren't actually paying attention to the material that's being presented every day in the classroom, or on the clinical setting. That's a whole podcast because I'm sure you can have a big conversation about that. But when you look at it in this context of, well yeah if you actually want to create competent, compassionate doctors. Just rebuild your medical school from the ground up with that as your goal, what did that look like? And if that requires mastery of some basic sciences and some knowledge, great. What is different about how you're delivering that knowledge at Baylor College of Medicine versus at Duke University versus at Vanderbilt versus at Harvard. It's the same material. It's not like there's some special codified material that's restricted to only Baylor College of Medicine students that they get this. So if you put the burden back on hey, pass step one, and you get into med school, and now we're gonna provide you the rich…now we have more time to give you the rich experience of the bedside skills…that the feedback evaluation skills, the real, you know, rubber meets the road skills of the challenges of everyday being a great physician and just put more, emphasis on that and give more time to develop those skills that you know. That's just an idea.

Dr. Pillow: Yeah, I also am speaking for myself, not for Baylor College Medicine. The…my disruptiveness is not as disruptive Dr. Agrawal. But you know I agree he's got some great ideas and they're great core principles. I think the method is blended and I think the method gets away from 8:00 to 5:00 Monday through Friday, and actually says how do we learn on the continuum. So I like to anchor a little bit more in competency-based. I like the ideas mentioning, so, for example, pass Step One and then do clerkship sort of things. I like ideas like that. When I look at it, and I'm drawing from again that I've had the privilege to work with dr. Reddy and the other faculty on pharm this year, I saw a range of learners. I saw—and this is actually in the literature I forget the actual author, but talks about stages of learning going from a dependent learner in stage one to independent learner in stage four—but you…we had learners who would ask application questions from the moment I got into the class and we had learners who struggled to get some of the basic concepts, and that's okay. But how do you create a model that supports all of them and really gets at that competency-based piece? Some people for mastery will take longer, but you can get to mastery level. Some people will get there faster, and how do we create infrastructure that supports that. And as I mentioned I agree, we do have—this is definitely a personal opinion—we do have this idea…this permeates almost everything, not just medical education that I must show you information on a slide to be able to hold you accountable for it. Then you get to an ER shift, and the patient doesn't care that you've read the book or not, and you're gonna end have to intervene. And whether or not you remember that slide is not nearly as important as being able to integrate what you've learned. Take your knowns, take your unknown to make the best decisions for that patients and save them. And so I really feel like again a blended model where you know maybe the length of medical school training doesn't have to change, but the…absolutely the way we do it has to change to create these competent, compassionate, excellent physicians.

Erik: On that note, I'm curious what your opinion is Dr. Pillow, especially as somebody who has taught the first years pharmacology course, or help teach, what are your opinions on streaming?

Dr. Pillow: The…so you're asking streaming from the standpoint of?

Erik: You know, that translates into less people in the classroom when you give your lecture.

Dr. Pillow: So I actually reject that theory. I actually think that these are slightly separate issues. The number of people in the classroom is dependent on what content, what applications, what activities you have in the classroom.

Erik: If you don't record it.

Dr. Pillow: If you don't record it, or if you do record it and make them responsible for application, right. So we actually did some of that in pharmacology this year. We definitely had the didactics, but then you come in for a case review, and you applied it. And we actually were very happy; we had great attendance at all of our optional case reviews. Now partially because yes, we did not record them, but none of the material was new, we provided answers, and people still came because they want to know how to apply the material and actually use it in meaningful ways. I think the challenge of streaming is not if we stream we will lose people. The challenge of streaming is if we stream how do we continue to make the medical school meaningful. How do we continue to make the time, face to face time, meaningful? How do we move to a more competency-based, because honestly at the end of the day if I create a competency benchmark—you want to stream, you want to read, someone else just comes to the class to do active learning, and some we all hit my benchmark— I'm okay.

Dr. Agrawal: Sounds like different learning styles.

Dr. Pillow: That's true, the VARK, he's a VARKer.

Dr. Agrawal: I like what you said, are you an individual learner where you want to sit in your little…in your bedroom and watch that, or do you want to have a social experience, and that's how you engage.

Dr. Pillow: I think it's both, right it's blended, it's both.

Dr. Agrawal: I agree.

Dr. Pillow: And if you, if you…so I don't think of streaming or class time. I think of how do we leverage streaming in a way that augments class time. And we got to get away from these ideas that if we don't teach it to you directly on the slide, then we can't hold you responsible. I'm gonna teach you—I think I even said this during pharm—I'm gonna teach you A, I'm going to teach you B, and I'm gonna test you to see if you can figure out A plus B equals C. And I'm gonna give you some examples, A plus D equals E, B plus C equals P, whatever. And then you come in, and you figure out, okay I can apply this now. That is where I think…so I'm actually Pro streaming, and I challenge the educators, myself included, to do better to keep pulling students to…face-to-face time, and make it meaningful.

Karl: So a lot of our discussion is kind of bounced back and forth around different settings for this education but focus a little bit more on the traditional classroom or larger group setting, and we're just curious like if you have some real clear specific—I think we talked a bit about like Google glass and stuff—but specific education technology innovations in mind for bedside education experience.

Dr. Agrawal: So that's where I do most of my teaching there. Unlike Dr. Pillow, who does predominately mostly classroom with some clinical. Mine is pretty much majority clinical, and that's where currently, the current tool, my preference…preferred tool is the iPad or the tablet. And what it is, is, do you think about…where unlike the classroom, what I pitch is that as an academic educator, clinician educator, my classroom is a mobile classroom. So I am on the go where…the team is on the go; we're going from patient room to patient room, we're spending time in hallways, we're spending time in our team room. We can be anywhere in the…in the building, and what kind of device or what kind of tool is there that you can have as a mobile tool. I mean no one wants to be carrying their laptop around, you know it's the bulky mobile factor, sure it's mobile, but it's not exactly designed to do that type of thing. Sure you have the Wow's, the computers on wheels, or workstations on wheels, but again that's not…that's more for the care of the patient, there's not going to be ability to do other educational type things. So again for me what I've found currently is something like in the iPad, which is…which is that ultimate tool of having access to all types of applications. And there's the specific—we've talked a lot about white board type ones—but then there's very specific medically oriented applications. Another one I'll throw out there and mention that's great is called Draw MD. It's free and available I think on different platforms, and it's a…it's designed…the creator's have designed it as a patient education tool, but for me, patient education is just the other side of the coin of medical education. They're the same …they're you know different sides of the same coin. And it has fantastic templates and pictures, and again this goes back to getting the visual learning of the learning style. You know if I'm trying to explain to somebody how their thyroid works, are they gonna get it if I'm just talking out loud and, err well you know your pituitary is you can create this hormone called TRH and your thyroid was gonna…you know versus if I draw it out. I think there's something to be said there that it doesn't matter what type of learner, you're gonna prefer a learning style that's gonna be visual. And so it's crazy that I think that there's so many complicated concepts or just physiology that we teach at the bedside to the patients, as well as to our students and residents, that gosh, we wish we could just draw or have cartoons of things, and that's what the device lets me do. And it lets me have what are called, you know inside the actor studio here tips, if you have a fantastic medical educator it's because they've done it a few times. It ain't their first rodeo; they have a teaching script. They have refined and finessed how they teach this concept, and it's been, you know battle-tested with hundreds of other learners and students. And so, the technology allows for efficiency, allows you to have that same content but now in a much more robust style that you don't have to redraw that picture every time. You have…you have that picture already there, so your starting point is a little further down the road.

Karl: That makes a lot of sense.

Dr. Pillow: For the bedside, I agree. I love whiteboard apps, so that's what I have; that's what I go to for both patients and learners. I think the other part too is I go off script a little bit and actually don't care about the tool. I try to teach curation of the apps that are available, the materials, even just the idea of, yes you have up to date, how do you use it real-time? Right, how are you…how are you going to take this and actually make decisions with patients? And it gets into this idea of information management. The information deluge, and how we actually look at this and say, alright this is how we practice to stay up to date to challenge our assumptions even when you did something one way yesterday, is there anything new today, or next week, or next month, and how you actually pull that in. And so again, the tech, computers have been around for a while. So the tech is not necessarily new at all, but the way we use it, we actually have to train ourselves, train our learners, and even train our patience, right. They can't…I would rather they not Google three symptoms and then come in with XYZ, and so how do you…how do you actually help your patients to navigate in a meaningful way? Curating information, knowing which sites to refer them to, teaching them how to use them in a more meaningful way. So that's what I try to do bedside.

Erik: Well, how do you see advances in technology impacting educational opportunities and specific sub-specialties and specialties?

Dr. Agrawal: Well I think I alluded to one concept earlier, which I feel like we are…that we currently have a deficiency, and I would say, or we could do better in medical education, which is direct…more direct observation. Because really that at the end of the day is the best way to validate and verify that this individual has the competencies and ability to perform as a physician. But it takes a lot of time and effort for faculty to always be in the room, and I think if something like Google glass 2.0 or what-have-you can get…the usability index can again become lower, so it's low-hanging fruit, anybody can pick it up and do it where you can just stream it. Stream it live. I can be sitting in the conference room in the same facility, and you don't feel like I'm necessarily right there in the room when …it's different when I'm in the room watching over your shoulder, you notice my presence. But sure, you know I'm watching you on the glass, but you probably subconsciously, after a minute or two you're just…you've forgotten me, you're wearing them, and you're just doing the care. And I can now provide you some real honest feedback of how that visit went.

Erik: Right, put it on the medical student?

Dr. Agrawal: Yeah, exactly. It's like a GoPro let's just… look, hey, it's happening in other areas look at the police force, right. You got the body cameras, same thing. I just mean body cameras for med students and residents so we can kind of see what are they actually seeing, what did the patient actually say, what implicit biases are they not recognizing in their own care delivery. And I think that's where I see the next big leap, and I think what's been the barriers again, having something that's cost-effective, easy to use, integrates with our systems that can make it happen. I think like…I feel like we're just one…very close.

Erik: It sounds like do you see that specifically…I mean obviously, for your end, family medicine affecting that, but do you see that across the board? It might not be…that might like, for surgery, for instance. Like would you see something like that?

Dr. Agrawal: I don't know, we could see what Dr. Pillow thinks.

Dr. Pillow: Oh I definitely think…I think any skill set where one must demonstrate procedurally, especially. If I can actually record you performing the procedure, even to the point of…there's actually some literature, very interesting literature and forgive me because I don't know all the references, that are suggesting that educators no matter their gender are actually rating female trainees lower on milestones than males. And there's actually several articles out now about that. So, we're trying to look at that and figure that out. Is that a matter of faculty bias? Are there factors of the learners themselves? We're not sure. We're looking at that. Wouldn't it be amazing if we could judge someone's procedural skills not based on whether we knew it was a man or woman or…but actually look to see, watch their skills and look at their outcome? So things like that, and breaking bad news. I've …we've absolutely, every attending everywhere ever has had the experience of your resident tells you X and you walk in the room, and the patient tells you the inverse of X. That is just something that happens, and I then I've had it happen to me myself. I'll go in a room, one time the patient will tell me yes to a question, the other time they'll tell me no, and how do you resolve that? How do you reconcile that? Well actually having that input you can actually say, oh here's where you've led the patient to answer that question, here's where they were actually going, here's where they were uncomfortable. So lots of opportunities there and I think to…the other area I think is something that already exists but we don't use a lot is just video education. So if we're gonna consent patients for procedures wouldn't it be nice if they knew what we're gonna do, right? Now if you want to go put together a car engine and you had no idea where to start what would you do?

Erik: Google.

Dr. Agrawal: YouTube.

Dr. Pillow: YouTube, you look it up. Alright, so sir we're gonna take out your appendix. Sign here, I've explained that to you, you should go. Alright versus sir, so we're gonna take out your appendix, okay here's an instructional video about that, and here's what we're actually gonna do, here's how we're gonna make you comfortable, here's why we're doing it, here's the alternatives ready for them to go, right. So I think there's medical education at direct observation, I agree with dr. Agrawal 100% that when we figure out how to do it easily, manage the issues of HIPAA, FERPA, everything else, then that's gonna revolutionize the way we do education. It's gonna take a lot, but it will revolutionize. But then also on the standpoint of other aspects, there are lots of applications.

Dr. Agrawal: I'll mention a couple that, Dr. Pillow I'm surprised you haven't brought up. Simulation, and of course the other rising tide is pocus or point-of-care ultrasound. I think those are all there to advance this technology that are gonna continue to grow and have a significant impact in educational opportunities.

Dr. Pillow: Wearable technologies as well. We will…we will be walking around at some point, we'll be walking around with the tech—whether we're part of the board or not I'm not sure yet—we'll be walking around with tech that we'll be able to report heart rate, blood pressure, it'll be able to sample things through our skin to decide when we're stressed, when we're not stressed. At some point it'll take small little blood samples or— just throwing out ideas here, that'll give us an indication of where patients are with X-Y-Z. And then from that standpoint, patient education on use, provider education with how you manage patients in an outpatient setting with wearable technology versus having to bring everyone in at regular intervals. Those sorts of things. All sorts of different applications.

