ASCO Education

Getting into oncology requires a lot of education and training. How does one deal with the success and stress of such a journey? In Part One of this ASCO Education Podcast, moderator Dr. Aakash Desai – fellow at the Mayo Clinic along with guests Dr Madison Conces – Hem/Onc Fellow at Cleveland Clinic, Dr. Lori J. Rosenstein, Hematology and Oncology fellowship program director at Gundersen Health System and Dr. Deepa Rangachari, fellowship program director explore the past, present and future of Oncology Training. They discuss their motivation of pursuing oncology (1:55), the rewards (5:51) and the stresses (8:44) of fellowship, coping with the loss of a patient (12:52) along with methods to keep up with advances in the field (19:50). TRANSCRIPT Dr. Lori Rosenstein: What I learned in fellowship is completely different than what I know now. And I passed the Boards, I did well on the Boards, I stressed about them, but the Boards do not define who you are as a cancer doctor; they are just a step along the way. And so, really, I am much happier if a fellow has that thought process and that self-reflection and knowledge of what they do and do not know; they're going to be amazing when they're done. Dr. Aakash Desai: Hello, and welcome to the ASCO Education podcast. My name is Aakash Desai, and I'm a Hematology/Oncology fellow at Mayo Clinic in Rochester. I will moderate this episode focusing on how Oncology training has changed in the last couple of decades. Do you think today's fellows have it easier with the electronic medical records, or is it rather harder with that? Given the much bigger pool of treatments to choose from and the constant stream of information, is it more difficult for Oncology fellows in this day and age? On a personal level, what challenges persist? How might we reimagine Oncology training in the future? To discuss all these questions and more, I'm joined by current Oncology fellow Dr. Madison Conces from Cleveland Clinic and two former fellows; Dr. Lori Rosenstein, a Hematology/Oncology Fellowship Program Director at Gundersen Health Systems in La Crosse, Wisconsin, and Dr. Deepa Rangachari, a Medical Oncologist, Assistant Professor of Medicine at Harvard Medical School, and Director of Hematology/Oncology Graduate Medical Education at Beth Israel Deaconess Medical Center in Boston. As we are all colleagues, I'm going to refer to everyone by their first names, if that is okay. And so, I'm going to pose my first question to Madison. Question is, what motivated you to get into Medicine and specialize in Oncology? And then, I will have Lori and Deepa answer the same. Dr. Madison Conces: Thank you, Aakash, for having me join this conversation today. So, I'll kind of answer the Medicine and Hematology/Oncology portion at the same time. I was in college when I actually was shadowing Dr. Pat Loehrer at IU over the summer, and I worked in the lab while also doing clinic with him one day a week. And I think being able to see the science and working to improve patient care while also witnessing the patient interactions, and the relationships, and the trust between the physician and the patient, is something I really admired, and that really drew me. So, I think that's kind of when it first sparked. And then, just during residency in medical school, my recurrent interactions with Oncology patients is what kind of definitively made me go that route. Dr. Aakash Desai: Lori? Dr. Lori Rosenstein: So, I was a little bit slow to figure out what I wanted; I thought Neurology or Internal Medicine, and then I had no plans after that, and I really debated a long time. You know, ultimately, now that I'm a Hematologist-- and this totally makes sense with my personality and everything else, what I love about Hematology is the mystery and the detective work that happens. It also happens in Neurology. That's what I liked was figuring out where the lesion was based on your exam. But in Hematology, we figure out where the lesion is, and then often, we can fix it. And to me, that was really exciting. So, I joke with my fellows all the time that I'm a blood detective, and the best thing ever happened yesterday - is that one of my fellows knocked on my door, and she came in, and she said, "Today, I'm a blood detective. I figured this out." And it's super cool. I think that's a really fun part about Hematology and Oncology. Dr. Aakash Desai: How about you, Deepa? What are your thoughts on this? Dr. Deepa Rangachari: My inspirations mimic those shared by my colleagues already today. At a very young age, a very dear family friend whose mother is a Pediatric Hematologist/ Oncologist, and I think I was immediately enthralled by her demeanor. And later in life, as a medical student, I had the opportunity to shadow her and really see her in action. And I think she really embodied all of the things that I always considered in terms of being a consummate physician. And I think, on a daily basis, what inspired me to become an oncologist is, really, what to this very day holds me deeply, devotedly to this lifelong career which is the ability to exhaust and frankly apply all of my intellectual, emotional, and interpersonal skills to achieve the best possible outcome for a patient and their loved ones in what is often very challenging and/or devastating circumstance. The inspiration, in many regards, from years ago is the ongoing inspiration. Even today, I'm very much informed by early experiences, seeing such folks practice in a way that I felt was truly the art and science of Medicine. Dr. Aakash Desai: I guess the next question I would want to ask both of you is: What is the most rewarding part of the fellowship? Lori? Dr. Lori Rosenstein: I hate to say this; I'm the oldest one of the group here, so I've been here the longest since I did my fellowship. But I will say, the best part of being a Heme/Onc doctor is the longitudinal relationships that you develop with those patients over time and the difference that you make in people's lives in the really short amount of time that sometimes you're with them. I think fellowship-- we'll talk later about the stresses and difficulties of fellowship - but knowing that you're in that final stage, you know, everything up until fellowship is, "I'm doing this to do the next thing. I'm doing this to do the next thing." There is really not a next thing after fellowship. That is what you're going to do. And I think that's the most exciting part - everything you're doing is for that purpose. You know, once you pass the Boards. Dr. Madison Conces: I agree with what Lori just said, and I think as someone who's in their final-- I'm a third-year Heme/Onc fellow right now, and I would agree where you're just like, "This is it. This is what I am going to do for the rest of my life." And there's excitement with that, there is some little bit of anxiety, I guess, under it, but there's a lot of excitement with it, and I think-- like when I sit and talk with patients now, I know we keep kind of reiterating a human connection, but I feel like at least as a fellow now, I'm able to explain things or understand things in a way I didn't before. And I feel like that makes me even more connected in their care, and also in a way kind of, I wouldn't say I understand, because I'm not in their position, but I'm able to, I feel like, meet them closer to the middle than I was before. So, I really appreciate that, I guess, growth I've had during fellowship, that's allowed me to, I think, be closer with patients and their journey. Dr. Lori Rosenstein: Madison, this is Lori. So, I was just going to ask based on that; I see externally as my fellows are going through their training, there's usually just this moment where I can suddenly see that it's kind of clicking, and, you know, the hardness of first becoming a fellow all of a sudden, starts to get easier; and they really start to fly - they start to do fantastically. Do you remember if that was something that you experienced? Dr. Madison Conces: So, I was on Oncology consults August of my first year of fellowship, and I am September of my third year of fellowship. And I just noticed how quick I can be. Like in July, I was like, "Oh my gosh, I'm a third year. How am I going to be ready for next year?" But now that I'm on Oncology consults, again, seeing every type of solid tumor malignancy, specifically for solid tumors, obviously, but I see the pace I'm going compared to before; I know the depth of knowledge I have is much greater, I kind of am more aware of my deficits of knowledge. So, I would say, just even in the past week, I've noticed, like, "Wow, I've definitely gotten better." I don't know if I'd call that an aha moment, but I've definitely had that perception of myself in the past week. Dr. Aakash Desai: Yeah. I think, as a third-year fellow myself, I agree. I think that's, you know, very rewarding. Essentially, recently, I was giving a talk to our first-year fellows as a primer talk on lung cancer. And, you know, I realized like some of this comes so naturally to me now, and I remember myself being a newly-minted, first-year fellow, and just thinking like, "How am I ever going to make sense of all this data and everything that's coming out?" That's also, I think, the part of the personal growth - you grow as a fellow. I think it's also very rewarding, as the fellow that I've found. So, with that, I think one other thing that's been, you know, obviously, more recently brought out is resident burnout, fellow burnout. Just in general, position burnout has been the theme, and we are becoming very aware of this. And I think fellowship, being the training, it obviously has its own stressors. So, what are the most stressful aspects of fellowship that you've found? Tell us about the most stressful day you've had so far and how do you cope with stress and workload. And any tools or strategies that you would recommend to current fellows and other peers that would be useful. Dr. Madison Conces: I would say, probably, it's twofold in terms of what's most stressful about fellowship; one is the information which you had already mentioned, Aakash, and I think with that, is kind of the research aspect and balancing that. Like, how do we dive into research and look into spaces that are unknown, if you will, and then at the same time, know the data of the cancers we're already treating? I think the outpatient stressors are different from the inpatient stressors in a way because I think during inpatient, you're constantly engaged in these difficult situations patients are in, and there's not much of a break. And so, I think sometimes, not that we don't have difficult clinic days, but I think there can be a little bit more emotional drainage, and I think, in terms of trying to deal with that stress, like you mentioned-- I'm a distance runner. And so, even when I'm on service, I actually still make time for a run, even if it's just a quick run in the evening, or get it in before work if I'm on call that night, or something, sometimes just some light weights. That's been my crutch, if you will. I've done that all my medical training; I've been running for most of my life. And I've been very deliberate and diligent about continuing that, and I think, somehow, it kept my head above water some days. I do wonder what else I could do to help because I definitely have days where I feel like my running isn't enough. I think, as many people have felt since the COVID pandemic started, there's been a real struggle with burnout. Dr. Aakash Desai: Lori? Dr. Lori Rosenstein: Yeah. I think there's a lot that's stressful about Heme/Onc fellowship, and as a Program Director, you see the cycle. You know, first-year fellow comes in; they're brand new. That first six months, as I said previously, is just so, so hard, and you, as a program director, want to help. You know you want to get them through that. Because, you know, many people are coming in, it's a new hospital, it's a new system, it's new diseases, it's working in the clinic instead of the hospital-- most Internal Medicines are very, very hospital-focused. And then all of a sudden, you're in a clinic where it's almost all outpatients, and you don't know how that works, even though you should. You know, like people