ASCO Education

"An advanced practice provider's scope of practice can vary drastically depending on where you practice; listen to the ASCO Education's third episode of the advanced practice providers series, and learn more from our co-hosts, Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams, (Northwestern University Feinberg School of Medicine), along with guest speaker Heather Hylton (K Health) on what scope of practice is, who or what defines it, and why knowing this information is critical to your oncology care team success. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org TRANSCRIPT Todd: Hello everyone, and welcome back to the ASCO Education Podcast, and the third episode of the Advanced Practice Provider series. I'm Todd Pickard, your co-host for this series, along with Dr. Stephanie Williams. We'd also like to introduce you to our guest panelist today, Heather Hylton. Heather, why don't you share a bit about yourself, what you do, and where you're from. Heather: Sure. Well, thank you so much. It's a pleasure to join you in this podcast. My name is Heather Hylton. I'm a physician assistant based in New York. Most of my career has been in oncology, but I've been fortunate to have been able to serve in administrative and clinical roles in organizations in multiple states. So, I'm currently working in the remote care space, and I'm excited to bring this experience to our conversation. Todd:And Stephanie, why don't you remind our listeners today about your background, and why you have so much experience and really just have a really true appreciation for working with advanced practice providers. Stephanie: Thanks, Todd. I've worked in oncology for almost 40 years and I've had the opportunity to work with advanced practice providers, both physician assistants, and nurse practitioners for a couple of decades now. I've been in stem cell transplants and cellular therapy, and they're absolutely integral to our practice, both inpatient and outpatient in that particular field. Todd: Well, in today's episode, we're going to be talking about advanced practice providers' scope of practice; what it is, what it means, who defines it, and why it is important for oncology APPs to know and understand what their scope of practice is. So, why don't we jump right in? So, I think it's important to define scope of practice first. So, I would like to just offer a little bit of a perspective around that language of scope of practice. Generally speaking, it is what is allowed by law at any particular state for an advanced practice provider to perform care on patients; what types of patients they can see, what kind of medications they can prescribe and write, what kind of activities they can be in, what kinds of relationships they have to have with other providers and delegating or collaborating physicians. So, generally speaking, a scope of practice can be very, very broad or it can be very, very narrow. And it really depends on the state and how the state defines it. So, I'm going to ask Heather to jump in here and can you provide an example or a story, or a case that comes to mind that helps illustrate scope of practice for an APP? Heather: Sure, I'd be happy to, you know, in terms of how I think about this, very simply stated is, what it is that I'm permitted to do as an advanced practice provider. And the boundaries, as you said around this, are really determined by a number of factors. So, education, training, experience, my competency, federal law in some cases, state laws, regulations. And this may also include, as you mentioned, specific physician collaboration requirements, facility policy, clinical privileges that are granted by that facility, sometimes payer policy factors in, and then of course, the needs of the patient. So, one very common question that comes up in the oncology space is, can APPs order or prescribe systemic therapy? And the answer of course, is really going to be determined by going through that checklist of the entities that determine if this is something that that APP can actually do. So, one example I have is a facility where the module that they utilized for ordering systemic therapy provided system rates only to physicians. And the facility that had been using that module before APPs were widely integrated. So, there were some innocent assumptions made that the absence of the APPs in the module meant it was "illegal" for APPs to order systemic therapy. So, in working with this group, we were able to go through this checklist. So, there were no federal or state restrictions on this particular clinical activity, but it needed to be written into the facility policy. So, criteria for establishing competency were devised. And then an education training plan was designed, implemented, and driving systemic therapy became part of that privileges requests from the APP, and then the systems' rights issues were also addressed. So, this was truly a success story in being able to safely expand the number of clinicians, who were able to prescribe systemic therapy in a busy and growing facility. Stephanie: Heather, what does it mean to you (this is a term that our administrators throw around a lot and our nurse managers throw around as well) to practice at the top of your license, whether you're a nurse, physician assistant, or an advanced practice nurse; what is the top of your license? Heather: Well, this is a hot topic. And top-of-license practice really comes down to role optimization. It is just good business. It means that the patients and the caregiver's needs are being met by the professional with the appropriate training, experience and competency for each function or task that the professional performs. And from an engagement standpoint (which I know is not the topic of our conversation today, but it is important) we know that people want to engage in work that they find meaningful. While that definition certainly is individualized, a common thread is being able to leverage that education, training and experience you have to help others. And often, the reason why we really pursued our careers. Todd: I think this is such an important topic to talk about, is the top of license practice, because it really impacts all of us, Stephanie. You know, as physicians, you want to do what you've been trained to do, which is to assess a patient, have a differential diagnosis, do a diagnostic workup, arrive at a diagnosis, create a treatment plan, and have that treatment plan implemented so that you can care for the patient. And APPs are the same way. So, when you have folks, whoever they are, whether they are the nurse or the advanced practice provider or the physician or the social worker or the pharmacist, whoever it is; if they are utilized in a way that does not take into account all the skills and competencies that they have to deploy and provide for that patient, they're really working below the top of license. As an example, if you had an APP go from room to room to room with you seeing patients and the only thing that you had the APP doing was scribing, that APP is working well below their licensure. And in fact it's incredibly wasteful with limited resources in healthcare, to have folks who have lots of skills and competencies working at a level where you really should have a different member of the team providing that service. Like if you need a scribe, you should get a scribe. And so, I think that kind of illustration really makes it salient to folks to think about; we should all work to stretch the knowledge and skills and competencies that we spent so much time developing in all of our training and our certification. Because otherwise, it's just wasteful. And as Heather said, it's not very satisfying. Stephanie: Todd, I think that those are excellent points that you bring out and I think that's very important for people to realize that APPs aren't scribes, they aren't there to extend me. They're there to help me as a physician in my practice, to help the patients actually. And then we should work together as a team to give the best patient care that we can. But many times I see my colleagues, just as you said, going from room to room with their APP and expecting the APP, you know, "I'll pontificate and tell you do this, that, that and the other, and then you go out there." I think also from a career and job satisfaction rating, it's really important to have that team around that can help each other out. And I think that really does help in terms of decreasing burnout and other things like that. Todd: So, Heather, can you give us some idea of how is scope of practice defined at a state or an institutional level? How do people arrive at those kinds of decisions or, you know, how does an institution decide what the scope of practice is? How does it work? Heather: Taking a step back and just, you know, kind of thinking about it through different lenses. So, you know, in contrast to physicians whose scope of practice has minimal variability from state to state, we know that there can be a bit more state to state variability for APPs. And the regulatory bodies or agencies can also be different. And there may be multiple agencies that weigh in on what that APP can do within a particular state. And so, it's certainly important to be familiar with the Practice Act for each state in which you are licensed. And I would also add onto this, in certain geographic areas, this may be particularly relevant to you if you are in a practice that has multiple locations in multiple states, but we'll come back to that a little bit later. But, you know, again, kind of going through your checklist, starting off, looking at what the Practice Act says, and these can all be written up in many different ways. Sometimes it comes across as what I would call like a laundry list, which when you first read it, seems pretty straightforward, but it can also kind of lead you into some issues because if it isn't on there, then what does that mean? Some Practice Acts are written up really more on the basis of what activities are excluded or things that you cannot do as an APP. And then some are just kept very broad, which sometimes makes people uncomfortable, but I would encourage you to not be uncomfortable with that because sometimes, they're written this way in order to give you more flexibility to set that scope of practice at facility level, which is ideally where you really want to be cited. You don't want to create something more limiting or more restrictive than what the state actually allows you to do. Todd: That is a critically important point and one that in my 24 years as an advanced practice provider who happens to be a PA, that has come up often and frequently is, "Well, it doesn't say this" or, "It doesn't specifically exclude that. And so, we're uncomfortable." And my response is, "Well, that gives us an opportunity to create this space", because, you know, many times, as you point out, Heather, these kind of ambiguities are written intentionally, so that local practice decisions can be made, so that physicians and advanced practice nurses and PAs can decide as a team, how do we work? You know, in my state, it was very specific that they wanted APPs and physicians to collaborate on 'what does our practice look like?' And every local level, outside of those very large kind of rules about who can prescribe and who can pronounce a patient dead or write a restraining order — outside of those very large things, they really want us, they want the care team to figure it out and to do it in a way that's best for our patients. I think that is the best approach, is when we get to decide how we work. You know, the places, some of the states that have these laundry lists, you're right, Heather, it seems like, "Oh, that's easy," but then you're like, "wait a minute, there's only 10 things on this list and we do, you know, 57, what does that mean?" And so, I think it can be very disadvantageous when you have those lists. And I do think it's important to think through these things, work with your legal colleagues to analyze these things, and then take an approach, stake out some territory, you know, once you've gotten informed and say, "This is what our scope looks like, we've all talked about it and this is how we're going to work as a team." So, that's wonderful when you've got that level of flexibility. I think that's really great. Stephanie: Does insurance reimbursement play any role in terms of scope of practice, either locally or nationally? Heather: It absolutely can. And it's important to know, for example, if you are in a practice, where you're seeing Medicare patients, to understand Medicare conditions of participation. If you are in a practice where you are taking care of patients with Medicaid or certainly private payers as well, like understanding what is actually in those contracts, so that you can make sure that you are either updating them if you need to, or making sure that what you need to be able to bill for is billable within those contracts. Todd: It's really interesting because I always have a sense of feeling like I need to cringe when somebody says we can't do this because of a reimbursement issue, and also, partially laugh. And the reason why I have both of those reactions is it's typically a misunderstanding, because saying that we won't reimburse for oxygen unless a physician's order is present to prescribe the oxygen does not equate to only a physician can do this. And so, you constantly have to kind of explore these issues and say, "Okay, so yes they use the word physician, but as an APP who has a collaborative delegatory relationship with a physician, and according to my state license and scope of practice, I write physician orders." So, if you connect those dots, if I, as the APP, have written the physician order for the oxygen, it meets your criteria. It doesn't say a person who holds a medical license, it says physician order. And so, I think that's where you have to really constantly be on guard about these misconceptions, misunderstandings, and these ambiguities. And as Heather said, working with APPs, you just have to say, "Look, there's going to be ambiguities, we're going to work it out, we're going to figure it out. And, you know, reimbursement is important." But you have to remind folks that reimbursement doesn't define practice, it defines how you get paid. Stephanie: Excellent point, Todd. Excellent. Heather: I'll add a story to that as well. When I first came to New York, I became aware of a situation where the narrative at a particular facility was that a major private payer would not reimburse for services provided by PAs. Now, I thought that was a little strange, but, you know, I was a new kid in town, but at that time — there are more now, but at that time there were 10,000 PAs in New York. That's a pretty big number. And so, I thought, you know, I probably would've heard something about this if this major payer would not reimburse for these services. So, to help with the situation, I started doing the research, you know, looking at specific information from the payer, checking with connections at other facilities to learn about any issues that they may have experienced with this payer, checking with our national organization and so forth. And really, nothing was coming up, suggested that the payer would not buy reimbursement for services provided by PAs. And ultimately, it came down to something very simple, which was the facility just didn't have this in their payer contract, they hadn't needed it up to that point. So, it made perfect sense and it was fixed once the issue was identified. So, this goes back to just being very vigilant about the research that you're doing. And sometimes, it takes a little time to get to the solution, but really that perseverance does pay off. Todd: Heather, I'm sitting here, I'm laughing because I just had a recent example of where the right and the left hand within a state had no idea what was happening. So, an employer who does ambulatory outpatient treatments at different retail locations (we'll just leave it at that) there was this concept that PAs as an example, were ineligible because of the state requirements that then were reflected in this company's policy. And what was so interesting is that a PA colleague of mine started investigating and I said, "Well, what does the state law say?" And she went and she looked and she said, "Oh, it was changed last year that this thing that was causing this policy in this employer was changed." And I said, "Well, does the company know that the law was changed?" So, she reached out to the medical director who was a physician, whose daughter was happening to want to go to PA school. So, she had an in, she had an in right away, which serendipity does play a part here. And she said, "Did you know that the state law changed?" And they said, "No." And so, she sent them the state law and then within a week, the medical director said, "Oh, just so you know, we're hiring PAs now, we've updated our internal policies to reflect state law." So, sometimes it's just these small things that people forget the details, that when something changes, you have to reflect that in your policies of companies or institutions or your practice group. And that's the one thing that I think is so different for APPs from physicians. Physicians are kind of just granted this big broad authority and it rarely changes. It's very stoic and it's kind of fixed. But for APPs it is constantly in flux, constantly in flux. And that's just the nature of it. I don't know why it's been that way. We've organically developed this in the United States over the past 50 years, maybe 50 years from now, it'll be different, but right now, it's not. And so, I think that's the important thing is there's more space out there for advanced practice, scope of practice and top of licensure, than you think is possible. It just requires a little work. Heather: I will say that I 100% agree and, you know, when you take a step back from some of these, like these Practice Acts, they tell a story about the climate in the state and the history in the state. And it's quite fascinating if you like that. I'm not the most fun person at a party, but, you know, these things, they tell a story and it gives you a good sense of what's actually going on in the micro environment in that state. In the last year plus, I've spent a lot of time reviewing Practice Acts of most of the states of the union, and so, I have this ability to really compare. And I also know which states I really, really like and which ones are a little bit more challenging. But there are things like even legislation that's left over from the industrial revolution that's actually influenced how a particular pharmacy interprets, you know, whether or not they can accept a prescription without a counter signature from a physician. And so, some of these things, like when you start drawing some of these lines, it becomes very interesting and it definitely comes down to some interpretation as well. So, always being able to work with a good legal team or people who do understand Practice Act information and working with your state resources as well, as well as your national organizations can be very impactful. Todd: I would also say step one is to pull up whatever Practice Act is influencing something and read it. They are in English, they're not in Latin or French, they're in English. And many times, you can find something very plainly said. Other times you do need your legal friends to help you understand, "Okay, now what does this mean? I read the words but it's not clear." But sometimes it will say, you know, "An APP may prescribe a controlled substance." Period. So, oh, well, there's an answer right there. Now, there may be a how-to section later, in another part of the regulatory or administrative code within a state, but for the most part is, don't be afraid to look, don't be afraid to phone a friend and explore and ask questions. Stephanie: You're eligible though for controlled substance licenses nationally, right? A DEA number? Todd: That's a hot topic. Stephanie: Is it? Heather: There may be other things that you need to do within a state as well in order to prescribe. So, for example, in Massachusetts, even to prescribe legend drugs, you need a Mass Controlled Substance Registration, because any substance that's not a DEA scheduled substance is considered a category 6 substance in Massachusetts. So, if I'm going to write a prescription for Omeprazole, I need to have a Massachusetts Controlled Substance Registration, as any prescriber would in the state. So, again, some of these little nuances, making sure that you're very familiar with that and doing the research. Stephanie: So Heather, you're in New York, I'm sure you get patients from Massachusetts. So, you have to make certain that you can prescribe both in New York and Massachusetts and probably, Rhode Island and all the states around there? Heather: Well, you bring up a really good point, which is, you know,when you are in a practice that has locations in multiple states, and we can talk about telehealth a little bit later. But if you are in a medical group that has practice sites, say in Connecticut, Massachusetts, and New York, licensed in all three states, and you work at sites in all three states, say you're an APP who likes to float and you make these commutes each day. So, all three states may have significant differences in their Practice Acts or what you need to do in order to optimize your practice in that state. And that includes collaboration requirements. So, some states have the ability for nurse practitioners to have autonomous practice, but there may be other steps where you may need a particular license, in order to be able to do that within that state. So, again, being very aware of those steps that you need to take is really important. Stephanie: So, Heather, you mentioned telehealth, which is a big topic through COVID. I don't really have to tell people how big a topic that is. So, what are the changes or what is going to happen with that now that we're "getting to the other end of COVID"? Heather: That's a big question mark, right? So, certainly, the advancement of telehealth was an important development during the pandemic. And many states have a separate set of laws, regulations that govern delivery of healthcare services through telehealth. So, if your practice is utilizing telehealth to deliver medical services, it's necessary to be fluent in this information. So, this can include important information such as how a patient provider relationship is established. And, you know, it may also include information on prescribing practices, what may or may not be permitted or the conditions under which a prescription can be provided and so forth. And so, some states relaxed telehealth-related rules under state of emergency declarations. And so, making sure that you are up-to-date on this as some of those rules have returned to the pre-pandemic state and some of those relaxations actually became permanent. And of course, if you're billing for these services, knowing the payer requirements and then the policies and procedures you need to follow, in order to bill for those services. And where the patient is physically located at the time that the service is being provided, is the state in which you need to be licensed in order to provide that service. So, if Todd is performing a telehealth service for a patient in Oklahoma and he's not licensed in Oklahoma, he won't be able to see that patient. Todd: It's really strange because telehealth has brought a different layer of perspective around scope of practice and licensure that we hadn't really faced as much before, right? So, for example, I've been a PA for 24 years. I have been able to call across state lines and interact with patients and talk to them on the phone, get updates on their surgery, if they're having, you know, a postoperative infection, get them an antibiotic and do that kind of work forever. But as soon as you add that technology and that billing entity called a telehealth encounter or a virtual encounter, it becomes a different animal all of a sudden. And this really came to light during the pandemic. And we quickly realized all of these things made it impossible. And that's why all the states did all of these emergency declarations saying, "Just forget it, just take care of people." But now that we're getting past that, we're kind of going backwards, not because anything bad happened, but because folks are saying, "Well, we want to go back to the older ways where, you know, every state could have differences in regulations and make folks pay those professional fees to get licensure." So, it'll be interesting to see how this space develops, particularly since our patients are becoming more consumers. Really, they want to talk to who they want to talk to, when they want to talk to them, and they want service here and now. And I think we're going to have to continue to respond and adapt to that. And some places will lead and some places will lag. But those lagging places quickly are going to start having conversations within the state and our legislators will respond. I mean, politically, it will change over time. It just, you know, matters how quickly. So, it's really an interesting thing to watch unfold in real time. Stephanie: Heather, any final remarks, concerns, advice to those out there, both physicians and advanced practice providers, about how to handle questions about, my God, what is your scope of practice? Heather: I'm so glad you asked Stephanie because I have a list I might be able to pass them along. So, here we go. Do take the time to review the state Practice Act information and laws and regulations and of course facility policy governing a practice where you are. And as the license holder, you are responsible for knowing what you are permitted to do. Please do not make any assumptions about others' knowledge of this. Unfortunately, I've seen people get caught up in that and always own it, yourself. Generally, recommend facility policy not be more restrictive than what is permitted under the Practice Act of the state. Fact check, challenge your assumptions, and if you haven't had the chance to already do so, do check out the ASCO Advanced Practice Provider Onboarding and Practice Guide for more resources. Stephanie: Well, I'd like to thank Heather for her excellent insight into this very complicated topic. Todd, as always, is always on top of everything. And sharing both your experiences and your ideas with us on APP scope of practice, which can vary quite drastically depending upon the state and also the type of institution you practice in. Stay tuned for our next episode. Until next time, take care. Voiceover: Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. Voiceover: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

