ASCO Education

"What exactly is implicit racial bias? How does it manifest in physician-patient interactions and what is the potential impact of such bias on oncology patient outcomes? In this ASCO Education Podcast episode, Dr. Lauren M. Hamel (Wayne State University) and Dr. Nimish Mohile (University of Rochester) share their insights and perspectives on these topics with host Alissa A. Thomas (University of Vermont). If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. Resources: Blindspot: The Hidden Biases of Good People by Mahzarin R. R. Banaji and Anthony G. Greenwald Implicit Associations Test 21-Day Racial Equity Challenge   TRANSCRIPT Dr. Nimish Mohile: We had a patient a few years ago who had presented to our clinic, who ended up having a diagnosis of primary central nervous system lymphoma, and she was a young black woman, and it took about nine months for her to get that diagnosis. She had gone into multiple emergency rooms, she was only 22, had not had prior interaction with the medical system, but based on some of her socioeconomic demographics, her skin color, she was never given the kinds of testing that any other patient I think should have gotten at that time.   Dr. Alissa Thomas: Hello, and welcome to another episode of ASCO Education podcast. Today's topic is, 'Implicit racial bias and its impact on patient care.' My name is Alissa Thomas, and I'm a Neurologist and Neuro-Oncologist at the University of Vermont College of Medicine. I'm delighted to introduce our two guest speakers; Dr. Lauren Hamel, who is an Associate Professor of Communication and Behavioral Oncology at Wayne State University, and the Co-program Leader of the Population Studies and Disparities Research Program of the Karmanos Cancer Institute. Her ongoing research explores racial attitudes in non-verbal behavior of oncology patients and physicians, and how those behaviors influence treatment decisions. Dr. Nimish Mohile is a Professor of Neurology and Oncology at The University of Rochester. He also serves as the Diversity Officer, Associate Chair for Career Development and Leadership, and Neuro-Oncology Division Chief. I'll get us started with the first question, really a definition. What do we mean by the term, ‘implicit racial bias’? Dr. Lauren Hamel: I'm happy to go first. I think understanding what the definition of what implicit racial bias is is really important. You know, for good or for ill, over the last few years, it's gotten a lot more attention. And I think what's important to remember about it is that it's not a cognizant or a conscious bias, and it really is implicit, and it really is more of an association than it is anything else. It's sort of like the built-up associations that we have for anything. You know, could be race, could be gender, any number of demographics, or other factors that make our lives as humans. So, you know, associating certain aspects of people with positive or negative valuations. I think when we're talking about implicit racial bias, it's kind of like the gut associations we have for members of different racial groups. So often, it's kind of paired with "white is good, black is bad." It's a very rudimentary description of it, but that's a real kind of basic association that this kind of definition is built around. Dr. Nimish Mohile: Yeah, I would agree with that. I think that's a great discussion of what this is. I think it's really important for us to remember that these are really ingrained behaviors. It's, based on, you know, how we've been socialized and conditioned. And I think it's helpful to also put it in the framework of knowing that we all have some biases, we all probably have racial biases, and age biases, and other kinds of biases, and there's no sort of good or bad about having these biases. And the important part of this is, how do we recognize some of the biases that we have so that we can be more conscious about how we might fix those or think differently about the patients that we're seeing so that it doesn't result in actions that can be harmful. Dr. Lauren Hamel: Yeah, I agree with everything that Dr. Mohile just added. It is these ingrained associations. Really, it isn't about blaming ourselves for them because it's kind of the result of how our brains are structured. But to his point, it's once we know that we have them, and you know, we have data showing how they affect our behavior, it's then on us to identify them and then work to mitigate them. Dr. Alissa Thomas: Thank you. How do racial biases in patients and physicians influence treatment decisions or ultimately, how does this affect patient outcomes in Oncology? Dr. Lauren Hamel: You know, I think the direct relationship between certain biases and outcomes is still kind of being uncovered and investigated. But there are some interesting patterns that have been uncovered in data, specifically in the Oncology context too, because as you can imagine, a variety of professional organizations and groups examine the influence of bias. But just within Oncology, we see physicians who have higher levels of implicit bias who tend to see their patients who are black as less trustworthy, less educated, and less adherent to treatment recommendations. We also know that higher levels of implicit bias may be associated with less aggressive treatment programs recommended for black patients. We see some associations between levels of implicit bias and verbal dominance. But what was I think, especially interesting, is that we also see patterns of kind of perceptions from the patients that these physicians are communicating with. So, we see some manifestations in behavior, but we also see patients kind of “picking up” on some of these, whether or