think, "I could be an internist; I could be done." And yet all of a sudden, I'm right back at the bottom of the barrel, so to speak. You know, not knowing how to do anything. And so, that first six months for sure is really stressful because you feel like you've had autonomy; when you're a third-year resident, you're ready to go out, and then boom, you don't know what you're doing again. And so, at the same time, you are a young adult who often is having families, thinking about settling down, buying homes, you know, growing up, and that just adds to all of the stress because you have the stress at work, and then potentially, stress at home. For me, I had my first child when I was a resident and then had my second as a third-year fellow. And so, I had these different stresses as I was going through my training. You know, some of my fellows have had parents die while they've been in fellowship or parents that they're helping to take care of. So, not only are us older people in kind of the sandwich generation, but I think younger people in fellowship are seeing that as well. So, yeah, I think there's a lot going on that can make it challenging. But my encouraging part of it is that it gets easier. You start to figure out where you can find the information that you need, how to make things happen, and there's just this tipping point where suddenly it becomes easier, and then I see that they're back having fun again. You know, that, "Oh, this is such a really interesting disease, and I've never seen this presentation before, and I looked in the literature, and there's only three cases." You know, that passion and that excitement for finding new things, or, you know, "I wasn't sure if this chemo was going to work, and I gave it, and they're back today, and they are so much better." Just that excitement and passion. It's so wonderful to see as a program director. Dr. Aakash Desai: The other thing is also; I feel like the stresses are different as you kind of evolve through your fellowships. So, I think, as Lori very rightly pointed out, like the first year is, you know, just getting used to the information, the flow, and everything. But what I've found particularly challenging is, as you enter the second and the third year, and when you have patients that you continue to follow, just by the nature of the disease and the field that we are in, you will end up having some patients who you lose along the way. And I think that dealing with it emotionally; I think because during the first two years of your fellowship, you know, you meet them every few weeks, you kind of get attached to them, and you know what their life is like, you share part of your life with them. How have you found your way of coping with loss of the patients that you kind of have a deep connection with? I think that's part of the stressful aspect of, like, later years of your fellowship, I feel. Any insights on that, Lori? I mean, you've obviously been doing this much longer than me and Madison. How do you deal with this kind of loss and keep going every day, even with the same enthusiasm? Dr. Lori Rosenstein: Yeah. I think that absolutely is a really challenging part of our field, but it's also part of the blessing of our field - is that we are there, and we can help negotiate people through difficult times. And if we're doing this well, we have seen this coming. We have been able to prepare people; we've been able to make sure that we're honoring the things that are important to them at the end of life, and we're working to make sure they're not in pain and that they have their family members near them. And so, for me, that's always that rainbow at the end - is that I was able to assist them in this process. We all know we can't stop death. We may, you know, fool ourselves into thinking this carbo/etoposide is going to change the world for this patient. But I think being realistic about what we can and cannot do. For me, having a great conversation with a patient and their family and knowing that I've helped them, even if the end result is not that they have another 20 years to live, is super meaningful. And I think most oncologists that can do this for a long time find the value and the meaning in that part of their job. I think if you're constantly trying to stop death and trying to, like continue chemo till the very bitter end, this could be a very draining job. Dr. Aakash Desai: You know, and more and more, we are realizing the importance of supportive care in Oncology. And I think what you just pointed out is that, you know, improving someone's quality of life, even for two months, is also very rewarding in its own way. So, thank you for saying that. The next question I have is especially geared towards you and Deepa for fellowship program directors: How has Oncology training changed since you were a fellow? And is training for current fellows harder or easier do you think? Dr. Lori Rosenstein: You know, any program director who trained a long time ago will give you the woes of, you know, 'I had to walk both ways with no boots in the snow'. I think that probably the biggest change since I was a resident is work-hour restrictions, which came sometime during my residency. So, I was a fellow when there were work-hour restrictions. But to be very honest, in fellowship, you almost never are reaching that 80-hour work week like you would've been when you were on an ICU rotation in Internal Medicine. Most of my fellows, you know, they log their hours every week, and we're somewhere around 40 to 45 hours a week, depending, you know, there's going to be times where it's busier. So, I think the work hours are less of an issue, but that doesn't mean it's easier. And I think now, the most difficult challenge is, all the new treatments, all of the options-- it used to be-- we had two choices; you could do this, or you could do this. And now, there's all these nuances, and nuances are very challenging when you're first learning. You know, you can see this study, and it was this compared to this, and option A was better. But then you would talk to your attending, and they say, "Well, option A was better unless you were from some esoteric country," and then you know you did worse. So, you start to really piece apart, and you know, you gain your basic understanding, but then start to try to apply that to your patients. And that is, I think, a very big challenge. Dr. Aakash Desai: How about you, Deepa? What are your thoughts on this? Dr. Deepa Rangachari: I think it's become harder in that it has become incredibly more nuanced than incredibly more sophisticated. Three things, in particular, come to mind; one's are the burgeoning evidence basis for what we do and the prospects for advancing our knowledge and understanding and thereby have better interventions that's certainly been a seemingly explosive growth in our knowledge and understanding, especially considering the humble origins of our field. They work daily with colleagues and friends who remember those days when Heme/Onc was sort of an esoteric field of people whose methods were considered bizarre at best, and that's absolutely not where we are anymore. It's an incredibly exciting time, so a lot of information to keep up with. Secondly, one of the things that maybe we didn't really appreciate at the time was true before but is increasingly true now is the importance of recognizing your role as the leader of a very sophisticated interdisciplinary team. Thankfully, I think this is true for all patients with any illness, but thankfully, in our disease area, care by an expert village is really the new norm, not the exception. And sort of learning how to function in those interdisciplinary teams in an incredibly collaborative and productive way across the spectrum of a patient's care and needs is incredibly nuanced, more so than ever before. And something that fellows, at the earliest instance of their training, really need to learn to be agile with. So, I think that's something that is also both a sign of progress, but also an added layer of nuance and sophistication. And I think the final thing is that there are so many diverse ways in which someone can have it truly impactful and fulfilling career within Heme/Onc, and I think this makes fellowship also that much more exciting and complicated, nuanced, really trying to understand within your career span, what is the pathway or the different pathways, honestly, that you may choose to train and prepare for and conduct yourself is really dizzying. And I think we really are expecting a lot in terms of our fellows these days to sort of be willing to understand those options and understand which options are most meaningful to them and then prepare in a very deliberate and rigorous way for those specific career interests. So, kudos to all of you. You guys are doing an incredible job; you are the future of our field. And those of us who run programs, direct such programs, we really have a continued challenge and inspiration to meet your needs. Dr. Aakash Desai: The field is moving so fast that I can say, like when I joined fellowship in first year compared to now, I think there is a lot more treatment options. And I think as fellows also, it's so difficult to keep up with this, you know, constant stream of information. So, Madison, how do you think things have changed since you joined fellowship, and how do you envision yourself, you know, resources to use to kind of keep yourself updated? Dr. Madison Conces: I would agree with both of you. It's definitely changed. It's also interesting because it's not always the addition of treatments; it's sometimes showing that adding this extra drug does nothing. And so, all of a sudden, you've now changed the paradigm again for how you treat that patient. And I think for me, what I've found during fellowship is-- and maybe Lori would enjoy this part, but the thinking of it, right? So, even Hematology, I definitely think of as the puzzle, but in general, all these patients, there's something about them, whether their tumor's genetics, or the family history, or any of their germline mutations they have. So, there's always this kind of; every patient is very specific. And so, I think what has helped me, at least during fellowship, is in clinic, to go through that, in that mindset with the staff I'm working with. And I think sometimes, at least, I've been fortunate to have staff who do a great job of making sure I'm thinking of everything, which is like, "Oh, if this doesn't work, what are you going to do next?", which makes me think about, "Well, what do we know about the patient? What do we know about their tumor? What are the other options?" I'm someone who learns by doing, which I think is many of us at this point, and so, I think the constant feedback from staff of kind of pushing us to think on our own is going to be helpful in the long term, rather than expecting us to come in remembering, you know, every part of the NCCN guidelines, because those are going to change as well. So, we've really got to be able to think through these patients' cases like puzzles, and also, you know, a lot of these patients don't read these textbooks a lot of times. Lori was talking about seeing the excitement of her fellows. Again, you know, yesterday I saw a patient who has paraneoplastic nephrotic syndrome. It's like these things; we have to be able to keep pace with essentially our patients in their pathophysiology. And the more we learn, the more kind of breath that's going to be. It's going to be wider and wider in terms of what we have to know, and I'm not sure knowing it all is going to be the way to go. And for me, I try to know the basics, and then beyond that, really look at the patient. And instead of thinking about every treatment for that whatever cancer of the patient, look at, "What do we already know about it, and what can I go from there?" Dr. Lori Rosenstein: That's so interesting, Madison. And Deepa and I had talked about this; you know, as program directors, my goal for fellows is that they learn how to think about cancer, and how to have a really regimented way of going through a new patient, and thinking through, "Do I have the diagnosis? Do I have the stage? Based on those things, what do I know about