"Have you ever struggled to remember or pronounce a colleague's foreign name? In part two of this ASCO Education Podcast episode, host Todd Pickard (MD Anderson Cancer Center in Houston, Texas) continues the conversation on creating more inclusive oncology practices with medical oncologist Dr. Timothy Gilligan and clinical psychologists Dr. Lauren Wadsworth and Dr. Stephanie Pinder-Amaker. They explore identity-related aggressions in the workplace and tips for practicing to recognize and address them. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org." TRANSCRIPT Todd Pickard: Hello, my name is Todd Pickard. I'm a PA specializing in genitourinary cancers at MD Anderson Cancer Center in Houston, Texas. This is the second half of our Cancer Topics conversation on increasing diversity in Oncology, with Clinical Psychologists, Dr. Lauren Wadsworth and Dr. Stephanie Pinder-Amaker, and Medical Oncologist, Dr. Timothy Gilligan. In part one, we discussed workforce diversity in Medicine in the various prejudices, biases, and microaggressions that can take place in the workplace. We also explored real-world examples of bias in healthcare from Dr. Wadsworth and Dr. Pinder-Amaker's book, Did That Just Happen?! Today, we're going to continue our conversation by exploring cultural-sensitivity tips for individual healthcare providers and practices. Welcome, everybody. You know, we could have a great conversation about this for hours, I'm really enjoying this conversation, but I do want to get back to the book. Dr. Wadsworth, are there any anecdotes from the book that you would like to share with us that might illustrate some of the things that we've been discussing so far? Dr. Lauren Wadsworth: Yes, we would love to. So, each chapter of the book starts with a real story. So, a vignette that's been de-identified of an identity-related aggression happening in the workplace, or some other type of, Did That Just Happen?! moment, as we like to call them. And then after the vignette, we break down what was problematic about that dynamic and what to do about it, both in the moment how to make a repair, and how to change your workplace culture to prevent this kind of thing from happening again, or to reduce the incident. Our hope was that if we started with vignettes, to a point that you made, Todd, earlier, we might be able to welcome folks in that are maybe on the fence about reading a book like this, and instead of bringing up defensiveness, trigger empathy. So by telling a real story, our hope is that folks will have empathy, come up, and then curiosity about how they might be able to do things differently. Dr. Stephanie Pinder-Amaker: The title of the chapter is, "What's in A Name?", and this is Dr. Daisy's story. "Adaeze Adebayo-Opeyemi arrived as the highly recruited young doctor to a tier-one academic medical center on the West Coast. Like many young professionals of color, she had grown accustomed to being one of the few or the only physician of color in her class. Throughout her medical training, she'd rarely seen her identities reflected among the professional staff but knew that she could readily find people who looked and perhaps sounded like her among the hospital's food services and environmental services staff. Sometimes she retreated to those spaces for respite." "Dr. Adebayo-Opeyemi knew exactly how to respond to her patients' surprise when she introduced herself as their doctor. She knew to pause and wait for them while they awkwardly set aside the meal-request cards they had hurriedly tried to complete when seeing her enter the room. She knew to take a deep breath when they scanned the room for some external confirmation of her credentials - perhaps a nod from an approving white hospital staff member - if she was headed toward their medical chart. Along with reading a chest X-ray and delivering devastating lab results, she had honed these skills in medical school. Still, she was unprepared for the series of identity-related aggressions (IRAs) she faced in this prestigious setting. IRAs, a term we coined to remove the "micro" from microaggressions, would come in all forms - from patients, fellow peers, and supervisors." "First, due to a misspelling of her last name in the hospital system, Dr. Adebayo-Opeyemi was not able to begin the year with the other incoming physicians. Until the error could be rectified, she was locked out of the medical records she would need in order to care for her patients and complete their orders. Two weeks later, when she was finally permitted to start, her supervisors were frustrated that she was "just learning" to access the medical records and complained to the training director that she was not of the "same caliber" as the other residents. In addition, she found that some of her colleagues struggled mightily to pronounce her name. Others barely attempted. Dr. Adebayo-Opeyemi, ever mindful of how awkward these interactions could be for her colleagues and patients alike, quickly granted everyone permission to "just call me Dr. Daisy!" Unbeknownst to her colleagues, however, in Nigerian culture, an individual's surname is a source of great pride and significance. "Dr. Daisy's" father, Onye Opeyemi, had been a chief. Dr. Adaeze Adebayo-Opeyemi is a descendant of royalty. Her gesture of collegiality in the context of a seemingly simple clerical error had not only undermined a critical professional transition, but it had also begun to erode her sense of self and reputation in the workplace." Dr. Lauren Wadsworth: Why this is problematic: Dr. Adebayo-Opeyemi's experience illustrates how institutions that are ill-equipped and under-practiced in working with individuals with a range of ethnic backgrounds, and other rising identities can erect significant barriers to employee success. It's easy to see how enduring an environment like this could lead anyone with an underrepresented identity to shut down, lower expectations, and bring only part of themselves to the work. Only a culturally humble and responsive setting would recognize that when Dr. Adebayo-Opeyemi acquiesced, asking the staff to "just call me Dr. Daisy!", and staff complied, they became co-conspirators in the erasure of her ethnic identity. This is an extremely common occurrence where individuals are urged to take on an ethnocentric name, to make things easier for the privileged group. Todd Pickard: You know, this vignette really resonates with me because I work with many individuals, and I've worked in ASCO with many individuals who have very different names than my European name. Even though people might want to say, "Picard" versus "Pickard", they're both pretty close. And I find it interesting how many folks will take on an "American name." They may be Asian and they'll say, "Call me Steve," because people can't say their real name." Or they'll have a very long last name which is very common from where they're from, and they'll say, "Just call me Dr. O." So, I can only imagine how that resonates with folks who experience this. So, what can we do about this? You know, on an individual level, how can we learn to recognize and ultimately overcome biases and assumptions? I'd like to ask all of you, but I'll start with Dr. Gilligan to bring him back into the conversation, and then we'll each take a turn. Dr. Timothy Gilligan: Well, I want to start with the brief observation. One of the things I took out of that story, which I think is really central to this whole conversation is, "Whose identity is centered?" And I have many colleagues who don't have European names who adopted European names. My sister-in-law is a Urologist at Harvard, and her name is Golbarg. But in training, she went by "Cathy." "Cathy" is not a name from her family or her background, but it was to make it easier for the white European mainstream American culture. And I think one of the things our trainees encounter when they enter the training environment is that very certain identities are centered, and other identities are not. And for underrepresented minorities and other people with marginalized identities, typically their experience is not centered, and they notice whose identity it is. And when you have a privileged identity, and I hold multiple privileged identities, you get used to being in a world that caters to you, and I think we have to become aware of this. And this issue of learning people's names is not trivial. When we survey our medical students about their complaints, one of the top two is students of color getting called the wrong name, because they get mixed up, because residents or the faculty don't distinguish different black students from each other or different Asian students from each other. Todd Pickard: It's a great observation. One of the easiest places to start to have awareness and to be open to learning is to take the time and effort to learn somebody's name, and to recognize people as individuals because we all are. I, myself, have difficulty with names that are not Eurocentric or Czechoslovakian, because I'm also am Czechoslovakian, and also am French. So, anything outside of my comfort zone is difficult for me, but I recognize it, because I respect and value my colleagues. And I know if somebody called me Fred all the time, I'd be like, "But my name's Todd." So, this is something that's important, and I think you bring a great point. I mean, that's a great place to start, but there's more, right? So, Dr. Wadsworth, what else can one do to learn to recognize and ultimately overcome biases and assumptions? Dr. Lauren Wadsworth: So, one of our favorite things in life and in the book, for Dr. Pinder-Amaker and I, is to come up with real-time practices that people can do. So, our experience is that so many books on diversity, equity, inclusion, really emphasize what you were just talking about, Todd - building awareness. And then they kind of stop there. You know, it's like focus on building awareness and then get better. And what we're finding is that people really want to do better, and are expressing that desire, but are really struggling to say things like the word "racism" in the workplace, or name "I think a microaggression just happened." We were socialized not to do that, not to talk about race, but we think that practicing words, practicing language, practicing names, can be so helpful. So, when it comes to names specifically, some practices that we recommend in the book, and that we've expanded on since are; one, asking someone if you can record their name when they share it with you the first time, so that you can practice it independently, maybe download the VLC app and play it on loop while you're driving into work one day, and that would probably be sufficient to learn it. We also have met with groups that whenever a new person joins, whether their name is Eurocentric or not, everyone in the group repeats their name four or five times as you go around the circle. So, I would introduce myself as Lauren, and everyone would say that four times, and same for anyone else. You could also, say you are teaching a class, or you have a new resident coming in and you're going to have to take attendance, and you might have to say people's names for the first time before they introduce themselves, which is something that gives people a lot of anxiety. Many of the names that folks have are on YouTube, and you know, three-second clicks, you can look up common pronunciation and do some of that practice on your own independently. You might be wrong about how they're pronouncing it, but you're probably going to be a lot closer than just making something up in your own mind. We can also practice things like using they/them pronouns in our groups by doing things like deciding that every staff meeting from now for the next three months, we're going to only use they/them pronoun to refer to everyone. So, whether it's a patient or a colleague, we know their gender identity, or we don't, we're just going to use they/them pronouns for everyone so that we can get better at integrating that as something that we do in our everyday language, so that when a patient comes in that uses they/them pronouns, we are able to just do it automatically versus stumbling and trying to learn it for the first time in the presence of someone that could be hurt by our never having practiced it before. Todd Pickard: That's really an interesting point about practicing. You know, practice does make perfect, right? And you learn from the mistakes along the way. So, Dr. Pinder-Amaker, what other advice would you have? Dr. Stephanie Pinder-Amaker: One of the things that we really emphasize in the book and in working with organizations directly is giving people both permission and the opportunity to practice naming the -ism. As we talked about earlier today, for reasons that go directly back to some of the research cited at the outset of this podcast, as society, we have become much more comfortable, for example, with naming sexism, when it occurs in the workplace, right? We know how to use those words. It's not uncommon to hear someone maybe call someone in for a sexist remark, or to call someone out, as the case may be, for having made a sexist remark. But what we're finding is that as people are increasing their sense of urgency and desire to get some of this right, that it's really important to give people permission to name additional -isms, to name racism when they see it. And to hear themselves saying the words, and to hear each other saying the words, because as we talked about earlier, historically, we've really been taught not to say these words in the workplace. And we really struggle with calling a thing, a thing. To the point made earlier about the importance of validation, that's a big part of validation. Being able to say, "I hear that that happened, and you know what, that really sounds like it stems from a place of racism and it's not okay." That's what validation sounds like. And it's important to give people opportunity to practice saying those words. Todd Pickard: This is such a fascinating conversation; I'm really enjoying it. I know that we are getting close to our time, so I'll start to wrap us up with a final question for the three of you. Dr. Gilligan, I'd like to start with you about what tools and strategies and medical practices are you aware of, or that you have used to increase diversity or at least to do diversity awareness and reduction of microaggressions or biases within your own practice. Dr. Timothy Gilligan: So, my approach, I think is very similar to what Dr. Wadsworth and Dr. Pinder-Amaker are talking about in terms of trying to develop some muscle memory, that this isn't a question of transmitting cognitive knowledge, and if someone just understands it, they'll stop doing it. They need opportunities to practice. Recognizing it, and then also to practice responding to it when they see it. Whether it happens to you or whether you witness it happening, people need to feel some confidence. Because I think just like oncologists are notorious for talking about death with patients who are terminally ill, even though patients with cancer naturally think about death because people associate cancer with death, I think we have the similar version to talking about racism, as she said. And yet it's guaranteed that the other person's already thinking about it, you're not introducing a new topic. But people need comfort bringing this stuff up and knowing what are some skillful things to say. I mean, I have a colleague who uses the phrase, "I'm curious why you're comfortable saying this to me," which I thought was a wonderfully gentle way of pushing back when a microaggression was committed. So, we could teach people phrases that work for them. And what works for me may be different than what works for you, but people need a chance to build on that. And I think the other thing that we're trying to do is, honestly, there's huge disparities in care. There's abundant evidence that black patients are treated differently than white patients, and Latino patients are treated differently than white patients, and women are treated differently than men. There's actually a meta-analysis in a major journal showing that if you're a woman with an acute coronary syndrome, you're 5% less likely to die if you have a woman taking care of you than a man, because men don't follow guidelines when they take care of women with acute coronary syndromes. And so, just getting the news out there that bias is real, is measurable, is well documented. So, the question isn't whether or not it's happening, the question is, how do we reduce it? And the skills practice I think is really fundamental to them, in addition to the awareness. Todd Pickard: You know, one of the things we've done in my practice is, we have cultural-sensitive care. So, when patients with different cultures request respectfully, you know, "I want a woman provider because I'm a woman," and that makes complete sense, it's very easy to accommodate those. But when we find overt aggressions, "I don't want to see a black person. I don't want to see an Asian person." We frame it in terms of safety, and quality, and competency. And so, we change the conversation around the concern and we frame it in, "Well, this is our healthcare provider who is best qualified to give you this safe, quality care." And so, this is how we make sure that you get the care that you need. That generally has worked for us, not always, of course, but I think that's a good way to remind folks that, yes, you can provide cultural-sensitive care, but when there's overt aggression or microaggression, you have to have a strategy to address that with patients, or even with other coworkers. So, Dr. Pinder-Amaker, what are some other advice that you would give for practices to do better in this arena? Dr. Stephanie Pinder-Amaker: I think another bit of advice that we often recommend and find helpful, at least we get feedback that people find it helpful, is to decide together as organizations, as groups, as practices, how you want to receive feedback around some of these issues. Really doing that proactively acknowledges that we are going to mess up, and can help free people up from the state that we often experience of paralysis, that we're so afraid that we're going to make mistakes, that we do nothing, and that is not acceptable, that is not going to get us where we need to be. And so, it's sort of, again, about giving permission to folks to say, "Yeah, we're going to get better at doing this, and it's not going to be perfect, but we are perfectly committed to doing this. And one way that we're going to demonstrate that is to think together as a group, as a practice, how we want to receive feedback when we do mess up, when we make an identity-related aggression, or practice racist behavior, or oppressive sexist behavior." How do you want that feedback? So, it just gets people sort of comfortable and thinking about not being comfortable with making mistakes, but comfortable with the inevitability that they're going to make a mistake. But as an organization, as a practice, we're going to be able to move through this so that we can keep getting better. Todd Pickard: Good advice. Dr. Wadsworth, any final thoughts or recommendations, or things to bring to our listeners' awareness? Dr. Lauren Wadsworth: Sure. I think I'm going to build on Dr. Gilligan and Dr. Pinder-Amaker here and say that it can be helpful to build very explicit step-by-step guidelines for what to do when we've messed up. This is an awkward, uncomfortable, unpracticed topic for, I think, everyone. It's uncomfortable for folks making mistakes, it's uncomfortable for folks who are being harmed, and it's uncomfortable to then talk across identities about these things. So, one example of something that people can do, building on talking about how they want to receive feedback is to make a series of community guidelines for exactly what we want to strive to do when we've messed up. So, for example, on the table in our meeting room, we have, when you've messed up when you've received feedback that you've engaged in an IRA: Step One: Take a deep breath, you know, notice any defensiveness coming in. Two, say 'thank you'; express gratitude for people taking the great risk, and great labor, an emotional labor of educating you in a moment when you've caused harm. Three, recognize and name where your IRA came from. So, "That statement I just said came from racism." You don't have to say, "I'm a racist person." We're naming the societal training that we've been given by saying, "That statement came from racism." And then, talk about, express commitment to exploring why this came up, why you said that racist thing, and a commitment to doing less of it and how you're going to work on that. So, "I'm going to do some reading on other microaggressions that come up around race by quick Google search and try to catch these in advance" and say "sorry" briefly. So, not going on and on, "Will you ever forgive me?" or, "I'm so embarrassed, I feel terrible," and then making yourself the emotional focus, taking the stage, but making a quick succinct apology. So, by having something that's concrete like that, that's written out, giving the group permission to literally pause and pick up the sheet helps people start to do something that's really uncomfortable with a lot more structured framework, giving us permission to use supports and structures to start practicing this work together. Todd Pickard: I really appreciate that concrete example. And in my mind, I said, "Wow, I want to use this anytime I mess up." It just gives you a framework to acknowledge it, but not to suck all the oxygen out of the room and take the stage. It's just to say, "Here it is." Well, you know, this has been a wonderful conversation. I'm so appreciative to all of you. So, thank you so much, Dr. Pinder-Amaker, Dr. Wadsworth, and Dr. Gilligan, for all of your candid and insightful conversations today about the lack of diversity in the workforce, and microaggressions, and implicit biases. I'm sure our listeners are going to appreciate the personal anecdotes and these practical communication tips that you have all shared today on how we can maintain awareness and work together to sustain a diverse workforce. So, thank you all very much. Dr. Lauren Wadsworth: Thank you for having us. Todd Pickard: Thank you all so much to all of our listeners. We appreciate you tuning into this episode of the ASCO Education Podcast. Thank you for listening to the ASCO Education Podcast. To stay up-to-date with the latest episodes, please click "Subscribe." Let us know what you think, by leaving a review. For more information, visit the Comprehensive Education Center at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

"In part two this ASCO Education Oncology, Etc. podcast, healthcare policy expert, pulmonary physician, epidemiologist, and writer Dr. Peter Bach shares what it was like to face his wife Ruth's cancer and eventual passing − as a husband and as a doctor. The episode also explores delivering difficult news to patients. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. Resources: Cancer Topics - Delivering Serious News" The Day I Started Lying to Ruth by Peter Bach, MD After a Cancer Diagnosis, Wishing for a Magic Number - The New York Times TRANSCRIPT Pat Loehrer: Hi, I'm Pat Loehrer, Director of Global Oncology and Health Equity at Indiana University. I'm here with Dave Johnson, a Medical Oncologist at The University of Texas Southwestern in Dallas, Texas. This is the second half of our Oncology, Etc. conversation with health policy and payment expert, pulmonary physician, epidemiologist, and writer, Peter Bach. In part one, we chatted with Dr. Bach about his upbringing, the trajectory of his career from English Literature to Medicine, and from academia to industry. We also explored his seminal work on drug pricing and improving health equity. Today, we're going to continue our conversation with Dr. Bach by asking about something deeply personal: his wife, Ruth, who sadly passed away from cancer at the age of 46. Probably about seven or eight years ago, you wrote a wonderful article in The New York Times, and there was another article you wrote, but the one that I liked reading was called, "The Day I Started Lying to Ruth", and this is where cancer stabbed you very personally. Can you tell us a little bit about that, and tell us a little bit about your wife, Ruth? Peter Bach: So, it was in New York Magazine, just to give credit where it's due, I'm very grateful to them for running it. I wrote that after she died, and it followed on a series I had in The New York Times called, The Doctor's Wife, which I wrote while she was getting her initial treatment for breast cancer, and then I walked through the steps of adjuvant therapy that she received, in my experience. And then the piece in The New York Magazine talks about her last months basically, and my experiences then. The story goes that she was tragically taken from us and tragically taken from my son when he was very young, and my experience being at her side-- and I think I was a good husband, I was present -- was an alarmingly dissociative experience along every dimension. You know, I'd go to her appointment, I would swipe in with my badge. You know, this was my place, and the doctor who took care of her is and was a dear friend, and so were the other doctors in most cases. And the visits, you know, I had nurses and people in the hall would say "Hi" to me. And then I was going through this absolutely devastating experience, you know, tearing apart the sort of prevailing narrative and experience and structure of my life and our family. And so, for whatever reason, it was this out-of-body experience where I could see stuff very, very clearly. Not only clinical realities, like I knew what was happening, but also the mechanics of healthcare, the interactions, and I felt like I should journal it, if you will. And then when I journaled it, I thought I should publish it, and so I wrote about what it was like to stand there when my friend, Chip Cody, the surgeon said, "This is cancer, I can feel axillary lymph nodes, you've got cancer." And what that morning was like between the-- look, most people have a lump, what's the big deal? We'll go, we'll deal with it. She's young. She had just had a mammogram actually, to that. And then the experience of, you know, and I was in Biostat at MSK. So, I'd sat for a gazillion protocol reviews, I'd read a gazillion informed consent forms, and then there was one in front of her for a randomized trial for adjuvant therapy. I mean, it was Avastin versus placebo versus a longer period of Avastin, if I remember correctly, and ultimately a negative trial I saw at ASCO. But sitting there and actually thinking about like, "What is this like for somebody who doesn't know all of this stuff?" And my wife was way smarter than me, that you guys know me, that is the least surprising fact ever. But it was still dizzying for her. And so, I wrote about that, like, hawt was our conversation like that night after that whole, like, "Do you want to join this trial?" And her peppering me with questions, like, essentially, "What the hell is wrong with you guys? Why don't you know these answers?" And it was sort of like, "Okay, this is why we do randomized trials, this is why we have placebo. This is–" And she's smart, not irate. She was much more relaxed and philosophical through the whole thing up until the day she died, or a few days before, than I ever was. So, I wrote about that. Like, what was that conversation like? What was she being asked to do, and how important was it that she did it? And I remember sitting in the room when that trial was presented, and The Kaplan-Meier overall survival curves, and I was pretty sure I saw the step in that curve. I'm pretty sure I saw her on that graph. And it made me-- obviously, I'm desperately sad that she's gone - but it made me proud that she had contributed to it, even though, you know negative studies are important, too. So, I wrote about those things, and I wrote about prognosis and what it was like to have a conversation when she asked about prognosis, and in an article called 'Waiting for a Magic Number', where I described her oncologist saying, "Fine, I'll tell you what are your chances of living five years, you tell me what's the cut point. Essentially, above or below, what number are you going to change things in your life? When you tell me that number, I'll tell you whether you're above it or below it." And it was like, "Wow, philosophy from an oncologist, fantastic." Really sunk in with both of us, and that was it. We never asked that question again, he never gave us a number. And I've been greatly rewarded over the years to run into people from here and there who say, "You know, I always hand my patients that article to put that in perspective." And then when she died, I wrote about the sheer horror of what was happening to me. And the title wasn't mine, but it was worked right on point. I found myself in a situation where I didn't want to reveal to her just how bad things were, and it was terribly weak of me. And ultimately, and I describe it in the article, got to a point where I just was ready for it to be over, before it was. And I think it's actually not that hard, to be honest, after you've gone through something like this like I don't really care what people think of me. I went through something really hard. And again, I'm someone with resources, I'm someone with knowledge, I could call her oncologist at two in the morning and he'd answer, that's not something normal people get. And you know, even for me, like this was completely disorienting. And so, that article was very rewarding to write because it allowed me to put it somewhere where I've gotten to revisit it. A couple of years ago, of course, he was young when I published it. He said he had read it; he liked the part about the dog. But I got a lot of notes afterwards from strangers saying that it provided them some comfort that even someone like me went through basically the same experience they went through. And look, this whole, like, "even something like me" seems odd, but I think to the external world, somehow, we're like, "You know, we get those white coats. Stuff is different for us," and of course, it isn't at all. Since that time, and we're all in the same world, so we have the same sets of friends. We probably have many of our overlapping friends who we know have lost spouses. In recent years, I routinely get phone calls from folks like, "I'm going through this, what's the first step?" You know, and it's about everything. "How do I deal with my kid? Should I go dating?" Stuff like that. Dave Johnson: You know, Peter, that article should be required reading for every Oncology fellow. I think it was beautifully written, clearly from the heart. I think your undergraduate degree shows in terms of your writing style, but to write that, I'm sure was emotionally challenging and difficult. In fact, Pat mentioned at the start of our podcast, Trillin's book, About Alice. In a book review that was written in The New York Times, About Alice, Trillin made a comment similar to the one you just made, where people that he didn't even know wrote letters in which they conveyed to him a sense of knowledge of Alice, even though he knew they had never met Alice. And I think your article about your wife conveyed that same sense to anyone who did not meet her. And I think you memorialized her in ways that are really fantastic. But I want to just read something from an article in The New York Times, and this is quoting Trillin. He says, "They may not have known her, but they knew how I felt about her." And he went on to say, "Yes, I got a lot of letters, like the one from a young woman in New York who wrote that she sometimes looked to her boyfriend and thought, "But will he love me like Calvin loves Alice?" I think the same could be written about your relationship with Ruth. And thank you for sharing that. I can't imagine how challenging that must be even all these years later, and I'm glad your son had the opportunity to read that. He should be proud of both his mother and his father. Pat Loehrer: It was a gift to all of us and mankind. You know, again, as I saw that article, there's a photo of you and Ruth on your last vacation. I think it was from Versailles, and I think you were in the Hall of Mirrors. And I think there's a poignant metaphor there about the reflection of your lives and being with her at that time, and we really thank you. We have all experienced this and it's so powerful there. There's this time when you get a result of a test of someone that you know and love and there's this limbo between, they're so naive and life is good, and it really is a time between heaven and hell in which you're the only one there, in which you know that you're going to go in the room now and change their lives forever by sharing this news. And we've been there and we pause, and again, you talked about that - I think being in a car looking at the x-ray. And that's the essence of when you said, the day you started lying to them, which is understandable because you just don't want to shatter that moment there. You know, we pause and reflect on that enormity of the moment there and I thank you deeply for sharing that with us because it's something that we physicians find, and this uniqueness of being a physician, and having someone you care about and knowing something that they don't quite know yet. Thank you for all of that. Peter Bach: The important message is that to patients, it's very isolating. And part of what I think the article did, and this was the message I got at least, was, send a message to other people that you're not alone. That others are going through it, others have gone through it, and I don't know what "it" is in that context, but loss. And there's that wonderful article in The New Yorker called 'The Aquarium', which is by man who had a sick child-- and I don't remember all the details, but the aquarium metaphor is, I can't remember if he's in the aquarium and the rest of the world's outside or the other way around, but it's that isolation that is particularly frightening. And when I talk with my friends who've gone through it, it's part of it. As I just said, you know, there's a lot of us out there. I don't know if it gives so much reassurance. You know, 40,000 women die a year of breast cancer, so there's a lot of people out there. Dave Johnson: Pat, you had, I think, a final question? Pat Loehrer: Briefly. You know, now I'm asking to be an academic person there, but if you had a young medical student and you were going to try to give them one lesson about communicating bad news to patients, what would that be? Peter Bach: I've obviously been in this situation many times. I'm a Pulmonary Critical Care doc, so I've watched bad news be delivered many, many times. And the first mistake I see people make is trying to fill the silence with words, and I think I made earlier reference to it. One of the key skills doctors need to develop is the ability to listen. And sometimes listening to silence is a version of listening, but it's delivering what you have to say without euphemism, with directness. Not everyone's enamored with it, I am. But then giving time to listen, even just space for people to feel safe, that that communication is part of a relationship, not a sort of text message. You know, in today's metaphor, right, that just arrives and the person moves on. That is really hard for people to do; not experienced doctors, for trainees because it's frightening for a lot of reasons. Over my career, I've certainly rehearsed it many times with people. I made the mistake myself too, of just sort of talking over the thing in the room to avoid, you know, just sort of as you said, the enormity of what you just communicated. Dave Johnson: So, Peter, I think you're right on. I think that's one of the most difficult things to do, is to allow that pause to take place. And so many, even highly experienced physicians attempt to fill that void when it doesn't need to be filled. Been there, done that, been on the receiving end as well as the delivery end of that. It's always challenging. You know, we're out of time, and I'm sad about that because we could go on, I'm sure for quite a long time. Want to end this by asking you, Peter, we talked about a book on the front end, both Pat and I love to read, and we share recommendations all the time. I wonder, is there a book or a podcast, or anything that you think we should read or you think our listeners should know about? And by the way, you can include anything that you wrote if you'd like. Peter Bach: Yeah, it'd be very au courant to pitch my own stuff here, I would never do that. I like to read as well. And so, I just finished Rules of Civility by Amor Towles. Of course, there's a few health events in it, but it's not to do with anything, but, you know, it's a book about New York. I live in New York, so I just enjoyed every single word of it. I'm newly married- Dave Johnson: Congratulations. Peter Bach: -thank you. I feel very lucky. And my wife has noted that I often like to read nonfiction at night. Typically, books about how the world is just going completely to hell. And she's noted that outrage is my happy place, that I sleep extremely well if I read something that's absolutely infuriating. So, the other thing I'll recommend is the book about the Department of Justice has essentially lost its mojo when dealing with corporate crime. If your best soporific is being absolutely furious, it's right up there with a full dose of Ambien. So anyway, those are my two recs. Pat Loehrer: I love it. Yeah, Dave and I both love non-fiction. We love that. So, it's great. Dave Johnson: We've come to an end of another podcast, and we want to thank our listeners for tuning in. We really appreciate your participation. Remember, Oncology, Etc. is an ASCO Educational podcast, where we'll talk about virtually anything and everything. So, if you have an idea for a topic or a guest you'd like for us to interview, please email us at: education@asco.org. Thanks again. You know, speaking of interesting nonfiction, Pat, if 'pro' and 'con' are opposite, what's the opposite of progress? Pat Loehrer: Oh, I love that - Congress. Dave Johnson: Yes, Congress. I knew you would get that. Peter Bach: That is a 'Dad joke' if I ever heard one. Dave Johnson: We don't have good jokes on this show. Pat Loehrer: We're going to have to redo the ending to this because, Dave, you said this was an ASCO Education Podcast. I'm not sure we've taught anybody anything on this one. Dave Johnson: Now, Peter has taught us a lot. Pat Loehrer: That's for sure. Thank you so much, Peter, for a wonderful interview. Dave Johnson: Absolutely perfect. Wonderful. Peter Bach: Thanks for the privilege. It's wonderful seeing you both. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click, "Subscribe." Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