Erik: Well, and how about AI, I mean that's the hot-button topic now. Obviously, people talk about it mostly pertaining to radiology but do you see that affecting even just medical education in any way? Or…

Dr. Pillow: The interface I think, because you will have to learn—there are probably things I'm not thinking of right now obviously, or we're not thinking of—but the interface, just knowing how to use AI in a way that is useful and meaningful and continues to add value. So if you have…we see this some with our electronic medical records. So when do you accept the recommendation of the electronic medical record? When do you actually reject it? Most people now anecdotally will tell you, see that click cancel, click cancel, just click through it. Well actually it's based on data, and it may have some applications. The same time you have to know when the patient that's not flagging for CAD risk factors and ACS shouldn't go home. I still need to bring them in. So I think we're gonna have to teach, learn ourselves, and then also teach how to use these technologies that are going to be so important for patient care.

Dr. Agrawal: Yeah, I think it reminds me of the book by Daniel Kahneman, that Thinking Fast and Slow. It's almost like AI is type 1 thinking, it can recognize the patterns and come to the diagnosis, and it'll be right 80% of the time. Versus…Pillow is giving me the up arrow. Higher.

Dr. Pillow: More like 92%.

Dr. Agrawal: But then what's our role gonna be? Ours is gonna be to think slow and catch the other, say 15-20% where AI's got it wrong in terms of what it could do. And so I think there's...yeah a lot…I think with us as a profession, this is speaking more broadly, we should be kind of thinking ahead of this because this is a potential disrupter to our own profession, in terms of what is going to be the role of a physician. Because I can see a day where if I have a sore throat I don't need to go see the doctor I go to CVS, pick up a kit, swap my own throat, put it in the thing, gives me a positive or negative like it does with a urine pregnancy test. I enter my weight, my age, it kicks…ask me allergies…it kicks out a prescription…

Erik: Vancomycin, right away. I'm just kidding…

Dr. Agrawal: It's right over there at the CVS counter, I go pick it up, and there's my amoxicillin waiting for me. I don't need me. You don't need an MD. So I think I see roles for AI, and then again, how does that …what's the role the physician in that new world. I think it's for the higher-order thinking, for the complexity that we are get excited about. That's what you know, as students and residents, you know that's what gets us up in the morning is when we see those cases that are really challenging and make us think that makes it more rewarding. So I think it would help us by doing more rewarding and meaningful work day-to-day, but I think yeah there can be a risk where we can erase ourselves from the equation of that…what is health care if we're not careful.

Dr. Pillow: That's a good push for emergency medicine; people will still shoot and stab each other.

Dr. Agrawal: I don't know those Da Vinci robots may be able to repair you on their own.

Karl: Yeah, I think it's been very fun talking to you guys. Thank you very much, Dr. Pillow, Dr. Agrawal.

Dr. Pillow: Yeah, it's been great.

Dr. Agrawal: Thanks for having us; this was a lot of fun.

Karl: I'm seeing a common trend here, with all these innovations it's really important, but that decision-making process at the heart of it is something that us doctors very much will still be needing to do moving forward.

Dr. Pillow: Thank you all for having us.

Dr. Agrawal: Thanks, guys.

Outro

Brandon: All right, that is it for now, we would like to thank everyone who took the time to listen to this episode of the podcast. Special thanks to Karl for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for help with the production and website and thank you again to Drs. Pillow and Agrawal for taking the time to be interviewed by us. We hope everyone enjoyed it and hope you tune in again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 44:31 | Published: Oct. 16, 2019

Drs. Agrawal and Pillow will discuss how rapid technological innovation has affected medical education, and how institutions are adapting to better instruct tomorrow's physicians.

Transcript

Erik: And we're here.

Brandon: We are here.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.

Brandon: And I am another host, Brandon Garcia.

Karl: And I am Karl Lundin, I am the writer for this episode.

Erik: Yes so today we're gonna be talking with Dr. Agrawal and Dr. Pillow who are both physicians here at Baylor College of Medicine, and also have a specific interest in medical education, and how technology is influencing it, and how we can basically meld the two so that we can be more efficient with our educational practices, and kind of bring us into the new era of medical education. But before that I think we wanted to talk about a little bit of, you know, where have we come from with medical education and what some of the acronyms really that we're gonna be talking about like SAMR and VARK. So, Karl, you want to start us off?

Karl: Yeah, obviously, medical education is something that's existed for a long time. Going back to Hippocrates in the 5th century, people have been getting sick, and we've been trying to figure out how to heal them, right. And various schools and systems have been established. For a long time, it was kind of focused mostly on an apprenticeship model, so one or two students would follow around a doctor and kind of learn the craft from them through apprenticeship, just kind of studying them in that one-on-one relationship.

Erik: And that was for a while, right?

Brandon: Oh long centuries, right?

Karl: Yeah, we did not really start even getting away from that until towards the end of the Middle Ages when the university system developed. I believe the first medical school was in Italy, at least in the West, either the 9th century somewhere around there. And obviously, even there they were still doing an apprenticeship-based model. It was only over time there kind of developed this understanding as the university system grew up throughout the Renaissance— we're talking mostly about the development of Western today, not other traditions.

Erik: Yeah well and the apprenticeship model in America was around for until pretty I mean relatively recently like the end of the 19th century right?

Karl: Yeah so the idea of viewing the study in the education of Medicine in a very systematic scientific way didn't really get solidified at least in the United States until the very late 19th century, so the 1890s. That's where Johns Hopkins kind of got it's claim to fame, right. They were one of the first institutions to really start implementing a very scientific systematized way, and viewing medical education as a science, right, which requires laboratories, dedicated teaching facilities. The idea of the teaching hospital was something that was really kind of solidified and developed there. I'm going on rounds seeing patients, a lot of the stuff we think of today in modern American medical education would come sort of from that model.

Erik: Well, so how does, I guess, how do you think technology is kind of innovating this?

Karl: Well, I mean obviously, technological innovation has influenced medicine a lot even just from the transmission of knowledge. Originally people had to pass things on through oral traditions, right, direct one-on-one conversations, or you could have written works, but they would have to be handwritten. The printing press was a big revolution. Obviously, a lot of anatomical studies that took place, which we've talked about in previous episodes were really important for helping us kind of develop our understanding. And then also the university system, the development of various advances in the natural sciences were really important for advancing our knowledge, and then now we're kind of entering a new age of computers—the internet.

Erik: .com

Karl: You know the cloud, all these fancy electronics-

Erik: And we talked about the cloud with Dr. Pillow and Dr. Agrawal.

Karl: Yes, yes.

Brandon: I'm interested to hear a lot about with technology and things like that if there's any opportunity for simplification. Because I don't know how you guys felt but like with coming into medical school and stuff like that you've got firecracker, you've got Anki, you've got powerpoints; you've got Reddit, you've got all these different resources, full...chock-full of ways to study now. To me, like the biggest hurdle, I think for medical school wasn't necessarily the content so much just trying to pick out and figure out a way to-

Erik: What to use?

Brandon: Yeah, what to use, and I'm like, I'm a year deep, and I still don't know.

Karl: Well yeah and like streamlining that process I think is one of the big things that Drs. Agarwal and Pillow really focus on in their talks. They talk about for them one of the most important things they try to teach when they do their workshops and what not—and they'll get to explain this themselves—but is how do you curate all these tools. How do you pick and choose, you know which things are most useful, which are most salient for whatever task you're trying to accomplish, which is another really interesting thing we get into and talking about.

Erik: So can you tell us, because we will be talking about various educational I guess...you could call it philosophy or at least pedagogical styles, can you tell us a little bit about what some of those are?

Karl: Yeah, so, first of all, we're gonna talk about a couple of concepts in education today. The first is the S-A-M-R or SAMR model, this is kind of a model that's come into fashion recently, pretty recently, and it stands for: S which is substitution, A which is augmentation, M which is modification, and R which is redefinition. It's basically a framework that's used to discuss how we implement technology for education and the different ways that technological advances can cause sort of paradigm shifts in education through substitution, augmentation, modification, or redefinition. We'll get into that more when we have our conversation with the doctors. There's also the VARK model, V-A-R-K, which basically stands for visual, auditory, reading, writing, and kinesthetic. And that's the idea of learning styles, which is that different people have different preferred ways they like content delivered to them to help them learn. So a reader might prefer to read something and take notes, or as a visual person might prefer to look at like flowcharts and visual displays.

Brandon: And I remember taking that test, I think they had us all take that the beginning of the year, right?

Karl: Yes, yes, yes.

Brandon: And it helped for like two weeks, and I went right back to doing what I was doing before. I think it's kind of interesting, what they're gonna have to say about these models.

Karl: Well, the important thing about something like VARK, and I think we do get into this in this podcast, is that it's what works for you, right. And so it's all about customizing your education, and if you had already had what worked for you, then that's great. We also do get in a few other discussions about some things, like there's vocabulary like Bloom's taxonomy that's mentioned, which is basically just a taxonomy describing hierarchies of different levels of thoughts. So you guys have heard this, like synthesis versus just straight-up rote repetition and memorization, right. So that's just talking about levels of knowledge, not very important to know but for those of you who are curious, that's what that is.

Erik: Yeah well so, and it should...it's worth noting at this point that we're gonna actually be splitting this episode into two parts because we had such a long conversation with them and we think everything that we talked about is important for people to at least hear and mull over because it is very topical. And so we'll go in, and we'll have about a 30-minute discussion with them but please do tune in for the second part, which will be coming out shortly after. So to introduce our faculty that we'll be talking with, Dr. Anoop Agrawal received his BA from the University of Missouri in Kansas City, his MD from the University of Missouri in Kansas City, and completed his internship and residency here at Baylor College of Medicine, and is now currently the program director of the internal medicine and pediatrics residency program. Dr. Tyson Pillow, which is the other faculty member we'll be speaking to today, actually spent a lot of time here in Houston. He got his bachelor's degree originally at Rice University, and then he went and studied medicine right here at Baylor College of Medicine. He did his residency up in the University of Chicago in emergency medicine, and he came back here, and he is actually now our program director for our new emergency medicine department, as well as having roles as an associate professor and the director of a new simulation and standardized patient program. So we're very excited to get to talk to both of them, it's a fascinating conversation. We hope you guys enjoy it.

Karl: All right. Dr. Pillow, Dr. Agrawal, thanks for joining us. Just to start off, I thought we'd ask you to tell us a little bit about yourselves. So what's your background, what's your medical practice look like day to day.

Dr. Agrawal: Well, day to day here at Baylor College of Medicine, I am a program director for the residency program known as the combined Internal Medicine and Pediatrics residency program. And my medical practice, it's mainly in an academic and educational setting. So I am predominantly supervising resident learners, as well as student learners, and I do that both in the inpatient setting as well as the outpatient setting. You might encounter me over at Ben Taub on the inpatient wards, or in the outpatient setting also in the Harris Health System over at the MLK clinic.

Dr. Pillow: Tyson Pillow. Was actually a Baylor student here, went away to do residency. Came back. So currently also a program director for emergency medicine—actually helped start the program starting in 2010 here at Baylor. I'm also a vice-chair for education for our department, pretty busy, and very similar my practice is almost exclusively at Ben Taub. And so hanging out in the ER, seeing patients, teaching, etc. And then do a lot of work with other partners too, with resident education, but also faculty development, faculty education, etc.

Erik: So well, and as people listening to this will be well aware, today's topic is technology and medical education. We were just wondering what drew each of you to this?

Dr. Pillow: I think for me I've always been really enamored by the why of the things we do. So with medical education, there's so much to learn and do, and what you'll see is that early on maybe as a survival technique or otherwise, we find practitioners who we think practice excellent medical care and we do what they did, right. But there's still that layer missing that you want people to attain as their training, which is the why. Why are we choosing this treatment over that, why are we treating this patient a little bit differently than that patient based on their presentation? And that's what really kind of creates a lifelong learner and someone who understands what they're practicing rather than practicing the same way for the next 20 years as they did the last day of residency. And so when you look at tech, it really is a tool to get at the why, right. There was a time where we would use transparencies, and we moved to PowerPoint, and in some ways, the transparencies were a little bit superior because if someone asked a question that was off the planned didactic for the day, the lecturer could just write on the transparency to answer the question. So there's some freedom of movement. Most of our tools are great and as far as electronic tools, able to teach, reach a lot of people, but more recently we're seeing a lot of great tech that allows us to get outside of the standard linear teaching and go off-script, answer whatever questions may come up, think of things differently, and I think that gets to the why much more actively than we have been able to do in the past.

Erik: Well and by transparencies, so you're talking about overheads?

Dr. Pillow: Overheads right, yes, yes.

Erik: I remember that in elementary school and a little bit in high school.

Dr. Agrawal: Yeah you know for me, I'm not as poetic as Dr. Pillow in how I came to this, for me I was really, I'm a gamer, and I'm an Apple fanboy. So I just got to put that out there on front, I've never owned a PC in all my days, my first computer my father brought home was a Macintosh back in 1985 and never looked back. So for me, it was interesting that the two fields of technology and medical education were always separate, they never really converged and it wasn't until I think some time around when the iPad came to being that the two started to cross paths. And then all the potentials, just as Dr. pillow kind of alluded to, started to kind of go...epiphanies started happening. Aha, we can actually do this more efficiently, do it more engagingly, and make it more exciting. I will also admit, I'm also a former owner of a Palm Pilot. So if you guys remember those things so looking back and asking this question it makes me realize, I've always kind of dabbled in technology, as a toy, as a tool to try to make whatever I'm doing more exciting and fun. I remember us trying back in residency, 1998, trying to do our little H&Ps on our Palm Pilot, and people had created software back then and see how well that's done.