the patient and their disease to make my treatment plan?" And that's the same for every cancer. Essentially, you're going through this regimented process. If I have a fellow that I know can think through a cancer, to me, it doesn't matter if they know that Merkel cell is associated with the Merkel polyomavirus virus. They may never see a Merkel cell, or they may see it once. So, that regurgitation of information that you are so used to doing for Boards and for tests, to a program director, is really so much less important than, "Can you think through the process? Can you find the own holes in your knowledge base? And then, can you find where to fill those holes so that you can take great care of patients?" If I could tell any first-year fellow coming in, don't panic about your knowledge base because what I learned in fellowship is completely different than what I know now. And I did well on the Boards, I stressed about them, but the Boards do not define who you are as a cancer doctor. They are just a step along the way. And so, really, I am much happier if a fellow has that thought process, and that self-reflection, and knowledge of what they do and do not know; they're going to be amazing when they're done. Dr. Aakash Desai: This kind of reflects how the program directors in our field actually, you know, are thinking beyond just like, "Oh, you need to score good on the Boards," because they realize the importance of thought process, and how to come up with treatment plans. So, thank you, Lori. I think this is phenomenal, and I'm sure all the fellows listening to this podcast will be delighted to hear what you just said. Dr. Lori Rosenstein: Now, you still have to pass the Boards; that's still a key component. But I think if you polled program directors about what we think about Board passing, most of us would say it's probably sixth or seventh on the list of importance. Dr. Madison Conces: Yeah. I would actually add onto that. We've been talking about thinking through processes, and through these cases, and using, you know, the thinking process more than just memorization. And I think also in fellowship, we are trained to also have these conversations with patients, right? Because it's not always what would be the right answer when we think about it in a treatment sense, but if that doesn't match what the patient wants, then it's not the right treatment. And how do we adjust that based on what's in the patient's best interest or what the family wants, depending on what the situation is, obviously? I think fellowship is about this critical thinking, but also in the context of the fact that we're taking care of this human being in front of us. Dr. Aakash Desai: Well, this concludes part one of our discussion on the past, present, and future of Oncology training. My guests have been Dr. Madison Conces, Hematology/Oncology fellow at Cleveland Clinic, Dr. Lori Rosenstein, Hematology and Oncology Fellowship Program Director at Gundersen Health System, and Dr. Deepa Rangachari, Fellowship Program Director at Beth Israel Deaconess Medical Center. In the second part of this episode, we will explore the different ways to stay current with new treatments and guidelines, as well as our guests' insights into how Oncology training should look like in the future. Thank you to all of our listeners for tuning into this ASCO Education podcast. If you have an idea for a topic or a guest you'd like to see on the show, please email us at: education@asco.org. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click "Subscribe." Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Resources: ASCO Education Podcast: Cancer Topics - Burnout in Oncology: Trainee Perspective ASCO Education Podcast: Cancer Topics – Career Paths in Oncology (Part 1) ASCO Education Podcast: Cancer Topics – Career Paths in Oncology (Part 2) If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org

Vaccine development is a tremendous scientific breakthrough. In Part Two of this ASCO Education Podcast episode, Dr. Doug Lowy, Principal Deputy Director of the National Cancer Institute describes overcoming the hesitancy of taking vaccines in the era of Covid (:57), the scientific impacts of other nations like China (3:54), the importance and the standing of the NCI (5:10) and the future of oncology (10:36). If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. 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 colleague and friend, and Medical Oncologist at the University of Texas Southwestern in Dallas, Texas. This is the second half of our Oncology, Etc., conversation with Principal Deputy Director of the NCI, and Chief of the Intramural Laboratory of Cellular Oncology in the Center for Cancer Research, Dr. Doug Lowy. In part one, we chatted with Dr. Lowy about his interest in cancer, which was developed through his personal academic experiences, including that of his parents, as well as his groundbreaking work on the HPV vaccine with Dr. John Schiller. Today, we're going to continue our conversation with Dr. Lowy by asking him about overcoming the hesitancy of taking vaccines in the era of COVID. Dr. Doug Lowy: Pat, it's very difficult. There was some vaccine hesitancy when the HPV vaccine was introduced initially. My view is that the people you want to speak to and with, are the people whose minds can be changed. So, I don't try to change the minds of people who are opposed to vaccination for one reason or another, but instead, try to talk with people about evidence, but directing it towards those people whose minds potentially can be changed. A big advantage with the HPV vaccine is that this has been going on over a number of years. With COVID, everything happened in a greatly truncated way. So, the vaccine was introduced less than a year after the pandemic. But concomitant with that was a lot of vaccine hesitancy, and I think that that's going to be difficult to overcome. What I have really worried about is whether the vaccine hesitancy associated with COVID might extend to other vaccines and not just to the HPV vaccine, but to childhood vaccines, et cetera. The national data for 2020 and 2021 for HPV vaccination is almost counterintuitive and provisionally reassuring, both. Compared to 2019, the last full year without the pandemic, the number of people being vaccinated with the HPV vaccine went up between '19 and '20, and between '20 and '21, went up again. So, at least by that metric and through that time, it doesn't look as though the vaccine hesitancy associated with Covid is extending to the HPV vaccine, at least in the short term. So, what we've seen between 2019 and 2021 is that HPV vaccine uptake among teenagers actually has gone up each year. So, at least in the short term, the vaccine hesitancy associated with the Covid vaccine does not seem to have extended to the HPV vaccine. Dave Johnson: So, Doug, I'm going to shift gears just a little bit. I read recently, in Science, that China had overtaken the United States in terms of scientific publication and impact; and I'm wondering what you think about that, and what we need to do to retain our longstanding leadership in that role. Or does it really matter? Dr. Doug Lowy: If China's research, if their quality is outstanding-- I mean, there's nothing wrong with another country making important contributions to biomedical research. I don't see this, per se, as a competition. Perhaps, it's because I'm just looking at it through the lens of cancer research, and we think that cancer research is much too big to be done exclusively through support of NCI, exclusively in the United States, et cetera. So, to me, if other countries are doing high-quality research that can help people all over the world with regard to cancer- Pat Loehrer: -Let me ask you this, Doug, you've been at the NCI for 50 years. And I calculated that you've served under nine presidents, and of the NCI's 16 directors, you've served with 10 of them- Dr. Doug Lowy: Really ancient. Thank you. Pat Loehrer: -so, with all that, what do you think; one, about the importance of the NCI, and then also, we'll ask you a little bit about the reflections of the directors, and lessons learned from them, and maybe, some good stories. So, where do you think the NCI stands, and why is it important for the world, and for the country? Dr. Doug Lowy: What's really important is the funding from Congress. It is long-term and sustained. Cancer research can't be done in two or three years. It just takes a while to do really high-quality cancer research. And what really counts, from my perspective, is you can rely on the government to be strongly supporting cancer research through the NCI. In other words, private philanthropy is very important, but private philanthropy can decide, "Tomorrow we don't want to be doing what we have been doing." It's very much like pharmaceutical companies - they can decide that they're not going to be doing it. But it's almost impossible for us to say, "We are no longer going to support basic science research. Okay? We're not interested in investigator-initiated research," because, of course, we are. And that's the bedrock of development. We can't say, "We're no longer interested in doing clinical trials," because, of course, we are, because we can't make the progress that we need to make without clinical trials. We can't say, "We're not interested in doing implementation research," because it's one thing to have a new approval, it's something else to have it widely and equitably disseminated, and doing some kind of research with implementation. Science is critically important, and this applies for prevention, screening, diagnosis, treatment, survivorship, all of these areas that NCI supports, and will continue to support. The proportion may vary from one year to another, from one director to another, but all of those areas are going to continue to be supported. Dave Johnson: So, Doug, during your various tenures as the interim director, what program or programs are you most proud about? Dr. Doug Lowy: Instead of programs that I'm most proud of, I would say that working with NCI staff is what enables the achievement. The mission of the NCI is just incredible, and virtually everyone on the staff buys into the mission; which is, to help people live longer and healthier lives through research-related advances in cancer. That's what people do. And the first time when I was Acting Director, was the first Cancer Moonshot, so I was involved in that. But tremendous amount of credit needs to go to the Obama administration for wanting to do it, to the Congress for its strong bipartisan support for the initial Cancer Moonshot, and to my NCI colleagues, and then extramurally, for everybody who really got on board and tried to do things. So, this is very much a team effort, and it's not limited to NCI, you know, extramural colleagues are critically important to everything that we do. Pat Loehrer: Doug, you've alluded to the fact that you've served under so many different presidents and directors, and they all have different leadership styles. If you were gonna be a mentor on leadership, what advice would you give to the listeners as to what makes a good leader, and perhaps, what makes a not-so-good leader too? Dr. Doug Lowy: I think that there is a spectrum - there are some people who lead by intimidation, and some people who lead by example; and all of them can be effective leaders. My own view is that I like to lead by example because I really feel that that leads to very high morale. People who lead by intimidation may get a lot of work out of people, but it is nowhere near as satisfying as knowing that you are an extraordinarily, highly-valued member of a team and that the whole is greater than the sum of its parts. So, I think that having tremendous admiration and respect for the people that you work with, is absolutely number one, and number two, is listening to them. You don't always need to do what they advise, but people really thrive on being listened to, and everybody wants to make a difference. And so, help them to achieve that goal. When they look good, you'll look good. Dave Johnson: So, Doug, I'm attending on the general medical wards right now. Just got asked today by the medical students to give them