"In part one of this two-part ASCO Education Podcast episode, host Todd Pickard (MD Anderson Cancer Center in Houston, Texas) sits down with licensed clinical psychologist Dr. Lauren Wadsworth, Harvard Medical School professor Dr. Stephanie Pinder-Amaker, and medical oncologist Dr. Timothy Gilligan, to discuss diversity in the US oncology workforce today. Dr. Pinder-Amaker and Dr. Wadsworth share excerpts from their book "Did That Just Happen?!" along with personal experiences to illustrate how various prejudices and micro-aggressions can impact healthcare providers and practices. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org." TRANSCRIPT Todd Pickard: Hello, and welcome to the ASCO Education Podcast series. My name is Todd Pickard, and I'm a Physician Assistant specializing in Oncology at the MD Anderson Cancer Center in Houston, Texas. As today's host, I will be moderating a discussion on increasing diversity in Oncology practices with three guest speakers: Dr. Stephanie Pinder-Amaker is a Clinical Psychologist and Harvard Medical School professor; Dr. Lauren Wadsworth is a Licensed Clinical Psychologist in New York and Massachusetts, specializing in OCD and anxiety disorders; and Dr. Timothy Gilligan is a Medical Oncologist and Associate Professor of Medicine at the Cleveland Clinic Taussig Cancer Institute. Welcome everybody to this interesting discussion today. I'm very much looking forward to hearing from all of you about this important issue. Let's start with Dr. Gilligan. How diverse is the US oncology workforce today in terms of race, ethnicity, gender, age, culture background, and any other identity factors? Dr. Timothy Gilligan: Not nearly as diverse as we'd like, particularly, with regard to race. We've made significant progress with gender diversity, and there are many more women in Oncology now than there were previously, and more and more in leadership roles as well. But if we look at underrepresented minorities in medicine, Latinos, Blacks, other groups, the numbers are still very low. 3% of practicing oncologists are black, and 4% of oncology fellows are black, for instance. Fewer than 5% are Latino. And we haven't seen a lot of progress over time with those numbers. Todd Pickard: That's really interesting to me, Dr. Gilligan, because our population has changed. So why are we not reflecting that? So, can you think a little bit about that? What have you noticed in the diversity in medicine - oncology specifically? Has there been any kind of change in the past couple of decades, or have you observed any cultural shifts during the span of your career? Dr. Timothy Gilligan: I don't know how to explain the racial disparities other than obviously, the broader issues of systemic racism and bias and gaps in educational opportunities. But even if we look at medicine, 6% of graduating medical students are black and we're still seeing a significantly lower percentage going into oncology. Specifically, if we look at even just Internal Medicine subspecialties, oncology is at or very near the bottom of subspecialties that black residents apply to, to train in. So, I think we haven't done a good job of recruiting black doctors into oncology, and we certainly need more black doctors. And similarly, we need more Latino doctors in oncology as well. And it's a complicated issue. I think honestly, those of us who are working on that now really see it as a pipeline issue that we need to start as early as high school, to make this career seem attractive. First of all, to get more students of color to go into Medicine in the first place, and then hopefully, once they're in Medicine, to see oncology as an attractive subspecialty to go into. Todd Pickard: That's really interesting, because we see the same thing in advanced practice for PAs and Nurse Practitioners that we still have a diversity issue in recruiting folks. So, this is something that is widespread in our medical teams. So, this is a really important conversation to be having. I'm going to start with a different series of questions, and I'd like to ask Dr. Pinder-Amaker if she could respond first. What are the benefits of having a more diverse workforce? What's the impact on our wellness as teams, but also the patient experience? And then we'll ask Dr. Wadsworth to also chime in. Dr. Stephanie Pinder-Amaker: Thank you for the question, and thank you for having me. The evidence is compelling, and it's overwhelming. We know that there are many, many benefits. Diverse teams are stronger, they're smarter, they're more innovative, more profitable even. We know that this is true across industries, and across organizations, including medicine, and therefore, in academic medical centers. The challenge is that many organizations and systems and academic medical centers struggle to create a true culture of inclusivity and belonging. So, while there is, and has been an increased focus on the recruitment of individuals who historically have been underrepresented in Medicine, we know that the increase in recruitment doesn't necessarily translate into retention. There's a gap there, and it's really incumbent upon us to close that gap so that we can not only recruit, but retain diverse talent and achieve some of those superior outcomes, including improved patient care, more innovative research, and so forth. And we're aiming to close that gap in a very specific way by creating systems and organizations that are much more culturally responsive. Dr. Lauren Wadsworth: Yeah. I will just add, this is Dr. Wadsworth speaking, that when we have more diverse clinicians, we know that patients that have minoritized identities like black patients or queer patients, feel more comfortable working with their teams. This might be due to experiencing less microaggressions from black doctors to black patients, for example, and could also be for a number of other reasons. But additionally, we know that even if a patient isn't being seen by a provider that identifies the same as them, teams that are more diverse have the opportunity to have more cross-pollination, more conversations about cultural practices, microaggressions, et cetera, that can then improve the ability for the whole team to provide culturally-responsive and humble care to the patient. Dr. Stephanie Pinder-Amaker: Incidentally, the whole practice of cultural humility was originally founded by two women physicians of color, specifically to address this gap within hospital systems. And now it's of course taken root across other industries and other relationships that where there's sort of a critical imbalance of power, but it originated to look at addressing the power imbalance between doctors and patients. Todd Pickard: I am really fascinated to hear Dr. Wadsworth and Dr. Pinder-Amaker's perspective because they are both authors of a recent book, Did That Just Happen?! And I want to talk a little bit about the book, but before that, Dr. Wadsworth, you used the term microaggressions. Could you let our listeners know a little bit about-- I think they may assume what that means, but I'd like to hear an official version of what it means. Dr. Lauren Wadsworth: Sure. You might be sorry you've asked, because I actually have a lot to say on this topic. So, microaggressions historically has been a term used to describe often common, subconscious slights or statements, or physical movements that enact stereotypes. So, for example, a white woman seeing a black man walk down the street from the other direction, might clutch her purse or change her purse to the other side, which would be a physical manifestation of a stereotype that black men are dangerous. And that would be a microaggression, whether or not she was conscious that she was doing it. Dr. Pinder-Amaker and I believe that the term microaggressions is really helpful in starting to bring white people and other folks with privilege into the conversation, to start to recognize these unconscious biases playing. And the micro part of that term, we think really prioritizes the person with privilege, in that, it focuses on the smallness of it, the unconsciousness of it, which makes it a bit more palatable for people with privilege to recognize that they might be doing these things if they're not intending to. In our book, we actually coined a new term, 'Identity Related Aggressions' or IRAs, which is a new way of describing the same concept, but prioritizing the impact or prioritizing the person that was hurt or harmed in the instance. So, by saying Identity Related Aggressions, we're taking out the 'micro' and acknowledging the exponential burden that these experiences can have much like IRAs in financial terms. Todd Pickard: Yeah. It's really interesting because, as a person who might be identified as a person of privilege, it's really difficult to remember…you may meet somebody that you don't know, and they may have a very interesting accent. And I've done this before, and I've said, "You have a really interesting accent, where are you from?" And I had some social workers with me at the time, and they said, "Todd, I can't believe you're having these microaggressions." And I said, "I am?". And so, it really is so easy just to slip into these things without even realizing it. And it's great to have this conversation. So, Dr. Pinder-Amaker, what was the reason to write this book? Why now? What was that about? Tell us more. Dr. Stephanie Pinder-Amaker: We had many, many motivating factors for writing this book, as you can probably imagine. I'll start with a couple, and then Dr. Wadsworth, you can take it here. One thing is, really to focus on what we're talking about now, like, how do you address this disconnect between diversity and create real inclusivity? It's pretty accurate to say we're fascinated by, intrigued by the practice of inclusivity and cultural humility. How do we work with organizations and people within organizations to move beyond what we refer to as, diversity by the numbers, which also matters, but to actually create systems that are welcoming and inclusive so that when people of diverse backgrounds do enter our spaces, in this case, we're talking about oncology, which have been historically white, that that diverse talent feels welcome, and valued, and seen, and heard. So, we're just really intrigued; What does that look like? What does inclusivity in practice look like? How do you break it down? How do you teach it to people? How do you explain the skills so that people feel empowered to learn them?" You mentioned, Todd, having been maybe called in by a social worker-- I'm not sure if you were called in or called out in that instance, but even knowing the difference there, is a skill that we want to be able to teach people so that we can get better at creating inclusivity and belongings. And there's real significance in those kinds of details. A second motivating factor; we're both psychologists, we're both clinical psychologists, we're practitioners, but we're also researchers. So, we were highly motivated naturally to apply evidence-based practices from within our field to understanding and explaining, operationalizing inclusivity. We wanted to do it in a way that would be accessible so that people could really hear it. Like, keep the science, but lose the jargon. How do you make this information practical, accessible, so that people can hear it, not turn away from it, lean into it, and also feel empowered? Like, "I could actually do this." So, there's effort to both do it, but also to make it plain. And those two things were significant motivating factors. And Dr. Wadsworth, why don't you talk about a broader one? Dr. Lauren Wadsworth: Sure. I'm guessing you mean our personal motivations? Am I right? Dr. Stephanie Pinder-Amaker: I think you're right. Dr. Lauren Wadsworth: Okay. So, as people who hold marginalized identities or rising identities, which we're also trying to use both of those terms interchangeably, me as a queer woman, and Stephanie, as a black woman, we often had the common experience of being the only, or the pioneer in each of the places that we worked. Coincidentally, those were often medical settings or academic medical centers. So, to Dr. Gilligan's point, we experienced the lack of diversity ourselves. As a result of being the only, or the pioneer, we frequently experienced not only Identity Related Aggressions, but simultaneously requests to train those of our colleagues on how to become more culturally aware and responsive. So, we were given the label 'diversity expert' just by entering the room, in Dr. Pinder-Amaker's case, or coming out, in my case, in the workplace. And so, there was a lot of ambivalence there. We didn't seek to become diversity experts in our careers yet we're continuously given that forum and felt that we did have things to share just from our personal experiences. So, over the years, we ended up working in the same institution, and experiencing the same pattern, and finally finding each other, and finding a lot of support and solace in our work, discussing that experience together. And our hope was that we could create a booklet of advice that could be both validating, to those who are also experiencing Identity Related Aggressions in the workplace, and informative, and welcoming, for those in leadership to change things at their institutions. Todd Pickard: I really enjoy your story. And if folks could see us, they'd say I'm nodding my head a lot when you guys were talking, because so much of what you say really resonates with my own experiences and the things that I've witnessed in my 24 years practicing. I appreciate the fact that you are trying to make this welcoming, because when people become defensive, they stop hearing, and they don't learn. So, when it is presented in a way that brings them in and gives them permission to engage and ask questions in a truly thoughtful way, I think that's where you have the most impact. I'm very, very much aware of and appreciate the fact that y'all are doing it. I want to pull Dr. Gilligan back into the conversation, and I do want to hear more about your book, so we'll come back to that. But Dr. Gilligan, from your experience as the Diversity, Equity and Inclusion Officer for the Cleveland Clinic's Graduate Medical Education Council, could you tell us about diversity and inclusivity in medical training programs? Are the trainees prepared to succeed in a diverse workforce, or do they experience any issues in this area? Dr. Timothy Gilligan: They certainly experience issues. And you raised one of the issues; microaggression and Identity Related Aggressions are commonplace. That's been studied and documented, that trainees experience these regularly, both women and people of color. I don't know as much about the LGBTQ space in terms of how much that's been documented, but I do know anecdotally from colleagues here, that that happens as well. So, it's a big issue. This takes place at some of the levels that we already discussed; you show up in the program, and you're the only person who looks like you. And you're trying to find a mentor, and you can't find a mentor who looks like you. And so, there's structural problems that the lack of diversity makes it harder for people of color and other oppressed identities, for people to feel welcome, at home, competent. There's an issue of stereotype threat, which describes the process where people underperform because they're worried about conforming to negative stereotypes that people hold about their identities. And so, there's been interesting research on this, that black students or other students of color may not perform to their potential if they're noticing they're not set up to succeed intentionally. So, I think the learning environment issue is important. One of the things that we're trying to do is to train faculty to be more aware of these issues, issues of implicit bias. There's evidence that people performing at the same level are judged differently based on their identities, particularly around racial identities. Written documents; if you tell someone that is written by a white person it will get evaluated at a higher score than if you tell them it was written by a black person, there's been evidence in the legal world about that. So, students come in and they encounter the same bias in medicine that they're going to encounter everywhere else and that can feel like a hostile environment, or unwelcoming environment. So, I think a lot of the stuff that has been discussed here already in terms of making people aware of oppressive behaviors of microaggressions, of implicit bias, so that we can start to do those behaviors less, or at least be aware of them when they have been, and respond to them. And then put into place support so that people feel like they are supported. So, one of the things we're doing is put in mentorship programs so that people can find mentors who look like them, and talk about their experience. It doesn't mean that all your mentors are going to share your identities, but at least to have access to people who share your identities, and could share the difficulty attached to those identities, of succeeding in a world that is to some extent, still dominated by white men. But again, it's a multifaceted thing. I think we're trying to change the culture from the top-down. If we diversified the institution, then the students are training in a more diverse environment, and feel more welcome, feel more supported. As people have more tools for recognizing bias, and reducing it, and responding to it when it occurs, people feel, I think, more supported there. I think one of the things that I find is that there's a sort of crazy making psychology where someone experiences bias and no one believes them. And then they're left wondering, "Is it just me? Is it just in my head?" And so, I think validating people's experiences… The last thing I'll say, one of our Diversity Officers we asked him, "What are some things that we can do today?" The first thing he said was to begin validating other people's experiences of their own life. If we just do one thing, like just focus on microaggressions, that's not going to do too much, it requires a much broader strategy from recruitment to faculty training, to the educational environment. Todd Pickard: I think that what you've said is so important. I want to highlight; it is not just about microaggressions. Implicit biases that we all bring from our experiences are really important to acknowledge. It's very easy to say, "Oh, this person looks like me, so they must act like me, and share the same values as me." And I'd like to ask Pinder-Amaker, what we're discussing is something that is not just a white person issue. It's about all of us, all of us depending on where we come from, and our background, and our experiences may have biases. Can you expand on that a little bit? I have friends who are from Africa, they're from Ghana. They have black skin, but they have biases against American black people because they think American blacks are lazy. And so, what I'm talking about is how it's not just the color of the skin that makes you capable of having implicit biases or microaggressions. It's larger than that. Dr. Stephanie Pinder-Amaker: In the opening question, there was a nod to what we mean by diversity. We're talking about diversity across social-cultural identities. We use a specific framework to help remind us about how expansive social-cultural identities are. And that happens to be what we often refer to as probably the longest acronym in the world; it's The ADDRESSING Model, by Dr. Pamela Hays. And ADDRESSING each letter of the word reminds us, directs us to a very specific aspect of identity, so that we are focused on, "Oh yeah, there's diversity." Yes, we're talking today, a lot about race and ethnicity, but also, there's age, ageism and ableism. And people hold historically minoritized identities, and oppressed identities, and statuses across these social-economic status, and sexuality, national origin, as you may have referenced earlier, religion, and so forth. And so, when we're working with systems to think about just what Dr. Gilligan mentioned earlier - why it's so important to have multi-pronged, systemic and holistic approaches - we don't have time to do one thing at a time when it comes to really addressing some of these very structural and systemic barriers that occur across a broad range of social-cultural identities. Todd Pickard: Well, this concludes part one of our discussion on increasing diversity in Oncology, with Clinical Psychologists, Dr. Lauren Wadsworth, and Dr. Stephanie Pinder-Amaker and Medical Oncologist, Dr. Timothy Gilligan. In the second part of this episode, we will discuss the importance of using correct pronouns, and consider different approaches to learn or pronounce a person's name. We will also explore culturally-sensitive tips for individual healthcare providers. Thank you to all of our listeners for tuning into this ASCO Education Podcast. If you have an idea for a topic or a guest you'd like to see on the show, please email us at: education@asco.org. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click "Subscribe." Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

"In part one of this two-part ASCO Education Oncology, etc. podcast, hosts Patrick Loehrer and David Johnson chat with health policy and payment expert, pulmonary physician, epidemiologist and writer Dr. Peter Bach about his background and career. Dr. Bach, who created the Drug Abacus, shares his views on cancer drug pricing, based care, and health equity. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org." Dr. Patrick Loehrer: Hi. I'm Pat Loehrer. I'm Professor of Medicine at Indiana University and Director of the Center for Global Oncology and Health Equity. Dr. Dave Johnson: And hi. I'm Dave Johnson, Professor of Medicine at UT Southwestern in Dallas. Dr. Patrick Loehrer: And this is Oncology, Etc. Welcome to the show. Dave, what have you been reading. There's a book that we chatted about earlier that I think might tie in today's discussion. It was called About Alice. And we both had a chance to read that book. I've met Calvin Trillin. Dr. Dave Johnson: Yeah. We read it a few years ago. I think I recall us being at a meeting in San Francisco, and you mentioned the book to me. And actually, Calvin was a guest and a speaker at that particular meeting, so we both got a chance to have our copies autographed by him. It was an amazing book. Dr. Patrick Loehrer: Yeah, just for the listeners, Calvin Trillin is a wonderful writer for The New Yorker, and his wife had cancer, had treated, and unfortunately developed complications in that. And this was kind of a memoir to this. One of the things I love is when they first met, they met at a cocktail party, and Alice was just stunningly beautiful—there's a picture of her in the book—and Calvin is not. He looks like Dave and I combined. But their eyes glanced, and in the book, he talks about the fact, years later, Alice said to Calvin, "You have never been as funny as you were that night." And Calvin says, "You mean I peaked in December of 1963?" And Alice goes, "I'm afraid so." So that resonates with me a lot, actually. But Dave, why don't you introduce Peter? Dr. Dave Johnson: Yeah, happy to do so. It's been terrific to have him on today. Peter is a health policy and payment expert, pulmonary physician and lung cancer epidemiologist. He's a true Renaissance man. Peter spent nearly a quarter of a century at Memorial Sloan-Kettering, where he served as director of the Center of Health Policy and Outcomes. He has devoted his career to repairing defects in the healthcare delivery system that impede access to high-quality cancer care, and working to ameliorate healthcare cost crises. His work spans seminal studies, including the identification of racial gaps in lung cancer care, the development of the first lung cancer risk prediction model, lead authorship on multiple lung cancer screening guidelines, and definitional work on pharmaceutical pricing and value. Last year at about this time actually, Peter moved to become the Chief Medical Officer of Delphi Diagnostics, a developer of blood tests for early detection of multiple types of cancer. Peter received his undergraduate degree from Harvard and medical degree from the University of Minnesota. He then took internal medicine training at Johns Hopkins, followed by a fellowship in pulmonary and critical care at the University of Chicago, where he served as a Robert Wood Johnson Foundation clinical scholar. Along with his prolific scientific writing, Peter is a regular contributor to The New York Times and other newspapers. He is a frequent but fair critic of pharmaceutical drug pricing in cancer and a staunch advocate for value-based drug pricing. In addition, he has written extensively on a number of personal and provocative topics ranging from the death of his wife, medical school tuition funding, to setting physician reimbursement based on market forces. Not surprisingly, he's amassed a number of accolades over the course of his stellar career, including, to mention a few, election to the American Society of Clinical Investigation, the Association of American Physicians, and the Johns Hopkins University Society of Scholars. So Peter, welcome. Thank you very much for joining us. Dr. Peter Bach: Oh, it's a real pleasure, Dave and Pat. Dr. Dave Johnson: Well, why don't we kick things off by starting with a question we ask almost all of our guests? And perhaps just give us some little of your background, your upbringing, your early life? Dr. Peter Bach: I'm a faculty brat from the University of Wisconsin. Both of my parents were on the faculty there. I grew up in Madison, which was a bucolic place. And I think early on was expected to be a doctor. My major defection from that was I majored in English literature in college, but I ultimately had a chance to circle back to that opportunity, spend a month with Nancy Ascher actually following her around one summer after I graduated from college, holding retractors during liver transplantation surgeries and other things. And it was a transformational summer for me. I hadn't been, you know, sort of pre-med, but that summer after college, the proximity to the human experience that being a doctor afforded and the opportunity to help people and use the few abilities I had in a productive way convinced me I had to go be a doctor. And so I taught English for a couple years after college at two different boarding schools, and then went on to medical school with that very much in mind. I'm really privileged to have practiced for as long as I did before I turned most of my attention about a decade ago exclusively to research and policy. Dr. Dave Johnson: That experience as a literature major, I think, is really an important one for medical students today. We still focus on science, which of course, is absolutely critically important. But the humanities are also extremely important, in my opinion, to that transition from being a doctor to being what I call a physician, someone skilled in the art of healing, and not just the knowledge of science itself. Dr. Peter Bach: I agree with you. I think a core competency of practicing doctors who are empathetic and also who are better diagnosticians is having good listening skills. Listening and elicitation skills. I don't know if that comes from majoring in English, but you know, I think those sorts of perspectives that the person is more than just a vessel of signs and symptoms, I think, lays the groundwork for doing that well, I hope. The origin of the word doctor is, of course, teacher also. And