Erik: Wow, well I guess coming on that and you touched on this, but what would you say some of the core technologies that are innovating a change in medical education, especially that you guys are interested in, are?

Dr. Agrawal: I'll start off by saying what I'm seeing is, it's the whole movement to the cloud. I think that's really driving the ability to do asynchronous learning tenfold, and this may sound a bit controversial to say that, do you really need to go to med school for the first two years? And receive the training that we are currently providing. I think that's the gauntlet that we need to throw down, and what's the value that classroom education, or attending an institution education brings that you cannot get on YouTube, or Khan Academy, or someone else's podcast where they created some rich content, that's asynchronous and can drive and meet your needs. Rather than repeating reciting content that you already know well, and you're bored, and the content that's being discussed at the lecture is something you already mastered.

Dr. Pillow: I might piggyback on that specifically first and say that, so I agree with the gauntlet, the challenge that has to go out. I would even say that the answer to this challenge of when you look at LCME, ACGME, all the things we're changing, realizing the importance of wellness, of professionalism, of communication, breaking bad news, informed consent, empathy, etc. We are trying to cram all of this in the same four years of education, and so one of my potential answers to your...to the challenge is yes, we still need four years, but they need to look different, right. We should not come to class necessarily all the time to just get content. We shouldn't consider a PowerPoint that's delivered with facts to be, I have taught you this content. And I think the other thing too is really driving competency-based education as well, and so how are we going to challenge the status quo to not only say yes, you have seen and/or heard this content, but you can apply it. Because I guarantee your patience will appreciate when you can problem-solve actively with their issue and their complaint, rather than just recite something you've memorized from a course.

Erik: Pilocarpine.

Dr. Agrawal: One thing I see what Dr. Pillow is referring to is, I think the ability to do more direct observation. And I feel like we're right...we're almost there. Where I can taste that we're on the cusp of having the second area of core technologies, which is mobile tech and things like maybe Google glass 2.0. Things that you can actually take anywhere with you and do those exotic things of a direct observation where I can maybe directly observe you doing an H&P from my living room couch. And you're wearing the glasses in the hospital, and I'm watching you, and therefore limiting those constraints that we all come against as educators, which is time and ability to be available for them when the learning moments are happening or procedural work, you know in the ER, or wherever you have it. So I think cloud technology, mobile technology, and addressing the competencies, addressing I think direct observation is where I see, I can, again I feel like it's right there.

Dr. Pillow: Yeah, I agree. I think, so I'll add to...going back a little bit to your original question too, and building on what Anoop has talked about. I think the other thing to realize is that where Anoop and I do a lot of work with our other colleague—I'll send a shout out Jared Howell who's with the orthotics and prosthetics program—here what we see is that it's not that there are necessarily quote-unquote new technologies, it's that we have to go back and figure out how to innovate and do better with the technologies that exist, right. And so you get in a place where you realize that many courses, whether it be med school, K through 12—who is actually probably doing better than us from this standpoint—but high school education, college education, whatever it may be, we have these technologies, and we've stopped innovating, we've stopped kind of trying to figure out new ways to incorporate, right. So PowerPoint is outstanding as a tool, I'm a keynote guy but, and I have no vested interest in anybody, so that doesn't make me any money, but PowerPoint, keynote these are Prezi, whatever it may be these are outstanding tools, but you realize the uptake is just incredibly low. And that's where I think Anoop and I see when we go nationally, we've had the pleasure to talk nationally at many meetings, and you just see people, their eyes light up when they think, oh I can use it like that? I can do this instead? I can try that? And so these are actually existing technologies, which have been around for years as well as some of the newer technologies, the VR technologies, augmented reality, etc., right. I just...my son's just old enough to do Pokémon Go, right. So I am running around, making sure I'm not driving, and I realize we're behind the curve, but he loves it. So I'm running around catching Pokémon, and so you see Pokémon on top of your natural environment with the camera, I mean there...there've got to be applications to these things. So not even just the newer technologies and what we do with them, but actually, existing technologies and how do we leverage them better to again ask these why questions, and get to understanding an application rather than memorization.

Erik: Yeah, that's a good point.

Karl: So, what do you think is really interesting that's happening here at Baylor with education technology that you'd like to showcase? And then kind of as a follow-up to that we've been hearing about this SAMR model, I'm wondering if you could talk a bit about that?

Dr. Pillow: Yes, so we're doing a lot of great stuff at Baylor, there are many different people involved in the education technology push at Baylor, so forgive me if I leave names out. But for example, I know that Jim Walker, who's the nurse anesthetic program director, he has been using online courses for his trainees for a very long time. I mentioned Jared Howell, who actually has completely digitized his entire curriculum years ago and talks about that nationally. Anoop and I, along with Jared, we've been to several conferences, several institutions talking about different ideas of ways to do it—whether it be bedside or larger large group presentations, these sort of things. And I think that what you're seeing is a realization of how we leverage these tools. So, for example, we've had blackboard for a very, very long time at Baylor. Recently I've had the opportunity, great opportunity to work with our pharmacology course and the great instructors there, and we actually leveraged the discussion board, even just a simple tool as a discussion board of learning management system, and it got such great feedback that they've ...students actually have actually asked that discussion board be used more regularly across other courses to centralize questions, have a central area of answers, and expectations, etc. So again, I think a lot of it is not just innovating, which we're definitely doing at Baylor College of Medicine, but also just looking at the tools that are in front of us and leveraging them a bit more actively.

Dr. Agrawal: And you know you brought S-A-M-R, which is an acronym for a something known as we call SAMR. It's something that I actually first stumbled across back I want to say in 2013-14, and it's something that was actually developed by an educational professor in somewhere in the Northeast, I think maybe somewhere in Boston or Cambridge, by the name of dr. Ruben Puentedera. And what it was it's kind of answering what Dr. Pillow raised earlier. It created a framework for people to understand how to use these tools we're talking about. So before, as we said, people have these tools in front of them, like PowerPoint being a basic example, but they're not necessarily using it effectively in driving educational outcomes and learning. And so SAMR is an acronym that stands for: Substitution, augmentation, modification, and redefinition. And these are looking at how you can use technology to achieve the outcome you want based on the level and how it looks when you apply it. And surprisingly, as we alluded to already, those of us in undergraduate medical education, as well as Graduate Medical Education, are...we're surprised how far we are getting behind when it comes to the K through 12 and even college level, kind of evolutions that are happening in education. And SAMR, you find this concept very prominent in those other areas, and it's something that's still relatively new when you talk about those who are medical educators in terms of how they can use technology and integrate it into how they teach.

Karl: Okay, so yeah I think if I recall from my research on this we kind of talked about, it's in levels right? So, substitution might be considered like the most basic level of technology implementation, where basically using technology—like the example using PowerPoint instead of overheads—it's just doing something a previous technology did maybe a little bit more efficiently right?

Dr. Agrawal: Yeah.

Karl: Whereas if you go up to like modification, could you think of an example for something like that?

Dr. Agrawal: Yeah, a classic example, it's become now. I'm doing happy to see is becoming more ubiquitous is the flipped classroom.

Karl: Okay, okay.

Dr. Agrawal: Yeah, so same thing, right? You're using PowerPoint.

Karl: So flipped classroom, meaning it's a classroom where students would look at the PowerPoint and do readings beforehand.

Dr. Agrawal: Exactly.

Karl: And then they come in and do a problem-solving session or something?

Dr. Agrawal: Exactly, then when they are in the classroom, they're doing team-based learning. And you have cases that drive learning and students can kind of address their weak points rather than the lecturer just reciting the parent slides that are on the PowerPoint, which they could do at home. So example of taking asynchronous learning and also piggybacking on to a team-based learning, and that's again...you're using the same tool, we're still using the same technological tool to deliver the content, which is PowerPoint.

Karl: Yeah, yeah, but you're just kind of pushing the students to utilize it was in a different way. Could you think of like an example of redefinition or modification and something that you'd like to see implemented here in our classes?

Dr. Pillow: Well one way I've seen it done—and we've actually been successful in doing—is actually creating mind maps actively on shared spaces like by board, not to specifically advocate for one product or another, but that's one we use commonly. Whiteboard apps, Google sheets, Google Documents, where lots of groups...lots of different people even separated in in space, so we could be in different parts of the country, even the world, and work in the same space at the same time. And so that's redefinition because beforehand everything had to happen in the classroom at the same time with the same sort of proximity, now you can actually look at problems from different perspectives and bring even up to hundreds of people in the same space at one time to put their ideas together and create something new. So that's my example of redefinition.

Karl: Very cool, very cool. We've also, here Baylor, had a lot of talk about the VARK model for education. It's a model that has some debate going on in academic literature on education, so the literature in education. I was wondering what your guys' perspective on that was if you had any thoughts?

Dr. Agrawal: Yeah, so I'm, I think between the two of us I'm I think it's clear I'm more the VARKer, which I don't know if everyone that's listening to this understands...it's a concept of learning styles. Is there such a thing where you versus me have different learning styles where...it's an acronym again. V standing for visual, A auditory, R read/write, and K is kinesthetics. So it's implying that I can take this little questionnaire, it'll help me learn about myself. Am I a person who prefers to learn by visual, versus audio, versus read/write, and kinesthetic. And what you're alluding to, and which is very true, that there has been no study— double-blinded, placebo-controlled, etc. studies—showing that this...knowing your VARK style has resulted in better educational outcomes. And it kind of gets the heart of the question of what is learning...what does it mean to learn something and how do you demonstrate it. On the flip side where I come in as a kind of a pro still of VARKer is the idea of understanding that it also hasn't shown any harm. Because you have learned this about yourself, it...none of studies show that because you may try to approach something this way you have worse outcomes. So if anything it's neutral. And as we get into the further the conversation what I've seen is when I do try to create content that incorporates these different modalities, I tend to see greater engagement and...what we do know from literature is when you have greater engagement with the audience and the learner, there is a better outcome. And so tangentially I think it's worth trying to keep VARK in mind when you developed your tools.

Karl: So your kind of saying is like if I'm a visual learner, I might like to see visuals more. If you give me a book and say read the chapter and write a summary of it, maybe I could learn just as well doing that but am I going to engage with that as well and actually do it? As opposed to if you give me like, construct a flowchart or something more visual.

Dr. Agrawal: Right, and unfortunately the science or the at least the studies shown that given two people...give them the two different modalities and there's no difference in how they end up actually performing—in their abilities.

Karl: Right, so you think engagement might be better?

Dr. Agrawal: Yeah, and that's a really hard thing to put your thumb on, and I'm sure these things are hard things to actually study and measure and get definitive answers for. And that's where the creator of this, Neil Fleming, I think he's an Australian back in the ‘90s is when he developed this concept of VARK. That's how he defends it is...he says well, there's also no evidence against it in terms of again showing bad outcomes, and no one's really done a true double control placebo trial type thing. It's really hard to put your finger on.

Dr. Pillow: I think there's something in there, I'm definitely not a hardcore VARKer as It were, but I absolutely think there's something to the fact of, if we create things that are multimodal and engaged learners we will win, right. And what...I've had the privilege of taking a course on teaching online through Quality Matters recently that was a sponsored by the institution, so thank you very much, Baylor. But one of the things we get in that is, that you know when you look at a lot of these theories right, pedagogy versus andragogy, early learners versus later learners, dependent learners versus independent learners, etc. You realize that it's not just a one-size-fits-all for any one person; it varies by topic, right. If you were to put a medical topic in front of Dr. Agrawal and I we would be advanced learner's/teachers, right. If you put a recipe in front of me or I think Dr. Agrawal is an avid baker so that may not apply.

Dr. Agrawal: You'll have to ask my wife, I think she would differ.

Dr. Pillow: But in different areas, you end up being at different levels and need different things, and so I definitely agree there's preference—I have a preference with how I like to learn—but that depends on what I'm learning, when I'm learning it, where I met when I start, etc.

Dr. Agrawal: Yeah, it's kind of like Susie. If Susie says, you know I prefer to study in the morning, when it's quiet, at the library, that's a learning style. And does that work for me or you and so there's something...there's more to it. We can't...it's hard to-

Dr. Pillow: Exactly, and versus, no not versus but in conjunction with many of the theories that social learning is very social and you know medical is a perfect example of that there are parts there are times in med school where you got to go away, and you got to memorize the building blocks. And then there are other aspects of med school where you got to come in, and you gotta learn to work as a team, you gotta learn to manage a patient with other thoughts, consider things actively, so absolutely.

Erik: So just to summarize that it seems like the key thing that VARK is trying to get at is maximizing the individual's engagement with the material. Is that what VARK is kind of trying to get at? Is like how do you maximize your concentration on a subject?

Dr. Agrawal: I would agree with that. I'll present it in a whole different way. If we don't really care about VARK, then we really are wasting our time creating different multi modes of content. Why are we wasting our time? Just...here's a book. It's in...there's words in there. Just go at it, go at it read this book and you'll be fine.

Erik: Correct me if I'm wrong, but is that not how your medical education was?

Dr. Agrawal: Yes, that's correct, and look what I got, look where it got us.

Erik: Yeah, you guys are doing alright.

Dr. Pillow: We're doing alright, it's OK, we made it through.

Dr. Agrawal: But are there others who failed because maybe the content wasn't available? That's a hard question to answer.

Erik: Yeah, okay. We know as we've talked previously that you both, like you said before, have presented at national conferences conducting a three-hour mini-course at the Accreditation Council of Graduate Medical Education. Would you be able to tell us a little bit more about that?