not they can identify them as bias necessarily. But for example, we see that patients who are seeing a physician with higher levels of implicit bias tend to see their physicians as less patient-centered, and less trustworthy. And I think that's a really important piece to identify because these biases are by definition kind of operating outside of our own consciousness, but they're manifesting themselves in a way that the people that we're communicating with are noticing. Dr. Nimish Mohile: We had a patient a few years ago who had presented to our clinic, who ended up having a diagnosis of primary central nervous system lymphoma, and she was a young black woman, and it took about nine months for her to get that diagnosis. She had gone into multiple emergency rooms, she was only 22, had not had prior interaction with the medical system, but based on some of her socioeconomic demographics, her skin color, she was never given the kinds of testing that any other patient I think should have gotten at that time. That was a real sort of wake-up call for our clinic, because as some of you know, this is a disease that we can really treat, especially in younger patients. So, there's real consequences to these kinds of biases. And some of them are personal, the ways they're ingrained in us, but some of them are built into our systems, and it's based on; what our ERs are designed like, where our hospital systems are, what kind of relationships we have with primary care physicians in different communities, what kind of access some of our patients have to primary care physicians. This patient in particular didn't have great access to primary care, so she didn't have this other team of people to advocate for her and to say, "Hey, you know, this is something really different in this patient, and we need to take this seriously." So, I think it can get complicated as we think about biases in ourselves, in other people, in the whole health system, and then also as we get out of our health system, some of these things are so influenced by what's going on in our communities. Dr. Lauren Hamel: Yeah, I think that's a really important point. At least with my work, I examine kind of at the interpersonal level, but these biases, as Dr. Mohile points out, exist in all levels of our society, and they interact, and they're-- I don't want to say additive, it's probably much more exponential. But yeah, it's a layer, on top of layer, on top of layer problem. Dr. Alissa Thomas: So, Dr. Mohile, you commented earlier that part of it is recognizing these biases in ourselves. Can you discuss how we might approach this with the impact of an anti-racism education program has been in your department and applications for that? Dr. Nimish Mohile: So, we've worked on anti-racism in our department on a couple of levels. One of the main levels is just building awareness for individuals to understand that they have biases, that they have racial biases, and starting to understand why they have those. So, we've gone through exercises like book clubs and talks, for people to really do some of that self-reflective work to understand how they've been conditioned as they grew up. I've personally done that and have found it very revealing and understood some of the biases that I grew up with based on people I was around, and based on my schools, and based on segregation within my school systems. So, I think that that's one piece of it. I think another piece is we don't often get taught about the history of racism in the United States, and how widespread it is. It's a very small part of our curriculums, and I think we have to take it upon ourselves now in our medical systems to go through that education. Education that we probably should have had all through elementary school, high school, college, we have to do that learning now because then we can really start seeing that impact of race on our society. And I think for physicians specifically, what is that impact of racism on patient care in our medical systems and how it's been ingrained in US healthcare. Understanding that we had segregated hospitals right until the 1960s, those are all things that were in the lifetimes of still practicing Oncologists. One of the things we did for our other professional society that I belong to, The American Academy of Neurology, is we did develop an anti-racism education program that focused on understanding this history and this historical lens in healthcare, reviewing the impact that anti-racism has on our colleagues. So, what does that mean for black physicians or physicians from other underrepresented groups and how they interact with our health systems, how they're treated, what does it mean for their roles in academic departments? Then talking about how we can connect being anti-racist with the goals of health equity. So, how can we change the systems that we have control of to have healthcare that's more fair? And then finally, how do we engage trainees and physicians in really developing anti-racism action plans? One of the important things about anti-racism is that you really have to be active, it's not a passive experience. You have to take action to change all these systems around us that are embedded with racism. Dr. Alissa Thomas: Thank you. Along the same line, Dr. Hamel, you recently co-authored a study of a longitudinal implicit bias training curriculum. And can you tell us something about this project and what’s come of it? Dr. Lauren Hamel: Yeah, so it came about a little more than a year ago and kind of coincided happily with an executive directive made by our state’s governor requiring implicit bias training, so we were able to kind of design it so it met those requirements. But really what