so, communication is vital. Dr. Dave Johnson: You mentioned that your parents were teachers at the university. What were their specialties? Dr. Peter Bach: My father, who's gone now was a physician, but never practiced. He was a transplantation immunologist, laid much of the groundwork for solid organ transplantation and major histocompatibility complex was defined in large measure by his work and several others. He was the scientist who did the immunological compatibility work that led to the first bone marrow transplant, actually. And then my mom is a biochemist and also worked in genetics on the faculty there. And then they both moved, although separately, to the University of Minnesota, where I ultimately went to medical school. Dr. Patrick Loehrer: So did it break their heart when you said you wanted to go into literature? Dr. Peter Bach: No. What broke my father's heart was that I became an epidemiologist, which he always considered not really science. Dr. Patrick Loehrer: Actually, I was thinking one of my favorite poets is William Carlos Williams, who just hung out in Paterson and delivered, I don't know, 1000 babies, but he used that experience with the patients to help guide his poetry. But I think as we get older, every patient we see, there's a little story in there that's really kind of unique. And so it's a great opportunity. Tell us a little bit about this transition from academia to industry. Is that an easy role? Tell us a little bit about that journey. Dr. Peter Bach: Yeah, the transition was easy although not pre-planned, expected at some point. I'd reached a point in my life where I had done a great deal of things in the academy that I'm mostly proud of. I had accomplished a number of things that I wanted to accomplish. And like many researchers and, my health care policy work I consider to be research and exploration, I had reached one of the many plateaus you get to where I thought many of the questions and issues I'd worked on, I'd sort of resolved. Not that they had been fixed, but I had done the amount of disarticulation that I sought to do in that work. And so I had reached a point where I wanted to figure out what my next new topic was, which I do, and have always done in my life for about a five-year cycle. And I decided my next topic was I wanted to do something new and work on something totally different, although with a lot of resonance to my past work. And the new thing I wanted to do was to be an operator, to work in a in a startup environment where I could play a small role in developing not only potentially important technology, and there's a scientific question in there that matters, but also build the culture of an organization and take the management and leadership abilities that I did trying to hone in the academy into other environments. The most sophisticated word I can think of to describe it as it's awesome. I went not understanding the first thing about the technology, but understanding the clinical use case of it pretty well because of my background in prevention, early detection in lung cancer screening particularly, which is our first product is lung cancer prescreen biomarker test. I'm lucky to work with serious scientists who are also educators like Victor Velculescu who spends a huge amount of time, especially early on, spent a huge amount of time just teaching me about the technology, about echoes of DNA fragmentation, changes that you see as a result of cancers, abnormal mitotic cycle. All words I knew, but none that I've seen put together in a cohesive way. So I'm really excited about it. And I think it may be the case that circulating DNA analyses or other kinds of biomarker assays for early detection of cancer, it could be that these are really transformational discoveries. I want to be part of defining that field of keeping the rigor at the level it needs to be to think first and foremost about the tested subjects rather than sales of a test, and making sure that clinical studies and clinical use are carefully defined to ensure or make as likely as possible that the benefits exceed the risks for everyone who has a test like this. That is difficult to do. The field is quite nascent. The reason we started in lung cancer, and the reason I was attracted to Delphi specifically, was that lung cancer has established clinical utility for screening itself. And the real problems we have with lung cancer screening relate to uptick, where at about 5% of eligibles being screened right now, even conservative calculations suggest we're losing 10,000+ people a year due to that shortfall. And my entire career has been focused on access to technologies, treatments, and other things like that, procedures at the level where we're bringing some of the health benefits that the technologies could provide. And so this is a different version of that same story. Dr. Patrick Loehrer: If I can take you in the past a little bit, we had Deborah Schrag on a few months ago, and we were talking about Zaltrap and your role in that. It was really a rebellious moment, when you, I think, led the charge to challenge the price of this drug. Can you briefly tell us that story for our listeners? I think it's kind of interesting. Dr. Peter Bach: Zaltrap. So I didn't lead the charge. I happen to be first author of the op-ed, but Len Saltz who ran Pharmacy and Therapeutics Committee is obviously a world-famous GI oncologist really was the motivating source of this. I got involved because he reached out to me and said, "There's this new drug, and I'm on the P&T committee. And we're going to reject it because it costs too much and it's no better than this less-expensive drug Avastin." He called me. We're friends. And I said, "Okay, you know, that's outrageous and exciting. How can I help?" And he said, "Well, I want to make sure we're right that it costs more than Avastin" We already had this system in place at that point. Since 2009, we've been posting cancer drug prices, which we calculated in certain ways that were robust and defensible and in the peer-reviewed literature and stuff. And so that got my interest very considerably. And then as he and I started to talk about it, I honestly don't remember which of us first proposed the idea that we not only reject it, but we announce it in some very flagrant way. And I think for whatever reason, you know, we ended up saying, "Okay, let's just write an op-ed. Let's see if we can get an op-ed into a major outlet." Then I'd written about this extensively. The basic argument is, there's so many layers of opportunity where pricing could be dealt with where it isn't. And we were sort of the last frontier. So FDA could care about price. It doesn't. The Medicare could care about price. It doesn't. Although the new legislation that passed the Senate will change that if it passes the House and it's signed by the President, but back then that wasn't true. And so we were like, look, we're the last man standing, if you will. We're experts in this. We can say definitively, we're comfortable with not having this drug because we have this other drug Avastin, which costs half as much. That means it costs half as much for patients, means it costs half as much for society. We're not going to use it. And so we wrote an op-ed in The Times that got more coverage than we expected. Then a miracle happened. The maker of the drug, Sanofi, lowered its price to match Avastin. There was a little kerfuffle prior to that which all played out in the Cancer Letter where they initially said that our math was wrong. And then I think that was a mistake because then we showed that our math was right, at which point they had used up the one shot in their musket. So yeah, so they lowered their price and a lot of good things happened as a result. Not the least, of which patients had access to Zaltrap, a perfectly good product for less money. But it was one of the events over the early last decade, that showed what a Potemkin village, this whole drug pricing thing is and has been all along, that these prices are not calculated based on the therapeutic value or the value to patients. And they're not carefully constructed, back calculated from the years of R&D from which they emerged or carefully titrated like the launch coordinates on a moon shuttle or something. They're made up simply based on what the market will bear. And that market has continually softened by rapidly rising prices. And the truth is the market isn't the patients paying for drugs, it's the doctors administering them. And because this was an infused drug, doctors make more profit on drugs that cost more. So, what was terrific about Sanofi, essentially, overnight, although I think it was about a week, cutting its price by half, is it revealed the fact that the price in the first place was just a paper tiger. And they could just as easily charge half as much, just as easily cost twice as much. And that was terrific, because I think then, like I said, it was one of the events that began to drop the veil on how all of this pricing worked and how little it had to do with any of the claims the industry was making. Dr. Dave Johnson: I mean, I saw that as a transformational moment. I think kudos to all of you - Len certainly and yourself, for bringing that to the public's attention. And you've actually even created a tool that I think you refer to it as your abacus. Could you tell us a little bit about that, perhaps? Dr. Peter Bach: The Drug Abacus was a 2015 thought experiment. My team and I built it to essentially empirically counter or, if you will, test the pharmaceutical industry's narrative that their pricings were based on therapeutic value. And so the narrative up till then went like this: "Well, we price our drugs based on the value they deliver to patients." That's what someone would say. And then I or somebody else would say, "Great. How do you define value?" "Oh, you know, it's like love. You can't really define it." Which makes the supposition or assertion both untestable and de facto untrue. But nevertheless, the exercise was about okay, fine, let me dimensionalize love or value along the maximum number of dimensions I can think of. And actually, we did an update where we added more dimensions after we heard objections to the first. We basically said, "Look, the only things this could be is if it lengthens life, has low toxicity, it's for a rare disease, it costs a lot to develop, it's a particularly novel compound." We just gleaned from prior statements from the industry and different companies what these dimensions would be. And then we took, I can't remember off the top of my head, 50, 60 of the most recently approved cancer drugs. And we measured each of these things. And we normalized them and we put them into equations. What was I think a good idea at the time, and the Drug Abacus, is the name of the tool is we didn't assign any values to each of these dimensions. Instead, we built a calculator, essentially a slide rule, where you could go in and whatever your vision was for how you should value a drug, like really life expectancy gains matter, really scientific novelty matters, or orphan status matters, you could re-weight them, essentially change the coefficients in mathematical language to see like, what should the prices be if you really care about X and care less about Y or whatever. And then the other thing we did is we summed the total spending on these drugs based on real sales figures, and then allowed the total spending to change based on the modulated prices emerging from this calculator and carried with it two lessons. One was, there was no way to set these dials, and they were pretty close to infinitely flexible, to achieve current prices. There was no solution equation. And other people had shown that as well using different methods. But the other is that you had to trade things off or you spent more money. And that is a key issue that I think has been recapitulated a lot over the last several years. And it's recapitulated again in the bill the Senate just signed, which was we want to lower out-of-pocket costs and total spending amongst Part D Medicare beneficiaries, we are capping it at $2,000, for instance. And if we're going to do that, the government's going to spend more money, where are we going to get the savings? It will be through lower drug prices on older drugs. And so there's that classic trade off. The drug advocates illustrated both of those things. Then, like I said, we updated it later and added some other, I think, two more parameters. Results were the same, but if you will, it's a sort of classic empiric debunking tool with a lot of computer programming behind it. A lot of the work I'm proud of may not seem very 'researchy', but it derives the ability that my team developed to operationalize and empirically test claims about pharmaceutical innovation. And by doing that, you can essentially debunk if your instincts are right, or reaffirm or whatever. Dr. Dave Johnson: I find it a fascinating tool. And, again, kudos to you and your team for doing so. I think it helps bring to light the challenges of pricing a drug appropriately in the market. You've mentioned a couple of times now, the Inflation Reduction Act. What are your thoughts about that? Are you happy that this is happening? Do you think it's finally time that Medicare has the opportunity to negotiate drug prices, although hidden beneath that statement is for some drugs, I think is what the real bill says, but what are your thoughts about that? Dr. Peter Bach: This is considerably more than half a loaf. You'd really have to never walk out and come out of the Ivory Tower to say it's not exactly what I would have done. And so I'm dissatisfied. The burden in just the Part D part, just if you look at the burden that beneficiaries in Medicare face on Part D drugs, it is alarming and unconscionable. The majority of people in Medicare, all of us, come from lives where we cannot relate to this, the median income in Medicare is $28,000 a year. And most people, they are not sitting on a few million dollars in savings. There's a sort of drip, drip declining asset value for them. And one of the five purposes of insurance is to catch people when something catastrophic happens to them and D doesn't do that. People are wiped out. A third of people stop taking medicines and, recapitulating this theme of my work over, not just me, of course, many people work in this area. But from earlier, I think failure to develop new therapies is a scientific reality. Failure to figure out a way to make sure people can get them and benefit from them, that shows that we don't care as a society. And then I was really glad our team has done, back when I was at MSK, a ton of work clarifying that the real problems with drug spending were due to a fractured implementation of an established policy approach to how we pay for drugs, which is that they get time-limited monopolies during which the market sets their prices. And then those monopolies are over. And then society gets the benefit afterwards. So there is this very clear transfer of who's getting the benefit, from the drug company to the people. And the people are taking the risk in that, in the sense that those new products are routinely eclipsed in terms of technological breakthroughs before it's time for us to get them super cheap. So we're bearing all that risk and that system has been broken. Like in the biologics, we still see biosimilars just chipping away and in some cases many biologics that should face competition don't. And this institutional, and this is what we've been pushing for, for years, is that if you're going to talk about negotiation or changing prices or price controlling in certain markets, you need to focus on older drugs. Let the companies have their return and then focus on the older drugs and institutionalize that transfer the benefits to people and away from the companies. And so that absolutely thrilled me. That is a recent change. The original propositions were all about launch prices, which I think is much harder to do. And if you want to do value-based pricing and assessment, with the current FDA standards about drug approvals, not necessarily even focusing on clinical endpoints, you are guessing, and so are the companies. But I think it's a much harder math problem and much more prone to error to do launch prices. This is like axiomatic. Since the '80s, this is the idea, the time-limited monopoly. So I'm thrilled about that. That's really appropriate. And then the whole insulin thing is just a mess. And I'm sure you've or maybe you haven't, but Mark Trusheim at MIT and I have been calling for profit regulation of insulin for a very long time. It's not full-on socialism, but this could be done at production plus, and it should have been done that way a long time ago. Dr. Dave Johnson: Yeah, no doubt. This concludes Part 1 of our interview with health policy expert and author Dr. Peter Bach. In the second part of this episode, Dr. Bach will share a deeply personal story of what it was like to care for his beloved wife, Ruth, who unfortunately succumbed to metastatic breast cancer at the much-too-young age of 46. We will also explore the challenging topic of delivering difficult news to patients. For now, thank you for all of our listeners for tuning in to Oncology, Etc. This is an ASCO educational podcast where we will talk about just about anything and everything. If you have an idea for a topic or a guest you'd like us to interview, please email us at education@asco.org. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.

"There are different types of advanced practice providers that you may meet in an oncology practice - PAs, APRNs, NPs, but what's the difference between them? In the second episode of ASCO Education's podcast series on Advanced Practice Providers (APPs), co-hosts Todd Pickard (MD Anderson Cancer Center) and Dr. Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guest speakers, Leslie Hinds (Centura Health), Martin Clarke (Arizona Oncology), and Kathleen Sacharian (Main Line Health), break down the differences and similarities between physician assistants and advanced practice registered nurses, share what their days might entail in each of these roles in an oncology practice, as well as address some common misconceptions surrounding these types of APPs. Duration 35:52. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org." TRANSCRIPT Dr. Stephanie Williams: Hello and welcome to ASCO Education's Podcast Series Advanced Practice Providers, APP 101: Physician Assistants and Advanced Practice Registered Nurses in Oncology. I am your co-host, Dr. Stephanie Williams, with physician assistant, Todd Pickard. Today, we are joined by Leslie Hinds and Kathleen Sacharian, both of whom are nurse practitioners, along with physician assistant, Marty Clarke. All three of today's guests are a part of the APP Task Force. Thank you all for being on our panel today. Leslie, Kathleen, and Marty, could you please tell our audience a little bit about yourselves, starting with you, Leslie? Leslie Hinds: Good morning! I am a nurse practitioner in the Denver, Colorado area and I am in community practice. Kathleen Sacharian: Good morning, everybody! I'm Kathleen Sacharian, and I'm an oncology nurse practitioner. I've had over 20 years of experience in both academics setting and community practices in the Philadelphia area. Marty Clarke: Hello, everyone! I'm Marty Clarke. I'm in Tucson, Arizona. I've got closer to 30 years of practice in general medical oncology, as well as a fairly lengthy stint in cancer psychiatry. I'm also a clinical psychologist. Dr. Stephanie Williams: Thank you all. Today's episode will be a deeper dive into the specifics of what physician assistants and advanced practice registered nurses or nurse practitioners do on a day-to-day basis in an oncology practice, as well as addressing some common misconceptions of what PAs, APRNs, NPs do in practice. So, jumping right in, I'd like to ask you all to shed some light on the general differences between a physician assistant and an advanced practice registered nurse or nurse practitioner. Who would like to start? Todd Pickard: I'll get the ball rolling. This is Todd. This is a great question. It's one that people ask a lot, you know, what is the difference? And honestly, in the clinical setting, there really is no difference. When you see an advanced practice provider, whether they be an APRN or a PA, you're going to get the same kind of team-based care with quality and safety and that really focuses on the totality of the patient. PAs and NPs arrive to their clinical work from different educational perspectives. But the work we do really is the same high-quality level of care. I'll defer to my colleagues to add some to that conversation. Leslie Hinds: Yeah, I would agree with you, Todd, that in practice, NPs and PAs provide the same quality of care and the same type of care but our education and background is oftentimes different from a nursing role versus a medical role. Kathleen Sacharian: I'll add that, you know, I think when we think about some of the main differences, really focusing, as Leslie said, like how are we prepared? How are we trained? A nurse practitioner is typically a registered nurse with a bachelor's degree and then goes back for a graduate degree in either a Master of Science in Nursing or a Doctorate in Nursing Practice. And typically, some of the main educational differences in a nurse practitioner role are that their focus in education is population-based, meaning it's based on a specific patient population or health condition. So, you might have an adult gerontology nurse practitioner or a pediatric nurse practitioner. Marty Clarke: Kathleen, I have a daughter that happens to be a GYN oncology nurse practitioner. And so, her focus is a little different than mine but it's always fun when she reminds me how much smarter she is in certain areas. Dr. Stephanie Williams: Just from my standpoint as a poor old physician here, are there differences from state to state between what you guys can do? That's one question. Two, your histories are so different in terms of how you came to become PAs, how the field of PAs and how the field of nurse practitioners developed, which is, in my opinion, very fascinating. So, I wonder if there are any comments on any of those issues? Todd Pickard: Yes, Stephanie. That's a great question. I was just thinking about how really, when people see differences between APRNs and PAs, it's generally because of state law or an institutional policy. And that's what's very unique about advanced practice providers is that their practice can vary wildly from state to state, unlike physicians, who basically have one standard national type of practice. An APP in Texas looks very different than an APP in New York or Alaska or Hawaii or Mississippi. And so, you do have to be very cognizant of the fact that it is important to be aware of what each state says or what even individual institutions say. Leslie Hinds: At my institution, physician assistants are not allowed to supervise infusion, which is a big part of medical oncology. So, unfortunately, in my practice, we have nurse practitioners only and have been unable to hire PAs because of that limitation. Dr. Stephanie Williams: So, these institutional guidelines, are they based on state regulations or just based on current practices at those institutions? Kathleen Sacharian: Well, I think it's really dependent on the institutional experience, you know, there might be a large academic center that has a very well-developed advanced practice provider program compared to maybe a smaller community practice that has one nurse practitioner or PA. So, I think the experience with the individual institution or clinic, but overall, that really is dictated by the state licensure and regulations. So, that is the first thing that needs to be looked at when considering these roles and responsibilities of advanced practice providers. Todd Pickard: Stephanie, you bring up a very good point, which is whenever an institution or an individual practice takes a position, it's always good to explore the 'why'. Is this customary? Is it a habit we've been in? Or is it based simply on a misunderstanding or even a preference? Many times, when you go to explore these things, you'll find that it's either a misunderstanding or a preference. It's not because something is required that way. At my institution, for the longest time, we only hired nurse practitioners on the inpatient side, because somebody thought that PAs didn't learn how to take care of patients in the hospital. And we had to have a conversation. I said, "No, actually, when I was in PA school, I actually had to sleep in the hospital, and for 6 weeks on my inpatient medicine rotation, so that I could give care 24 hours a day." So, no, we are trained there. So, it was completely a misunderstanding. And so, I think that's why it's very important that you have advanced practice providers who are part of your leadership in your governance, so they can help you craft good practices, good policies, top of license practice so that you really maximize all the team members. Marty Clarke: All these points are really poignant. The example of PAs not being able to oversee infusions, that probably stems out of an assumption that PAs, unlike oncology nurses that then become NPs, are more qualified somehow for infusion. And it goes back, I think, to what we talked a little bit about the training, where PAs are trained in the medical model. There are assumptions that are made around that that sometimes are not correct, just as the nurses are trained under nursing theory. And there are assumptions that are made around that. In my practice, there's a belief that the nurses can't function in the hospital, which is, you know, kind of ironic to me. And I think it's an assumption based on their training and an incorrect assumption. So, again, Todd, you're right. You need leadership and an open mind to this and also, you've got to pay close attention to what the individual, you know, state laws are, but they're more similar than they are different, I would say. Dr. Stephanie Williams: Just as a for instance, guys, I practiced for several years in the state of Michigan, the law has changed now, thankfully, but I had a combination of nurse practitioners and physician assistants, and my nurse practitioner, by law, could not order a consult for physical therapy, only my physician assistants can. So, I think it gets frustrating for physicians, because then how do I know what a PA can do and what an NP can do if, you know, I go to Illinois now and I practice under a different set of state laws. When I started in my career over 30 years ago, PAs were quote, "surgical", they held retractors, they stitched people up, they did our urology consults for instance and put Foleys in. And nurse practitioners were more bedside, taking care of patients. I think some of that has changed. But I don't know if you guys have any comments, how does a physician who's in practice in the rural community, and a more cosmopolitan community and academia, how do these things differ in your daily day-to-day routines? Todd Pickard: This is a great transition, you know, Stephanie, that's a very salient point, is really to take a little bit of a deeper dive into thinking about how PAs and APRNs are trained. So, Marty, we'll get you to say a little more about PAs, and then Kathleen and Leslie a little bit more about the APRNs. But generally speaking, PAs attend schools which are generally housed in medical schools. And so, we share the same faculty, we rotate with the medical students, sometimes we take the same courses as the medical students, and we're really trained in that medical model, which is basically a little bit of everything, the same thing as medical students. And one thing that we have included in our training, which is different than nurse practitioners and APRNs, generally speaking, is we have surgical training, not to say that APRNs cannot be in the OR, they do some extra training as an RN first assist certification for that type of role. But for PAs, that's just simply built into our training. And the reason that PAs are trained in this way is, you know, because we have our background in the military. In the military, we were part of the medical units. We were field medics. And then, after folks started coming back from their military service, they realized there really wasn't any civilian role for those highly trained folks. So, some physicians at Duke University created the PA profession. And of course, they built it to work alongside physicians. So, they taught them the only way that they know how, which is the medical model, which is how they were trained, and it's interesting that PAs and nurse practitioners were born in the same year, 1965, but just in two different parts of the country. So, Leslie, Kathleen, tell us a little bit more about the training that you receive, and why does the population model matter? Kathleen Sacharian: So, I'd say when you think about the nurse practitioner, you know, typically, and not always, but a lot of times, they'll have some registered nursing experience. And then, they decide to go back for an Advanced Practice degree. They choose a specialty based on interests, so that might be Adult-Gerontology or a Pediatric focus. So, we're really focused and trained clinicals, you know, all of that training is really built around that population focus. So, once you graduate, national certification, and licensure is then required. It really then takes on what happens next of roles and responsibilities, I think really goes into the training, the onboarding, and training of the provider, is a lot of times, you know, built into that on-the-job training. There might be fellowships that the nurse practitioner is a part of. For example, there's a lot of new oncology fellowships that are coming out for advanced practice providers, which really gives them a good additional focused training to be able to be ready to provide that advanced practice care for oncology patients. Leslie, I don't know if you have anything to add to that. Leslie Hinds: Yeah, I agree with the background and the education. you know, there are a lot of different specialties that you can graduate with an Advanced Practice Nursing degree, and I completely agree that most of the education for practice is learned after graduation. And then, you learn the specialty that you're interested in, or family practice, whatever you choose to do, but the education that you receive after graduation is mainly affecting your practice. Marty Clarke: Leslie, I really agree with what you were saying about, regardless of your training model, what really happens in my experience working with PAs and NPs is that you develop a way of practicing that is consistent and congruent with how the team that you're on practices, whether it's just you and a physician, that's a team, and you develop a pattern of practice that is complementary. And I think that both PAs and NPs, at least in my experience, are able to make those adjustments on the fly, really. Having said that, there are times that I'll have questions about a patient I'm seeing. And in my practice, I can go to a PA or to an NP, and there are times that I'll go to one of the NPs because they have a just a little different flavor, a little different take on something that I think might help me sort things out a little better. Other times, I'll choose to go to a PA because I know that their training is going to lend itself to kind of my way of thinking. The medical model piece is to me an advantage and a disadvantage, and here's how I mean that. One of the things I tell the oncologists I work with, when they're looking for us to see a certain number of patients in a certain period of time, they're operating out of their experience. And because of their training, they can see to the bottom of the bucket faster than I can, and faster than any of my peers can be it PAs or NPs. So, I'm constantly reminding the oncologist one of the things that we all bring to the table as APPs is a little more time with the patient. But the medical model sort of is focused on the biological, the pathological aspects of what's going on with the patient. The personhood often becomes after that. And that's sometimes why I'll go to an NP because a lot of times that personhood is closer to the surface with them. So, my personal experience with the medical model, when I applied to get into the clinical psychology program, I was told, "We can't let you in this program because you've been taught in a medical model, you think in a medical model, and you'll never unlearn that enough to be a good psychologist." And I had to beg and plead with them for an opportunity to prove them wrong. And fortunately, I guess I said something that allowed me to do that, but they were right, it was a very, very difficult task and challenge. To me, the medical model is, you kind of, is a little bit like being a Marine, you sort of go for the meat pretty quickly, and there's sometimes some finesse and some touch that's lost in that. And other times, it's really great. You know, it's exactly what's needed. Todd Pickard: Marty, you have said so many profound things in such a small amount of time that I'd like us to take a little bit of time to unpack that. And so, one of the things that you really clicked on, and Leslie and Kathleen also did this, was the concept of, we all come with our educational backgrounds with a certain foundation of knowledge, and we build upon that as advanced practice providers in our team-based care and our partnerships with our physician colleagues. Any physician can trust that a new grad APP is going to know how to do a history, a physical, manage basic issues around a patient's symptomatology, and that they're not going to let patients get harmed. We know that much. But the things that we have to learn are the specifics to the practice that we're in, whether it be lymphoma, leukemia, stem cell transplant, breast medical oncology, GI medical oncology, whatever it is. And so, that's critically important that when you have an APP that comes to the table with that foundation, and then build from there, unless they've worked in that same specialty before. One other thing that Marty said that was really important, I think, is that we all, whether we're APPs or physicians, really have to recognize that we treat whole human beings, not just the cancer cells in their body. And so, I think that's a mindset that has changed significantly over time. I mean, I went to my medical training in 1990, and, you know, as an educator and as somebody who works with trainees now, I know that that approach is different because people think about the social networks, the support that folks have around that, their own mental health, can they comply with medication orders? Can they get to their appointments? Do they have resources? So, we're really thinking outside of that box. And I think another thing that you said, Marty, that is so interesting to me is why do people focus on so many misconceptions in medicine? 