Dr. Pillow: Yeah, that's actually pretty exciting. I think one of the things that has been great while we're doing this work, you know because we're both young in our careers. I guess technically speaking we can't call ourselves during your faculty anymore, we lost that that designation, but I wouldn't go senior faculty yet. We've come up with these ideas, we've had these experiences, and we go share them, and the response has been outstanding. You have the thing to realize at the end of the day is that everybody wants to do an excellent job and is looking for ways to do better. And sometimes excellent educators, like anything else, they may get stuck in their thinking or not know about new things coming out, etc. And so we've had the opportunity to go, we've actually presented at the ACGME meeting in 2018 and 2019 on this topic. I had a chance to do we did the AAMC a few years ago as well on similar topics, and I had a chance to do ACGME meeting back in 2013 I think. But even from this last year, so in 2018, it was great. We had a great conference. We actually got asked to do a webinar on educational technology, we did. And then got reaccepted in 2019 to kind of build on what we've done and we absolutely have plans to...the deadlines actually coming up, we're going to present it at the ACGME in 2020, fingers crossed, as well to continue this. And the uptake is, it's just outstanding. People want to do the best job possible for education, they like the innovation, and the...one of the things you'll see is that people have also had the realization—I think it's Eric Mercer who talked about this a lot—is that he was someone, I believe he's a college professor who was winning awards left and right, and then and realized that his students weren't actually learning the material. Right, they're passing the test, he was winning teaching awards, and so he went back and kind of redesigned his curriculum and actually makes the statement—there's some YouTube videos, there's some materials online—but makes the statement, he stopped winning awards but then the students started learning, right. So really going back to just the fundamentals of how we create content, deliver it, the expectations we put on students, application of that content, and we've just got nothing but excitement across the board as we do this.

Erik: So you focus...that's what your focus is? Is the presentation, or..?

Dr. Agrawal: No, it's a three-hour workshop, and that's I think what adds to the that's why people leave super excited, is we present them tools, and these tools are low-hanging fruit for how they can just literally walk out that door and start using them right away. And I think that's where...that's where when we get back to why technology and medical education is such a nice intersection, what's changing is all of the tools and things that these content products that you would create, normally you would have to, maybe ten years ago, you'd have to hire somebody. You'd have to hire a designer, a technologist to actually build for you. Now, these tools have become so simplistic and yet so powerful that anybody, you have to have very little you have to know how to turn on a computer on, and maybe you have to invest in a tablet, and that's it. And you've got everything in your control to create. And an example that we brought up earlier was, for example, on the iPads and tablets, there are apps that are whiteboard apps. So it's just like you have whiteboard, but you know the ability to draw and do so much more. Not just can you draw; you can actually I can have a former PowerPoint that I normally would just live in my desktop and never see the light of day except once a year when we give that lecture. Now, something comes up in the clinical arena, whether inpatient or outpatient, I have that PowerPoint with that slide that I want to share with you the Kaplan-Meier curve, or whatever, right there at my fingertips. I can pull it up on that whiteboard app, annotate, use it to teach and so when people see that in these workshops and get exposed to...you know they're like Dr. Pillow said, there they're excellent educators. They're looking for that new edge that can give them that new wrinkle of, yeah I was teaching that, but I was getting...it was getting old, it was just...it was it was tiresome. Now they leave with a little more fire, a little more excited to go out and say, you know that's really cool, I can add that new wrinkle to my tool deck.

Erik: As you say that it makes me think like when we touched on this before but...how you guys kind of came upon this. Did you come upon this yourself like to learn how to use a whiteboard? Like how did you guys decide, like hey, this is actually a great tool? And so you know Dr. Agrawal: Yeah for me it's a very clear, I have clear dots that connect, that I connected and it was...there was a professor at Baylor College of Medicine back in the late 90s. He would win all the teaching awards. And one of things that he did that was so unique. He walked around with a whiteboard that was about-

Dr. Pillow: Dan Hunt.

Dr. Agrawal: Dan Hunt, yeah professor Dan Hunt back in the early 90s, the late 90s, would walk around on medicine wards with a whiteboard that was about four by 6 feet. Not small. Not one you can put in your pocket and you can hide and like, I don't have a whiteboard. No it's right there, you cannot avoid it, and you always saw his team in the hallway gathered around that thing propped up on the ledge, and he had figured out back in the 90s what stimulated individuals, got them to learn. And again, for him naturally, those teaching awards followed. And so I was too shy and insecure myself to mimic that, and I haven't seen anyone else do the same in terms of that size whiteboard. I've seen folks walk around with a kind of a normal 8 and 1/2 by 11 type. But then around when the iPad came out in 2009 or 10, whenever, it was...that's when something clicked. I don't know what that...how that epiphany happened, but I say hey, I got curious that on this device, could there be something similar that is a whiteboard app. And I will tell you it was not really there in 2010/11. It took a few years of hunting. I used some things that were kind of close but not quite, and in really around 2013 developers started you know creating some really exciting applications.

Dr. Pillow: Yeah, I think for me I've had the, I was a paramedic in college, and I actually didn't stop my education. So there were two semesters where I took over 20 hours of coursework across two colleges, as well as ambulance rides and everything else so, that was fun. It was actually fun. I really enjoyed it, so something's wrong with me, I know. But the, so I learned the basic rote memorization necessary to you know be a paramedic for me at the time. I'm not saying that's all paramedicine training, but at the level, I was doing it that's where I was. And so when I got to med school, I realized I kind of know enough of the basics to know I don't want to just know facts and started to kind of dive deeper. And then, as I started to do this more and more I also realized that I had a real love for presentation design, and a lot of my early work as far as presentations and conferences was on doing presentation design better in a way that facilitated education. And there are actually two nice articles by Dr. Issa et al. I-S-S-A, that actually look at modified slide design and how it enhances education, looked at in the surgery clerkship context. And so as I was doing that, I realized that the core of presentation design is not only great design, but also limiting the message, kind of streamlining what you're saying, and then also creating flexibility in the presentation. And so then that naturally led me to say, how is there some way to have active flexibility in the presentations rather than planning it, right. You can plan for an arrow to come into a PowerPoint presentation at any point in time. It's really hard to plan when the students gonna ask, or another learner is going to ask a question that's three slides down or two slides back. And so that's when I started to find those same sorts of tools that allows you to really just minimize the slides you use and maximize the active learning aspects of things and the engagement. So that's where that piece came from as well, and the last part is that really love curriculum design, and I will give a shout out to our faculty development group here as well that do an excellent job of kind of making sure that core piece is there too. And so I realized how important that was because at the end of the day the tech is just the tool. I think where people make the mistake is they grab a piece of tech, and they say I want to use my iPhone. They don't know what they're gonna teach; they don't know what's going to...they just decide they're gonna use your iPhone. That's not how it works, what you figure out is how are you going to deliver this content, what ways you want to get it across, and then ways tech can actually get there better, more efficiently, more actively. And I love that idea. So I think as that built on itself, I just became enamored with this idea of using tech to just do what we're doing better.

Erik: Well and I'm curious do you guys try to give...like tell that story at all? About how you came upon this? Because I mean we all know teach a man to fish...he'll, you know. It's like if you instill those skills of like actually trying to think about how to innovate as you go. I'm just curious.

Dr. Agrawal: That is a core, core piece. That's what we start with. Because these are educators that we're talking to. So they need to hear that buy-in of just that. We're not just, and it gives us more validity in what we're trying to share. We're not, because one thing we do emphasize is we're in 2019, and these are the current tools we have. So we can walk out of that workshop and the next thing you know Google drops a new device and everything we've just discussed, and the tools we've shared are now antiquated and no longer applicable to what we want to do. So we're trying to teach concepts and frameworks, hence why SAMR, VARK, these are frameworks of how to package the technology into things like Kern's model of Education and in Bloom's taxonomy, which are core pedagogy principles. So that people when they encounter on their own they'll discover a new technological tool, they can take that tool and put it into action in a way that's effective and creates and promotes active learning.

Dr. Pillow: Yeah, we actually have slides to that effect in the presentation, talking about it's just a tool; it's going to change. We make references to Google glass and those sort of things as success...some success stories, some failures around that area. But again, really just echoing what Anoop said, really making sure they leave with the idea of, and that's where also the cloud technology is so critical to...because if there's any piece of tech that isn't going anywhere in a while you know and can be used as an anchor for most, almost every major tool one can use has a functionality to connect to the cloud, right. So how do you create content that lives in an accessible protected, HIPAA protected, encrypted safe but accessible way, and then utilize that across platforms where that platform is currently available or doesn't even exist yet.

Karl: Hmm, fascinating.

Erik: Very interesting.

Brandon: All right, that is it for now. We would like to thank everyone out there who took the time to listen to this episode of the podcast. Special thanks to Karl Lundin for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together. Thank you to the Baylor communications department for helping us with the production and website. And thank you again to Drs. Pillow and Agrawal for taking the time to be interviewed with us. We hope everyone enjoyed it and hope you tune again soon. Goodbye for now.

iTunes | Google Play | Spotify | Stitcher | Length: 39:17 | Published: Sept. 25, 2019

Dr. Michelle Ludwig describes her journey through school and to her current career as an oncologist. She discusses her research interests and what it's been like to learn and practice as a person who is deaf.

Transcript

Erik: And we’re here

Brandon: We are here.

Erik: This is the Baylor College of Medicine Resonance podcast. I am one of your hosts Erik Anderson.

Brandon: I'm another host Brandon Garcia.

Erin: And I'm the writer for this episode, Erin Yang.

Erik: Yeah so today we're gonna be talking with Dr. Michelle Ludwig about her work as a radiation oncologist, and all that goes into that, and some of the research that she's done. And, yeah, Erin if you want to take it away.

Erin: So, radiation oncology - pretty crazy and interesting and complex field. I think they have to work very closely with I guess the two other kind of branches of oncology which is medical oncology and surgical oncology, so I think they have to do a lot of interdisciplinary work but at the same time they have to be super specialized in their field

Erik: Yeah, and one thing that Dr. Ludwig talks about you know today you hear a lot about how medicine is becoming more and more team based. I mean it's always been team-based, but it's not so much now you have the doctor that sort of dictates everything. It's more spread out and yeah, a little bit more egalitarian. And I think this has been especially true for the oncology field for a long time, as she talks about. Because like you said, you have the medical oncologist, a surgical oncologist, a radiation oncologist; and then she specifically talks about with her work at the Smith clinic, which is a safety net hospital for you know lower-income patients. There's a lot of counselors that are needed and so you know there's a lot of other people of the medical team that don't normally get talked about but are an integral part. And she talks a little bit about that, and it really is a team-based thing so and I think she does a good job of explaining that.

Erin: Yeah there's psychologists, there's genetic counselors, there’s social workers so definitely a lot of people involved. I think she, you know, she also mentions that she did her a lot of her training at MD Anderson and I'm sure all of our listeners know that MD Anderson is like the number one place for cancer treatment in the U.S., probably in the world there's all sorts of crazy things going on at MD Anderson I think the fact that we are here and we get to I know do some rotations there and learn from the faculty there - I think it's just amazing. I'm very humbled by it every day.

Erik: Definitely, and she'll talk a little bit about her story of how she got into oncology; she also has an interesting story in that she did a Masters and a PhD sort of in an untraditional way, which is I think always good for people to hear especially because you know, we are all taught that we need to have everything figured out at you know whichever stage, but things have a way of working itself out. It was a really good interview.

Erin: Yeah Dr. Ludwig did her medical degree at Emory and I think she mentions that she took a year off or took a break in the middle to pursue her MPH just because she found such a calling to understand epidemiology and how to use statistics and big data especially in cancer. And after that she started her residency down in Texas at MD Anderson and then surprisingly started to pursue a Ph.D. in the middle of her residency which is just mind-boggling to me. I don't understand how anyone can do that, but she finished up her Ph.D. here and then stayed here at Baylor and is now an assistant professor and an adjunct assistant professor of epidemiology at UT School of Public Health. So, she's definitely got her hands full.

Brandon: She sounds like she's one of those people that shows how when you find a direction in life doing whatever you take to get the education you need to do what you want to do.

Erin: Oh yeah.

Brandon: So, I'm excited to hear what she has to say about that.

Erin: Yeah, I'm excited to hear too.

Erik: Alright, and here's our interview with Dr. Ludwig

Erin: So, we are here today with Dr. Ludwig, who's gonna tell us a little bit about her life and her research and what her daily duties as a physician scientist looks like. So, Dr. Ludwig do you mind sharing a little bit about your path through medicine and did you ever get tired of being in school?

Dr. Ludwig: I think I would say in school as long as I could. Now I've really enjoyed my studies. I think I decided I wanted to go into medicine when I was three. My grandfather was a physician - he was an immigrant from Italy and worked his way and went through medical school and so I kind of grew up thinking that that's what I would do. But because of my hearing impairment I was not sure that I would get accepted into medical school. So in undergrad I majored in pharmacy, which at that time you could do a BS, a bachelor's in pharmacy, and I figured well, if I didn't get into medical school then I could work as a pharmacist or maybe work while I was trying to get into medical school. But then I got in and then I took a year off after my third year of medical school to get an MPH, which was fascinating. It's a whole different way of thinking about a population instead of an individual and trying to solve problems that affect six million people instead of the six people you see in that day in that clinic. And then during residency, I started my PhD coursework in epidemiology kind of looking at the same thing, so it's kind of a nice balance between - I'm seeing the individual and then trying to solve problems on a wider scale.