some advice about the future of Oncology, and where did I think it was going. Before I go back and meet with them, I'd love to get your thoughts. Dr. Doug Lowy: Well, the future of oncology is extraordinarily bright. On the one hand, we've made tremendous progress. On the other hand, there are still 600,000 people dying every year in the United States from cancer, and worldwide, the problem is even greater. But what's going to happen in the future is, we will understand the causes of cancer better, and so, that will enable us to prevent more cancers. I think there's going to be an enormous increase in the opportunities for screening, and to reduce either the incidence of cancer or increase the outlook for people with cancer, because asymptomatic cancer will be diagnosed at a substantially earlier time point. And then when it comes to treatment, my view is, we've barely scratched the surface. With the opportunities for making drugs, immuno-oncology, and who knows what other areas lie in front of us, are almost limitless. The Biden administration has a goal for the reignited Cancer Moonshot of decreasing the mortality rate over the next 25 years by 50%. What I think we need to do is to decrease mortality over the next 25 years by even more than that, and in addition, to make progress against those cancers where progress thus far has been limited. Take pancreatic cancer as a specific example; 10 years ago, the RAS oncoproteins were thought to be undruggable targets. But last year, we had the first approval from the FDA of a RAS-specific inhibitor. The good news is, that can target about half of lung cancer that has mutant RAS. The bad news is, it targets very few people with pancreatic cancer who have mutant RAS. On the other hand, there now are G12D inhibitors where there's excellent preclinical data and hopefully, sometime next year, be starting clinical trials. G12D mutations account for about half of people with pancreatic cancer. If the success there mirrors the success that we've seen thus far with lung cancer, it means that we are potentially on the way to actually making a difference in outlook for people with pancreatic cancer. But I just see this as one of many opportunities as time goes forward. Pat Loehrer: You did, this week, something that no one has done, and that is, to turn the reins of the directorship of the Cancer Center, over to the first woman director, Monica Bertagnolli. What was in your letter that you left on the desk that you gave her? What kind of advice did you give her? Dr. Doug Lowy: My advice that I gave her was really, "How can I help you the best and the most?" Dave Johnson: That's awesome advice. No doubt about it. It's a really historical moment, and of course, we, who are members of ASCO, are particularly proud that Monica has taken the reins, as a former ASCO president. And Doug, we really appreciate you taking the time to spend with us. It's been incredibly interesting, and congratulations on an amazing career. Pat Loehrer: Absolutely. Dave Johnson: And also, thanks to our listeners for tuning in to Oncology, Etc. As you know, this is an ASCO Educational podcast, where Pat and I will talk about just about anything. If you have an idea for a topic or a guest you'd like us to interview, please by all means email us at: education@asco.org Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click, "subscribe". Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center, at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

Vaccine development is a tremendous scientific breakthrough benefitting countless human lives. In Part 1 of this ASCO Oncology, Etc. Education Podcast episode, you will hear from the pioneering co-developer of the HPV vaccine Dr. Doug Lowy who serves as Principal Deputy Director of the National Cancer Institute , He speaks about how he got into the cancer field through the influence of his parents (4:49), the path that led him to focus on HPV (8:04), and his collaborative professional partnership with fellow HPV vaccine developer Dr. John Schiller (9:31). He also discusses his ongoing trial of one-dose administration, which promises to boost HPV vaccine uptake and reduce the burden of cervical cancer globally. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. TRANSCRIPT Pat Loehrer: Hi, I'm Pat Loehrer. I'm Director of the Center of Global Oncology and Health Equity at Indiana University. Dave Johnson: I'm Dave Johnson. I'm a Professor of Medicine at UT Southwestern Medical Center in Dallas, Texas. Pat Loehrer: And this is Oncology, Etc. Dave, what have you been reading lately? Dave Johnson: Well, you and I have talked about a couple of books, but I thought in light of our guest today, I would mention a book I actually read probably nearly 60 years ago called The Microbe Hunters by Paul de Kruif - very interesting book, written, if memory serves me correctly, in the '30s, about many of the early bacteriologists and physicians who were interested in microbes; Pasteur, for example, and others. And I don't remember all the details, but it certainly was one that was influential for my choice of Medicine as a career, much like Arrowsmith. It was a really impactful book. I doubt many of our listeners today would've read that book, but if one is interested in the history of Medicine, it's a really interesting book to read. Pat Loehrer: You said 60 years ago. Okay, when I was reading books back then, it was about Dick and Jane. Dave Johnson: It's my understanding that you're not past Dick and Jane yet. Pat Loehrer: Good, good point. Good point. Well, it's such an incredible honor today, we have Dr. Doug Lowy as our interviewee today. Doug is the Principal Deputy Director of the National Cancer Institute and Chief of the Intramural Laboratory and Cellular Oncology Program at the Center for Cancer Research. He has served as Acting Director more than any other person - he served as Acting Director between April of 2015 and October of 2017, between April of 2019 and October of 2019, and most recently, he served as an Acting Director until Monday of this week, October 3rd. I had a chance of seeing Doug, I think, about a year ago, a week after he took over, and this is great to have that bookend here. He has had this title of Principal Deputy Director since July of 2010 and he leads many of the NCI's key scientific initiatives. He graduated from Amherst College, I think in Art History, I may be wrong on that, received his medical degree from New York University School of Medicine, trained in Internal Medicine at Stanford, and did a Dermatology Residency at Yale. His focus has been on papillomavirus and the regulation of normal and neoplastic growth. The papillomavirus is in close collaboration with Dr. John Schiller with whom he's co-authored 150 papers over the last 25 years. In the 1980s, he studied the genetic organization of papillomaviruses and identified oncogenes that were encoded by the virus, and he's been integrally involved and instrumental in the development of the papillomavirus vaccine. His laboratory did work with the RAS gene family and other suppressor genes, and as you can guess, he's just one heck of a smart guy. For his body of work and together with Dr. Schiller, they received the Federal Employee of the Year Award in 2007 and the Partnership for Public Service Award, the Dorothy P. Landon American Association for Cancer Research Prize for Translational Research, the Albert B. Sabin Gold Medal in 2011. In 2007, he got the Medal of Honor for basic research from the American Cancer Society, and President Obama awarded him the National Medal of Technology and Innovation in 2014. And in 2017, he received the Lasker-DeBakey Clinical Medical Research Award, which is considered one of the most prestigious honors in biomedical research. He is listed in the Institute of Scientific Information as one of the most highly-cited authors in Microbiology, and obviously, he's a member of the National Academy of Science and the National Academy of Medicine. Although these are notable honors, I'm told that none of them match the opportunity to speak with Dave and I today, and we really thank you so much, Dr. Lowy, for joining us. Thank you. Dr. Doug Lowy: Pat, I am speechless. Pat Loehrer: I so wish that Dave Johnson was, but could you tell us a little bit about your upbringing and your early life? Dr. Doug Lowy: Sure. I grew up in The Bronx, in New York City. I'm the younger of two boys. My brother is two and a half years older than I am. Both of my parents were general practitioners. My parents were both Americans, but my father had a classic sophomore slump when he was an undergraduate and was unable to get into a medical school in the United States. And so, he actually went to medical school in Austria, in the University of Vienna, and needed to learn German in order to go to medical school. But my parents were both very successful private practitioners. They had separate practices but practiced in the same office, and I learned about medicine, in large part, through them. They would go to lectures, and from the time I was probably nine or 10 years old, they would be telling me about cancer, and I became interested in that area. And then, when I was 16, my mother developed a deep melanoma on her leg, and so, cancer literally came home. And luckily, she had very good surgical treatment and lived for almost another 40 years - she lived until she was 80 and actually died of metastatic stomach cancer. But I got involved in thinking about cancer really through my parents. They talked with me about the role of tobacco in the development of lung cancer, and I heard about the Hammond and Horn report from the mid-1950s when it came out. Pat Loehrer: That was when Dave was reading the Microbe Hunters. Dr. Doug Lowy: I was reading it at about the same time. I must say that, although I found it very interesting, it didn't really speak to me, and now that's what I need to go and do. Although, in retrospect, that's what I've ended up going and doing. Pat Loehrer: Was it because of your mother that you had an interest in dermatology? How did you swing into there? Because we think of you mostly as a translational researcher. Dr. Doug Lowy: The dermatology was really when I was at NYU. I worked in the laboratory of Jan Vilcek, who had recently come from Czechoslovakia to NYU, and in his lab was Alvin Friedman-Kien, who was a dermatologist. And Alvin subsequently was among the first people to identify the AIDS epidemic through the Kaposi sarcoma. But Alvin talked with me about dermatology, and potentially, this might be an interesting field for me to go into. And then, when I went to Stanford, I did Internal Medicine for internship and a year of Medicine, and I did a rotation in Dermatology. And I was very impressed that the people who smiled the most were the dermatologists. And they had time also to think about what was going on with patients. And since I was at Stanford, it was a tertiary care facility and so we were taking care of people who were terribly sick, largely people with lymphoma and other types of cancer. And I thought that I might be better suited to taking care of people who were less sick than that. Dave Johnson: Is that where your interest in Papillomavirus started? Dr. Doug Lowy: Well, that was indirect. I first went into dermatology and then said, "Well, I want to be doing research. What can I do in research that might be connected both with dermatology as well as with cancer?" And the closest that I was able to come was Papillomaviruses. And when I started working on them, they were not yet clearly associated with cancer the way they are today. It was known that they were associated with an uncommon condition called Epidermodysplasia Verruciformis or EV and this is a condition where people have widespread HPV infection. And on sun-exposed areas, a subset of them develop skin cancer, but it's distinctly uncommon. The real interest, if you will, came from the identification of HPV infection and cervical cancer, which is one of the more common cancers, especially on a worldwide basis. And that was really the link with cancer. Pat Loehrer: You had an incredibly long-term collaboration with John Schiller, and as I mentioned, you published more