'Well, you can't X because you're a Z.' That makes no sense to me. And for some reason, we spend a lot of time, I'll just say what I think it is, with these turf battles, 'don't play in my sandbox, go be in your sandbox'. And so, I think that's the thing that APPs are really committed to. We want to play in all the sand boxes because our focus is on the patient, not whose turf we're on. So, Leslie, Kathleen, Marty, what do you think about that kind of team-based approach and why does that matter to advance practice? What does it mean? Because I feel like it's in all of our DNA because that's how I grew up as an APP. What are your comments on that? Kathleen Sacharian: I completely agree with both of you. I think it's just the importance of how we work together. Our patients are at the center of all of our goals, right? Our outcomes are to improve patient care and provide them the quality of care that they deserve. And that takes a village, that takes the entire team from the oncology nurse to the PA, to the physician, to the nurse practitioner, you know, it really takes all of us to be able to provide that care that they need. And that's, you know, knowing when to say I need help, right? Who to ask that question to, using your resources. I also think like not making any assumptions. Don't assume that because a nurse practitioner has been an oncology nurse for 20 years that she's ready to go, and to be able to provide that advanced practice care. She's going to need that support and training. So, I think just not making any assumptions and just really being open-minded and working as a team is just critically important to providing that patient care. Leslie Hinds: Yeah, I agree with that. And I do think going more on the assumption of a nurse practitioner coming into practice: if they have oncology experience as a nurse, and they've been working as a nurse for a long time, there can be challenges with the change of the mindset between the roles between a nurse and nurse practitioner. And I think that that is underestimated by a lot of physicians or other practices and just assuming that this nurse has a lot of experience as a nurse, so they're going to transition to this role easily. And in my experience, that is not the case, and oftentimes, the nurse practitioners that I've trained that are coming in with a lot of nursing experience are much more difficult to train to be a nurse practitioners with that mindset of an advanced practice provider. Kathleen Sacharian: I don't want to negate that experience. I think that oncology nurse experience is invaluable for how they treat the patient, how they take care of them, how they assess the patient. And just bringing that experience to practice is incredibly invaluable. But just recognizing that difference between an advanced practice role and a registered nurse role is just important to consider. Marty Clarke: Yeah, and I'll add to that for what it's worth, all of us work in a very demanding environment and the brain is designed to be as conservative as possible in its energy consumption. So, it takes shortcuts, cognitive shortcuts, it makes up answers to questions, sometimes whether the answers are correct or not are not important. So, that's how assumptions I think get played out. And Leslie brought up a good sort of assumption that sometimes physicians will make about a nurse practitioner that, 'Well, they were an oncology nurse so I'm going to have them just kind of do more of that sort of thing and a little less of what I would be doing', going back to the sandbox sort of analogy. And it's really just almost a reflex. But if we can be aware of that and train our physician partners that that may be a tendency they have to think of us in a constricted way because that's cognitively easier. It's what keeps us often from practicing to the full extent of our capability and our license. Dr. Stephanie Williams: Todd, can I just say one thing from a physician standpoint? I mean, this is great and I agree with everything. You know, there are still physicians who think that an APP is an extension of me, and you do what I tell you to do so that you can make my life easier. That's not where the focus should be. The focus should be on that patient sitting there in front of you, and how can we make their life easier. How can we all work together in the sandbox. Marty, our psychologist, was going through our brains and how they function. How can we work together to better the care of that patient, and the care of ourselves? We have to help prevent ourselves from burning out. How do we change that focus? There are still many physicians, unfortunately, out there who want you just to be there for them, instead of being there for the patient. How do we change that? Todd Pickard: Stephanie, that is a profound question. I think that it is one that takes a lot of thought individually because what I think is at heart here, you know, the heart of the matter is that folks are so focused on surviving day to day. They think of the tools that they can use that make their life easier. I think what we're all saying is that we need to flip that around and think of who are the partners on my team that help me care for the patient, and we do our work together. So, if you approach it from the mindset of 'this is all my work and what are the resources that will help me complete my work', then you don't think of partnerships in teams. You think of people who do the work the way you want the work to be done and it's all about you. When you flip that and you really embrace the power of the team, what it is a group of folks who are all sharing the burden, and who will make sure that the patient, instead of the work, the patient is cared for, and all the services and all the things that the patient needs are done by the right people. And so, it's not about my work. It's about our work. And so, I think there are highly-functioning teams out there and they've really embraced that concept. But Stephanie, you're absolutely right. There is a model that there is 'physician work', and everybody around the physician is there to help the physician. But I do think that that is changing because we really are looking at how folks work in teams. So, I'd be interested to hear how, you know, Kathleen and Leslie, and Marty, think about this whole 'my work' versus 'our work' and what are they experiencing. Kathleen Sacharian: Well, I would add to that I do agree, again with that patient-focused and patient-centered care being everybody's outcome and goal. But what does that look like in day-to-day and when talking about burnout, you know, you think if you're just being delegated all of the really difficult tasks or, you know, the things that people don't want to do, that certainly can lead to burnout. I think we need to maximize people's interests, people's focus, and specialty. Maybe it's a procedural. You know, maybe the PA or nurse practitioner really enjoys doing procedures or doing consults. There are so many specific examples of those roles and responsibilities of how they can, you know, take some of the burdens of day-to-day patient care and maximize them based on patient interests, specialty, and again, with that overall outcome of just improving the care and being efficient, and providing that quality of care. But really like identifying, talking, as a team working through it, have quarterly meetings about what's working in your practice, what's not working, and how we can improve this, using your resources, too. I think there are a lot of great resources out there that can help to educate the teams about best practices in a team-based model. Leslie Hinds: Yeah, I agree, team-based care is definitely best for the patient and whole patient care, and there are definitely still barriers out there that we deal with on a day-to-day basis that are coming in between team-based care. And I really believe that is to the detriment of the patients. You know, I think there should be more education for physicians on how to work together as a team, instead of working together just as, 'you are my servants so you're going to do what I want you to do', and not allowing the team around them to practice to the top of their license, and ability, and interest. Marty Clarke: Yeah, I think this real a, really important subject that needs a great deal of exploration and education across the board. My way of thinking about it is everybody has a little bit of magic and sometimes we're not able to figure out what our magic is because we're forced or pigeonholed into a certain role, but allowing every participant on the team to sort of find out what they learn, figure out, and sort out, what their magic is and to be able to bring that to the table. You know like what Kathleen was saying, that's what keeps people engaged and what keeps them motivated. When I grew up, the term was 'scutwork' you know. I was taught 'a pound of scut for a pound of teaching', but we all have to do work we don't particularly enjoy, and that has to be rewarded by allowing us to do something we really do enjoy. And when we do that, we bring some energy to the patient and to the team. That's when synergy starts happening. But that's not, going back to what we said earlier, that's not how the medical model, it doesn't start from that position. That's what we have to, over time needs to be I think re-engineered a little bit. Dr. Stephanie Williams: Leslie, can you give us an idea of what your day is like? Leslie Hinds: Sure! So, for the most part, I'm in the clinic, but we have patients who are admitted then oftentimes they do go to the hospital to see them and then run back to the clinic to see my scheduled patients for office visits. A lot of my time is spent answering questions from the infusion nurses, from the MAs, and from patient calls coming in. We do procedures, so, bone marrow biopsies, Ommaya infusions if needed, and another good portion of my time is spent analyzing results as they come in. The sheer volume of the inbox and the results of it coming in is quite overwhelming sometimes. But, you know, taking the time to analyze results that we're hoping not to see, like a positive scan, and then developing an evidence-based plan for what to do next to help manage these patients appropriately - that's time-consuming. I do a lot of patient education. And also, manage a lot of emergencies that happen during the infusion. So, we basically manage the infusion center and see patients and answer questions. So, that's mostly my day. Dr. Stephanie Williams: Thank you! Kathleen, how about you? What's your day like? Kathleen Sacharian: Well, it depends. You know, I've been in outpatient, it looks very different from inpatient, and the outpatient experience really looks very similar to Leslie's treatment visits, seeing follow-up patients, they might be a longer-term follow-up, providing symptom management, working with our triage nurses to, you know, escalate significant problems, or treating them at home, providing that emergency and infusion-related care. But I think there's also to think about part of my role was developing a patient-specific clinic for survivorship patients. So, my role when I was a survivorship nurse practitioner was very different. I was providing program development. I was seeing patients in survivorship in long-term follow-up providing survivorship care plans. And I really think about that when thinking about the roles and responsibilities of an APP, just how vast that really can be. You know, there could be a genetics specialty that the APP chooses where they're providing these APP-led clinics to take care of these special populations of patients. So, just to kind of bring another idea of what the day-to-day could look like, it could be running a survivorship clinic or genetics clinic or palliative care. You know, there are so many, so many things that the APP really can provide in that day-to-day practice. And it's really from diagnosis to survivorship to end-of-life or palliative care. So, we see the patient across that continuum. Dr. Stephanie Williams: Thank you. And Marty, how about you? Marty Clarke: Well, I have for the last several years been working in the office seeing patients, and what I would explain to patients is the oncologist's job really is to decide what your treatment plan is going to be. My job is to get you through that treatment plan successfully and with the greatest amount of comfort. And so, I would see patients, you know, sort of on, sometimes weekly or every other week or every few weeks basis, assess them for where they are, whether, you know, review their labs, make sure that they're fit to continue with treatment, order and evaluate their restaging imaging studies so that we have a good sense of whether or not what we're doing is working as well as we want it to. If it's not, the patient goes back and sees the oncologist for adjustments to the treatment plan. And that's really sort of the just what my office day was like. I did, still do bone marrow biopsies and punch biopsies pretty regularly. The last couple of months, I've been out of the office and working in the hospital sort of as the hospitalist for the group. So, I'm doing consults in the hospital and follow-up while folks are in the hospital. At the time of discharge, I get them, if they're going to have follow- up within our group, then make sure that all that gets set up so that they're not lost in follow-up. I just see my role as being there to help the patient negotiate this very difficult period of their life, to help the physicians that I work with, to be able to use their time most effectively. And to be able to do the things that only they can do. There are some things that I do better than them and that's what I enjoy doing. But it always just goes back to where we started with this earlier. I show up to work every day just trying to help my patients have a little better life. I suspect I'm not unique in that regard. Dr. Stephanie Williams: Thank you! Todd, is there anything else that you would like to add? I know you have more of an administrative lean right now. Todd Pickard: Yeah, absolutely. When I was in full-time clinical practice, a day in my life was really focused on the patient care and how the team could get through the day because normally our schedule in a busy urology oncology practice, we'd have 70 or 80 patients per team that needed to be seen whether they needed a prostate biopsy or a cystoscopy, or they were a pre-op, or post-op, or a new patient or a consult. And so, really, our focus was how we would get through the day, and we would all communicate with each other and support each other. But really, we were focused on each patient getting what they needed and we all were there to serve the patient. And there was a lot of good collaboration. You know, there are times the physician would say, "Hey, I don't know how to get this thing done for this patient. How do we navigate the system?" Or times I'd say, "Hey, you know, this patient is here for surveillance and I've got some concerns about either their labs or this, and this is what I'm thinking. What do you think?" So, it was really that collaboration. I think that's where the strength of APPs and physicians working together is. As an administrator, I spend my time thinking about how policy, and top of license practice and how we credential and make sure that people have good quality care, and I collaborate and partner with all of my other fellow physicians, administrative leaders, and administrative folks. Thank you, Dr. Williams, Leslie, Kathleen, and Marty for sharing your insights today and giving the listeners a glimpse and a better understanding of a typical day in the life and how important it is to understand the differences between APRNs and PAs. They are all an integral part of your oncology practice. Stay tuned for our next episode, and until next time, take care. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity or therapy should not be construed as an ASCO endorsement.

Drs. David Johnson (University of Texas) and Patrick Loehrer (Indiana University) host this live ASCO podcast with award-winning documentary producer/director Bill Brummel. After undergoing a laryngectomy in 2016, Mr. Brummel produced and directed a documentary film titled "Can You Hear My Voice?" that chronicles the one-of-a-kind Shout at Cancer choir, whose members have all had their voice boxes removed, as they prepare for the most ambitious concert. This podcast features audio clips from the film. Mr. Brummel, who is joined by his surgeon, Dr. Uttam Sinha, of Keck Medicine of USC, reflects on his own cancer experience and the psychosocial impact of losing one's natural voice. For more information about the film or hosting a screening, visit www.canyouhearmyvoice.com or email info@bbprods.com. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Dr. Dave Johnson: So we're back here with another episode of our world-famous Oncology, Etc. podcast with two very distinguished guests, Pat. Dr. Pat Loehrer: Well, we're thrilled to be here to record this episode in front of an audience. Usually it's just Dave and I, and supposed to be a live audience. Although after three-and-a-half days of ASCO, I'm not sure if anybody's still alive. We have two very distinguished guests today. Mr. Bill Brummel is the award-winning documentary producer and director. He and his films have been recognized with the Peabody Award, two International Documentary Association Awards, five national Emmy nominations, and have been named for the Oscar shortlist. Many of Dr. Brummel's films have focused on civil rights and human rights issues. After having his voice box removed in 2016 due to complications from radiation therapy, which he received for his head and neck cancer, Bill produced and directed Can You Hear My Voice? This film, which has not yet been publicly released, was shown on Saturday afternoon here, chronicles London's Shout at Cancer Choir, whose singers are living without voice boxes. It's amazing. The ASCO Annual Meeting attendees saw this on Saturday, and today what we're going to do is hear and see some of the clips from the movie and hear from the director himself. Dr. Dave Johnson: We're also joined by Bill's physician Dr. Uttam Sinha who encouraged Bill to create this documentary about the psychosocial aspects of living without a voice box. Dr. Sinha is an Associate Professor of Otolaryngology at the University of Southern California where he tells us he spent the bulk of his life. He's also the Watt Family Endowed Chair for Head and Neck Cancer at his institution. Dr. Sinha's holistic medical approach was really truly critical, Bill tells us, to his both physical and emotional recovery following laryngectomy. So Bill, Dr.Uttam, welcome to Oncology, Etc. Mr. Bill Brummel: Thank you very much. But one thing your audience should know and you should know is that after having a laryngectomy, speaking with a voice prosthesis, we lose the ability to laugh out loud. So, Pat and Dave, if you happen to tell a joke or say anything funny, know that I'm laughing inside. Dr. Pat Loehrer: I think Dave and I think that most of the people that listen to our podcasts probably have had laryngectomies because we hear no laughter at all from anything we say. So, Bill, we're really here today to talk about your documentary. And we're going to show a few clips. But before we show the first clip, can you set this up for us? Mr. Bill Brummel: This clip sets up the choir and the premise of the film. We follow the choir as they prepare for the most ambitious concert they have ever attempted. So it's really just setting up the premise. Dr. Pat Loehrer: Now this is extraordinary. So if you could run the first clip for us. Appreciate it. [Clip starts playing] Speaker 1: I'll remember quite well, when I first suggested let's form a choir. They responded with laughter and surprise and disbelief. Speaker 2: It just seemed ridiculous that you would expect a group of people with no voice boxes to stand up and sing in a choir. It didn't seem realistic. But Thomas had confidence that we could do some things. We went along with his mad scheme. And then one day was sort of now, what about a concert? What? [Jazz playing] Speaker 3: Well, the people in the choir are just normal people. Speaker 4: I really admire the courage that it's kind of taken to come through all of their treatment. Speaker 5: After all the stuff they'd gone through, they're able to turn that into something creative and artistic. That's really, really impressive. Speaker 2: The concept is something new. It's almost a defiance, which is what people need, is to be defiant. Was that a F sharp I sang or what was it? You know, it doesn't matter. Speaker 6: Most of them never read poetry before. Most of them never sang before. Most of them never were on stage before. And they were going to put on a show. And they're going to add this other two or three layers of emotional vulnerability. Speaker 1: All right. Everyone, just like we prepared. We know what we're doing and we're going to enjoy ourselves. Yeah? Speaker 6: We're doing a concert. People have paid money to come and see us. The adrenaline rush is incredible. I can't describe it really. I never thought I would do something like this. [Applause] [Clip ends] Dr. Dave Johnson: Tell us a little bit about how this film came about. Obviously, you had a personal connection to it. But give us a little bit of background information, if you will. Mr. Bill Brummel: Well, about nine months after my laryngectomy and after getting through some of the emotional and psychological problems that a lot of people who've had the surgery experience, and we'll go into that later on, I went to an appointment with Dr. Sinha, a regular scheduled appointment. And out of the blue, he suggested that I make a documentary about the psychosocial aspects of recovering from and living with a laryngectomy. Now my first thought was stick to medicine, doc. I'm the professional here. Just kidding. It was an excellent idea. But why on Earth did you suggest that? Dr. Uttam Sinha: We never get to see the psychosocial aspect or the challenges or the suffering they go through, and most importantly, the head and neck cancer is not so well known in the society, unfortunately. So all my life, in my 25 years of practice, I always tried to promote head and neck cancer awareness in our society. One day I told my friends, 'I need to raise money for research for head and neck cancer.' So they asked me, 'What is head and neck cancer?' I said, 'This is head, this is neck – cancer of this area is called head and neck cancer. So anyway, so that was one of the driving forces then to create awareness within the society and also how the head and neck cancer patient live after going through the treatment and surviving the cancer. Mr. Bill Brummel: When Dr. Sinha suggested it, it was an excellent topic. But I knew I needed a story to illustrate it. So right after the appointment, I went home, fired up Google. And very quickly, I discovered the Shout at Cancer choir on a website. Shout at Cancer is a London-based nonprofit charity, that among other things, uses some breathing techniques and singing techniques to improve the vocal outcomes for laryngectomy. Now, I knew that if I could get all the pieces in line, that this would be a great way to produce the film that I wanted to produce, that of a group of people who've undergone a life-altering surgery, and all the hardships and drama that goes with that, but still leading a meaningful and productive lives in a very entertaining fashion. Dr. Dave Johnson: There's some really extraordinary people in this film from the Shout at Cancer choir. How did you happen to select the specific individuals within that choir group? Mr. Bill Brummel: Well, I took two production trips to the UK after we found funding and after I got the choir on board. I took two pre-production trips to the UK and went to every choir member's home individually and met with them and their spouses. Now, they all have compelling stories. But for reasons of time, I couldn't have personal profiles on all of them. But I eventually settled on five. And I knew even then, that only four would probably be included in the film. I say that they have compelling stories. I think I could have done a Netflix limited series 10 episodes, one on each choir member. Dr. Dave Johnson: I think you should consider doing that. Mr. Bill Brummel: That might be too late to do that. But they're really excellent and articulate and all have slightly different stories. Dr. Pat Loehrer: You told their stories. And again, for those who haven't listened to the documentary, I really encourage you to do this when this comes out. But just I have a question. You've done so many different documentaries about so many important things over the years. Do you think you would have done this documentary had you not had a laryngectomy? Mr. Bill Brummel: Definitely not. A laryngectomy was not even on my radar. I don't think I knew what it was before I was faced with having it. So no, I definitely wouldn't have done that. Dr. Pat Loehrer: It really is a terrific service that you've done. You've helped so many people. Dr. Sinha, there may be a listener or two that listens to the podcast that is not a physician. Can you explain just in lay terms what a laryngectomy is and what it means and the process behind it? Dr. Uttam Sinha: So, as you know, that larynx is an organ that produces sound. It doesn't produce speech. This a misconception within in our society that the patient undergoing laryngectomy they cannot talk. A laryngectomy patient, they talk well, but the patient when I remove a portion of the tongue for a partial glossectomy, then they have a hard time to speak because speech is produced within the oral cavity. So a laryngectomy is basically, the removal of the voice box removing the trachea from the esophagus so that they can breathe well and also they don't aspirate because that's a big challenge. Aspiration pneumonia, is a consequence to fibrosis induced by radiation. So early on in our practice at Keck School of Medicine, 25 years ago, we started this program where we decided to do neuromuscular electrical stimulation swallowing therapy to reduce the fibrosis so that there'll be less chance of aspiration, and aspiration-related pneumonia. So the laryngectomy we perform, especially in Bill's case, he's a cancer survivor, but he had a hard time breathing and talking and also mild aspiration. So that's why we had to do a laryngectomy where we remove the voice box, and that improved his overall quality of life. Mr. Bill Brummel: I remember as my breathing difficulties increased, Dr. Sinha advised me that a laryngectomy was in my future. And like I said, I didn't even know what it was. But he advised me that my quality of life would improve in the long term. But I was in denial. So I stalled. I didn't have it when he first advised that I have it. Dr. Pat Loehrer: Here at ASCO, we have 30,000 to 40,000 people there, many of them are cancer survivors, and I'm thinking about when we think about most cancer survivors, Dave is one of them, and we'll talk about that in a little bit, most