Erin: I'm just curious - I think it's pretty rare to hear anybody starting a PhD during their residency. It seems like a pretty busy time - how did you manage to do that?

Dr. Ludwig: well my residency was fortunate to have a year of research, dedicated research time, so during that research time I did my Ph.D. coursework and then finished my defense after I became faculty which was, that was challenging, but it was, it was good. It kept me engaged and it's kind of nice to take a break, take a step back from clinic, and have successes in other fields.

Erik: Well, so can you share a little bit about your experience of becoming deaf at a young age?

Dr. Ludwig: So, I lost my hearing when I was two. I had pneumococcal meningitis and it was a fortunate time for me to lose my hearing because I was already speaking. I'm profoundly deaf now and when people talk the only thing I hear are the deeper tones, which are the vowel sounds, so I have to kind of interpolate in between the vowel sounds. So, it's kind of like doing a crossword puzzle and thus I can lip read. But having lost my hearing at that young of an age, your brain is plastic enough that you can learn how to do those things like lip-reading and figuring out words that people are saying without really having to be formally taught just like learning a second language. And in addition to losing my hearing I also lost my vestibular system, so I had to learn how to walk again and how to learn how to walk without a vestibular system. You can do it - you just have to use your eyes a lot more than the average person would. So, I’m very fortunate that it wasn't you know six months or a year earlier, or much later in life because I think it's harder to adapt.

Erik: Well and you began to talk a little bit about this, but can you share how this impacted your life as a student and then also as a physician?

Dr. Ludwig: I was very fortunate. In college I went to the office of disability services and said, you know, what can you do? I figured maybe I could have a note taker or something because if you think about it, looking down on your paper to write - if you have to lip read then you miss the next thing that somebody says. So, they have a program called court reporting - computer activated real-time - and it's kind of like a court stenographer where they take notes real-time to what the professor is saying, and it pops up on your laptop. So, I could literally read word for word what they were saying. And in the beginning the stenographer had to come to class with me but then as technology became more advanced - remember the internet was basically just invented when I was in high school. But now when they do that, they just log in remotely as long as the room is wired for sound, and then I click a button and a screen pops up on my computer and it's a real time transcription of what's being said. And it's pretty accurate. It's the same people that do medical dictation. And so I use that now when I have a conference call, and it's not perfect and I don't know who said what, which can sometimes be difficult for a conference call, but it really, I don't think I would have made it through med school without having that available. The most tricky part during medical school in addition to that was my surgery rotation, because with the mask it's hard to lip read. They've actually just invented a clear plastic mask for use in the OR, and I just placed my order today. So, after all these years I’m really looking forward to when I go to the OR to giving out everybody the plastic masks and for the first time actually being able to understand what's being said.

Erik: That’s amazing. It's also amazing it took this long to make one.

Dr. Ludwig: Well, there’s not that much of a demand. I mean, if you think about it, you know, the people that would want it. Although I think it would be helpful for kids like in a pediatric hospital, because I would imagine it would be scary for a child to see the anesthesiologist all covered up. So, I think there might be a little demand there, but for the most part the demand would be hearing impaired physicians that lip read, and I don't think there's a huge number

Erin: So, you mentioned you're still going to the OR, you’re still doing research, you're doing all this stuff. How did you get involved in like medical school curriculum, and how did you manage to find time? Because we had the privilege of working with you through our PRN, which is the Peer Resource Network, through our first year curriculum and we really enjoyed that. So, I was wondering how you managed to find time to work with us MS1s.

Dr. Ludwig: I think you kind of make time for the things that are important to you. In my field I'm able to limit my clinic to two days a week and then maybe one or two mornings a week in the OR. It's just because the way my field is structured. And I really like having that balance between clinic and research and teaching. I think as an oncologist it can be kind of a depressing job sometimes. We have some days where it seems like every patient that come to see me has a terrible story. And doing research and teaching, if you work on that, you know, can kind of I think keep you from getting burnt out.

Erik: Well, as a student advisor how has your own journey as an oncologist and just your own experiences impacted your advising?

Dr. Ludwig: I think as an oncologist I have a chance to talk to my patients a lot about quality of life. Things like work/life balance. There's a kind of a standard phrase that I tell my all of my patients that are metastatic, that at this point in your life the way that you beat cancer is by not letting the cancer keep you from being who you are. And I think I kind of take those things to heart and encourage my students to think about their life outside of medicine. Think about their relationships outside of medicine and make sure they cultivate those and make sure they take time, maybe not every day, but every week to make sure that they're well rounded person so that they have something to give back to their patients.

Erik: Yeah, it's hard. Yeah, only just finished the first year but it's like just making time for all that stuff and spending ten plus hours a day sometimes studying.

Erin: Yeah it seems to only get worse from here. Seems like you just have less time the older you get, I guess. So, I was curious - we had heard that you have a hearing dog who helps you out I guess sometimes in the clinic. Can you tell us a little bit more about that?

Dr. Ludwig: I do. Her name is Marguerite and she turns 14 next week. So sadly, she has actually starting to lose some of her hearing. She is from an organization called Canine Companions for Independence. And what she does - she's a Lab/Golden cross so half Lab half Golden. When my doorbell rings, when my pager goes off, when my phone rings, she comes and taps me on the leg, and I say “what” and she takes me to it to the sound. That could be an oven timer or doorbell, and now a baby cry. And she's actually very helpful because before that I would have to, if I was on call I didn't sleep very well, cause I was afraid I'd missed my page, or if somebody knocked on my door when I was at home before I got married, that I would miss them coming over. And if you’re waiting for a package that you have to sign for, just all these other things. When we're driving if there's a siren that comes, she’ll pop her head up and look at the siren so I can tell where it's coming from. Sometimes I can hear it, but I don't know where coming from and where I need to go so, she’s actually very helpful. And she’s semi-retired now. Just because she’s 14 it’s hard for her to come to work with me but she used to come to clinic with me. And if I had to have a family conference, basically where I sat down and have a goals of care discussion with a patient, I would ask them ahead of time if they wanted to bring their kids and if they would like my dog to be there for that. So, she's come and kind of helped out with a lot of difficult discussions, and she's been good for the kids if they have kids to give them something to focus on.

Erik: How long have you had her - how long has she worked with you?

Dr. Ludwig: So, she's been with me since she was 2 – a long time – they’re raised until they're 18 months by a volunteer puppy raiser. And then at 18 months they're sent to have a basically a personality test to see, should they be a guide dog - which is the former term for a seeing-eye dog - or a wheelchair dog for kids or adults in wheelchairs, or what’s called a facility dog. Sometimes they work in a court room for like if a kid has to testify about a violent crime, or a bomb dog. So, they give them a personality test and then depending on what they're, what they show, then they go into that training for six months and at the end of the training period they have a what they call a team training, which is a match process. So, I went to Santa Rosa, California, which is where they do the hearing service dogs for the program. And the first day I worked with eight dogs. It's kind of like The Bachelor/Bachelorette. And the second day their trainer cut the list down to four and then the third day two, and the last day was like the rose ceremony where they match you with a dog. And the dogs usually end up picking the people. The trainer watched and most of the dogs turned around in the kennel and took a nap when I was working with the other dogs, but Marguerite was watching me work with all the other dogs. And the trainer said, she's trying to learn what the sequence of the commands is gonna be so when it’s her turn she can impress you. One of the neat things that she does since I don't have a vestibular system is, we can go stand-up paddle boarding and she balances the paddleboard for me. She lays on the front and she wasn't even trying to do that, but she just figured out that I needed help with it.

Erik: That's amazing.

Erin: Yeah, wow and speaking of I guess like bringing her into clinic, like what is a day in the life look like for you? Are you in clinic most of the time, are you doing research? What does maybe a week in the life look like for you?

Dr. Ludwig: Well one of the neat things about my job is every day is different. Two mornings a week I have tumor boards so different specialties - my specialties are gynecologic and breast cancer. So, Monday mornings from 7:00 to 8:00 I have breast tumor board, which is where the medical oncologists, surgical oncologists, radiation oncologists, pathologists, radiologists, get together and they go over difficult cases. And we all discuss, or maybe argue, what the best course of action should be about different patients. And then on Monday the rest of the day, I'm in clinic. I see all the patients that are on treatment once a week just to see how they're doing. Tuesday mornings some mornings I’m in the OR or doing procedures and in the afternoon, I catch up. And Wednesdays I work with the Learning Communities advising and wellness and do tumor board. And Thursdays I see new patients and follow-up patients, and then Friday mornings I'm in the OR. So, my academic time is Wednesday morning, Tuesday afternoons and then Friday afternoons. So I have that time to work on my clinical trials, or meet with people, make phone calls, prepare for clinic.

Erik: Well I have a two-part question actually. I guess the first is what made you, well, can you define radiation oncology and then what made you want to go into that?

Dr. Ludwig: So, radiation oncology is the concept of using therapeutic radiation for mostly for cancer. We can use it to definitively treat cancer so to shrink cancer without having to take out the organ. For example, laryngeal cancer, if you take out the larynx people have less quality of life. So laryngeal cancer, we can actually cure the cancer with radiation. Anal cancer, once again, you know, the surgery can be life-altering. We can actually do radiation to kill the cancer while preserving the organ. In cases like lymphoma we do what’s called consolidated variation where we do radiation after chemo to where the cancer used to be to basically sterilize the area. We often do that for breast cancer, for example after surgery, to sterilize microscopic disease to reduce the risk of local recurrence. This is done with again therapeutic radiation - either external beam radiation with a linear accelerator that makes mega voltage X-rays or what’s called brachytherapy. Brachy from the Greek word meaning short. Brachytherapy is with a radioactive isotope – iridium, cesium – that we place inside the tumor, and it releases, it disintegrates inside the tumor.

Erik: And then what made you get into this field?

Dr. Ludwig: I initially thought I would go into pediatric oncology. I worked for St. Jude Hospital in Memphis for two summers. And I really like the multidisciplinary nature of oncology. We work very closely with surgery, pathology, radiology, child life psychology, and pretty much every case presented was discussed before anybody did anything and I kind of like that approach to patient care. That was when I was in pharmacy school, so I did some time at the onco-pharmacy, and then in medical school I got exposed to radiation oncology, and we’re one of the few oncological specialties that deals with every single cancer. So almost every single cancer in some stage or another, there could be a role for radiation. I liked how comprehensive that was and I liked the procedural aspect of it, to do the brachytherapy, to go to the OR to do short procedures, to think about the anatomy, everything from high-level anatomy to social determinants of health.

Erin: Can you tell us a little bit about I guess your clinical research interest or maybe basic science research interests -- whatever you're working on at the moment?

Dr. Ludwig: I have basically three clinical trials that are going on right now in kind of different areas. One of them is a quality of life study. We are trying to prospectively evaluate what quality of life metrics impact patient compliance, whether it's physical, emotional. So, we're giving our cervical cancer patients a quality of life survey that they fill out at baseline every week during their treatment, and then at follow-up, and then we're going to go back and correlate that with compliance to radiation treatment and chemotherapy. This started because we went back and looked to see if patients that had higher side effects were more likely to miss treatment, which sounds intuitive. But in our population, they actually weren’t. So, we looked at again what patients were missing treatment and our patients that had a history of mental health disorders were, that was the most significant finding that was associated with patients missing treatment. The reason it’s such a big deal is because for definitive radiation, so if I'm trying to cure cancer with radiation, they have to go about 25 to 30 times, and it has to be in a row. And every day that they miss decreases their chance of local control by 1.2 to 2%. So, it’s to our advantage to figure out what we can do to intervene early if we think a patient might be at risk of non-compliance. So that's one kind of a behavioral health project. The other project that I have going on is an investigator-initiated trial using what’s called a PARP-inhibitor with poly ADP-ribose. It works on homologous recombination. It's an oral chemotherapy that was initially developed for BRCA sensitive ovarian cancer. They found out that it didn't just have to be in the BRCA cell line, that our patients had gotten a chemotherapy called Cisplatin, and if they were responsive to that then that oral chemo would work on these patients. So, I'm combining it with radiation for metastatic cervical cancer patients to see if they can take this oral chemo instead of IV chemo with radiation. The IV chemo they have to go, it’s a four-hour infusion. So, thinking that this might improve their quality of life and also because it's targeted therapy, maybe be a little bit less toxic than some of the traditional chemotherapy. We just enrolled our first patient on that trial. It’s taken me about four years to work and develop and write it. My first experience writing a clinical trial. There’s a big learning curve with doing that so I'm very excited to have our first patient. And the third thing I'm working on is developing a topical agent to prevent radiation dermatitis. Radiation dermatitis is basically a sunburn that’s caused by radiation for – this one is for breast cancer or head and neck cancer – because the skin is part of the target, and the skin does get an acute reaction meaning during the radiation they get a pretty intense sunburn. There's no real standard of care for managing that sunburn. Some people use a corticosteroid ointment but the problem with that is that leads to thinning of the tissue with long-term use, and then especially in patients that have diabetes you can get bacterial or fungal overgrowth with long term use. So, we’ve been developing a topical agent for radiation dermatitis and we are working with the FDA on getting what’s called an IND, which means investigational new drug. This drug is currently available in an oral form but we're repurposing it in a topical form. We had to develop a method that a patient could put it on their skin and the agent would take it down to the dermal layer which is where the fibroblasts are. So, we had to work with the formulation of the cream to get it to do that. Once we hear back from the FDA, we’ll be ready for patient studies.

