Healthcare Unfiltered

To provide an update on the COVID spike and response in India over the past 6 weeks since Chadi’s previous episode, Aju Mathew (@ajumathew_), MD, oncologist practicing in southern India, joins the show. Dr. Mathew begins by describing the tradeoffs of moving home to practice in India while leaving his academic career behind in the US, offers critical remarks on India’s government use of resources to combat COVID up to and during the “tsunami,” shares how vaccine hesitancy around the world bled into India’s population, provides a status on the current vaccine and resource availability in the country as well as the percentage of the population vaccinated, and plenty more.

In early May, a Lithuanian doctor named Laura Silinskyte committed suicide after facing constant bullying from her superiors at her regional hospital. To shed light on the issue of medical bullying and physician suicide, Chadi is joined by two friends of Dr. Silinskyte—Monika Arzanauskaite, a radiologist, and Gil Morgan, a medical oncologist—as well as a personal friend Laurie Gordon, an adult and child psychiatrist with experience treating healthcare workers. Monika and Gil share who Laura was as a person and some insight into her life leading up to her final days, how the outdated and hierarchical structure of the health system in Lithuania likely contributed to her final decision, explain the differences between “bullying” and “mobbing,” and wrap up with what can be done by the medical community to keep a tragedy like this from happening again.

For this special episode, Chadi invites John Marshall (@marshalj23), MD, Chief of the Division of Hematology/Oncology, Medstar Georgetown University Hospital, and his wife Liza Marshall, a lawyer by training who was diagnosed with triple-negative breast cancer 15 years ago. John and Liza co-wrote a book, titled Off Our Chests, about their shared experience of overcoming her diagnosis – told from the perspective of the caregiver as well as the patient. The couple open up about their individual experiences through treatment, how difficult it was to speak candidly about their feelings in the moment, the struggles of remaining an objective physician when a spouse is the patient, the sometimes impractical nature of shared decision-making, and a host of personal anecdotes along the way.Visit the Off Our Chests website to order the book https://www.offourchestsbook.com/View Chadi’s review of the book on The Health Care Blog https://thehealthcareblog.com/blog/2021/05/27/off-our-chests-no-secrets-left-behind/

Chadi welcomes “Papa Heme,” or Aaron Goodman (@AaronGoodman33), MD, hematologist at University of California San Diego, and Matt Wilson (@mattwilson2287), MD, Beatson West of Scotland Cancer Centre (UK), to debate the importance and utility of CNS prophylaxis for patients with DLBCL. The trio explain the origins of the debate, who the high-risk patients are in the first place, whether better systemic control is a better strategy for these patients, how to weigh the benefits against the toxicities and other negative effects, and so much more. You don’t want to miss this informative and at times contentious dialogue.

Bishal Gyawali (@oncology_bg), MD, PhD, Queen’s University Cancer Research Institute (Canada), joins the show to discuss the measurement of clinical benefit of new therapies and optimizing clinical trial design. Dr. Gyawali recaps a presentation he gave at last year’s ESMO Annual Meeting on clinical trial characteristics leading to artificial improvement of ESMO-MCBS scores for cancer drugs, goes on to list in detail the ten trial design characteristics that inflate the scores (including the use of surrogate endpoints and quality of life reporting, among others), and wraps up with a comment on future opportunities for clinical trial reform.View Dr. Gyawali’s recent publication on clinical trial design https://www.esmoopen.com/article/S2059-7029(21)00075-2/fulltext

Recurring guests Saurabh Jha (@RogueRad), MD, radiologist in Philadelphia, and Vinay Prasad (@VPrasadMDMPH), MD, MPH, hematologist/oncologist in San Francisco, seek to settle the debate surrounding COVID vaccine passports. Both scholars defend their recently published viewpoints – Dr. Jha arguing for passport mandates and Dr. Prasad arguing against them. Will requiring proof of vaccination be driven by the business sector, local or federal governments, or anywhere in between? Will vaccines help jump start or continue to stall economies? When is the right time to impose a vaccine passport, if ever at all? This is a real barn-burner of a discussion that you won’t want to miss.View Dr. Jha’s publication on The Health Care Blog https://thehealthcareblog.com/blog/2021/04/29/the-market-forces-behind-vaccine-passports/View Dr. Prasad’s publication in Medscape https://www.medpagetoday.com/blogs/vinay-prasad/92107

To truly understand the gravity of the somber COVID situation in India, Chadi hosts Parameswaran Hari, MD, MRCP, chief of oncology, Medical College of Wisconsin, and Nikita Mehra, MD, associate professor of medical oncology, Cancer Institute Adyar (India). Dr. Hari begins by providing a ground-floor perspective of the COVID situation in India from his visit there just a few weeks ago, including how the country fared in 2020 compared to the current day and how hospital systems are managing in different parts of the country. Dr. Mehra then joins the show to share how shocked India has been with the second wave. The trio discuss the “hypotheses” of why COVID never hit India that hard last year, initial stages of vaccine hesitancy among health care workers and trust levels with the central government, and whether or not the situation is dire enough to consider rationing care on a patient-by-patient basis. The conversation wraps up with comments on the US actions to support India during this crisis. Spoiler alert: all three are very critical.

Chadi hosts three medical oncologists to break down “near equivalence” for alternative standard-of-care cancer therapies – a new paradigm published in detail in the Journal of Clinical Oncology. Ian Tannock, MD, PhD, Princess Margaret Cancer Center (Canada); Mark Ratain, MD, University of Chicago; and Daniel Goldstein, MD, Rabin Medical Center (Israel), describe what is meant by “near equivalence” and the practice of generating evidence to support global alternative cost-effective treatments. How do you design and implement studies that show lower drug doses are as effective as the labeled doses and treatment schedules? Does listing drugs at a lower price than comparable drugs impede innovation in a capitalistic society? How do poor control arms make it through regulatory and IRB approvals? How can the oncology world come to terms with “imperfect data” for supporting alternative standard-of-care treatments? These questions and more are answered in this meeting of the minds.View the publication in the Journal of Clinical Oncology https://ascopubs.org/doi/full/10.1200/JCO.20.02768

Chadi hosts two thoracic oncologists to dish and debate on the nuances of lung cancer screening: Charu Agarwal, MD, MPH, University of Pennsylvania, and Lecia Sequist, MD, MPH, Massachusetts General Hospital and Harvard Medical School. The trio start by making the case for screening the healthy, low-risk population as well as people with a smoking history, and then jump into a round-up of clinical trials that have shown a positive impact from screening. The highly-questioned JAMA publication on the USPSTF recommendations for lung cancer screening is brought to the table, including the risks and scalability across larger and smaller hospital systems. No stone is left unturned in this riveting dialogue.View the JAMA publication on screening for lung cancer https://jamanetwork.com/journals/jama/fullarticle/2777244

George Dawson (@dawso007), MD, addiction and neuropsychiatrist in Minnesota, joins Chadi to discuss mental illness and COVID – of having the virus itself, as well as the result of isolation and lack of social interaction. Dr. Dawson shares how individuals with drug or alcohol addictions have struggled to stay sober while being stuck at home without in-person meetings and human interaction, whether there is reason to believe the COVID lockdowns and social restrictions have worse health ramifications than the disease itself (eg, suicide rates), burnout and other negative effects pervading the health care provider workforce, and how fluctuating school schedules may be negatively impacting the mental health of children.