the goal is, is to approach implicit bias with a 360 view. So, what are all of the issues related to it? What are the scientific underpinnings? What are the measurements? What are the pros and cons of those measurements and what we’ve used, and what they’ve shown in terms of influence on our individual behavior, our decision-making, kind of how we relate to people who might be different than us. And certainly, expanding beyond racial groups — we’ve looked at gender, we’re looking at age, things like structural racism. So, we’re trying to kind of have a comprehensive view of it. And I think, you know, one thing, and it sounds like Dr. Mohile and his group have done a really nice job of tracking what happens after those. Because, you know, I think one-off sessions are better than nothing, certainly. Awareness is critical, but also, tracking like, what does this do for our attitudes, perceptions, and behavior? And that’s not easy. And so really, you know, trying to invest in tracking how things change. So, we’ve had a full year of assessments, we’ve seen some improvements in people’s attitudes and perceptions. But now what we really need to start doing is tracking certain behavioral aspects, and I think that’s where the next step needs to be. Our next year is just about to kick off in a couple of weeks. So, I think that that’s where we need to start putting our effort where it’s—okay, we’ve gotten kind of institutional support, the leaders of both the University’s School of Medicine and also the Cancer Institute have been encouraging this, which I think is really critical, because even though it’s a lot of individual work if you want these changes, you really have to have the support and buy-in from the leaders of the institution. So, we’ve got that, we have interest, you know, we’ve established a really consistent and impressive participation in terms of each session. We’ve had upwards of 200 people attending each session, so people want this information. Now, according to the state, they also are required to have it. So, I think building up on that now, we’ve established a lot of good pieces of it, but now let’s start doing a better job of tracking how does this affect long-term perceptions, attitudes, and behavior. Dr. Nimish Mohile: Every cancer center and department should be doing what Dr. Hamel is doing. The risk of the one-off trainings is that people come out of an implicit bias workshop and think, “Well, I’m fixed. I don’t need this anymore, now I can go on and take care of patients without bias.” And you really need that time to really work on those things and start to fix some of those attitudes that we have. Dr. Lauren Hamel: Yeah. Because the associations get built up over a lifetime. You know, that's not something you're going to fix in an hour. It's a campaign, it's a marathon, to be sure. Dr. Alissa Thomas: So, you've both touched on something that a lot of this is about perception, and it's not just what we say verbally, but non-verbal behavior. It plays into implicit racial bias. Dr. Hamel, can you talk a little about your study of non-verbal synchrony, and can you describe differences between non-verbal behavior with doctors and patients of the same race compared to those of different races? Dr. Lauren Hamel: Yeah, absolutely. And you know, a lot of my work focuses on nonverbal behaviors. On the study you referenced, we were looking at something a little bit more kind of in line with how implicit bias acts. It sort of manifested unconsciously. So, this whole idea of non-verbal synchrony is kind of this non-conscious coordination of movement that happens between two people. And this is a construct that's been studied for decades in a number of settings, but we were the first to be able to examine it in an oncology setting, and also comparing diads of different racial makeup. We were able to take like real video-recorded data of naturally-occurring treatment discussions. We had a set of videos that included black patients in a similar set with white patients. And we used automated software to track their behavior and determine how coordinated they were over time. We actually observed more coordinated behavior between black patients and their physicians compared to white patients and their physicians. Some literature is non-verbal synchrony is sort of seen as always good, and there's also some new data showing that maybe it could be evidence of trying to repair a relationship. We’re very early phases, I'm not in a position to offer kind of a best practice with this, but I think the point is, is that we do see differences. There is a coordinated behavioral difference between dyads. We're also starting to look at how that level of coordination is influenced by attitudes including implicit bias. So, I think identifying a difference is important, but now I think it's on us to now figure it out. Like, what is that the result of? And then, what does that do for the patient in terms of short and long-term outcomes? So, does that affect their perceptions of their physician? Does it affect their perceptions of the recommended treatment? Does it affect adherence to that treatment? Dr. Alissa Thomas: How can we do better? How can doctors improve non-verbal and verbal communication methods with our patients? Dr. Nimish Mohile: I can speak a little bit about verbal communication. I think this work on non-verbal communication is fascinating. I'd love to hear where that comes out because it's something I think we're not really thinking about very much, and I'm not surprised that there's differences there. I think sometimes with communication, just having an awareness in that you might be communicating differently with someone can be helpful. In