of them fit in with the crowd. The cancer survivors with laryngectomies something that doesn't. This is something that not only have you survived it, but you have the wounds to show for this. Can you tell us a little bit about that and briefly the thought processes of 'Listen, someone's going to take out my voice box. I'm a director. I need to have this.' I'm sure you stalled making this decision. And what was the final tipping point for you to have this done? Mr. Bill Brummel: Well, as my condition got worse and worse, it was really hard to speak. And it was really hard to breathe. At times, my wife could hear my labored breathing from the other rooms of the house. I couldn't even climb maybe three or four stairs without getting winded. And then I remember the date of March 10th of 2016. I went to another appointment with Dr. Sinha. And I don't think I got two sentences out before he interrupted me and said rather firmly and with a good sense of urgency, 'Bill, we have to do the surgery now.' He was obviously concerned that I would have a breathing emergency at home or in the market, paramedics will be called in, they do an emergency trach on me. I knew that Dr. Sinha would do a much better job than a paramedic. But I remember sitting in that exam room with Dr. Sinha and my wife, and the Dr. Sinha was basically telling me I was risking my life if I didn't have the surgery. My wife was worried sick. And although I was frustrated, I couldn't come up with any more excuses. So I said, 'Yes, let's do the surgery.' Dr. Sinha wanted to admit me right then and there, and not send me home, but the OR was booked on the next day. So Dr. Sinha, bless his heart, called an OR to come in to do the surgery on a Saturday. I was the only one in the recovery room or the pre-op room. And I remember that when we arrived at the hospital, I think we have a clip of our kids, my wife, and I, we were sitting in the admissions waiting room. And my wife got out her cell phone and asked if she could record my natural voice, although wheezy and weak, one last time. And this is the 35 seconds. [Recording starts playing] Frances Fitzgerald: Okay. What's happening today? Mr. Bill Brummel: It's 5:30 in the morning, March 12th, 2016. And today, I'm giving away my vocal cords. And walk out of here, hopefully within a few days, with voice prosthesis and a new voice. Although I won't be able to test the voice for several weeks, I'll have to be silent, which will please many people around me. So that is what is happening. Last time you'll hear this voice. So to all of you, I love you. Thank you for all your support and prayers. Here we go. [Recording stopped] Dr. Dave Johnson: So I'm sure that that probably brings back some very emotional memories to you, Bill, and as Pat asked, post-operatively, what did you think about your future? What was your psychological state at that time? And how did you feel physically? Mr. Bill Brummel: Well, physical recovery from the surgery was hard. And I vacillate by saying it was hard and it's awful, but it was physical recovery. But worse yet, I was saddled with insecurity and fear and doubt. People who have had the surgery can often lose confidence. They can sometimes retreat from society and withdraw into a world where we don't have to be seen in public. But when we do that, lonesomeness and depression are sure to follow. There were times I found it easier to isolate myself rather than navigate. I didn't want to go out. I didn't want people to see me. And I got depressed. It was just natural. Losing your natural voice is really traumatic. From the time we learn to speak, much of how we perceive ourselves is wrapped up in the unique tone of our voices. It expresses laughter and happiness. And with that gone, many patients really struggle with anxiety, self-doubt, and doubting their self-identity. Dr. Dave Johnson: So, Dr. Sinha, is that a common reaction amongst your patients post-surgery? Dr. Uttam Sinha: Yes, it's fairly common. That's why I started 16 years ago with my colleagues a survivorship program to support the psychosocial aspect of these patients. Whenever we can, we mentor the newly diagnosed patient with the established patient. Bill has done many, many mentoring for those patients who underwent laryngectomy after his laryngectomy. And I'm so grateful that our patients are so supportive to each other for the whole organization. So yes, this is very common and that's why we always talk about not just the physical but psychosocial aspects of our health. And also in our practice, we always try to promote not only the health of the patient but also health of the caregivers and the family to improve health. I think it depends on all four dimensions of health, which is the WHO definition of health, the best state of physical, mental, spiritual wellbeing, and not a mere absence of a disease process. Dr. Dave Johnson: You mentioned the family. We want to get back to that in a moment. I think we have a clip from Sara. She was one of the patients that was featured in his film, and there's a wonderful clip. I want to get to that in just a moment. But I just have an important question to ask Dr. Sinha. Was Bill a good patient? Mr. Bill Brummel: Was I a good patient? Dr. Uttam Sinha: I have to think about that. Dr. Dave Johnson: That's what I thought. We'll watch this clip while you think about that. [Video clip playing] Sara Bowden-Evans: I have two vivid memories of those moments just before going down to theater and having the realization that when I came back out, I wasn't going to be the same person. I would never be me again because they would taken my personality which would mean my voice. And then when I came around, I couldn't call for help. And that was so frightening, really scary. That was pretty awful actually coming to terms with all of this. I lost all my confidence and didn't want to speak. You can sound very angry all the time, even when you're not. I didn't want anybody else to really see me or hear me and all the other things to contend with as well, not being able to swallow properly and losing all my taste with radiotherapy, suddenly gone. I think the loss of laughter is one of the most difficult things for me. So it's just one thing after another after another and it just made me angry all the time. Speaker 7: Emotional changes were quite dramatic. She was very, very moody at times. She just felt that everybody was staring at her. And it just changed her personality. Speaker 8: We know from evidence that people who've had a laryngectomy can be much more likely to experience anxiety, depression, social withdrawal that can have a really important impact on relationships. Speaker 7: The emotional side is the hardest part of caregiving. That's part of a relationship. You take the bad times with the good times. Sara Bowden-Evans: I know that I wasn't a very good patient because I know that there were times when I was really horrible to him because I was dealing with my situation, and I took it out on him. But he's still here. He stayed with me regardless. [Video clip stopped] Dr. Pat Loehrer: As you watch this film, you realize what a remarkable human being Sara is. She's a writer, she's a poet, and even the title of your documentary comes from her. Mr. Bill Brummel: I stole it from her. Dr. Pat Loehrer: Yeah, it's extraordinary. Mr. Bill Brummel: It's one of the poems she wrote and we use in the film. Dr. Pat Loehrer: The question I'd asked Dr. Sinha, if you don't mind just following up on this, when a woman is diagnosed with breast cancer, as my wife was, there's this wonderful support community, and they even have a color of their own. And the women get together and they have runs and they do all the stuff. Similarly for several other cancers. I think with head and neck cancer, the inclination, I think, as Bill mentioned earlier, is to be isolated and almost withdraw yourself. This was a unique group of individuals that got together for this project. We'll hear about it more. But how common is it for laryngectomy patients to actually bind together? Or do they typically fight this battle alone? Dr. Uttam Sinha: So they feel very isolated, no question, and depressed. That's why it's very important to have that kind of support system. Head and neck cancer is very unique. Most other cancers, squamous cell carcinoma, the same cancer when it happens in the lung, and you remove half of the lung, nobody would know and person's quality of life would not be compromised. On the other hand, if same squamous cell carcinoma happens in the head and neck area, it compromises quality of life because all the function that makes us human beings - speech, swallowing, hearing, balance, smell, taste, all those things happen in this area. So when this area is damaged, whether by cancer itself or treatment related, that causes tremendous depression as their functional status goes down, and also they get isolated because they cannot go to the society freely, like to go to a restaurant and feeding himself with a G-tube with the rest of their friends or family are eating by their mouth. So that's quite depressing. In fact, I have patients, couple of patients who committed suicide because they were G-tube dependent. So head and neck cancer in that regard is very unique compared to other cancers. Mr. Bill Brummel: I would say, to just add one point in regards to Sara and other women who have a laryngectomy, obviously, we don't have a lot of breakage in our voice. Our voices are very low. And it's really the same for women as it is for men. But men's typical voices are lower and women's are not. So that is a factor in their emotional recovery. They really don't sound how they used to when speaking with a voice prothesis or through an electrolarynx. So it's really difficult for women. Dr. Pat Loehrer: As humans, we think in the past and the future, we go back and forth, but you've had a life as a very successful film producer, director. And I think in many ways, this is probably one of the most unforgiving professions for any kind of disability, whether it's even putting on some weight or having an accident. But tell me a little bit about your life before laryngectomy and after laryngectomy. How has this changed your life as a professional? What has happened? Mr. Bill Brummel: Well before even my laryngectomy, before cancer, I was originally diagnosed in 1997 with tonsil cancer. It was treated by neck dissection, not by Dr. Sinha, and seven weeks of radiation antidotes over wide fields. I had been in television production for about 10 years prior to that. And I was doing mostly silly reality shows, or music video shows, stuff that didn't have really any substance to it. I had started my own production company about a year before, but after my cancer diagnosis, I really thought to myself that if, God forbid, the cancer comes back and my life is cut short, do I want to spend my days, my effort in terms of my work life producing shows with no substance. And I said, 'No, I don't want to do that. I want to produce shows that feed the soul as much as the wallet.' Unfortunately, 20 years after that, my soul got a lot better than my wallet. But I wouldn't change it for the world. But having cancer, having that diagnosis definitely changed the trajectory of my career. I wanted to have a legacy and something that my children would be proud of. Dr. Pat Loehrer: Just a follow-up question, I had a very good friend of mine who had a glioblastoma. After his diagnosis, he said he learned things about friends. He said, there were three kinds of friends. There were these friends who were the loyal friends who he'd always had, who really were with him. There were the people that he had thought were friends that just disappeared. And then there was a third group of people who we never ever dreamed would be friends, but they came out of nowhere to become new friends for him. So reflect a little bit on that. Does that resonate at all with you? Mr. Bill Brummel: It definitely resonates. After my laryngectomy, and I went through this period of emotional difficulty, I was still one of the fortunate ones. I was blessed to have a supportive network that included family and friends, others, colleagues aided my recovery. And obviously, the medical team at Keck Medicine of USC, a lot of them became my friends and are still my friends. So they came out of the woodwork. My laryngectomy buddies are close friends. We have a supportive group that meets two times a month. They become real good friends. I can't imagine my life without them. But Dr. Sinha talked about his supportive care. It was really important to me. He's always preached about a hollistic response approach to health that includes traditional medicine, exercise, nutrition, physical therapy, mindfulness, and a bunch of other things, occupational therapy, speech therapy. To varying degrees, I embraced each of those modalities. But back to your original question, certainly, some friends fell off the map. I made new ones, the family and friends that I had, the relationships became really strong and a really important and critical part of my life. Dr. Dave Johnson: That certainly resonates with my own experience as a cancer survivor as well. And you've mentioned your family more than a few times. I'm confident that they were a very important part of that support system. Could you speak to that a bit? Mr. Bill Brummel: Well, they understood what I was going through. And if they didn't understand, they asked questions. They didn't ignore the elephant in the room. My wife, as a caregiver, I really don't know what I would have done without her after my laryngectomy. She was changing all my dressings, cleaning out the stoma, stuff that I assume if I was alone, I could have done it, but I didn't want to. I didn't want any part of it. So she got me the physical recovery. And then she started getting me the emotional recovery. When I was feeling sorry for myself and sitting at home, she very politely kicked me out of the house. And she said, 'If you want a cup of coffee, you get it.' I would drive down to Starbucks. It took me three months to speak because the swelling wasn't going down. But she kicked me out of the house and said 'Go to Starbucks' And I would just write on my phone my order and show it to them. And that seems like a very easy thing to do, but it was a big step for me. But it also started me thinking, well, maybe people are going to stare. But it seems like most people are understanding. And that's been my experience. I get stared at a lot all the time. And when I speak, people turn their heads. But most people are really understanding and want to help. In fact, they might even take the extra step for me that they wouldn't for some other person. Dr. Uttam Sinha: We established a caregiver support group, Coffee with Caregivers, and Frances is the president. Mr. Bill Brummel: Frances, my wife, yes, she facilitates the weekly meetings. Dr. Dave Johnson: Well, there's so many rich aspects of your film. For those who have not seen it, you really do need to see this film. But there are a couple of areas that really resonated with me and reflected my experience, one of which we have a clip from this family. But I have a daughter, who was 10 at the time that I was diagnosed with lymphoma. And my wife and I did our best to shield her from the possibility that I might not survive that. In retrospect, I'm not sure we handled it quite the right way. But you have a clip from Pug and his wife, Kat, and their daughter, Lily. And I think it so reflects my own personal experience with my daughter and her reaction to me. So maybe you might want to just comment on that before we show the clip. Mr. Bill Brummel: In the pre-interviews I did and selected a choir member for shooting, I developed an outline of what I thought the segment with life would look like. And you know when you do documentaries, you had to be able to change it at a moment's notice. So I had three interviews with Pug and Kat and came up with a sweet story that involves just them. When we recorded the interview, I was just blown away by Pug's daughter, 12-year-old Lily, and completely changed the focus of Pug's presence in the film to illustrate the impact that a cancer diagnosis and a laryngectomy has on families. [Video Clip Playing] Interviewer: When your dad got the laryngectomy, how did you deal with it? Lily: I think I was probably more upset than dad seemed because I thought he was really going to die. Pug Halliday: It's hard because we were always honest with Lily. But no matter how many times we said it was going to be all right, you know, you were worried, weren't you? Kat: Basically after the operation, Pug had a lot of black, like Frankenstein stitching and drains and tubes. And Lily hadn't really seen that sort of thing before. Because she was younge,. I didn't want her to be frightened, so I waited and I spoke to Pug. 'When shall I bring her up?' And he said, 'Why don't you take a photo?' Pug Halliday: The drain's around, so that would be five, seven days after my operation. Mr. Bill Brummel: And Lily, so that didn't scare you, the photo? Lily: No, because he was—well, I think that yeah, it scared me a little bit, but in that photo, he's like really happy, so- Pug Halliday: By the time when we asked Lily, she said, 'You were smiling and had both thumbs up.' So, you were reassured a bit by that, weren't you? Lily: Yeah. Mr. Bill Brummel: Lily, what did you do to try and make your dad feel better during his recovery? Lily: I made tea for him. Pug Halliday: Yeah, you came and you read me stories instead the other way around. Lily: I read you stories, and I made him lots of things as well. Like, I don't know, like little books where he was really amazing. To you, my favorite person in the world. You are the best. You're my inspiration. I love your facial hair and your mustache presentation. When you were ill, feeling depressed, I knew you'd make it because you're the best. You're kind. You're brave. You're funny, too. I'm so happy I have you. I can't believe that you're my dad. It turns out that you're not so bad. [Giggles] Pug Halliday: I keep these by my bed. And when she turns into a teenager and hates me, I shall read them regularly. [Video clip stopped] Dr. Dave Johnson: If that poem doesn't melt your heart, you have a heart of stone. Dr. Pat Loehrer: What you can't appreciate on a podcast this incredible poem. It's just incredible. Mr. Bill Brummel: He's a marvelous character. You know, you're mentioning your daughter, my daughter was eight years old. And my son was five-and-a-half in terms of when I had my original cancer diagnosis. In fact, we celebrated his sixth birthday in the hospital. On the last day of my radiation treatment I had to be hospitalized three times because I couldn't keep anything down. But my daughter commented, this was when she was graduated from high school, I think, that she really thought that I was going to die. And we said no such thing. In fact, like Pug, we tried to reassure her that my tonsil cancer diagnosis was not life-threatening. But in her mind, she remembers it as being a case that my dad might die. Dr. Dave Johnson: Yeah, my daughter reacted the same way. And she kept a diary at the time. When we went back and read her diary, she actually wrote, 'My dad is going to die.' Yeah. The other clip that really stood out to me also involved a poem, and it comes from Sara. Sara is a real star in this. It's a poem to her husband, Nigel. It's a cancer survivor's reflection on how they dealt with their cancer and their spouse during the intensity of the treatment. I wonder maybe if you could make a few comments and maybe we could show that clip. Mr. Bill Brummel: Well, definitely. The spouse or partner, the impact can be great. And in Sara's case, in her words, she took out her frustrations on Nigel. And Nigel was a great caregiver and just dealt with it and never stopped loving her. Interesting thing about this poem, it was not a poem for the choir. It was after we finished shooting one of the rehearsals. I was talking to Sara, and she casually mentioned that, "Oh, I've written a poem to Nigel, but I'm scared to show it to him. Like he hasn't seen it or heard it." And being a film producer, I said, "Wait. Don't read it to him. Don't show it to him." We were scheduled to go out and shoot the segment with her at her home in a week or two. So I said, 'If you would read it on camera, I would love you forever.' I would have loved her forever anyway. So what you see, it's almost one take of her reading the poem to Nigel. And none of us in the room, of the crew and me, Nigel, had ever read the poem. And Nigel had never heard of the poem. Dr. Dave Johnson: This is very real and in many ways, raw. I think it really illustrates that relationship. Again, not to talk about my own illness, but I felt the same way Sara did. [Video clip playing] Sara Bowden-Evans: So I need to read you something. Nigel: You need to read me something? Sara Bowden-Evans: Yeah. Nigel: Go on then. Sara Bowden-Evans: I wrote another poem that is for you. Nigel: For me? Sara Bowden-Evans: Yeah. I'm going to try to read it very easily now. Nigel: When did you write this? Kept that very secret. Sara Bowden-Evans: Because I don't know how else to say what I needed to say. Nigel: Okay. Sara Bowden-Evans: I'm sorry for the pain I caused. I'm sorry for the hurt. You were always in the firing line To take the brunt of course It's not that I'm actively directing it to you. It's just you're the one that's always there. And that's the truth. They say we always hurt the ones we love. And there's a reason. And that's because the ones you love the most know all your feelings. You've suffered with me. All the pain, the sadness, and my darkest days. You forgive whatever nastiness I throw. But I don't know how to ever repay all the things you've done, apart from writing down in words. Nigel: That was so beautiful. Thank you. That's amazing. [Video clip stopped] Dr. Dave Johnson: I know that there are no words that can describe that. Mr. Bill Brummel: Yes. Sara really is the emotional center of the film. And from a producer's standpoint, I don't mean to sound crass, but you always can get behind a person cry on camera. Dr. Pat Loehrer: When I was watching the movie, though today, could you get behind me because I was crying. Mr. Bill Brummel: Well, I usually, at any public screenings, and because of COVID, there hasn't been a lot of them, but I try and view the film from the back of the audience. And I'm scouring the audience to make sure they're laughing or crying at the appropriate places. And they usually are. Dr. Dave Johnson: So Bill, what message would you like for oncologists to take away from your documentary? Mr. Bill Brummel: Well, very simply. It's the message I would like oncologists to hear and implement, and a lot of them do, but it's to treat the patient and not just the disease. And that's it in a really simple form. The psychosocial consequences of any cancer diagnosis are challenging, and especially as Dr. Sinha said, in head and neck patients, where the treatments often leave a patient disfigured in a noticeable and visible way. Shame, anxiety, and depression are common enemies. Support the psychosocial health of your patients. And I'm convinced that if you do that, their physical condition will improve. Dr. Pat Loehrer: Well said. We certainly can't let you out of here without showing a clip from the choir's performance at the concert that you filmed. In fact, there were several, several songs. I think we're going to show one of them there. But can you tell us a little bit about the film distribution plans, the business of this, how will the public be able to see this film? What's happening on that end? Mr. Bill Brummel: Well, we have a commitment from PBS if I want to show it on the PBS network of stations. We're aiming for a 2023 broadcast, probably spring. Currently, I really want to maximize the impact the film will have with the general cancer community. And for the last six months or so, we've initiated impact and outreach campaigns. And by that I mean we're doing branded screenings and webinars and speaking and showing films at conferences. We're aiming at the cancer advocacy and support communities, universities, medical schools, clinician associations. We've done a bunch so far. We're doing more. We're also trying to partner with corporations or nonprofits to bring these screenings to cancer advocacy and organizations that might not be able to afford a screening. And we're looking for underwriters with the PBS podcast. But the film will get out there. I just really, for the time being, want to concentrate on the cancer community. Dr. Pat Loehrer: That's terrific. So we're going to show a one of the performance clips. Do you want to set that up for us, there. Mr. Bill Brummel: COVID shut down the choir. So every time I see a performance, it makes me long for more and more performances. But this clip is as rendition of Ain't Got No, which was popularized by Nina Simone in the '60s. It was originally written for the musical 'Hair', but one of the unique things about the choir is that they at times rewrite lyrics to songs to make them more illustrative or the lyric to explain the full impact of having a laryngectomy. So this is the song we're playing last, it's the finale of the concert and the film. The first half of the song speaks to all the things we've lost by not having a voice box. Second half, which we'll see, speaks to all the things we still have, can still do in life. Sara helped adapt the words. It was a group effort. [Video clip playing] Singer: [singing] What have I got? Why am I alive anyway? Yeah. What have I got? Nobody, nobody can take it away. I… Choir: [singing] got my hair, got my head, got my brains, got my ears, got my eyes, got my nose, I got my mouth. I got my smile. Got my health, got my tongue, got my teeth to make these sounds, in my head I change my breath, I got control. I got voice. I got poems, I got friends, got my songs, got my limbs, got my heart, got my soul, got my pride. I got my voice. Opera Singer: [singing] What have they got? Sing, what have they got? Choir: We've found our voice. [Applause] [Video clip stopped] Mr. Bill Brummel: Obviously, the woman that sang at the end did not have a laryngectomy. She's a professional opera singer. Dr. Dave Johnson: I think I can safely say, for all of us here today, that we thank you for producing such an inspirational film, and one that really I think captures the emotions that go along with, one, being diagnosed with cancer, two, going through treatment, three, experiencing survivorship and the support. And Dr. Sinha, to you, thank you for inspiring Bill to doing that. We have maybe just a couple of minutes if there any questions from the audience. We haven't received any via the text. So if there's any questions, there's a microphone here. And as an added incentive, if you ask a question, you get a free Oncology etc. t-shirt. Dr. Pat Loehrer: Better yet, we may not give them. That might be a great incentive. Dr. Dave Johnson: Don't trample one another running to the microphone. I see, there are people who want their t-shirt. So please. Question 1: Thank you so much. That was a beautiful film. I'm a nurse, and it's a great inspiration. And I'm sure it's a great inspiration to the patients. Are there any similar organizations in the United States doing a choir? Mr. Bill Brummel: Not that I know of to the extent that Shout at Cancer does. There's several laryngectomy support groups or laryngectomy clubs around the United States. And every once in a while, you'll see one that the patients get together and sing for fun or they do a Christmas performance at some event. But Shout at Cancer takes it really to an unheard of level. I've never heard of anybody doing this in the world as much as they do in terms of the original writing, the professional musicianship, the rehearsal. So I'm not aware of any that take it to that extent. Dr. Pat Loehrer: I just want to say from my own behalf, we're in this world. The best thing you can do at the end of your life is to say that you made a difference. And this film, what you have done has made a difference. As long as I have the capacity to remember, I will remember you and I will remember this film. So thank you very much. Mr. Bill Brummel: You're welcome. And thank you for saying that. I'm touched. And that exactly was the point. I think that was the point when Dr. Sinha said, 'You should do a documentary about the psychosocial effects of having a laryngectomy recovery and living with a laryngectomy.' I don't know that he thought I'd do it to this extent, but that is the message I want to inspire people who've had a laryngectomy, and I want the world to know and to relate better to people and understand people. Dr. Uttam Sinha: That gives me a lot of joy in what it means to recognize leaders like you and the society of head and neck cancer patients. And Bill has been a driving force for me to stay in head and neck cancer surgical oncology care. Dr. Pat Loehrer: The world's a better place because of both of you. Dr. Dave Johnson: Yeah, for sure. Dr. Pat Loehrer: For those that were here in the audience and those at home, don't forget, you can claim credit for this. Provide feedback. And if you could, I really would like to have a little bit about who's the best-looking podcaster, if you could. Dr. Dave Johnson: I think that's critically important. And I appreciate Dr. Sinha's recommendation. It's made me rethink my take two aspirin and call me in the morning recommendations. So I'll have to be more productive in the future. But this brings us to the end of this podcast. I don't know if any of you in the audience have listened to our previous Oncology, etc. podcasts. We hope that you did. And we hope that you will. As we've said at the end of each of our podcasts, we welcome ideas. We will literally talk about almost anything oncology related or not. That's why we have the 'etc.' on and it's been a great joy for Pat and me. Both of us enjoy doing this. We've been great friends for over 40 years. And it's a wonderful way of cementing the friendship. So thank you for all of you who are here in the audience. It'll take about an hour to file out with this large crowd so please be careful as you move to the doors. Thank you. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In part two of this two-part ASCO Education podcast episode, host Dr. Jeremy Cetnar (Oregon Health & Science University) continues the conversation with Drs. Lauren Abrey and Jason Faris, whose careers have criss-crossed academia and industry. They share words of advice for trainees today. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Dr. Jeremy Cetnar: Hello, and welcome to Part 2 of the ASCO Educational Podcast episode focused on career choices and transitions. My name is Jeremy Cetnar. I'm a Medical Oncologist and Associate Professor of medicine at Oregon Health and Science University in Portland. In Part 1, Dr. Lauren Abrey and Dr. Jason Faris about their motivations for pursuing medicine, and how they arrived at the different positions they've had. Today, we'll further explore career fulfillment, maximizing impact on patient care, and differences between working in academia and industry. Dr. Faris, what have you learned from the different roles you have had, and what aspects of your current work do you find most rewarding? Dr. Jason Faris: So, there's a lot to discuss here. In my academic and patient care roles, I felt extremely privileged to forge strong bonds with patients and their families, to offer support, counseling and hope in the context of making really difficult, challenging decisions... to rejoice in the individual victories, whether that was clean scans and normal tumor markers after adjuvant therapy for Stage III colon cancer, using the neoadjuvant therapy in locally advanced pancreatic cancer and watching them go to resection, helping to maintain quality of life by addressing key symptoms that a cancer patient unfortunately must endure, and providing emotional support when things do not go as hoped. Whereas the latter times in GI cancer patients are unfortunately all too common. And the moments or clinic visits where the cancer has recurred, or the treatments aren't working really do take their emotional toll on clinicians. I'll just say I took many of those losses personally. And as a general rule in medicine, I tend to wear my heart on my sleeve, which can be a mixed blessing. But that shared sense of purpose and the many times where you were able to offer something meaningful to patients and families provided real fulfillment and joy. I think at the time of the two transitions I've had, this was fundamentally the most difficult part for me, which was relinquishing these direct patient care interactions. So, another highly rewarding part of my role in academia was working with colleagues to open clinical trials or conduct clinical research. I had opportunities to be mentored by or collaborate with multiple people Ted Hong, Dave Ryan, Chin Wu, Jeff Clark, David Ting, and others at Mass General, as well as Lionel Lewis, Konstantin Dragnev, and Steve Leach at Dartmouth. Treating patients on clinical trials was always a stressful enterprise but highly rewarding, and I had the chance to be part of some really amazing groundbreaking trials at MGH, in some cases witnessing breathtaking responses in patients who were out of treatment options, in some cases for many months. Another highly rewarding aspect of my role in academia or my roles in academia involved all of the many opportunities to engage in teaching and mentoring, whether that's with medical students, residents, or fellows, where the enthusiasm for helping patients and learning was always infectious. Finally, I'd be remiss not to mention the wonderful nurse practitioners that I've worked with like Patty Tammaro at Mass General, with whom I cared for many GI cancer patients for years, and Elizabeth McGrath at Dartmouth, whose wisdom and dedication to patient care was really inspiring. On the industry side, on the NIBR side, I've had the opportunity to work on novel therapeutics that are making a bench to bedside transition from a drug candidate to a first in human Phase 1 trial, which to me is a thrilling, complex, and highly fulfilling endeavor that contributes critical knowledge to advance the field. And in the best of cases, identifies therapies that has the potential, that have the potential to alter the prognosis for thousands of future patients. As a clinician or clinical investigators, those times where your patients are responding to their treatment, whether it's on or off a clinical trial are wonderful and so incredibly rewarding. And I would argue that there's a similar phenomenon in running trials in industry, where there's nothing quite as magical as having a cadre of patients who had run out of treatment options, enrolled to a clinical trial designed based on compelling science, go on to experience sustained and significant responses. I absolutely love the commitment to patients and to follow the science, the collaborations among our teams, and interactions with our academic colleagues which I really treasure. I'm part of a team whose responsibility is to ensure the development of a clinical protocol to safely evaluate the potential of that therapeutic, carefully monitor for adverse events, evaluate the emerging pharmacokinetic and pharmacodynamic data, and most fulfilling of all, begin to observe responses in patients whose cancers had progressed on standard of care therapies. So I think the chance to have an opportunity to explore new therapeutics that might impact the eventual treatment of thousands of people with cancer is what keeps me engaged and fulfilled. It's been a wonderful opportunity and applies the clinical skills and patient focus from my prior roles and combines this with the resources and expert teams to run and analyze clinical trials. Dr. Jeremy Cetnar: If I can opine a little bit and ask you guys some philosophical questions. I think what I'm hearing today and what I've heard from other folks who have made that transition is that in industry versus academics, you work in a team, and you're evaluated as a team. And that's very different than in academics. You're very much rewarded for, whether it's patient volume or number of papers or leadership. That seems to me like a very big difference in terms of academic versus industry. And I'm wondering if you guys can comment on that a little bit more. Then you guys also mentioned, at least you just mentioned this, Dr. Faris, is that some will also say that when you go into industry, you're able to just impact a much bigger population of folks rather than typically in an academic setting where you are working one on one with patients. And yes, you have your IETs and whatnot, but there's just a bigger vision. Would you say that those are two accurate differences that are fairly significant, Dr. Abrey? Dr. Lauren Abrey: Yes. You are certainly part of a team. But I think if we're honest, you're part of a team when you're in the hospital. So I ran the team of research nurses. I ran the fellowship program. I needed people to manage the patients who were in-patient and to help me look after the clinical trial conduct paperwork, etc. and so I think that does translate into the setup that you find when you move to industry. It may be a little bit that your personal success, and industry can get very sometimes focused on metrics, like what have you contributed? What has the team been successful? So you do need to think about how to set yourself up for success. If you're leading the team, how do you set the team up for success? To me, that doesn't feel terribly different than academic medicine, but I could see where it could be a change depending on what your role was in the academic world. So I think that's reasonable. The other part of what you said, I struggle with that sometimes. I feel like we tell ourselves, that we're impacting more patients. And I think that's true. If we get a drug approved, and potentially that drug is used, not only in the US, but across western countries, in Europe, potentially in China, you get a sense of that. But it's like how do you feel that? You feel the story of an individual patient. Sensing the scale can be hard. News media know this well. They often tell the story of a particular person in the Ukraine right now to try to help us understand the scale of the war, because otherwise, it's a little impossible to digest. So for me, that doesn't always resonate. I think it resonates when I go out and talk to the different physicians practicing in different parts of the world. And I think that has been an incredibly eye-opening experience for me being in the global organization, is seeing the impact well beyond the US, because I think most companies are very indexed on the US. And we understand US practice well, but I think understanding the impact we can have across the world is also really inspiring, humbling, challenging, and something I think we all have to contend with because it's not the same everywhere. So yes, no, and in between, that's where philosophical lives, so thank you. Dr. Jeremy Cetnar: Yeah. Well, that's a fascinating perspective, the international perspective. Very interesting. Dr. Faris, how about you? Dr. Jason Faris: I completely agree with Lauren. I think on the team question, I definitely feel like we worked on teams in academia as well, whether we're talking about the multidisciplinary groups that are needed to take care of GI cancer patients, which always involves multiple specialties. I think at MGH, in particular, we would tend to go see the patient as a group, which is a bit unusual, to try to get everyone's schedules aligned, to be able to go into the room together. But it really presented an opportunity for the patient and the families to ask questions of us as a group and hear any disagreement that's in the room between the providers right there. There's absolutely a ton of teamwork that goes into taking care of patients. But what you were alluding to, I think, is also right, which is your promotion, your opportunities for advancement are sometimes couched on or developed from accomplishments on the individual side. And I would say more so than is true in industry. I think that's correct as well. I mean, certainly there are multidisciplinary grants that I was a part of, of course, publications that had multiple authors to which I was a contributing author. Sometimes I was first or last author, sometimes I was in the middle, but contributing to the paper. So there was teamwork there, but no question that there's an element of individual accomplishment. How many first- and last-author publications do you have? What's the grant situation look like in terms of ability to supplement the RVUs that you need to generate your clinical…? There's no question that there's an element of that that's not a present to the same degree in an industry role. And I just wanted to speak to the impact side, because I also agree with what Lauren said here. I think the idea and the hope is that in industry, we have an opportunity to potentially affect the lives of many, many, many patients, thousands of patients potentially, with a given cancer type if a new therapy is a homerun and takes off and is approved. That's a huge draw and I think something that motivates all of us is to be a part of something like that. But of course, not every drug, far from it, unfortunately, is going to end up as an approved drug that impacts thousands of patients. So I think it requires some recognition of that fact and patience and continuing to work on multiple projects, and always under the prism of doing the right thing for the patients while those trials are open. And I think that's the key, as well as working on scientifically exciting projects, really proud to say in NIBR that we follow the science. If there's an indication to be explored, based on the science, it may not be the most common indication in cancer, but if the science leads us to that place, that's what we work on. I think that decision making gets tougher, obviously, as you move through the system into a later stage, more commercially informed decision. But I think and certainly on the early phase trials side, that's something that's really exciting. I think on the academic side, taking direct care of patients, you have incredible impact on individual patients, and there's a lot of individual patients. I think you have tremendous opportunity for impact there as well, and your impact can be measured by those that you mentor and teach as well, the committees that you serve on influencing other trials that may be open at your institution. So I would in no way suggest that the impact is less in academia. I don't think that's true at all. I think it's just a different approach. And it is true that if you're lucky enough to work on a program in industry that ends up being an approved drug, you can help thousands of future patients or your team has helped thousands of future patients. That's also true when you're on the academic setting, serving as a PI, contributing safety data and efficacy data, really giving the best information back to the sponsor that you can or maybe you're running your own investigator-initiated study that can change a standard of care down the road. So that's the homerun. That's kind of the Grand Slam of situations that might develop as a medical oncologist on either side of the divide. Dr. Jeremy Cetnar: Thank you. I'd like to shift gears just a little bit and ask you, for people who are deciding for a transition in their career, what are some characteristics or skills or other attributes that you think would make one successful in industry? What are some things that are really, really important to be successful? And that might be different than in an academic situation or not? I'm not sure. And maybe that's another question is, you know, what are some of the things that make people successful in a career in industry? Dr. Abrey? Dr. Lauren Abrey: So I think there are so many things that you can do in industry that depending on what your strength is, I think you have the opportunity to play to that. So again, I think if you are very entrenched in the science, and that is really what makes you want to get out of bed in the morning, being in the early research group, whether it's Novartis, Roche, other companies or small biotech, you can really dig in and spend time thinking and contributing in incredible ways. And if you're the person who is much more interested, perhaps in finding out, what's influencing the patterns of care and why people are using certain drugs or certain treatment paradigms, you could absolutely work on the absolute other end and work in medical affairs and be the person who's out there, who's the critical partner to whether folks at MGH, OHSU, major cancer centers around the world, to figure out how do we bring those two together. And I think the group in the middle typically, like the drug development group that's getting the approval, so running the large Phase 3 studies, that requires people who are in it a little bit for the long haul. Those tend to be large studies. They run over several years, you're constantly looking at the incoming data, and yet you're blind to the results. So you have to be pretty diligent while you're in that space and willing to just buckle down and work hard. But I think there are things for everyone. And I think it's a little bit similar to what I discovered when you went into medicine. Not everybody's going to be a cardiothoracic surgeon. Only a few of us end up in this weird oncology space. But I think it does give you the chance to reinvent yourself and explore a few things. So I wouldn't say you have to have something. I think probably what you should do is talk to a lot of people. I think people make a lot of assumptions about what a change to a career in industry is or means. And you probably don't know what you don't know. So call people like me or Jason or someone who's done it and talk to people, because I think that's probably the best way you can make an informed choice. Dr. Jeremy Cetnar: What do you think, Dr. Faris? Dr. Jason Faris: Can I offer some advice? So are we in this kind of advice section? Dr. Jeremy Cetnar: Absolutely. Please do. Dr. Jason Faris: Yeah. So I would say my advice to oncology trainees would be to keep an open mind and stay flexible. I've got a Wayne Gretzky quote that I'd like to bring into this here, which is 'You miss 100% of the shots that you never take'. And I feel like I've probably taken that flexibility to a bit of an extreme with my career path and transitions. But ultimately, it's really enabled me to experience diverse career opportunities that I might otherwise not have had the chance to really experience. I think sometimes there can be assumptions or negative stereotypes about moves from academia to industry. But my own personal experience, now twice, at NIBR has been overwhelmingly positive. I've learned a tremendous amount from both environments, which I think provides me with a different perspective on design, conduct, and analysis of clinical trials and allows me to bring a patient-centric view into clearer focus in my industry role. I think it's also really critical to recognize that there are significant stressors and positives to each of these career paths. And they're not necessarily one way. I know multiple colleagues who have made a transition from academia to industry. Other colleagues like me who did return to clinical practice in a clinical investigator role or returning from industry to an academic lab, I've seen that happen multiple times, and multiple colleagues, of course, that have transitioned to other industry roles. So regardless of which path someone ultimately pursues, the real critical thing to me is to remember what brought us to medical school in the first place, which is a commitment and focus to patients above all else. I believe this can be achieved in many career options, direct patient care, teaching and mentoring, clinical investigator roles in the academic setting, or in industry by collaborating with academic colleagues and patient groups, focusing on programs that have high potential to advance treatment options for diseases with high unmet medical need. I happen to think GI cancers are the poster child for that, but you know, I'm a bit biased, and designing trials that are as patient-centric as possible. So that's the kind of advice that I would offer to people is not to think of these as mutually exclusive or there's only one way forward or if I make this decision, it's irreversible. I don't think any of those things are true. And I feel like I'm living proof. Dr. Jeremy Cetnar: Dr. Abrey, back to you. Any advice? Dr. Lauren Abrey: I can only agree with Jason, and I know a number of people who've gone in both directions, including some who have been in pharma for quite a long time, and then make a decision to go back to patient care. Sometimes, I'm going to say, like as a final career chapter, but it has been a bit like that, including in countries where it's quite difficult to return to practice, that they need to go back and redo some training. So I think, move forward, do things that make you want to get out of bed in the morning, and that probably will change over the course of your career. But I think don't be afraid to try something because the worst thing that could happen—that's always a good question to ask yourself, right? What is the worst thing that could happen? If it doesn't work out, you can probably make another choice. I also think you should, you know, I already said talk to lots of people. But pay attention to that network that you have and nurture it, cultivate it, because some of those people in your network might become mentors at some point, might become advocates or sponsors at some point. And always, always, always take the opportunity to mentor somebody else, including if you're young, do some reverse mentoring. I have gotten some of my best mentoring from somebody that I agreed to mentor, but he really ended up reverse mentoring me. And he's actually now leading a very small biotech and you could argue has leapfrogged part of my career. And that's a fantastic dialogue that I get to have. So, great fun. We only go around this once. So have some fun while you're doing good things, too. Dr. Jeremy Cetnar: Ain't that the truth? And I'll tell you, this is a small world. It does feel like the more people you talk to, all of a sudden, we all are connected. And so I just want to thank you, Dr. Abrey, Dr. Faris, for your time today, for your perspective, your interesting stories. And to all the listeners, we appreciate you tuning into this episode of the ASCO Education podcast. Dr. Jason Faris: Thank you very much. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In part two this ASCO Education Podcast episode, hosts Dr. David Johnson and Dr. Patrick Loehrer continue their conversation with Dr. Richard Pazdur, director of the U.S. Food and Drug Administration's Oncology Center of Excellence, focusing on his leadership and vision for improving cancer care worldwide. The conversation includes reflection on drug toxicities, approval processes, and complexity of clinical trials. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Dr. Pat Loehrer: Hi. I'm Pat Loehrer, the Director of Global Oncology and Health Equity at Indiana University. Dr. Dave Johnson: And hi. I'm Dave Johnson at UT Southwestern in Dallas, Texas. Dr. Pat Loehrer: This is the second half of our Oncology, Etc. conversation with Dr. Rick Pazdur, who's the director of the FDA's Oncology Center of Excellence. In Part 1, we chatted with Dr. Pazdur about his upbringing and his early career. Today, we're going to focus on his leadership and vision for improving cancer care worldwide. But first, we'll discuss how cancer has impacted his life personally. I want to flash-forward. I had the pleasure of knowing Mary. And there was no question, if you had a problem in oncology, you would go to Mary and not Rick Pazdur when you were a house staff member. But moving forward a bit, I'm not sure if all the listeners know that Mary came down with ovarian cancer. Dave himself had cancer. My wife had breast cancer. It is incredibly hard to be an oncologist I think when your spouse or someone who's close to you has cancer, and particularly, being married to a medical oncology nurse. Maybe just share a little bit about that journey of being a husband of a- Dr. Richard Pazdur: Yeah. It is interesting because going back to the Rush story, the first patient that my wife and I had in common, and this is so ironic, was a patient with ovarian cancer. The last patient that we had in common was her, which is some ironic fate, so to speak. And the story began of her illness was right around Labor Day. We had gone to Chicago in February driving back from Chicago. I noticed that she kept on taking a whole bunch of Tums and then saying - Oh, I just got a lot of GI symptoms, and she went to see her gastroenterologist or GP and he said, 'Oh, this is just, you know, indigestion.' And two weeks after that or not even that, she was in the hospital with a massive amount of ascites, needed an intensive care unit. It was readily apparent just on getting her CA 125 what she had and she wound up one day in debulking surgery and then IP chemotherapy, etc. I think something that I learned, and I think we knew from the very beginning that this was not going to be a curable illness, and how to deal with that on an emotional level. And I have to give my wife credit. She spared me a lot of the emotion because she was such a strong person. She made all of her own calls as far as what she wanted. She would ask me what I thought, but she would do her own research, she would go to her own doctors' appointments. She said, 'You don't really need to come with me. I'm self-sufficient.' She was very much interested in helping other cancer patients, and after she died, I think one of the most cherished conversations I had was a group of women that came to me and said how much she helped them during their support group because she was a nurse. She knew she was dying. She had emotional maturity not to fall apart but to accept the inevitable in a very strong way. My wife was a very religious person, had gone to Catholic schools, really embraced religion during those terminal years basically. And I think that was a great sense of comfort to her. But it did teach me a lot of lessons when you take care of somebody that has cancer, and that is, what a bad job we do with drug toxicities. Drug toxicities to medical oncologists and especially the people at the FDA are numbered, Grade 3, Grade 4, Grade 1. These toxicities are tolerable, tolerable to who, so to speak. And how to manage these toxicities and how they interrupt your life is one of the lasting experience I have, which I always will remember. And that has been one of my roles recently is forming several programs that we have in the OCE to look at dosing, to look at what is this definition if the drug is tolerable or well-tolerated or if the toxicities could be managed. I always say, yeah, every toxicity could be managed, even death. You call the undertaker to manage it. So what do you really mean by that statement. But I think the issue of toxicity is an important one. And then also going on clinical trials and having people considering what you want to go on, what risk you want to take, and what is actually in the informed consent and how meaningful that is. Dr. Dave Johnson: Really glad you brought that up, Rick. That matches my own experience with lymphoma and going through chemotherapy. And as an oncologist, one would think I would know what the side effects are. I'd recounted them dozens and dozens of times to people over the years, but until you've actually experienced them either personally or up close as you did with Mary, it's impossible to fully understand. I'll give you one example. Fatigue. Everybody thinks they know what fatigue is, but until you've had chemotherapy-induced fatigue, the fatigue that never abates, you just don't understand what it is. It's debilitating in ways that are unimaginable to most people. So I'm sure that experience certainly shaped your view and your role at the FDA. Dr. Richard Pazdur: Correct. Dr. Dave Johnson: I wonder, if you might share, you initiated a number of programs recently, including programs to try to improve coordination and co-operation amongst the pharmaceutical companies. Could you speak to some of those programs for us? Dr. Richard Pazdur: I think one of my favorite programs is Project Orbis. Project Orbis is an idea I had when I was walking down the street. It just hit me. When I came to the FDA, one of the things I rapidly noticed is how isolated the FDA was, even from the rest from the regulatory agencies throughout the world. There was very little cross-fertilization there. So one of the very first things that I did was set up a monthly tele-conference first with the EMA, the European Medicines Agency, and then we ended on Health Canada, Australia, Japan, Singapore, you name it. And one of the things that became really apparent to me, we at the FDA got applications always first—always. That's obvious. You know why they had given it to us first? The money. That's where the finances are going to be. So we got the application first, and it could be 2 years, 18 months, 12 months, that these other countries, Canada, Australia, Switzerland, and Brazil, Israel, would get these applications. And I said, well, this isn't right, really, because these people, they have cancer. They have every right to get these medications as soon as possible, and also we have such a large agency. We have 80 to 100 oncologists that work there, and most of these agencies have one or two oncologists. So our expertise in oncology at the FDA is so much greater than these other regulatory agencies. How can we leverage that to help these other countries? So we started Project Orbis, and what it was is that companies come in and they submit an application and they simultaneously submit the same application to the countries that want to participate in the program. They are all preselected and have confidentiality agreements with each other. And we worked together on the applications, basically reviewing the applications. So we had many meetings, tele-conversations, telephone conversations with countries. So that expedites these drugs. This has really had a lasting impact because from a worldwide perspective, it's really promoted more rapid development of drugs and rapid approval of drugs, and that's important because that establishes sooner new standards of care that will impact future trials. So in addition to the humanitarian issue of improving healthcare for patients in these countries, it has an impact on the global clinical trial system by having new standards approved much faster and accepted by world authorities. Dr. Pat Loehrer: Let me just jump on that for a second, just to make a comment. Back when we were growing up, there would be like three to five drugs approved- Dr. Richard Pazdur: Yeah. Dr. Pat Loehrer: And today, it's like once a week, there's a new indication for oncologists. Dr. Dave Johnson: Our listeners have another question that might be appropriate to ask at this time. What is the most common mistake that drug companies make in their applications to the FDA or in the process of trying to get their drug approved? Is there a frequent mistake that you can advise them? Dr. Richard Pazdur: Well, they don't come and talk to us. That's number one. They want, not necessarily what the best registration pathway is, but what the quickest registration pathway is. And sometimes the quickest registration pathway, especially single arm trials, are not the best registrations pathway. So my advice is rather than playing games with the FDA, to put it in the vernacular, just do the right thing and say, what is the optimal information that patients need when I develop this drug. We're seeing a lot of problems now with various drugs where people are developing in a refractory disease setting a drug, and they plan on getting accelerated approval on a response rate. So they push and push the dose. And with a single arm study, you can't really evaluate safety that well. Everything is attributed to the drug, and they want to get the highest response rate. And they get it, and there's a confirmatory study, and the arm of the confirmatory study, the control arm may not be as toxic as theirs, and we're seeing a wave of drugs that now have inferior survival compared to controls, which probably is predicated upon, they got the wrong dose. And I think that is one of the major programs that we have, that we need to address is dosing in oncology, this 'More is better, more is better,' and 'Let's push the dose as high as possible.' More isn't even probably good in cytotoxic days, but certainly, not a good idea in targeted therapies and certainly not a good idea in biological therapy. So we've really got to think about dosing more, penetration of targets, what's the optimal dose rather than what's the highest dose. You know as well as I do, pharmaceutical companies want to go with the highest dose because the major hurdle is the demonstration of efficacy, even in a randomized study. So nobody wants to be blamed by saying, well, you spent $100 million on a Phase 3 study and it's negative because you used too low of a dose. But then at the end of the day, we don't have a really good tolerable dose, and it's really hard to go backwards and look at dosing after a drug was already approved because the efficacy study has already been done. Dr. Pat Loehrer: The other aspect of drug companies is not only getting the dosage there, but also the duration. There is motivation for money, and so patients are going to and- Dr. Richard Pazdur: Oh, count on that. Dr. Pat Loehrer: So it begs a question, and I know the FDA can't do this, but in other countries, there is a monetary review together with the toxicity review. Can you reflect a little bit about that to the best of your ability? Dr. Richard Pazdur: Well, even within our