than Dave and I have written letters to our wives with this man. Tell us a little bit about that relationship, that friendship, and that professional partnership. Dr. Doug Lowy: John, actually, he was at the University of Washington in Seattle doing his PhD, and it was so long ago that he sent me a letter, and I had been doing research on retroviruses. He sent me a proposal that he was doing his PhD in bacterial genetics, but he wanted to learn about mammalian viruses and so was writing to me about doing work with retroviruses. I wrote back to him and said, "That's very interesting, but I had just started working on papillomaviruses." And I thought the room for development and learning more was even greater there than with mouse retroviruses, which is what I was working on and what he was proposing to do some post-doctoral research on. Of course, he had never heard of papillomaviruses, so he had to look them up. But he developed a project with papillomaviruses and was able to get an NIH award to come as a postdoctoral fellow to work in my lab, and he actually did the research that he proposed, and it led to our improved understanding of the genetic organization of papillomaviruses. But then, it was clear that John and I got along very well, and it looked like both of us might be able to work together. So, he ended up getting tenure after he had been at NIH for about 10 years. And it's just been an amazing collaboration for me because John knows a lot of things that I don't know, and he thinks that I know some things that he doesn't know. And working together has been terrific, really, because when one of us doesn't want to do anything about something, the other one tends to step in. And so, it's been an amazing partnership that we have had for this time. Dave Johnson: This is really important. One of the reasons we agreed to do this podcast is to provide insight to up-and-coming faculty and fellows about mentoring and partnerships. What is the most important aspect of your partnership with Dr. Schiller? Dr. Doug Lowy: I think treating him as an equal colleague from day one, that probably is important. And then, since I was senior and he was junior, trying to make sure that he got credit when discoveries were made because the default, otherwise, was going to be that it was Doug Lowy who was doing things, whereas it was very clear that John was a key part of this collaboration. Dave Johnson: Now that your relationship is a long-lasting and mature one, how do you make those decisions now? Dr. Doug Lowy: Well, we've just worked together for a long time, and we enjoy talking, and actually, over the last few years, we are collaborating less rather than more. We're still very close colleagues, and we're in the same lab. But since I've been Deputy Director, especially during the last seven and a half years, I've been Acting Director for about three and a half out of the last seven and a half years, and there just isn't enough time to devote to the lab. And it would've been inappropriate for me to have been considered a co-principal investigator with John, who has gone off and done a lot of amazing research, more or less independent of me. Like everything else in this world, it develops, it continues to evolve, but we still are very close colleagues. As Pat was mentioning, this is my first week in several months not being Acting Director, and yesterday, John and I simply reveled in the opportunity to talk informally for 30 minutes without having to look at my watch because I needed to go someplace else. Dave Johnson: I'm glad you've reviewed that. I think a lot of junior faculty and fellows think that being in a leadership position is a cush job, and I'd tell them that it defies the laws of Physics because all poop flows uphill in this setting, and you have to deal with it. Pat Loehrer: I do want to spend some time talking about the NCI and your role there, but talk a little bit about how you have seen and where you envision that vaccines, particularly, HPV and maybe hepatitis vaccine - where you see it's been, and where it's going, and the impact that this potentially has on cancer worldwide? Dr. Doug Lowy: Well, one of the areas that John and I are continuing to work on closely is more research on the HPV vaccines. We noticed, quite a number of years ago, that the HPV vaccine performance was quite different from that of other so-called subunit vaccines. So, this is not an attenuated live vaccine, but instead is a subunit - it's just made up of one protein of the papillomavirus, the protein that gives rise to the outer shell of the virus. And what we noticed in a clinical trial that we were doing with colleagues in the intramural program, but who are medical epidemiologists - they are the leaders of the research, and what was happening was that although everyone was supposed to get three doses, there were some young women who were getting either two doses or one dose, in the trial, and this is in Costa Rica, where historically, cervical cancer has been the number one cancer of women. And it turned out that there was no difference in level of protection whether the women got one dose, two doses, or three doses. And even more surprising was that the antibody levels over the first few years were remarkably stable. And this led John and me to wonder whether it might be possible to get away with just a single vaccine dose. So, a lot of the research that we have been doing with our colleagues over the last few years is to develop stronger evidence that one dose of the vaccine would be sufficient to confer strong protection that's long-lasting. We've now carried out the studies in Costa Rica, with the initial trial to more than 10 years, and the antibody levels continue to be very stable, and the protection does not seem to have waned. Because this was not a pre-specified outcome, it's not enough to change standard of care. So, we and our colleagues are conducting a non-inferiority efficacy trial that is comparing two doses versus one dose of two different FDA-approved vaccines. One, GARDASIL 9, which is the HPV vaccine that's available for sale in the United States. But also Cervarix, which is made by GlaxoSmithKline, it's approved by the FDA, but it's no longer sold in the United States. And we anticipate that the results will read out in another couple of years. And if the results show that one dose and two doses are pretty comparable, we're expecting that this will lead to a worldwide change in recommendations for the HPV vaccine. So, whether you are in a high-income country or a low or middle-income country, that one dose is what will end up being recommended. Pat Loehrer: They could almost completely eradicate this disease, the most common cancer around the world. It's huge. Dr. Doug Lowy: So, Pat, the problem is that although the vaccine was approved 15 years ago, only about 10% of eligible young women in low and middle-income countries have actually been vaccinated up to now. And we think that the logistics and the cost of one dose could really be transformative, especially for those young women. It also would save the United States a great deal of money because needing only one dose would be far less expensive, and the government actually pays for about half of the HPV vaccine that is delivered to teenagers through the Vaccines for Children program. Dave Johnson: Well, this concludes part one of our interview with Dr. Doug Lowy, Principal Deputy Director of the National Cancer Institute and Chief of the Intramural Laboratory of Cellular Oncology in the Center for Cancer Research. In the second part of this episode, Dr. Lowy will give his insight to vaccine hesitancy in the COVID era and the evolution of accomplishments over the past 50 years working at the National Cancer Institute. We want to thank all of our listeners for tuning in to Oncology, Etc. an ASCO Educational podcast, where we will talk about just about anything and everything. So, if you have an idea for a topic or a guest you would like for us to interview on the show, please email us at: education@asco.org. Thank you for listening to the ASCO Education podcast. To stay up to date with the latest episodes, please click, Subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center, at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

In Part Two of this Oncology, Etc. episode, hosts Patrick Loehrer and David Johnson continue their chat with hematologist-oncologist Dr. David Steensma. They explore his views of key opinion leaders and a lifelong passion – collecting rare stamps, including medical stamps. If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at education@asco.org. 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 from The University of Texas, Southwestern in Dallas, Texas. Welcome to the second half of our Oncology, Etc. conversation with Dr. David Steensma. He's a highly accomplished physician and scientist in the field of Hematology/Oncology. In the first part of this episode, Dr. Steensma told us about his Dutch immigrant roots, and how a single college biology course changed his career interests from astronomy into medicine. Today, we'll explore his views on Key Opinion Leaders and another passion of his, and an interest of ours - collecting rare stamps, including medical stamps. Dave Johnson: So, David, in addition to your scientific writing, you've been a prolific writer in many other sort of viewpoints and opinion pieces. There's a lot to choose from, but I know you've been interviewed in the past about your column called 'The Raven', which I won't ask you about, as an Edgar Allen Poe fan. You also wrote a wonderful piece called, 'Key Opinion Leaders', which I thought might be quite interesting to ask you about, now that you might be calling upon KOLs. Do you want to tell us a little about that? Dr. David Steensma: Yeah, that's not my favorite term. Thought Leaders is another kind of silly term, but we know what we mean when people are talking about it. Yeah, I've had a chance to write on a lot of different things over the years, and that's been great fun. And when I first heard that term, I couldn't figure out what it meant, KOL. And then, a pharmaceutical representative actually accidentally left a list of KOLs in my office and I realized that not only are KOLs cultivated very carefully, those relationships, but there's a hierarchy of KOLs. They were people who influenced the local formulary and local practice at the institution, there were those who had a regional impact, and then there were those who were on the NCCN guideline committees, and had, you know, much broader impact that they really wanted to make sure to influence the heart and minds of-- in my interactions now, this opinion piece was a sort of tongue-in-cheek about Key Opinion Leaders and Thought Leaders. And with Thought Leaders, I was reminded of Sherlock Holmes's brother Mycroft Holmes, who, by Conan Doyle's fiction, was a brilliant man, but unwilling to stir his ample backside from his Chair in the Diogenes Club to actually get out there, and do some real work, and solve mysteries. And so, it fell to his slightly less brilliant brother, Sherlock, to become the consulting detective. So, that was fun. Now, we're sort of on the receiving end of wisdom from people who are experts in the area. And it's very important what doctors think, and in different geographies about how they think their patients will be potentially treated in a year or two, five years down the road, what the issues they have with current approaches are, where they see opportunity for some of our new compounds, for some of those of other companies, and it's different in Europe versus the US versus Australia. And so, there's a lot that we gain from advisory boards. There's an arc to an advisory board. You don't want to convene an advisory board when there's no data, because then, everybody is just speculating. You don't want to do it too late after something is already on the doorstep of FDA approval because then not anything can be changed at that point. So, you know, doing it at an in-between point where there's some initial data, but where we can really be guided by academic, clinical, and other experts, is really helpful. Pat Loehrer: I'd encourage people to pull