Erik: So is this is the kind of work that you're doing now pretty similar to what you were doing in your PhD or has it changed a lot? And I say this because I'm curious, I'm actually in the MD/PhD program here, so I have a first-hand interest in how much do you have to actually stick to your PhD.

Dr. Ludwig: My Ph.D. was in cancer epidemiology, looking at big data...

Erik: Okay, and was it building off of your masters then?

Dr. Ludwig: Well my master's was in cancer epidemiology, too. So, I think basically a PhD teaches you how to think and how to solve problems and how to write, how to write grants, how to write a good research question, how to write your aims so that you can do any of these things. I don't think my PhD work is directly correlated with what I'm doing now, but I think that the case with a lot of researchers.

Erin: So, what you say is maybe the most frustrating part of your work as well as the most rewarding?

Dr. Ludwig: I think the most frustrating part of my job, as is the case with working with a safety net system, with the Harris Health system, is trying to care of patients that have very limited resources. When they have issues with transportation or lack of funding to buy over-the-counter drugs for their side effects, or food insecurity. Even though I know that these conditions exist, it's very hard to get them connected with the proper channels to address those in a timely enough setting to not impact their cancer care. I think I'm a decent oncologist; I'm a terrible social worker. And unfortunately, the social workers and support staff that is available through the county are stretched very thin. And I often have to rely on kind of a cobbled approach of my medical student trying to look up things and my residents trying to help the patients as best as we can, and it’s a different, it's a different approach for every patient.

Erik: So, you said safety net hospital. In case some of our listeners don't understand what that is, would you mind explaining a little bit about that?

Dr. Ludwig: I may not get all the details right, but a majority of the patients that I see in my clinic are below 200 percent below the federal poverty line, and Harris County is one of the few county health systems in the country that is able to provide excellent level oncologic care to medically underserved patients. There's not very many other programs like that in the US, so I'm very proud to be working for a hospital that does offer those services. We have the top-of-the-line radiation equipment, we have pretty much every chemotherapy option that they could need, we have clinical trials available for our patients. But they do often struggle with, as I said, transportation, childcare, food insecurity, and things that are beyond my level of expertise to be able to address.

Erik: And so, I guess jumping maybe into the future, what do you see cancer treatment looking like in 10 or even 20 or 50 years? Do you think it's gonna change a lot? I mean we've been – radiation is about a hundred years old right so we're still using it. It seems to be pretty good, but do you see any major changes ahead?

Dr. Ludwig: So, we've been using radiation since 1895. In fact, we were using radiation before anybody ever heard of chemotherapy. I think we cured our first lymphoma patient in 1896. And in terms of cervical cancer, I'm hoping in 50 years there won't be any. We now have the HPV vaccine. A lot of my patients are from countries that I don't know will have access to the HPV vaccine, so if that continues, I think we may still have a few patients, but I'm hoping that right now there's about 14,000 new cases in the US of cervical cancer. I'm hoping that maybe in 50 years that number will go down to two or three thousand. The Australians have already seen a decrease in cervical cancer and they're attributing it to the HPV vaccine, so I’m hoping that that would be something that goes well. I think we'll have an increased risk of obesity related cancers namely the one that I treat being breast cancer. I do think in terms of treatment we keep talking about personalized medicine. I think we're gonna see a lot more of that exploding as we see all of the -omics, radiomics, genomics, and we're seeing that again a lot in breast cancer -- Herceptin being one of the first widely available targeted therapies. And I think we’ll do a lot more, kind of like we do for antibiotic resistance, where you culture bacteria. I think it'll be more that kind of paradigm for cancer treatment whether that’s finding a chemotherapy, whether it's determining if it’s a radiation sensitive tumor. If we think about it, radiation is actually the ultimate immune modulatory technique because what we do only radiate somebody? We basically blast the cells open so that they're exposing their antigen to the body. If the body's not already terribly immune-suppressed then we're seeing a lot of the new MHC antigen being presented and activating the immune system. I think we need to figure out, and a lot of people are doing this, and combining radiation with immunotherapy for things like melanoma, CNS melanoma. So, I think we'll see a lot more combinations of radiation with immune modulation.

Erik: Well and that's interesting because you started mentioning something that for some reason, I didn't consider but I probably should have is, the idea of lifestyle treatments for cancer. I mean a lot of these can be prevented, like you mentioned HPV with the new vaccine and just obesity. Is that something that a lot of I guess oncologists are thinking about? Because I always hear about people funneling a lot of money into the newest treatment option, like the newest medicine, which was what my question was getting at. But do you see a lot of people focusing on that end of things, or maybe it's more of the family care physicians that might be thinking about that kind of stuff?

Dr. Ludwig: I think a lot of oncologists think about tertiary prevention. For example, a recommendation, if a patient has an obesity related cancer and they lose weight, do they lower their chance of it coming back? So, I think in the oncology world we’re concerned about that, but certainly primary care concerned about reducing obesity, reducing carcinogen exposure, lack of exposure, would go a long way. I think a lot of us are pretty active and talking about the HPV vaccine, anti-smoking to schools and things like that, but it’s an uphill battle.

Erin: I just wanted to –I was personally curious about—you have so much like going on at work and with like educating students and like doing all these trials and being in the OR. How do you unwind outside of work and what do you like to do for fun I guess in Houston?

Dr. Ludwig: I have a six month old daughter, so coming home and seeing her, and seeing her learn every day and learn new things, and spending time with her, and watching her smile at you is just a great way to make you forget about all the stressful parts of your day.

Erin: Any like hobbies or anything that you like? I remember during a class you were telling us that we had to try all these like new restaurants in Houston and that you were a big foodie. Do you like to do that still or is your daughter keeping you pretty busy?

Dr. Ludwig: I do! My husband, when we got married, he moved from just outside of New York City, and he was a little concerned about the food scene here. I said, I’ll put up a restaurant in Houston against New York City any day of the week. He didn't believe me, but I think he's been converted now. There's some great diverse and affordable food culture in Houston and we probably haven't been doing that as much lately with a six-month old. Look forward to getting back into that.

Erik: That's actually a really good point because I'm from outside of Chicago and so I always thought, not exactly the same, but I had I think some food snobbery in me too, but it's exactly what you're saying. It's amazing and you can find like any type of food that you would ever want. Maybe not deep-dish Pizza. Chicago’s still got that.

Dr. Ludwig: But that also contributes to the obesity epidemic.

Erik: You got me.

Dr. Ludwig: I’m looking forward to restaurant week benefitting the Houston Food Bank. A lot of my patients are recipients of meals from the Houston Food Bank. It’s from Aug. 1 through Labor Day. There's probably about 150 restaurants participating and I think they raised almost 12 million dollars for the Houston Food Bank.

Erik: Well, I think that's all the questions we had, if you have any additional comments, but if not, we will let you go. And thank you so much for taking the time to be interviewed by us.

Erin: Yeah thank you Dr. Ludwig. We really enjoyed talking to you today.

Dr. Ludwig: Thank you both and good luck with the rest of your medical school careers.

Jennifer: Well that's it for now. We’d like to thank everyone out there who took the time to listen to this episode of the podcast. Special thanks to Erin for writing the episode. Thank you to our faculty advisor Dr. Poythress for helping us put everything together and thank you to the Baylor Communications department for helping us with the production and website. And thank you again to Dr. Ludwig for taking the time to be interviewed by us. We hope everyone enjoyed it and we hope you tune in again soon. Goodbye for now!

iTunes | Google Play | Spotify | Stitcher | Length: 46:50 | Published: Sept. 11, 2019

Dr. David Rowley discusses his career path and how he ended up researching cancer microenvironments. He delves into the biological mechanisms of tumor microenvironments and talks about what excites him most about this particular research field in the future.

Transcript

Erik: And we are here. This is the Baylor College of Medicine Resonance podcast. I am one of your hosts, Erik Anderson.

Brandon: And I am Brandon Garcia, another host.

Phillip: And I'm Phillip Burkhart, the writer for this episode.

Erik: And so today we're gonna be talking with Dr. David Rowley about the tumor microenvironment and basically what that is and a little bit about his research on that over the past couple of years, or past many years. But to begin we wanted to give a little bit of background on what the tumor microenvironment is and also just cancer in general, so Philip, you want to help us out with that?

Phillip: Yes, so when thinking about cancer you know a lot of people think of it kind of as this dangerous you know mutating disease, and the nature of cancer is also described as a tumor, which is you know very accurate. But today we're kind of looking at the area around that which is called the tumor microenvironment.

Erik: So, what is the tumor microenvironment?

Phillip: Yeah, so that's a great question, and I think a lot of people, including Dr. Rowley, are still trying to figure that out. But it's been well characterized to this point, and that it's a cellular environment, you know that the cancer cell grows in, and it's got a lot of parts to it. So you have you neurons, you have immune cells, and you have your vascular components you know, your blood vessels, that bring the nutrients in there. And these are all pretty normal components of you know normal tissue, but where it becomes the microenvironment of the tumor is that...is that these can change and can react to the tumor itself, which is I think what we're going to hear a lot from Dr. Rowley today.

Brandon: And I remember from class and from some of the labs and stuff I've been in the micro-environment around the tumor is one of the big reasons why the immune system itself isn't able to fight off the cancer cancerous cells. Because this ...isn't it a fairly normal thing for when a cell mutates it becomes too much...too little like itself that the immune cells like macrophages and whatnot can come in and sweep that out, but something about that change in microenvironment allows the tumor cells to persist right?

Phillip: Yes, I think that is a little bit 2-fold... one that the tumor itself changes and that the immune cells don't recognize the tumor as well...you know for face value. That they don't have the same cell markers or they kind of...I think a lot of them down-regulate the normal marker that would present the you know "I'm sick" message that most immune cells kind of look for to take it out. But also the microenvironment has a lot of components that kind of down-regulate the activity of immune cells. So a lot of the current immunotherapies that are making a lot of waves right now in cancer treatment and very effective are targeting these signals that cancer cells produce and kind of build-in in this microenvironment area that interact with the immune cells that are coming in and basically turn them off. And that's one of the ways that the tumor can grow.

Brandon: Yeah, and that's kind of hijacking some of the normal processes around wound repair right? So you've got macrophages, and other immune cells come in, they clean up an area once it's wounded and then you start having a down regulatory response right? So that you can actually start having angiogenesis and then...

Erik: Yeah well so this is something we'll be talking to Dr. Rowley a little bit about, and I think what you're referring to is for...at least for the epithelium is something called the epithelial-mesenchymal transition or EMT, and that's been studied, actually being studied a lot in the case of cancer but historically was studied for development. But basically it is the idea that epithelial cells, you know to give the brief background, your body is made up of three layers, the endothelium, mesenchyme or middle, and then the epithelium. And the epithelial cells during wound or during development or during metastasis will take a mesenchymal state as they migrate, and so they take that when they migrate into a wound, and it's also been linked to maybe what cancer cells do to become systemic and metastasize. So we'll talk about that a little bit but Phillip, would you mind telling us a little bit about the background of...you know this idea that the microenvironment is important and potentially important for cancer?

Phillip: Yeah so when I was doing some research for this episode I came across kind of the first idea of this microenvironment was in 1889 by a paper by Stephen Paget, and he called this the seed and the soil hypothesis. And he noticed you know...he wasn't looking at cell markers, tumor biology, that sort of thing I mean this was...this was a while ago. So he was just noticing that the metastasis of breast cancer was non-random, that it didn't just spread around the body, but it went to certain locations, and so he called this the seed in soil where the cancer cell was a seed, and it grew preferentially in certain soils, certain other tissues that it liked to grow in. And well I don't think he...you know, he wasn't like the founder of the tumor microenvironment, but I think that kind of speaks a little bit to the fact that this has been recognized and can be recognized from a very simple level. That the area that a tumor grows in is also important.

Erik: Cool, well, so looking forward to hearing more about that from Dr. Rowley.

Phillip: Yeah, so, Dr. Rowley is with us today ...he's very kind to do an interview with us for this podcast. And so, Dr. Rowley did his undergraduate and Ph.D. work at the University of Iowa and then did a postdoc here at Baylor. And he's a professor of the Department of Molecular and Cellular Biology and faculty at the Dan L Duncan Comprehensive Cancer Center. His laboratory was the first to identify and characterize reactive stroma myofibroblasts as a key component to the microenvironment in prostate cancer and benign hyperplasia of the prostate. So Dr. Rowley is also a part of the leadership for the Baylor School of Medicine, and he gives many of our fantastic lectures in histology, and immunology, and tumor biology. So we're very happy to have him with us today.

Phillip: Thank you for being with us today, Dr. Rowley. Would you like to start by telling us a little bit about yourself, and how you got to Baylor, and what your position is here?

Dr. Rowley: Yes, as soon as I finished my doctoral training of my Ph.D. I came to Baylor College of Medicine as a postdoctoral fellow in 1980. Worked in a laboratory interested in understanding androgen action, so we studied an androgen receptor in the prostate gland. That led me to an interest in interactions in the prostate gland and prostate cancer interaction between the cells and then stayed on the faculty. Started I believe in 1985 and have been here ever since, in the Molecular and Cellular Biology department.

Erik: How did you decide to come to Baylor? Because for those of us who know you, if I'm not speaking out of turn here, you're from the Midwest, to begin with, and Iowa specifically. I'm from Illinois, and I know like part of me always thought like, I would just stay in Illinois, or Wisconsin, or around that region. But I'm curious what was your calculus that brought you to Baylor?