simpler agencies, they may communicate more than we do with CMS, but all oncology drugs that when they're approved are then paid for by CMS, okay? In these other countries, that is not so. They may get approval and then they have to go to these health assessment agencies that will decide and argue with the companies what the pricing of the drug is. I think it's a mistake, honestly, for the FDA to get into pricing. We have a hard enough time with efficacy and safety, and pricing is a very ephemeral concept because it could change on a dialing. Somebody could promise you, you should approve their drug because it's much cheaper on Monday, and on Friday, they could say, 'Oops, we made a mistake. We really think that this dose has to be X number of dollars.' And you could see competition hasn't worked well in oncology with seven PD-1 drugs approved, pricing has not really been of any movement here. Dr. Pat Loehrer: I'm sorry. Dave may have another question, but let me ask you this. Going back to the clinical trials and what industry asked you- the complexity of clinical trials is going up logarithmically compared to the way they were in the '70s and '80s. In many of the trials where we have to get all this data in order to soothe the FDA, what are your thoughts about simplifying clinical trials? Dr. Richard Pazdur: Oh yeah. I'm for it. I am for it. If you really look at it, these are not FDA requirements for the most part. The companies want them, all of this data because it's controlled. They don't want to be blamed at the end of the day for not capturing this data or that data. They have developed complicated bureaucracies, going back in my sociology days there, complicated bureaucracies to gather all of this data, the whole CRO industry to go out and pester you guys in practice by doing site visits. It's a complicated situation and it's really predicated a lot on the history and bureaucracies that have been built up and not money to strip away those bureaucracies for fear of failure, so to speak, of not catching something. Dr. Dave Johnson: So Rick, we're coming to the end of our time that we've scheduled. I actually have two questions for you. We've asked all of our previous guests, the first of which would be if you could talk to your 21-year-old self today, what advice would you give yourself? After you've done that, we'd like to know what books have you been reading lately or is there some documentary that you've seen that you would recommend to us and our listeners? Dr. Richard Pazdur: I would tell myself, when I was 21 years old, relax and be less anxious. All things pass. I think we get so anxious when we're young about relatively small things. I remember my first ASCO presentation, I was petrified. My heart was beating out of my chest. I was sweating. And like relax. It's one of a thousand presentations at ASCO. We tend to magnify things, and I think age puts things in perspective. This in the reality of the world is a small thing, and people probably won't even remember it. Dr. Dave Johnson: Excellent advice. Dr. Richard Pazdur: My favorite author that I'm reading now for the last couple of months is a presidential historical author, Doris Kearns Goodwin. I think many of you know, she's written many books. I love her writing style. And I like non-fiction. I like biographies and I like history books, history stories rather than mysteries or things like that, fantasy books. The two books that I really enjoyed, the first one was No Ordinary Time: Franklin and Eleanor Roosevelt: The Home Front in World War II. I don't know if anybody's read that. It's an excellent book. Most of our attention in World War II is directed toward Europe and what was going on in Europe, the battlefields, etc., which I'm not a big fan of reading about battles and stuff, but this was what was going on in The White House and the relationships of all of the people that came there. It was like a hotel almost with the personalities that were flowing through including Churchill and various princes and queens, etc. But also the interesting relation, the fascinating relationship that Eleanor and Franklin Roosevelt had, I don't know how to describe the relationship. It truly was an unconventional relationship based on some past history that they had of affairs etc., but it was just a fascinating one. The best book, though, again I'm reading now, is written also by Doris Kearns Goodwin, and it is Lyndon Johnson and the American Dream. Doris Kearns Johnson was his biographer and spent a great deal of time with him in The White House as well as when he left The White House. But it's an excellent book on management and reading people, success. One of the things that is most interesting about Lyndon Johnson, and especially when he was running the senate before he became president, was his ability to know what motivated people and how to use that to form a consensus. Does this person want to go on this trip. I'll give it to him and then he could help me with this. Does this person want to go to this party or get on this position in congress? So it was really a skillset that he had, which I think most leaders need to know. You have to motivate people. You can't lead by an autocratic masthead, but you've got to lead from what do people want and to make sure that they feel you have a personal relationship with them. As I say to my staff, everything in life is personal—everything. Dr. Dave Johnson: Well, it's been a great session, Rick. We so much appreciate your willingness to spend time with us. We wish we had twice as much time. I'm sure we could go on for hours. Thanks again, and we appreciate all you do at the FDA. You've been a fabulous leader, and we hope you continue on for many years to come. Dr. Richard Pazdur: Thank you so much, Dave, and thank you so much, Pat. Dr. Pat Loehrer: Great to see you. Dr. Dave Johnson: Pat, before we leave, any idea why our patients seem to get sick on Saturday and Sunday? Dr. Pat Loehrer: I have no clue. Do you know the answer, Dave? Dr. Dave Johnson: Yes. They have a weekend immunity. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

In part one, of this two-part ASCO Education podcast episode, host Dr. Jeremy Cetnar (Oregon Health & Science University) interviews two very accomplished physicians and researchers, Dr. Lauren Abrey and Dr. Jason Faris. We'll hear about their motivations for pursuing medicine and how they arrived at the different positions they've held in academia and industry. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Dr. Jeremy Cetnar: Hello, and welcome to the ASCO Education podcast episode on career paths and oncology. My name is Jeremy Cetnar. I'm a Medical Oncologist and Associate Professor of Medicine at Oregon Health and Science University in Portland. I'm delighted to introduce today's two guests, whose careers in oncology have crisscrossed academia and industry. Dr. Lauren Abrey and Dr. Jason Faris, I'm excited to chat with you about the inspiration and motivations that drive you, people you've leaned on, how you've made your career decisions, challenges you've faced, and more. So let's start by asking each of you, could you share a little bit about your early life and background, what attracted you to medicine, and who are some of your early mentors and role models? Let's start with you, Dr. Faris. Dr. Jason Faris: Yeah, I'd be happy to. Thank you. So, I grew up in a small town in South Jersey in Greater Philadelphia. My mom was a registered nurse in pediatrics in the maternal infant unit for many years at Cooper Hospital. I was always interested in science and medicine and my mom's dedication to her patients. Her altruism and compassion served as a real inspiration for me, for my eventual decision to go to medical school. But I took a long time to get there. I had a bit of a circuitous route to arrive to my career in medicine though it started off conventionally enough. I was initially geared towards a premedical track in college, majoring in biology, but an exciting summer research project, working on the biochemical mechanisms underlying osmoregulation in a marine crustacean with mentoring from my first true mentor, Dr. Don Lovett, led me to apply to and attend graduate school in molecular biology at Princeton. This was followed by a position at Merck as a molecular biologist in the genetic and cellular toxicology group. I went to veterinary school at the University of Pennsylvania where I met my future wife. And then finally, back to the original plan of attending medical school, but I have to say with a much better sense of why I wanted to attend medical school in the first place, now in my late 20s, which was a bit unconventional at the time. I really did my fair share of exploration of Allied Health careers. That's for sure. I attended Johns Hopkins for medical school, where I quickly discovered a passion for internal medicine. And that was far and away my favorite clerkship and sub-internship. That's the background to how I got to medical school. Dr. Jeremy Cetnar: Dr. Abrey? Dr. Lauren Abrey: Interesting. I love your story. We share... I grew up in a small town, not so far away, but I was in upstate New York. And I think there were two influences that kind of got me to my ultimate passion for brain tumors. And this sounds a little quirky to start with. But I had a pretty serious head injury as a tween. So I guess I was about 12. I had a skull fracture, epidural hematoma. And while I would never have said I woke up at that moment and thought I have to be a doctor, I think I became fascinated about things to do with the brain. In parallel, something that I think tinged a lot of my childhood was a number of family members who had cancer. So both of my grandmothers had breast cancer, while I was well aware of the fact that they were sick and battling this. And two of my aunts also had cancer. And I would say it's an interesting split in my family. So about half of them are survivors and about half ultimately died of their disease. So both of these things really motivated me or focused me on the need to do something important, but also to do something that really motivated me to get out of bed in the morning. I think I was much more to the point. I went straight to college, straight to medical school. I remember calling my parents and telling them I was applying to medical school and having them say, "Wait. You? Really?" So it wasn't necessarily the family expectation that I would do this, but I was very driven and motivated to make some of these choices and then discover my particular interests as I progressed through medical school. So I went to Georgetown for medical school and then have trained at a number of places in the US. I think that's a little bit how I took my first step on this career journey, let's say. Dr. Jeremy Cetnar: So take us through what the decisions were like in your head at the end of fellowship in terms of first jobs. Dr. Faris? Dr. Jason Faris: In terms of my choice to pursue a career in medical oncology, this goes back to medical school during an internal medicine clerkship. I had an assistant chief of service, ACS, at the time, Phil Nivatpumin. He'd go on to become a medical oncologist. He really inspired me with his optimism and bedside manner, including with multiple oncology patients on that clerkship. His enthusiasm for science and medicine, his teaching skills, and an absolutely legendary fund of knowledge. For Phil, he was just an incredible ambassador for both internal medicine and for oncology. After medical school, I went to internship and residency at Mass General Hospital. And in one of my first rotations, I was on the oncology service, which was not so creatively called Team Three. I think they can up the ante there, but oncology services on Team Three. I was caring for many extremely ill patients battling disease progression from their metastatic cancers, or sadly, in many cases complications of their treatments. During that rotation, I was intrigued by clinical trials offering novel treatment options based on cutting edge science, but also struck by the number of patients who just didn't have any clinical trial options. I became aware of the limitations of the conventional treatments that were offered. I was really inspired by the patience and dedication of the nurses and doctors caring for them. And I vividly recall a roughly 50-year-old woman I helped care for with AML, watching as the 7+3 chemotherapy caused lots of side effects for her and being amazed by her strength and grace, her resilience as she faced her illness, her potential mortality, and the intense chemotherapy she was undergoing. And I knew during those moments with that leukemia patient while caring for other patients on that oncology service that this was the field I would pursue. Oncology was really the perfect blend of humanism, problem solving, longitudinal follow-up and rapidly accelerating scientific progress leading to new avenues for clinical trial treatments. Like Lauren, I was motivated and inspired by cancer diagnoses in my own family. My maternal grandmother died of pancreatic cancer during my junior year of college. My dad was diagnosed with colon cancer during my first year of fellowship. So those are all really strong motivators, I would say. And after completing my fellowship at the combined Dana-Farber MGH program, my first position out of fellowship was in the gastrointestinal cancer group at MGH. I actually had been training in genitourinary oncology after my main clinically focused year of fellowship, but I did a chief resident year in the middle of fellowship, and that was the tradition at MGH. And as I was about to return to fellowship for my senior year of fellowship, the head of the GI Group and head of the Cancer Center at the time, Dave Ryan, offered to serve as a clinical research mentor for me in GI cancers. As a senior fellow, I wrote an investigator-initiated trial of cabozantinib for patients with neuroendocrine tumors under his mentorship that went on to demonstrate encouraging results, led to a Phase III study in that cancer population, and I ultimately accepted a position at the MGH Cancer Center in the GI cancer group about 11 years ago. And that was the start of my post-training career. Dr. Jeremy Cetnar: And how about you, Dr. Abrey? Dr. Lauren Abrey: So for people who don't know, I'm actually a neurologist. I finished my training in neurology and then pursued a fellowship in neuro oncology. I would say it was really patients and observations of things that were happening with patients during my residency. I did my residency at the University of Southern California at Los Angeles. I was at the LA County Hospital, which for people who don't know, is one of the largest hospitals in the country. I had the chance to see several patients who had paraneoplastic syndromes, and got the support from different faculty members to write those cases up, and really resulting in my first independent publications. That was what kind of got me bitten by the bug to understand this link between neurology and oncology. I very intentionally went to Memorial Sloan Kettering to have the opportunity to work with Jerry Posner. And I think I no sooner got there than I got totally bitten by the brain tumor bug, which seems a little counterintuitive. But the paraneoplastic work was kind of deep laboratory work. And I realized that I really enjoyed seeing the patients having the partnership with neurosurgeons and digging into what is still a pretty intense unmet medical need. So it was an interesting pivot because I really thought I was going to Sloane to focus on paraneoplasia. I still think I learned so much with that interest that I think we can reflect on when we consider how immunology has finally entered into the treatment landscape today for different tumor types and understanding is there a background in paraneoplastic disorders that could help us. But I have to say it was really the brain tumor work that got me focused and the chance to work with people like Lisa DeAngelis, Phil Gutin, and others that was kind of fundamental to my choices. I stayed there for two years of fellowship and then continued as faculty for about another 15 years at Sloan Kettering. So that's really the start of my academic career and the pivot to industry came much later. Dr. Jeremy Cetnar: So both of you have impressive career CVs, have been trained at very prestigious institutions. So at some point in time, take me through, what was that transition like between, 'Hmm, what I'm doing is enjoyable, but maybe there's something else out there that I want to explore.' And what I mean by that is mostly industry at this point. So that's an important question that I think a lot of junior faculty face, a lot of mid-career faculty, maybe even later-stage faculty. But I think that's a tension point for a lot of people because I think there's a lot of fear. I think there's a lot of anxiety about moving outside of the academic realm. So, tell us a little bit about what was the pull in terms of going to industry and what were some of the thought processes that were going on. Dr. Faris? Dr. Jason Faris: I've experienced two transitions, actually, between academia and industry. I like to do things in pairs, I guess. But the first was, after multiple years at the MGH as a resident fellow and as a clinical investigator at the MGH Cancer Center. As a new attending and clinical investigator, I was attempting to balance my work priorities, providing patients with GI cancers, which is a rewarding but complex and I'd say emotionally intense experience, given the phenomenally aggressive and devastating cancers these patients grapple with such as pancreatic cancer, alongside the other responsibilities of my clinical investigator position. Those other responsibilities included writing grants and papers and protocols, evaluating patients who were interested in open clinical trials, and serving as the principal investigator for multiple studies. I was serving on committees, mentoring and teaching. Patient care was always my top priority as it should and really must be. And I feel incredibly lucky to have had truly amazing colleagues at MGH across several disciplines, from medical oncology, nurse practitioners, practice nurses, radiation oncologists, and surgeons. It was and continues to be a dynamic place full of extremely talented and dedicated clinicians. I think we really all benefited from the coordinated teamwork in both patient care and research in a really tight-knit GI Group. But nonetheless, for me as someone who delighted in spending large amounts of time with my patients in the clinic rooms, and I think my colleagues would agree frequently agonizing over decisions impacting their care, achieving sufficient balance to really focus on writing and overseeing clinical trials was becoming increasingly challenging for me. And it was in that context, after spending roughly a decade and the combination of residency fellowship training and as an attending in the GI cancer group all at MGH that I made a truly difficult decision to move from my beloved outpatient clinical and clinical investigator role to industry to focus more exclusively on clinical research. And after interviewing for several industry-based roles, I accepted a position in the early-phase group at the Novartis Institutes for Biomedical Research or NIBR as we kind of pronounced those words in Cambridge. I absolutely loved my time at NIBR. It's an incredible place with a strong history of and commitment to innovation as well as passionate, talented colleagues, many of whom I've worked with in the past. When I first started at Novartis, I was amazed at the array of experts on the teams I was helping to lead as a clinical program leader. Our teams are the definition of multidisciplinary. They're composed of what we call line function experts in multiple disciplines. This includes preclinical safety experts who design and analyze data from studies that precede the filing of an IND, research scientists, chemists, preclinical, and clinical pharmacologists, statisticians, program managers, drug and regulatory affair colleagues, who focus on the interactions with health authorities, including the FDA, operational colleagues called clinical trial leaders, and many others. In my role as a senior clinical program leader, I also have the opportunity to collaborate frequently with research colleagues on preclinical programs, designing and writing first in human trials, followed by conducting the actual studies and in close collaboration with our academic colleagues, analyzing the clinical and translational results. Dr. Jeremy Cetnar: Dr. Abrey, how about you? Was there a moment or what were the moments that led to you deciding to make this transition? Dr. Lauren Abrey: I guess I have the other sort of story. I got pushed, I would say, in the sense that like many of us, I'm married, and my husband was the one who took a job with Novartis and said, "This would be an adventure. Let's go live in Switzerland." So similar to Jason, he took a position at NIBR, and I think for many of the same reasons, he really wanted to delve deeply into early mechanism of action and allow himself to dedicate really a chunk of his career to developing key drugs. But moving to Switzerland changes your options suddenly. I think I had spent most of my career at Sloan Kettering doing clinical trials. That was really my comfort zone, my sweet spot. And when we moved over here, I explored briefly, could I set up an academic career here? And very kindly, I was invited by a number of Swiss colleagues to look for opportunities to do that. But I realized what I loved was talking to patients, and that that was going to be difficult with the language barrier. And I equally loved running clinical trials. So I had a great opportunity to join Roche shortly after their merge or full acquisition of Genentech. This allowed me to continue the work I had been doing on Avastin for brain tumors. But I think the other thing that allowed me to do, that was something I was really looking for was to broaden my scope and to no longer be niched as just a brain tumor expert. And if you're in academia and you're a neurologist, obviously, you're going to be fairly constrained in that space. But moving into a role in industry really allows you to look much more broadly and work across multiple tumor types. And I spent the next seven years at Roche running not just the Avastin teams that were developing drugs for a number of indications, but really overseeing the clinical development group based in the European sites. And they had about 14 different drugs in different stages of development as well as partnerships with their early research group that was European based. So it was a fascinating time for me, and I feel kind of like I got thrown into the pond. I knew a lot about clinical trials. I had no idea about so many other aspects of what I needed to consider. And I think Jason started to allude to some of this with the different line function expertise and things I think we take for granted or maybe we simply have blind spots around them when we are sitting in our academic organizations. So it's been a really delightful plunge into the pool. I've continued to swim mostly. Occasionally, a little bit of drowning, but a lot of fun. Dr. Jeremy Cetnar: What would you say are the major differences between an academic career and industry? Dr. Lauren Abrey: I think, as you said, the things that are similar is that the purpose or the mission for both is in many ways the same. We would like to develop better treatments for patients with cancer. And so there's a huge focus on clinical trials. There needs to be a huge focus on patients, and that can get diluted in industry. I think the things that you don't appreciate sometimes when you're sitting on the academic side is just really the overarching business structure and the complexity of some of the very large organizations. So you suddenly are in this huge space with people focused on regulatory approvals focused on pricing, focused on manufacturing, focused on the clinical trial execution, and why you are doing it in different spots. And so I think some of the different factors that you have to consider are things that again, we either take for granted or are super focused when you're in one organization. And I think the tradeoffs and how decisions are made, particularly in large pharma, can be frustrating. I think we are all used to applying for grants or getting the funding we need to do whatever our project or trial is. And then you just start very laser focused on getting to the end. If you're in a large organization and they have a portfolio where they're developing 14, 15, 20 different things, you might suddenly find that the project you think is most important gets de-prioritized against something that the company thinks is more critical to move forward. And that could be because there's better data, but it could also be because there's increasing competition in the space or there's a different pull for a large company. I haven't seen the early development side as much. I've seen the development. I've now seen Medical Affairs for how some of those decisions are made, but I'd be curious to hear what Jason has seen in some of his experiences as well. Dr. Jason Faris: Comparing and contrasting a little bit between the two, because I've run early phase studies on the academic side, I'll talk more about that in a little bit in terms of another academic position that I held. So I've run early-phase studies there. I've run early-phase studies in industry as well. And they share a lot of similarities, certainly following compelling science, the excitement about new therapies that are going to be offered to patients. But I think the execution is a bit different, and I would say, when you're running clinical trials in the academic setting, you're meeting every patient that you're going to put on study or at least one of your colleagues is, if you have sub-eyes on the study, that's a major, major difference, right? You're directly taking care of a patient going on to an experimental therapy, consenting that patient, following them over time, getting the firsthand experience and data from that patient interaction, but not necessarily, unless you're running an investigator-initiated study, not necessarily having access to the data across the whole study. You're hearing about the data across the whole study at certain time points on investigator calls, PI meetings, dose escalation meetings, those kinds of things. But you're not necessarily having access to the real-time emergence of data across the whole study from other people's patients. So you're a bit dependent on the sponsor to provide those glimpses of the data, synthesize that and present overview. So those are some operational differences, I would say, because you're not taking direct care of the patients and having your time split among different commitments in that way I have felt a greater ability to focus on the clinical research that I'm doing in my industry-based role, which I like, of course, but I also miss taking care of patients. I love taking care of patients. So I think it's always a double-edged sword with that if we can use a sword analogy here. But I think they both offer really exciting options to pursue new therapies for patients, which for me, was one of the fundamental reasons that I pursued medical oncology in the first place. It was really this idea that the field is rapidly advancing. I wanted to be a part of that. I saw firsthand what cancer could do to my family or family members, and I took care of patients in the hospital as an intern resident and fellow where I think there's just a tremendous unmet medical need. And so having an opportunity to contribute to the development of new therapies was always a real inspiration for me. Dr. Jeremy Cetnar: With that being said, what led you to go back into academia? Dr. Jason Faris: This is an ongoing saga, I guess. So after several years of professional growth at Novartis, gaining experience with designing and conducting clinical trials on the industry side, I was actually at ASCO and I learned of an open role for the director of the early phase trials program at Dartmouth's Cancer Center. After extensive consideration, which I think you can see as my trademark at this point, I made another difficult decision to interview for the position, which was focused on helping to grow the early phase trials program at an NCI comprehensive designated cancer center that's unique in a way because it's in a rural area. And it had a new director of the Cancer Center, Steve Leach, who's a renowned laboratory scientist with a focus on pancreatic cancer and a surgeon by training. I ultimately decided to accept the early phase director position, moving my family away from Greater Boston, where we had lived for about 15 years, to the upper valley of New Hampshire. And while at Dartmouth, I was part of exciting projects, including writing and overseeing an NCI grant called Catch Up, which was geared towards improving access to early phase clinical trials for rural patients. I opened numerous sponsor-initiated immunotherapy and targeted therapy, early phase trials. Just to say a little bit about Dartmouth's Cancer Center - I think they also benefit from tremendous collaboration, this time across Dartmouth College, the Geisel School of Medicine, the School of Public Health. I think they provide really excellent care to their cancer patients. And I was extremely proud to be part of that culture in the GI Group, which was much smaller than the one at MGH, but also an incredibly dedicated group of multidisciplinary colleagues who work tirelessly to care for their patients. But nonetheless, less than six months into that new position, the COVID pandemic started, and that introduced some significant and new challenges on the clinical trials side in terms of staffing, infrastructure, those kinds of things. In that context, I made a decision to return to NIBR, refocus on clinical research, and hope to harness my background in running clinical trials in both settings, both academic and industry, as well as the resources and pipeline of Novartis to really maximize my impact on drug development. So for me, it was a question of where can I have the maximum impact at this crazy time, difficult time. I saw that my best option was to return to industry to work on studies to try to develop new therapies. Broadly speaking, my role as a senior clinical program leader in the translational and clinical oncology group at NIBR is to design, write, conduct, and analyze innovative clinical trials of early phase therapeutics. Dr. Jeremy Cetnar: Wow, that's fascinating, very, very interesting. A lot of stress. You should definitely be buying lots of presents for your family for moving them all over the place. This concludes part one of our interview with Drs. Abrey and Faris. Thank you so much for sharing your inspiring career stories. And thank you to all our listeners for tuning into this episode of the ASCO Education Cancer Topics podcast. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.