this article out. It is really, really good. 2015, I think it came out there. The end of it, I also love it. You're talking about Kanti Rai who came up with the Rai classification and he was at this Meet the Expert session at the ASH meeting, and he said at the meeting, and this is your quote from it, and I love it, he said, "I don't like the name of this session because no one's an expert in chronic lymphocytic leukemia. I've been studying this disease for decades, and still too many of my patients die. If I was truly an expert, the disease would've been cured by now." I just love it, but it's a great read. Dave Johnson: Let me ask you, very seriously, if a younger colleague were to come to you, David, what advice would you give him or her about being invited to be on an advisory board? We'll skip the term KOL or Thought Leader. What advice would you give him or her, and what should they look for, and how should they prepare for that activity should you think they should do it? Dr. David Steensma: Well, I think getting back to imposter syndrome, people should feel, if they're invited to be in such a meeting, that they're there for a reason because their opinion does matter. And sometimes, younger physicians are reluctant to speak up in this setting, especially when there maybe leaders in the field there that have been doing it for decades, and may have very strong opinions. So, not being afraid to share their perspective and realizing that they're invited for a reason. On the other hand, I found it very helpful when I was a young faculty member and, on these panels, to listen to how colleagues were assessing data, and the recommendations they were making, and their perspective. And I learned a lot from some of those advisory boards earlier on. Many of the people who are the senior leaders in leukemia and MDS, you know, Rich Stone, Peter Greenberg, you know, John Bennett, in MDS, Marty Tallman, Hagop Kantarjian, Clara Bloomfield, just people who had decades of experience. And in part, I think it's some of my comments at advisory boards that helped get me my job at Dana-Farber, because I'd been in a number of meetings with Rich Stone, and he apparently liked some of the things I'd said about approaching patients. And so, you know, when a faculty position came open, he invited me out to come visit. And so, they can have benefits that you don't anticipate. Dave Johnson: Yeah, I would definitely agree with that. And there's pros and cons to being involved in those activities, but there are an awful lot of good that comes from it. And I think you've just touched on some of those. I'm going to shift gears a little bit because Pat has been waiting anxiously to hear all about your stamps. So, out of the many, many things that you've done and written about, I would say you've got close to 100 publications on medical stamps. It's an extraordinary productivity, David. So, tell us a little about your interest in medical stamps. How did you get involved in this, and where do you find time to write about them, and how do you decide which ones you're going to write about? Dr. David Steensma: Yeah. Bob Kyle, is really the driver on that, and we continue to do these together. Bob turned 94 this year, and he continues to be intellectually engaged. He's fun to talk to, if it weren't for COVID, he'd still be traveling and coming into the office, you know, which he was doing until just a few years ago. So, I met Bob as an intern when I was at Mayo. Somebody said, "Oh, you should meet this guy, he's really fun to talk to." And we just hit it off. And when I was a boy, my grandfather and my great-grandfather had collected stamps. And my grandfather really got me interested in it, partly given our family history, those of The Netherlands and former colonies, but also just more generally. And then as often happens, I got to be a teenager and other things took over in terms of interest, and there was less time, so, I had fallen away from it a bit. But somehow in this conversation, Bob had mentioned this, and that they were looking for someone younger who had this kind of background, to help with this series that has been running. Initially, it was running in JAMA with a guy named John Mirt, beginning around 1960, and then about a decade later, moved to the Mayo Clinic proceedings when they published six stamp vignettes on medical science per year, and Bob has done over 500 of these going back decades. And so, I got involved in that, and writing about-- thus far, it's mostly focused on individuals, but I have done a few also about more general trends in Philately. I will say that there are fewer of us, certainly those under 50, who are involved in the hobby. There's so much other distractions, but I still find it interesting and fun. And I've learned a lot, putting those vignettes together. Pat Loehrer: I started collecting stamps when I was young, I still have my Scott's album down. And now it's not stored, in properly, but I remember US Number One, I could have bought for $35, but I was only like 10 years old, and that was, you know, like $500 to me. So, I still regret that. Are you collecting stamps yourself now, still that you've resumed the collection part of it? Dr. David Steensma: Yeah. I would say, only a little bit. So, my Netherlands and Colonies collection is now actually complete, except there's one elusive. There's always one, right? Can't find this thing, even at auctions and such. And I also collected coins as a kid, and you know, still have some involvement in that. It's hard to find the time because I do do so many other things, and my wife and I have children, they're now college and PhD age, so I do woodworking, I have a telescope, so I never lost the love of astronomy. It seems like there's always other things to do. But I still have my collection over there on the shelf. Pat Loehrer: Did you inherit it from your grandfather too? Dr. David Steensma: Some of it I did. Yep. The core of it, I inherited from my grandfather and my great-grandfather. And then once I paid off my substantial medical school debt to the University of Chicago with the help of, in part, from advisory boards, but also mostly from moonlighting in emergency rooms around rural Minnesota-- during fellowship, I was like a full-time ER doc who happened to be doing a Hem/Onc Fellowship on the side, and finally got it paid off and then I could start on filling in some of the gaps. Pat Loehrer: Before we change this thing, what is your most cherished stamp that you own? Dr. David Steensma: Oh, my most cherished stamp is not a Dutch one. It is a set of national park stamps from 1934, authorized by James Farley, who was the Postmaster General at that point. 10 stamps, different colors about, you know, Zion and Acadia-- and it was my grandfather's favorite, and he was a big fan of the national parks, took two big trips there back in the '50s out West. And so, at his funeral, I put together a little display of those hanging with the photographs of other things from his life. I have that display, it's very meaningful to me - it's a connection with him. He was certainly very influential in my life. I never imagined I'd be working for a Basel-based pharmaceutical company, like he did for his whole career. Never thought that that would happen, but life has some unexpected twists. He worked for Roche in Nutley, New Jersey for much of his career as a research chemist. And ironically, when my grandmother was diagnosed in the 1990s, pancreatic cancer, and she saw the oncologist and was offered a 5-FU infusion after surgical, he said, "5-FU. I worked on that in 1959, 1960, that's still the best that we have to offer?" He was shocked by that. I was a fellow at the time. I said, "We need better drugs." Dave Johnson: For sure. So, do you have a favorite medical stamp, David? Dr. David Steensma: A favorite medical stamp? Gosh, that one's I think a little bit harder. I certainly have medical stamps that have piqued my interest. One of the sort of most moving is one of the US stamps that came out in the 1950s that has the Sir Luke Fildes' 'The Doctor', on it. You know, with this concerned physician at the bedside of a young boy, and I actually wrote a vignette about the history and background there, and I think that connection with patients at the end of the day when we don't have good drugs, that connection with patients is still so meaningful, isn't it? As you guys really know. So, and as many of our listeners know, and so much of what medicine remains despite the molecular glue degraders and CAR T and gene therapy, is still that human connection, and being there for our patients. And so, I would say that that is probably one of the most meaningful. There's some real quirky ones, too. Austria's come out with some stamps in the last few years; one made of toilet paper, when the toilet paper shortage was happening, another, made of the mask material and the shape of the mask to remind people to mask up. You know, there's been a lot of creativity. And the Dutch are very good about design. They come up with just some brilliant innovations in postage stamps. Dave Johnson: I mean, stamps are really quite artful, by the way, the Fildes painting hangs on the wall of my office. You can't see it, but it's on the wall. And then behind me, you can perhaps see a couple of framed stamps that are some of my favorites. One was a gift to me from a former Group of Chief Residents, of an Osler stamp that Canada put out, and the other is one I received actually as a gift, as part of an award. It's the first cancer stamp that was produced in the United States. So, I love them both. They're quite nice. The Fildes stamp is actually my favorite of all, so I think that's a great stamp. Pat Loehrer: I have actually looked behind me. I've got a stamp collection on the frame that was given to me too that I love. It's stamps of medicine. There was one, a Dag Hammarskjöld stamp, that was famous because they printed it upside down when they put the color in, and I think it created a huge controversy from-- you know this better than I do because they decided then just to overprint them. Instead of making a few sheets that were incredibly valuable, they ended up printing out thousands of these things, which I have one now. It's only worth 7 cents, but at the time, it seemed really cool to have a misprinted stamp in your collection. Dr. David Steensma: Dag Hammarskjöld, there's an interesting connection with what I was talking about a little bit earlier with St. Elizabeth's Hospital. So, this relatively small teaching hospital had, at one point, a very strong hematology research program led by a guy named Fred Stallman. And in 1974, Fred Stallman, who was coming back from ISH, International Society Hematology, which was in Tel Aviv that year, and his plane exploded somewhere over the Aegean Sea, ultimately thought to be related to the PLO, and so he died. There was a big painting on the wall, in the hospital of him. And Dag Hammarskjöld also, at the peak of his career, you know, as the UN Secretary-General, was killed in a plane crash. But the interesting thing about Fred Stallman is, here, you have somebody who was so important in hematology. None of the fellows had any idea who he was or their connection to hematology. You know, it shows how fleeting fame is, unless you're an Einstein or Babe Ruth level. So, that was a good thing to keep in mind as well. Pat Loehrer: We could talk for another hour or two on this. Dave, we really appreciate it. But unfortunately, this is all the time we have for today. And I really want to thank you for joining us, Dave. This has been a wonderful conversation. I also want to thank all our listeners for tuning in to Oncology, Etc. This is an ASCO Education broadcast where we will talk about anything and everything, as you can imagine. If you have an idea for a topic or a guest you'd like to see on the show, just email us at: education@asco.org. Thanks, again. And, Dave, I've got a quiz for you here. Do you know why pirates don't take a shower before they walk off the plank? Dr. David Steensma: I do not. Dave Johnson: I have no idea. Pat Loehrer: It's because they wash up on shore. Dave Johnson: Oh boy. 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.