many of our institutions, we sometimes go through coaching with our communication, particularly with Oncology patients, where you have someone witnessing how you're interacting with that patient, and what kind of verbal and non-verbal cues you're giving, how you make eye contact. I think there's models there that we could really be thinking about, not just focused on some of the stuff that oncology has been focused on, like, delivering bad news or end-of-life discussions, but also on these issues of racial bias or age bias, and see what we could do differently in those areas. Dr. Lauren Hamel: Yeah, I completely agree. And I think decades of research have shown that patient-centered communication skills are something that can be taught, learned, and improved upon. Maybe not just regarding the issues related to racial bias and other racial attitudes, but you know, for helping to improve a number of outcomes for patients. So, I think, that kind of focus, I mean there are very clear, well-established frameworks and methods around that, I think that was just, you know, something we already have in our toolbox that we can use. But I think also things like building up trust within a community, I think is critical, for really any kind of medical institution that operates within a community should be, you know, trusted by the community it's in. And there's a number of strategies that can be implemented to build up that level of trust. So, you're kind of looking at like the outside going in. A lot of these the data that I'm referring to right now are coming out of the primary care setting. But I think people like us that are in an Oncology setting are certainly well poised to start testing these in Outpatient Oncology clinics. And I think just like what we're doing right now, making the topic of race, racism, implicit bias, something that we can have in a number of settings. And I think Dr. Mohile made a really good point. Like, we're not taught this like we're taught like grammar, and, you know, math. This is a part of our lives too, and you know, it's having big effects on huge swaths of our population. So, I think normalizing these conversations is a really important step, too. Dr. Nimish Mohile: In the United States, we're particularly uncomfortable talking about racism. Even within our medical teams, we don't know how to do that. So, what do you do if you're on rounds and you see another provider have some kind of verbal or non-verbal communication that, you know, might not be appropriate, or you think that there's a racial bias in the way we're treating or talking to a patient? That's not something we know how to deal with. We don't know how to bring that up. And so, I think that that's something that within health systems, we need to start working on. We have great models for this. When we think about the transitions we've made over the last 20 years in patient safety, we have elevated these conversations about patient safety. If there's a medical error by anyone on a team, it's something we're open to discussing, not blaming, and then really having a conversation about how can we fix this next time. You know, can we work towards doing that with something like racial bias? One of the things we've started doing in our department is that one of our mortality and morbidity conferences each year is focused on racism. So, a scenario where we think that there might have been differing treatment to a patient based on race, and then having an open discussion about that, going through some of the literature about that, and just practicing some of those conversations with each other as faculty, and medical providers, physicians, nurses, advanced practice providers, of being able to name racism as one of these problems. And then we really try to model that behavior on teaching rounds, so that with our medical students and residents, and fellows, we're also having these conversations about how could racism be at play in this patient's story, and how they got to their diagnosis, and in their outcomes, and an acknowledgement that racism is having some effect on this patient's ability to get screened for cancer, and potentially, their ability to have the same survival as another patient. Dr. Alissa Thomas: Thank you. That's so helpful to think about how to elevate this through departments and people who may be less aware of the issue and raising awareness. You both have touched a lot on communication between patients and providers, and there's a theme here that it's not just the doctor-patient relationship, but also the patient's community, and the medical team, that support that physician. Can you elaborate a little bit more about that, about how we communicate to the patient and the community they represent, and the provider and the team that they represent? Dr. Lauren Hamel: Having active, mature, genuine involvement of community members within a cancer hospital or cancer institute, I think is really important. I know my work has benefited from those who have come before me that established really strong connections with people who are, either survivors, care caregivers, advocates, you know, people who are very devoted to their particular neighborhood, community, that work really closely with us and provide feedback on a lot of the interventions that we design. So, one thing that I work in with all of my research is, as I'm developing an intervention that I think will improve either communication with a physician or another care provider, I certainly would never implement that without getting that thoroughly vetted by the people who it's going to affect. My clinician colleagues are always really generous with their time. It's a little bit more