Dr. Rowley: The cell biology department at the time, which became molecular and cellular biology was really the mecca to go to if you were interested in steroid hormone receptors, under the leadership and work of Dr. Bert O'Malley, as you all know. And so if you were interested in any type of steroid receptor, this was the place to come. And my doctoral work was also in prostate cancer, and so I was interested in androgen receptor, and really one of...Dr. Don Tindall was here as one of the top labs in the United States doing that, and so I came here to do my fellowship research.

Phillip: Most of your work now is in cancer research, and most people are familiar with the idea of cancer growing and mutating and invading tissues. But your work is on the tumor microenvironment, which is the area right around this. Can you kind of describe this environment for us?

Dr. Rowley: Well as its name implies it's the environment that's immediately adjacent to and regional there with cancer foci. They could be primary cancer foci, so in the primary tissues where the cancer arises, and it could also be at sites of distant metastasis where cancers travel to, and form colonies, and grow as metastasis. And essentially the microenvironment have both cellular components as well as non-cellular components. In terms of the adenocarcinomas, which are made up of a cell type called, as you know, epithelial cells...the microenvironment, which is primarily what we study, the major cancers such as prostate cancer, breast cancer, colon cancer, lung cancer, are those types of adenocarcinoma, and the cancer cell is the epithelial cell. So the cells around them are called stromal cells. There's also immune components in the tumor microenvironment, and there are vascular components, and then there are the what's called the extracellular matrix fibers— a lot of different fibers that are produced that help really hold the tissues together. And so these cells are sort of along the ride with the cancer cells, and as cancer cells grow they form a tumor, which is the mass, and in that tumor are the cancer cells plus all of these cells of the tumor microenvironment and fibers. There's also nerves in the tumor microenvironment, so blood vessels, nerves, immune components, and stromal cells, and the fibers that they make, along with all of the other factors, like growth factors and things that they make, means that this microenvironment is a very complicated environment with many cell types. Of course, it varies from site to site, tissue to tissue. The metastatic site is going to be different...probably, than the primary site and the major questions are how does this microenvironment affect cancer initiation, cancer progression, during the natural course of the disease.

Erik: Now you say probably, so does that mean that...I guess it's not quite understood fully whether it actually is different? Are there some cases where the cancer microenvironment is the same?

Dr. Rowley: You mean different between the primary site and the metastatic site?

Erik: Yeah like a normal site, if you will.

Dr. Rowley: Yeah, yeah, the question is how similar are these microenvironments between the different types of cancers, and I don't think that's a...that's a resolved question yet. I still think it's an open question. There are common cell types that are there, but then what makes them different is there's different amounts of stroma, there's different amounts of this microenvironment, there can be some tumors that are say...nearly 100% tumor cells and very little microenvironment cells. There are other tumors, such as pancreatic cancer, where the microenvironment makes up more, most likely more than 50% of the tumor, maybe 70% of the tumor is microenvironment and 10, 15, 20 percent of the tumor are actually the cancer cells. So although common components can be found, the amount of those components and their heterogeneity is different in different cancers, and even within a type of cancer, there can be a lot of heterogeneity between patients. And then even within a particular tumor if we're talking about prostate cancer, there can be heterogeneity in that tumor. So there can be regions of the tumor that are nearly all cancer cells and other regions that have 50% cancer cells and 50% microenvironment cells. The reason for that is essentially unknown.

Phillip: So when you talk about this microenvironment, you consider it part of the tumor?

Dr. Rowley: Yes, yes. And I think that's for many people, of course when we say the word cancer, we focus immediately on the cancer cell, and then when we say tumor if we visualize that many people visualize that as a mass that is essentially all tumor cells, cancer cells. But in actuality, there are a lot of cells in that tumor that are not cancer cells, and the question is how is... how does the biology of those cells affect the tumor? And does it promote the tumor? Is it inhibiting the tumor? Sometimes we tend to think of well...which one is it? And it's probably not one or the other, but the answer is yes, it's both at the same time. There could be some components that are stimulating the cancer cells to proliferate and invade, there are other components that are inhibiting the cancer cells to proliferate and invade, and maybe the question is what is the net effect of those two. Is it pro-tumorigenic or anti-tumorigenic?

Erik: Well I'm curious, so how did you...because most people that get into cancer research want to study the cancer itself, but I know that a lot of your research, as we've already alluded to and have talked about, is about the environment. How did you get into looking at the environment itself?

Dr. Rowley: When I was studying androgen receptor, we were looking at the makeup of the prostate gland and what cells have the receptor. And it's primarily in the epithelial cells, which are making the export product of the androgen reaction in the prostate gland. But there were many very important studies in the '70s and '80s, and particularly in the early 80s, investigators showed that the stromal compartment of cells had a great influence during development on the differentiation, and gene expression, and proliferation of the epithelial compartment. So during development, these compartments of cells co-evolve and develop together, and they greatly influence in a reciprocal manner each other's biology. So then the natural question would be as a tumor forms does this stroma...this microenvironment also affect the growth in the biology of the cancer cells much like it does during development. And so because my work was focused on androgen receptor and prostate cancer, we started thinking more about hey, what about this microenvironment? Might some of the biology that happens during development also be happening during the tumor, and if so is it early in tumorigenesis, sort of a pre-malignant stage? Is it as the tumor is growing and forming, does it promote the progression there? Does it promote invasion of these cells to invade outside the organ and go into a more of a metastasis? And those were all unanswered questions, and in terms of very specific mechanisms, many of these questions remain unanswered.

Erik: And just a quick clarifying, I guess question and statement. By stroma you're referring to like fibroblasts along with the fibers that they're excreting into the environment like collagen and fibrinogen and...whatnot, is that correct or...?

Dr. Rowley: Yes, yeah, the classical terms of tissues are parenchyma and stroma, as you know. The parenchymal was viewed as the cells that perform the major function of that particular organ so if it's a secretory gland-like salivary gland, mammary gland, pancreas, prostate gland, etc., the parenchymal would be the epithelial cells that are under very specific gene regulation to make the export products for that particular gland. And the stroma was considered support tissue. All of the tissue outside of the parenchyma was the stroma, so that means essentially the stroma is that entire tumor microenvironment and it would, as I said immune cells, vascular cells fibroblasts, nerves, they're all an extracellular matrix it's all part of the stroma.

Erik: I understand.

Phillip: So you briefly touched on this in the last couple of statements here, but when we talk about the microenvironment and cancers, cancers themselves have these mutations that are driving their, you know, tumorigenesis and their dangerous aspects...and the microenvironment you're talking about either feeds off this inhibits it or is affected by it. What parts of the microenvironment or maybe what proportion of the microenvironment do you think is driven off the cancer mutation versus kind of an existing biology.

Dr. Rowley: I think that's a great question, and the short answer is we don't have a complete understanding of that yet. I think an attractive way to think of this is that the microenvironment is a normal diploid...meaning no gene mutations happening in that compartment, and that it's following a pattern of almost a tissue repair type pattern, if you will a disruption of the homeostasis of the tissue inducing, you know, an existential repair mechanism. And that this repair process is essentially what happens in this stromal compartment in the tumor. Now the question is if there's specific mutations in the epithelial cells does that tweak or alter the stroma...that stromal response and I don't think we know the answer to that. I don't think a lot of studies have directly in an experimental setting compared a normal wound repair process to the exact same process in a tumor micro-environment. My particular view and bias on this is that that it is much the same. And I think if that is the case it's an attractive hypothesis because that means it's a normal response to an abnormal change in the cell that becomes the cancer cell, and as a normal response if that's true it's predictable what that response is ...it's from a normal diploid cell, and when pathways are more predictable they may be better targets for therapeutics—novel therapeutics or existing therapeutics. There may also be more reliable biomarkers because if that's true that compartment of cells and that biology may be less variable between patient and patient, more predictable, and that may give you a less of a moving target for your therapeutics. Or as the cancer cells are genomically unstable, they're constantly changing, they're evolving into the to the environment, they're becoming therapeutic resistant, and so the therapeutics are a living target. It's not to say that therapeutics to the microenvironment might not do the same thing, so we just don't know that.

Erik: Yeah well if I may, and this is becoming a bit of a mantra I think of questions that I've asked of actually previous people on the podcast too, but would you agree with the statement that maybe some of our misunderstandings about this...the stroma and how much it affects the actual progression of cancer is due to technical limitations of studying it? And I asked this because I did some research on keratinocytes in my past, I would say that was my wheelhouse, and I started trying to look at you know the collagen makeup, and you know the extracellular matrix because it's incredibly important, but it was very difficult. And the stains...you know you can stain for collagen, but you end up having to do it, or at least histologically you know there's preparation that takes place, and you end up maybe losing some stuff. I think there was an NYU paper recently that kind of tried to talk about that it's like the process of histology you could be losing important parts of the extracellular matrix that maybe we're not thinking about. Do you think that's true?

Dr. Rowley: Yes I think it's very much true, it's a good question that the technical limitations of being able to study that compartment of cells and their biology, does that limit our progress? In my view, the answer is absolutely yes. As a good example, we know there are tissue-specific promoters in genes that are specific to those epithelial cells between different tissues because they make different proteins, ergo they have different gene regulation. So we can take a promoter to a gene that is expressing...say a milk protein and target a transgene or a knockout gene to the mammary gland. Or we could take a gene that is androgen-regulated specifically to the prostate gland, and that would target a gene, a new gene, a transgene or a knockout to the epithelial cells. But we do not have tissue-specific, nor necessarily cell-type-specific promoters for many of those stromal type cells. Maybe we do for some of the nerves, and maybe we even do for some of the immune cells, but the fibroblast...and that's a very broad category; fibroblast is a very broad category, a lot of different types of fibroblasts, particularly in this repair tumor microenvironment. We have no good promoters or ways to target gene expression or knockout of genes specifically to that compartment of a subtype of cell. If we did, we could then better dissect the contribution of that cell to the overall biology of the tumor-like we can in epithelial cells.

Erik: Correct me if I'm wrong so...would that mean then like for instance you can't tell a fibroblast that's making type I collagen from one that's making type IV.

Dr. Rowley: Well with immunohistochemistry, you could do that yeah because you could stain the cells for a pre-pro form of the collagen and the ones making collagen I would light up and the ones making college IV would light up with a different antibody.

Erik: But there's not a genetic marker that distinguishes?

Dr. Rowley: I don't know if there is or not, I don't think so. I don't there are, there are some genes that we can you know tell a difference between say a mesenchymal stem cell versus a myofibroblast versus a fibroblast cell type that is... that is not more of a myofibroblast. So we can look at some immunohistochemistry stains and distinguish some of these cells, but it's ...imperfect, and we just don't have the ability to sort of distinguish those cells. At least to the level that we would like.

Phillip: So to switch gears a little bit, so one of my favorite sayings of you, when you lecture to our classes, is that cancer doesn't have a steering committee that decides it wants to promote this angiogenesis or metastasis, a lot of the hallmarks of the dangerous cancer...but these are normal functions of a wound repair and this normal biology we've been talking about today. So can you describe kind of what these dangerous actions of a tumor can be that can be attributed to this microenvironment and this...this biology.

Dr. Rowley: Yeah, it's ...it's a good question, and it's just a natural thing that all of us do, I've done it too, and we try to sort of personify cancer.

Erik: Anthropomorphize?

Dr. Rowley: Anthropomorphize cancer, and it's a natural thing to do I've done it too where we say you know essentially when we're giving our talks we're saying, this is an evil disease. Cancer cells want to kill you. They want to metastasize, they want to do this and want to do that, and at first hand it's ...it's fine, it's helpful. It helps us understand the devastating biology brought forth by this disease, and that's a good thing. On the other hand thinking of cancer that way if we take it too far can lead to the wrong types of questions that are asked in the research laboratory or even in clinical research as to the cancer. And so really when we think of the biology, cancer does not have a steering committee that meets on Monday morning and says, well you know we're a little behind schedule we want to be metastatic here by you know in the next 2-3 months because we would really like this patient to go downhill much more quicker than it...because we're evil and that's what we do. So sometimes cancer biologists are asked for why does cancer metastasize, and you know the answer is well ...that's just kind of what they do. So it changes the kind of questions that you ask. I think that again, in my view, much of the biology of the microenvironment is, and this could be an ironic thing, much of that biology is designed to repair tissue quickly. And if epithelial tissues everywhere, as you know and as you've heard, they are barrier functions, so they separate outside world from inside world. So the luminal side of an epithelial lined gland or the surface of your skin surface of your long service of your GI tract those are all exposed to outside environment, and when that epithelial layer is breached there must be a very rapid...there is a rapid repair mechanism. It's existential; if it doesn't repair rapidly enough, you would have gained access of microorganisms because of that breach, the microorganisms would get in and cause an infection, which could go and...be very serious. So repairing this rapidly is very important. I don't think that stroma that does that rapid repair knows that the defect is a knife wound or a cancer growth. I suspect that the signals that are received basically are communicating that a breach has happened, and a repair process must take place, and it's existential. So that repair process is designed to keep you alive under stress conditions, and if that theory is right that same repair process is what's promoting cancer progression and so if that's the case then the cancer ...it's a normal function that's actually designed to help keep you alive but it's promoting the cancer proliferation, invasion, and perhaps metastasis. Now that's one way of looking, and of course, there are many opinions, this is just my opinion. There are many opinions on this, and the other way of looking at this is that yes, there are different things that cancer cells make that are not made by normal tissues that maybe there is the foundation or the basis of this normal repair process. But because of the extra growth factors or extra other immune-suppressive functions of the cancer cell are somehow tweaking and modifying this response, so that's actually more promoting of the cancer. And in the areas where it might be inhibiting those cancers go away, and physicians never see those, we only see the cancers that progress, the ones that go away we don't know so much about. So one way of looking at cancer is that you're getting cancer possibly a lot and many of them are taken care of and gone away, but the only ones we see clinically or in the research lab are the ones that do survive and exist. The ones that might be more interesting to study are the ones that don't survive, to know why they didn't survive, and we could probably get a lot of clues from that.