"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 education@asco.org. TRANSCRIPT Dave Johnson: Hello, everyone, I'm Dave Johnson at UT Southwestern, in Dallas. Pat Loehrer: And I'm Pat Loehrer from Indiana University, in the Center of Global Oncology in Indianapolis. Dave Johnson: And this is another episode of Oncology, Etc. Pat Loehrer: Yeah. Before I get started, I'm going to ask you a quiz. Do you know what a myrmecologist is, Dave? Dave Johnson: Is that somebody who studies snails and conches, or no? Pat Loehrer: No. Not even close. Dave Johnson: Okay. Pat Loehrer: Do you know what a philatelist is? Dave Johnson: I thought it was maybe a small cardiologist. Pat Loehrer: Someone who studies mermaids - no, no. A myrmecologist, actually, is a subject of this book that I just read called, Scientist, it's a story about E.O. Wilson. It's a biography of him. And I didn't know that much about him. Dave Johnson: Oh, ants. Pat Loehrer: Yes. Yeah. Richard Rhodes wrote this book. Actually, it's a great read. I mean, he grew up in Alabama, at the age of seven, he was fishing. And fishing, the hook got caught in his eye, he kept on fishing. He didn't seek medical attention. And later on, he ended up losing his vision in that eye, and his other eye was perfect. So, he used that to focus on little things - he loved ants and butterflies, and at the age of 18, he discovered the first colony of fire ants in the United States, eventually, went to Harvard. He was instrumental in creating the Encyclopedia of Life in which they're basically doing this global database for 1.9 million species. He was a bit of a controversial, but a very proactive person with conservation. He said basically that destroying the rainforest for economic gain is like burning a Renaissance painting to cook a meal. And he's talked about the Brazilian rainforest in which less than 1% of it is now present as it was compared to 100 years ago. It's really quite amazing. His study of ants, the best quote I have from that is he said, "Karl Marx was right." He says, "Socialism works, it's just that he picked the wrong species." So, that's my book today, but I'm gonna turn it over to you, Dave, to introduce our speaker. Dave Johnson: Well, we're very fortunate today to have David Steensma on this episode of Oncology, Etc. Dr. Steensma is a highly accomplished physician-scientist, and an internationally recognized expert in the diagnosis and management of myelodysplastic syndromes. He has numerous academic accomplishments, ranging from characterization of the prevalence of JAK 617F mutations in MDS, first description of the involvement of the IR3G in human neoplasia, and more recently, the initial definition of Clonal Hematopoiesis of Indeterminate Potential, or CHIP - more about that later. Dr. Steensma is a graduate of The University of Chicago Pritzker School of Medicine. He obtained his Internal Medicine and his Hematology-Oncology fellowship training at the Mayo Clinic in Rochester. In the early 2000s, he served as a post-doctoral research fellow and visiting scholar in the molecular biology hematology laboratories of Dr. Douglas Higgs, and Richard Gibson at Oxford University. He has served the medical community in many ways, including on the FDA ODAC Committee, a fun activity if there ever was one, Educational Chair of the 2015 ASH annual meeting, and also as a member of the ABIM Hematology Examination Committee, as well as many others. He is currently the Global Hematology Head at Novartis Institute for Biological Research, where he oversees early-phase development of malignant and non-malignant hematology drugs within Novartis. Prior to moving to industry, he served as the Edward P. Evans Chair in MDS Research at Dana-Farber Cancer Institute in Boston. He's an enthusiastic philatelist. We'll talk about that a little bit more later in the podcast. So, David, welcome to Oncology, Etc, and thank you so much for joining us. Dr. David Steensma: Thank you for having me. Honored to be here. Dave Johnson: Well, why don't we start by asking you just to tell us a little about yourself. Give us a little of your background, where you grew up, about your family, and very importantly, what and who influenced you to pursue Medicine as a career. Dr. David Steensma: Yeah. So, my family is mostly in Michigan. My parents live there now, my sister, you know, extended family - my wife is from there. And when the Dutch came to the US during the great immigration wave around the turn of the 19th into the 20th century, a lot of them settled in Western Michigan- Pat Loehrer: Dave Johnson was there. Dr. David Steensma: -watching this happen? So, a lot of them settled in Western Michigan. I think it reminded them of home, you know, flat, sandy, big body of water to the left, similar kind of climate, and that's really my origin as Dutch immigrant community on both sides. I grew up in New Jersey though, partly because of the Vietnam war. And my dad getting a low number when he was drafted and having to move there, and then they stayed there for decades, and that's where I grew up. I went to college thinking I wanted to do Physics and Astronomy - was fascinated by Astronomy, Astrophysics. Thought that that was gonna be my career, had a job as an undergraduate, working as an observatory assistant, to this day, probably the best job I've ever had. And then, I finished all the courses for my major, I took a course in Cell Biology just for fun, and I thought, "Wow, this is really interesting," and started thinking about going to medical school instead, and took Organic Chemistry over the summer between my junior and senior years of college, and one thing led to another, I ended up applying to medical school instead. I don't have any doctors in my family. My grandfather worked for Roche as a chemist, his whole career. That's the closest we get to Medicine in previous generations. My father was an Aerospace engineer, my mom, a school teacher. You never know what pathways life is going to take you down. Dave Johnson: Actually, I majored in Mechanical Engineering and I love Physics, so I get it. I mean, there were answers there. Medicine has always been a little more puzzling where they create these different words that you have to memorize. But I love people who have gone through the sciences like this. Again, you've had a terrific career in academics, and now you've moved to industry. Tell us a little bit about that transition. What was the attraction, and what have you found to be the differences between the academics and your role now in Novartis? Dr. David Steensma: I love being an academic, and you know, I envisioned that I would retire as such, but you know, things changed a little bit in 2020. It was a very unsettled time, I think, a lot of us thinking about what we were going to do for the next stage of our career. I was also turning 50 at the end of that year, so, milestones like that tend to make us think about where are we going. And Jay Bradner, the head of Novartis's Research Institute, called and said, "You know, we could really use a hematologist for leading our Early Development." And I initially said, "No." I didn't think about it. Although, tremendous respect for Jay, he had been a colleague at Dana-Farber, brilliant guy. I had first met him as a medical student at The University of Chicago some decades earlier, and then he called back and said, "Well, just come out and visit and see what we're all about." And the research institute's just based in Cambridge, Ma. So, it was an easy visit, and one thing led to another, and a few months later, I was leading Hematology Development for Novartis. It really has been a fun transition. I think one of the big attractions for me was being able to do things at a different scale, and I loved Dana-Farber, but I was really getting frustrated with all of the staffing shortages. Clinical trials were really moving slowly, and so, the ability to work with a large range of centers around clinical development was very attractive. And there's a lot of great people at Novartis's Research Institute, it's like a biotech within a larger pharmaceutical company. It's been fun for me also, not just to have that narrow focus on CHIP and myelodysplasia, like I had before, but to be able to be involved in drug development, and lymphoma, and in CAR T, and in sickle cell gene therapy and all kinds of other really fun programs. So, one of the things I've been a little bit shocked by is actually how similar life as an early drug developer is compared to academia. I mean, the biggest difference is not seeing patients, although Novartis would've let me, Dana-Farber did not. So, I've stopped seeing patients, at least for now. But there's a level of emphasis on science, and on careful clinical trial development that I really appreciate. And in many ways, academia has become a little bit more corporate. You know, greater proportion of the funding comes from industry. There are companies that are spinning off all the time from academic institutions. I like to say my Conflicts of Interest declaration has gotten much easier now because there's only one company to declare compared to before. It was, you know, anyone who you'd done a trial with or an advisory board participation. So, it's more similar than it is different. I think it would be different-- People have different roles within companies, and I think if I was in late-stage development, really focused on what's gonna be the big value return for the company, that would be a different type of job, and I'd have to think more about the financial implications and the regulatory to a greater degree than I do. I get to work with scientists who are coming up with new molecular glue degraders and calling and saying, "Hey, where's the disease where this might be applicable?" And talking to the chemists about engineering out different liabilities that might be an issue for our patients, and you know, that really is energizing. Pat Loehrer: You're one of the pioneers in CHIP. Can you talk a little bit about it, and what it means to the average clinician or to the patient? Dr. David Steensma: CHIP is one of the coolest discoveries in the biology of aging, I think in the last 20 years. And we had long had the sense that as people age, the number of hematopoietic stem cells that they have is reduced. In the late '60s, early '70s, there really seems to be a bottleneck, when in childhood, in young adulthood, we have thousands of different hematopoietic stem cells contributing in our blood cell production. And then, there's like a colony collapse that happens and, you know, at age 75, it's a much smaller number, 10 to 12 in most people. In some people hematopoiesis is dominated by a single clone. But we really didn't have an understanding of the mechanism of why that happened. Until 2014, several groups, including Ben Ebert's, led by Sid Jaiswal, a young investigator who's