challenging to get community member feedback, but I do believe that it is, I mean, not just worth it for my own research success, but also for the mission and the purpose of what we're trying to do here. So, if you seek out feedback from a community group or community members who are willing to give you their honest opinion, and you know, you have to be in a position to receive that feedback with grace and professionalism, I think that's an important piece of it. Like, you want to have that connection, you don't want to just kind of have a checkbox. You know, you really want them involved in what you're doing. I'm using my own personal experience, but I'm sure there's far greater levels of, you know, system-level issues where something similar could be implemented. Dr. Nimish Mohile: I agree with that. I think this is really hard, and I think our medical systems are just starting to learn how to do some of this work. So, I'd echo what Dr. Hamel said about really getting input from members of those communities. I think many cancer centers are trying to do more outreach into communities, and that's not that easy. We have to really start by kind of building that trust, and building a philosophy where it's really about helping that community, as opposed to getting more patients from that community, or getting more trial participants from that community, or being able to check off boxes for our NIH grants from those communities. It really needs to be a genuine approach of, what does this community need? Because we don't often know that answer. And so, we have to start with that curiosity, and then determine how can we help those communities with the resources that we have. And I think cancer centers can do this optimally if the entire health system does that, that's where you can really start building some of that trust. Dr. Alissa Thomas: Thank you. For those of us that want to know more, would you be able to share some practical tools or resources that are available for healthcare professionals who want to learn more about implicit racial bias, either on an individual or institutional level? Dr. Lauren Hamel: I think one of the first things someone can do is take an Implicit Association Test, or an IAT, as it's often referred to. They're all housed at Project Implicit, at Harvard's website - google IAT, it'll take you right there. No identifiable data are collected from the individual test taker, but it gives people a sense of what's being measured. You know, it's not a character assessment, it's a measure that's designed to test your associations. And I think just having that experience makes you a much more informed consumer of this kind of science because I think it's important to keep a critical eye. You know, if we're scientists, we have to be critical. And I think this really helps people kind of get to a point where they can understand the science a little bit more effectively, but maybe also can reduce a little defensiveness that inevitably comes up when these kinds of data are discussed. So, I would do that. And then the second thing would be, there's a wonderful book called, Blindspot: Hidden Biases of Good People, it's written by Doctors Greenwald and Banaji, and they are basically credited for creating the Implicit Association Test, as we know it. It's a relatively easy read, and it can really give you a sense of how these kinds of associations affect our decision-making and communications. I would take those two, as a way to start. Dr. Nimish Mohile: I agree with both of those. I'd say that many of our health systems have implicit bias workshops and trainings, and sometimes they're online, sometimes they're in person. They do have varying sort of quality. I encourage people to just look at those trainings a little bit differently than they look at all of the other trainings that we're forced to do. To go into those with a little bit of an open mind and a learning experience, rather than one to just sort of check boxes and move on. I think you can learn some things about yourself from them. One of the things I encourage folks to do if they're interested in more information about anti-racism is to do something like the 21-day Racial Equity Challenge - you can Google that. Kind of small bite-size openings, and then there's talks about biases, but also helps you sort of understand some of the foundations of racial inequity in this country. Dr. Alissa Thomas: Thank you so much. That's all the time we have for today. I really want to say thank you to Dr. Hamel, and Dr. Mohile for sharing your perspectives on addressing implicit racial bias in oncology, and tips for improving communication with patients and providing culturally-sensitive care. And thank you to ASCO for providing this platform for us to discuss. Thank you to all of our listeners, we appreciate you turning into this episode of 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 this Oncology, Etc. episode, hosts Patrick Loehrer and David Johnson interview hematologist-oncologist and scientist Dr. David Steensma, who currently serves as Head of Global Hematology at Novartis. In Part One of the episode, Dr. Steensma shares about his career journey from astronomy to medicine, and from academia to industry. We’ll also learn about the discovery and significance of a new pre-malignant condition - Clonal Hematopoiesis of Indeterminate Potential (CHIP). If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at

"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

"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

"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

"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

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.