Erik: Yeah, well I wonder if this would be a good point to talk about...because you briefly alluded to it before the epithelial-mesenchymal transition and how that ...that's sort of a buzzword that you find a lot in cancer research now. Would you be able to speak a little bit on that and what that is and how it relates to cancer?

Dr. Rowley: Sure, it's the epithelial-mesenchymal transition or EMT...it's used a lot, and it describes the process by which these epithelial cells change their morphological phenotype and their physiological function and start to not look like an epithelial cell and start to invade the tissue much like a mesenchymal cell would. So, therefore, the name epithelial to mesenchymal transition.

Erik: Mesenchymal being, in this case, the fibroblast, which is the stroma?

Dr. Rowley: Right, more like the fibroblast. Now, this is a term that was not... at first, talked about in cancer, it happens in development. So most of your organs, all of your organs that have epithelial cells, these EMT processes happen in development, so this is not a cancer-specific term. Again, it's an open question as to whether this EMT happens in normal wound repair. So if you were to cut yourself with a knife I can tell you that the stromal tissue would start to grow in, the epithelial cells would start to proliferate on the surface of your skin, and they would start to invade across the site where the wound was. Is that EMT? Are the same genes that are turned on in EMT cancer turned on at that site? It's still an unresolved question. I don't think it's been thoroughly studied. Again, my opinion and bias is that it is much the same. I think EMT again is a normal process that's designed to rapidly effect and promote wound repair, which again as I said needs to be rapid. The difference is, if that's the case, the difference is those cells resume their normal polarization, their normal phenotype, as you know if a wound heals correctly the only thing that will be left is a collagen scar— those extracellular matrix fibers scar— and the cells that actually started to form the wound, some of those will go away, the immune components will subside, and the epithelium will have healed all over at the top, and the cells will resume, and that's a process that ostensibly takes place with normal diploid cells. If that same process is now taking place with cancer cells that are no longer diploid, have gene mutations—maybe oncogenes that have been activated or tumor suppressor genes that have been repressed—then that process is off balance. And instead of the cells stopping and polarizing and re-differentiating, they continue to grow and metastasize.

Erik: Yeah...no I think that's a very interesting field now, at least I have interests in that and I also just find it fascinating that...because we grew up kind of thinking okay an epithelial cells is an epithelial and a mesenchymal... is it pronounced mesenchymal I keep saying mesenchymal?

Dr. Rowley: Both works fine.

Erik: Both works, that's good. I don't want to look like an idiot here! But amazing to think that you could have...like they could change, and then this gets therapeutic options open up, and I think that's where a lot of people if people have heard of mesenchymal stem cells, that's a whole field now.

Dr. Rowley: And yeah well, that's a good ...that's a good point and a good question and a good point of clarification. Because in my opinion again, I don't think it's really a conversion to a mesenchymal cell type, it is an epithelial cell still that looks like mesenchymal cell and starts to express some of those genes, but a mesenchymal stem cell can be differentiated to a lot of different types of stromal cells that can be differentiated to smooth muscle, or to bone osteoblasts, or to cartilage chondrocytes, or to an adipocyte. And these cells that have undergone...that were an epithelial cell that have undergone EMT. I don't think it's been shown that they have that multipotentiality. So they're not truly a mesenchymal stem cell. They have mesenchymal properties, and oftentimes there's an MET, where these mesenchymal cells convert back to an epithelial cell. So yes they're mesenchymal in the way they look, but they're not really...and this is another good point because there is a lot of confusion with the terminology here with many of these things too, and you know there's other examples of this kind of terminology that can be can be very confusing.

Erik: I think there was a paper that recently showed that they took an epithelial cell and turned it into an adipocyte, but I could be... I'll have to look that up on the back end.

Dr. Rowley: It...that wouldn't surprise me, and I and I do think we have to keep our minds open, and you know we're learning more and more and more about these...about these processes. But the terminology can be confusing, for example, a cell type in the stroma that's associated with these cancers are appropriately called carcinoma-associated fibroblast. That's been the word that has been used for 20 years or more in the literature, but the problem with that is that it's biased and that's because of its name, it makes you think that it's somehow cancer-specific. Well, how is it possible to have a cell type that has evolved to be just...to serve cancer's role to grow. Doesn't seem to be...to makes sense, and really when you look at those cells, they have pretty much the same gene expression and phenotype as a cell in a wound repair if you cut your skin, or a cell that might be in the wall of a diseased blood vessel by a plaque—might have pretty much the same phenotype. So by calling it a carcinoma-associated fibroblast the people that are studying these cells in a vessel wall and studying them in wound repair might not study them because it's like, no we're looking at a cell type called a myofibroblast. In my view, a myofibroblast and a carcinoma-associated fibroblast is the same cell type. But one field calls it a myofibroblast; another field calls it a carcinoma-associated fibroblast, and it leads to some confusion, and I think that we could probably all learn from each other by looking at these other fields.

Phillip: I think that kind of leads well into my next question for you is....this...this idea of looking at the tumor microenvironment is definitely taking hold recently and becoming more popularized, but how much has this infiltrated the way we treat cancer currently in the clinics? Is this something that's being considered now, or is it something that's kind of coming up and going to change things?

Dr. Rowley: I think that's a really good question. I think that it's beginning to affect the field, probably the biggest change in...at least in my view, in the oncology field is the use of multi modalities in therapeutics and not just relying on one therapeutic. A hallmark of cancer is therapeutic resistance, and it's really...at first I think it's hard to understand that, but actually, it makes perfect sense. You know these cancer cells...biology is really...I mean we could talk for forty hours on this, but the biology of tissues is resilient, and when a pressure is applied they'll change from A to B, and then from B to C and biology finds a way to do that. This is what cancer is doing when a therapeutic is applied, it becomes therapy-resistant, and we say oh darn it. But if we look at biology, bacteria, we know for years we have...this is why we have you know antibiotic-resistant strains of bacteria because you evolve those strains because of overuse of or use of antibiotics. And so biology is going to adapt to the pressure, so whereas a therapeutic may destroy ninety percent, ninety-nine percent of the cancer cells, one to ten percent of the cells leftover are now...because they're leftover, are resistant to that antibiotic, and they grow as another tumor. And we say darn it that cancer is evil. Well, it's not evil, it's just a natural biology, it's a selection pressure. So there's a selection pressure, those cancer cells that are responsive die and those that aren't don't and so the tumor that evolves is no longer responsive to the first therapeutic, and so now that your question is how does the microenvironment affect that and we don't know the answer to that. But I think oncologists, in my view at least, they're more sensitive to this maybe we should not push the cancer to evolve into this before it evolves into this therapeutic resistant. Let's stop that and try something else, or let's try combination therapies, or let's mix things up a little bit, so it's less predictable. And I think lessons and clues can be taken from extinction of certain species on our planet where there's multiple pressures that have caused the extinction, but just one single pressure might not have done it. There may have been biological modifications to deal with that pressure, but multiple pressures do it, and I think if we use sort of those ecological principles to look at cancer, we may start coming...and I'm sure there are people doing that.

Phillip: Yeah and this reminds me of...we're in infectious disease block learning right now in medical school, we talk about treating tuberculosis, and I mean you start that with four medications. Because I mean over years of trying to treat it, they realize that if you start with one, two, even three, and you don't get rid of it a lot of times. So I think even our close friends in the ID department would recommend that as well.

Dr. Rowley: One of the things I think that...I think probably, I think all of us would agree, biology is far more complex than what we thought, and it's never linear, and there's always a plan A, plan B. There's redundancies, we know this, and you know we are in my view there's an awful lot of biology we don't know that we're still learning and...for example, what a nerves do in cancer? We know that nerves are very, very important and we have...there have been some very good papers over the last five-six years on this, but it's still in a field in its infancy. But for sure, for sure nerves affect cancer, but we just do not understand the mechanisms of how that works.

Erik: Well, that leads us in nicely to our second to last question here, so what excites you about you know future discoveries and applications of microenvironment field?

Dr. Rowley: Yeah, you know we're always pushing for better diagnostics and prognostics, and we're always obviously pushing for more therapeutic approaches, and as we talked about in the last question multi modalities of this and multiple therapeutics may be at once. So an overall, overarching goal here might be to say, can there be a diagnostic that we can find from this tumor microenvironment that can help distinguish patients that maybe need—in diseases such as prostate cancer—more of a watchful waiting, versus those that should be treated more aggressively sooner rather than later? And then in terms of the treatment might there be a way to target the tumor microenvironment, in other words targeting the niche of the cancer so at the same time you're targeting the cancer cell, so a double-barrelled approach: One at the niche that the cancer still lives in, one at the cancer cell. And then maybe even having several options for both of those compartments. I really think to control cancer...I don't know that cancer will ever be eradicated because as long as genes mutate, it's going to be hard to eradicate it. I think there's a lot of progress on that for a lot of reasons, but I think for treating it and controlling it this multi-pronged approach...and you know if you look at species that have left our planet, unfortunately, it's because their niche has been destroyed. And so if we take that same principle towards cancer, destroying their niche, not allowing them to start growing in the first place, or not allowing them to metastasize, or by somehow uncoupling the important biology that is ...that's synergistic interactive biology with the niche. If you can uncouple that I think that's a very powerful approach, and that's the rationale that we use in many of our research proposals as to why we think understanding these compartments, and really understanding things like general wound repair. It's incredibly complex, incredibly complex, and we still...we know the cell types that are involved, but we don't know necessarily all of the factors that regulated it, how those factors are integrated, the signaling pathways inside the cells. How do the cells, if you have a hundred different cell types doing wound repair at once, how do they all coordinate themselves so that everything happens in the right coordinate manner, so you end up with a perfect repair with a minor scar? How does that happen? We don't really know.

Erik: Well and the fact that you don't regenerate hair follicles, right? Am I wrong in saying that?

Dr. Rowley: Yeah as humans we...you know compared to lower organisms, we really don't regenerate. We repair our tissues, we don't necessarily regenerate our tissues, unlike lower organisms such as Planaria. Where you cut the head off a Planaria it grows a whole new head back; there's only one stem cell in a Planaria. We have a lot of different stem cells and rather than go to the complex process of regrowth of a new organ we would repair that organ much with this type of microenvironment repair type tissues. It's what happens in cardiac infarction. When the cardiac muscle dies, it's replaced by this fibrous repair tissue, it's not replaced by normal cardiac muscle, as you know. So if we were able to regenerate it would be a lot easier just to have that system just grow back a new heart tissue, right? But it doesn't necessarily happen. That's why we end up with scars when we were cut, the collagen stays, and it's not exactly normal, but it's pretty close.

Phillip: Yeah, I really like how you take that ecological niches is very interesting. I think for our final question today, just as one of our great lecturers in the medical school, I think talking a little bit about your teaching style is a little bit...unique, and would be a fun topic. A lot of times you talk about a design criteria that, you know, a bone needs to meet, and then we go into the histology and cell types of that. Would you like to talk a little bit about that?

Dr. Rowley: Yeah, yeah, sure. I guess I started this many, many years ago because I found it when I was learning all of this I just couldn't sit...well, I could, but it wasn't fun. I just couldn't sit down and memorize things for the sake of memorizing. A good way to learn is to understand the story of how something works. And you know you can try to memorize all the components of something, but if you understand how components go together and how they work with each other, pretty soon you end up knowing exactly how it works and what they do and it's a story of how it works. And so rather than give a lecture where we say, here's a list of things that we need to memorize for today because trust me you'll need to know this to practice medicine or to do your scientific research, or be a good medical educator, and our medical students do all three of those areas. So a better way to do this is to say, if you are designing bone how might you design it given that you need...these are the design requirements: Bone must be lightweight but must be strong, it must have an ability to be hardened, but those same ions can be used in blood chemistry—calcium and phosphate. How would you design it? Given...you've got some cells, you've got some fibers, and you've got some glue. How would you put it together, and sometimes I ask are there engineers that have looked at carbon-fiber technology and fiberglass and things like that? It's fibers, glues, and hardeners. It goes back to an Adobe. Mud, straw, and water. Okay, they harden, and it's an adobe brick, and if the wall is thick enough, they can last for hundreds and hundreds of years. If you don't put straw in it, it falls apart immediately at the first storm. So the fibers are important. So we go through all of those concepts, and the students learn how...if they are designing bone if there's a design concept. You know-how is an immune system, how would you design an immune system if you needed it to do A, B, C, D, E, and F? How would you design a blood vessel if you needed it to do this on the arterial side versus return blood to the heart on the venous side? You wouldn't put valves on this side, but you might put valves on this side. And so it makes more sense, it makes more sense to understand it from if you were making it how would you make it, and you can kind of have fun with questions like that.