now at Stanford, found that somatic mutations that are common in MDS and leukemia, like TET2 and DNMT3A, these are actually common in aging people with totally normal blood counts. And similar to monoclonal gammopathy of undetermined significance, there's just a portion of the older population that has these somatic mutations. And so, we kind of needed to name for it, and I feel a little bit like what my mentor, from Mayo, Bob Kyle, just one of my personal heroes, you know, he had taken an observation in plasma cell disorders that Jan Waldenström made, that was being called 'benign gammopathy', and didn't really have a good name. And he called it MGUS, Monoclonal Gammopathy of Undetermined Significance, a name that, now for more than 50 years, has been part of the medical lexicon. And so, we did that with CHIP. I wasn't the guy who discovered CHIP, clonal hematopoiesis; it was somebody else's discoveries, but we came up with a definition for it, and a term for it, and it really took off. I mean, that paper has been cited a couple of thousand times already, and it's part of the new World Health Organization classification of hematologic diseases that just debuted this summer. So, that's been a fun world to be involved with, and it has clinical implications. And so, with Irene Ghobrial, who has a special interest in MGUS and smoldering myeloma and their progression to overt myeloma, I founded a clinic at Dana-Farber for patients with CHIP and other related precursor conditions. So, the most interesting thing about CHIP, I think, is that it not only predisposes the human malignancy, but because these cells, these clonal cells, circulate, they interact with the vascular endothelium in different ways. It's a risk factor for cardiovascular events, it's a risk for death from cardiac cause, it's a risk factor for worse gout, worse COPD, but it protects, mechanisms that we don't fully understand yet against dementia. And we think that what's happening is these cells are getting in the brain and they are replacing some of the microglia that just undergo attrition with aging. So, that's fascinating. Somatic mosaicism has been described in lots of different tissues now; the esophagus, the liver, the gut, the skin. You know, these mutations that we normally think of as associated with malignancy can be found in many different tissues as we age. It's just part of life, as part of the entropy of existence. But in the blood, it's special because there's no anatomical constraints on that tissue in the way that there is with a clonal proliferation in the esophagus. And so, the circulation of the blood is what really makes that special. Dave Johnson: So, I'd like to go back just for a moment and talk about your corporate life, if I may. I think many of, if not the majority of our listeners, come from the academic world. And so, they're familiar with the day-to-day activities of an academic such as yourself, but perhaps, less so with what do you do during the day as someone who is responsible for early-phase drug development in industry, what does your day look like? Do you come in every morning and meet with the basic scientist, or is there a corporate meeting? How does your day-to-day activity go? Dr. David Steensma: That's a great question. It's one I get a lot actually, Dave, and I think, you know, because all of us train in academic medical centers, that's a life that's very familiar to us. And what happens in these other arenas - government, industry, biotech - is maybe a little bit less familiar. So, there's a lot of meeting that takes place; meeting with clinical trial teams, meeting with basic scientists, meeting with different operational experts and program managers. So that might involve, "Okay, we have a molecule that this is the safety profile of it. We have two other similar molecules that could go into the same indication, their safety profile is a little bit different. Which one is the one that is most likely to be tolerated and beneficial for patients?" It might then be submitting packages for regulatory consideration by FDA and other health authorities around the world, and then responding to their feedback when they come and say, "Hey, we're not ready to give you this investigational new drug designation and let you start on clinical trials until you do ABC, and then we have to think about how we're going to do ABC. It can involve business development, we call it, which is, "Okay, this is our portfolio, but we really need an X or we really need a Y, and biotech company A has these. Are they willing to talk?" And sometimes they come to us and say, "Hey, we've come up with this compound, we really need the power of a big company to take that forward and do a full development. Are you interested in partnering with us?" I meet with my team members quite regularly in one-on-one meetings, both to talk about specific projects, but also their career development - make sure they're happy and you know, just as in academia, people want to progress to different roles; that's true in the industry world too. You know, connecting people to others and helping them think about what's their next promotion, what's their next role going to look like. And then, there's a lot of governance meetings. So, these are meetings where we say, "Okay, this clinical trial, should we go forward with this or not? It's gonna be $100,000,000 investment, this is the data we have to this point, you know, should we do this? What are the considerations?" That's a big part of it. There is travel, you know, during the COVID pandemic era, been much less so. The one thing I always heard people in industry complain about before I made this switch was the travel. There's been a lot less of that, so it's made me happy because it's been a more balanced lifestyle, that's for sure. But there is still some of that; travel to investigative sites, travel to the big meetings like the ASCO annual meeting, EHA, the ASH annual meeting, and some smaller meetings. So, it's a real mix of things. Dave Johnson: So, let me just follow up with one further question. Do you find that your reading has changed? Dr. David Steensma: I think that my reading has changed a little bit, but mostly because of the breadth of programs that I am now responsible for. So, in the past, I was very heavily focused, at least within Medicine, on the myeloid world and trying to keep track of developments outside of that. But now, I really have to pay attention to new findings in lymphoma, and myeloma, and non-malignant hematology to a greater extent than I was. My reading of things outside of Medicine has also been a little bit broader and there's more time for it because there's not the, you know, staying three hours at night and finishing your Epic EMR inbox. One of the things I've really been impressed by is that in industry, there's not a lot of time wasting. A lot of things that we were asked to do in academic medical centers are things that doctors really don't need to be doing. So, I get to read lots of other things too. Pat Loehrer: Let me follow up on Dave's question. This is a confession on my part. There's so many things that I have done that I don't feel like I'd really qualified to do. There's this imposter syndrome that we talk about. You're now the Head of Global Hematology. Was there a sense as you're taking these steps that, "Wait a minute, this is really a job really too big for me, and I'll try it," or do you just have this innate confidence? How was that? Dr. David Steensma: I am definitely affected by that, it's a major transition. I'd never done anything like this, and even with the assurance of knowing a number of the people at the research institute that I was going to, being confident in Jay Bradner's leadership, and that of Alice Shaw, who is our Translational Clinical Oncology leader, a wonderful colleague, this was still unlike anything that I'd ever done. And so, I was anxious about it. You know, ironically, sometimes the things that we complain about become the best preparation for what's coming in life. And about six years ago, Dana-Farber affiliated with a community-based practice in the Brighton neighborhood in Boston, called St. Elizabeth's Hospital and provided hematology oncology services there, and they really needed somebody to go out for heme malignancies. And talk about taking me out of my comfort zone, instead of having a very narrow clinic where I was seeing marrow failure, and MDS, and leukemia, and MPN, and CHIP, patients with these conditions where I really had a comfort level, I was treating patients with HIV-associated lymphoma, and myeloma, and calling a lot of my colleagues back at Dana-Farber for advice. And I grumbled about being the guy that was asked to do this, but it turned out to be terrific preparation for what I'm doing now because my myeloma knowledge is not obsolete from fellowship 20 years ago. It's up-to-date, I've prescribed, you know, a lot of the newer agents and seeing what the adverse events were, and same with lymphoma, and seeing where the patients' needs were. So, I'm actually really grateful for that experience now, in retrospect. At the time it felt like a nuisance. I had to leave the site and go to the other site, and I had patients in two hospitals, which is not easy, but I'm glad it happened. Pat Loehrer: I think that's an interesting observation. I, too, was at one point in my career spending time between two facilities, with essentially a private practice that was broad and general, versus the more narrow practice I had at the university. And it was challenging, but I think, like you say, it's so rewarding in many ways, and helped me in my transition from being an oncologist to a Chair of Medicine of a major department, in my later years. Dave Johnson: Well, this will wrap up part one of our interview with hematologist, oncologist, and researcher, Dr. David Steensma. In the second part of this episode, we'll ask David about an article he wrote on key opinion leaders, published in the JCO a few years ago - very provocative paper to be sure. We'll also explore how he got into and stayed passionate about stamps; a subject about which he's written extensively. Thank you to all of our listeners for tuning in to Oncology, Etc. This is an ASCO Education podcast where we will talk about just about anything and everything. If you have an idea for a topic or a guest you'd like to hear on our show, please email us at: education@asco.org. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click, "Subscribe." Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at: education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy, should not be construed as an ASCO endorsement.

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

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

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

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