Resonance

Spotify | Apple Podcast | Amazon Music | Length: 44 minutes | Published: Aug. 29, 2024

In this episode, Dr. Andrew Lee shares strategies for residency applicants to boost their chances of a successful match. Listeners will discover how to highlight their unique qualities and characteristics in their applications. By doing so, applicants can create a personal "residency brand" that authentically represents them, enhancing their overall presentation.

Transcript

Gianmarco Calderara:
Hello, and thanks for listening to Resonance podcast, a podcast run by medical and graduate students at Baylor College of Medicine, where we interview clinicians, faculty, and researchers about their work in an effort to promote health, education, and ingenuity. My name is Gianni Calderara. I am a fourth-year medical student at Baylor College of Medicine, and I'm going to be co-hosting this episode today with my co-student and one of my close friends, Ryan Sorensen.

Ryan Sorensen: 
Nice to join you today, Gianni.

Gianmarco Calderara:
Ryan is going to be leading us through a conversation with Dr. Andrew Lee. I'm just going to give a brief introduction to Dr Lee. So, Dr Lee is the Herb and Jean Lyman Centennial Chair in Ophthalmology, and he's also the founding Chairman of the Blanton Eye Institute, Department of Ophthalmology at Houston Methodist Hospital. He's also a professor of ophthalmology, neurology, and neurosurgery at Weill Cornell Medicine, and an adjunct professor of ophthalmology at Baylor College of Medicine, Texas A&M, The University of Iowa, and the University of Buffalo. Dr. Lee has been an American Academy of Ophthalmology member for over 25 years. He has served in various leadership roles. He's also a past president and current chairman of the board of the North American Neuro-Ophthalmology Society. He's authored over 500 peer-reviewed publications, has written a few textbooks, and has given a whole bunch of named lectures. He also has a very large YouTube presence with over 80,000 subscribers. So, Ryan introduced me to Dr Lee. Ryan, could you tell us a little bit about how you first met Dr. Lee and sort of how this podcast came about?

Ryan Sorensen:
Yeah, Dr. Lee is one of my mentors. I'm interested in ophthalmology, and he's a neuro-ophthalmologist. I met him my first year of medical school, actually at an event that he was presenting on building our brand for residency applications, which is the subject of our podcast today. And since then, I've been on multiple research projects with him and helped with his YouTube channel. It's really been a pleasure to get to work with him over the years, and I'm really grateful to have him as a mentor.

Gianmarco Calderara:
Yeah, and like Ryan said, this episode is going to be all about preparing for residency applications, which are coming up later in the fall. Dr. Lee's going to be talking to us sort of about building our brand for residency and how we can sort of sell ourselves to programs and what we want our message to be, and how we can go about conveying that message in the best way possible. I'm excited to hear from him, and I think it'll be a good episode. So, without further ado, let’s hear from Dr Lee.

Ryan Sorensen:
All right, let's get to it.

Gianmarco Calderara:
All right. Well, Dr Lee, thank you so much for being here and agreeing to do this with us. I was really excited to hear about this topic from Ryan because I know applications are kind of, you know, around the corner, and I'm very excited for my own personal learning and some strategies I'm going to get just from a personal point of view. So, thank you so much for being here and taking the time to do this with us.

Dr. Lee:
Thanks for having me.

Ryan Sorensen:
Yeah, we're excited. We were just going over the introduction earlier, and I told Gianni that this is a really special opportunity for both of us just to sit down with you and get some insight into applying to residency programs. So, if you don't mind, we'll just get right into the questions. First, if you can just introduce yourself and tell us a little bit about what got you interested in ophthalmology and how you ended up in Houston.

Dr. Lee:
So, I'm from Charleston, West Virginia, but I went to the University of Virginia for medical school and college, and then I chose to come to Houston for residency. I was at Baylor College of Medicine for ophthalmology residency and was the chief resident. And in my chief year, my chairman decided that I would come back and join the faculty when I finished at Johns Hopkins in neuro-ophthalmology. And so I did. I was on the faculty at Baylor for 10 years, and then we were 10 years at the University of Iowa before we decided to come back to Houston, and I became the Chair of the Blanton Eye Institute here at Houston Methodist Hospital.

Ryan Sorensen:
All right, thank you. Can you tell us a little bit about why you're interested in academic medicine and why you chose to do academic medicine over private medicine?

Dr. Lee:
So I think, like most people who choose academics, you're going into it for clinical care, education, and research. But for me, the thing that keeps me in academic medicine is getting the chance to work with wonderful young people like yourselves. And there's nothing more rewarding for a teacher than to see the success of their students, professionally and personally. And so that's what keeps me going every day and keeps me in the game.

Gianmarco Calderara:
And I know we talked a little bit about your YouTube channel that you have. I talked a little bit about how I watched some of those videos my first year of medical school. Where did that idea come from and how did that YouTube channel start?

Dr. Lee:
So, over the years I've learned that young people learn differently than when I was a medical student, and young people of today want things that are quick. They like video formats, they want the information now and on-demand, and they don't want to go to the library. And so for me, it was a learning experience of my own to reframe my teaching style to meet those needs of the modern learner, short, digestible video vignettes about focused topics that are less than three minutes. It turned out to be the most rewarding thing that I've done in the education space in a long time because that YouTube channel has 6 million views and 80,000 subscribers, which is way more than any paper or any book I've ever written in my whole career.

Gianmarco Calderara:
Yeah, yeah, that's awesome. Can you tell us a little bit about sort of your experience, you know, interviewing residency applicants and kind of just looking over applications over the years?

Dr. Lee:
So as an interviewer, what we're looking for is two things, "fit" and "fitness." They're not the same thing, even though they sound similar. Fitness is what you bring to the table as an applicant, your credentials, your scores, your grades, your CV, your extracurricular activities, and that determines your fitness. And because there are so many applicants to ophthalmology, almost everybody has fitness. What we're looking for in the interview is not fitness. We're looking for fit. And for fit, what we're looking for is alignment with our value system. But also, can I see myself working with this person every day for three years, and is this the kind of person that I would want to see out in the community and be proud of. So for me, our product in academics, and education especially, is people. And so what we're looking for is fit and a good product.

Gianmarco Calderara:
So I guess kind of what we're talking about today on this podcast is really fit. We're really honing in on how we can kind of optimize our fit as applicants. And I guess at this point, when you are, you know, applying, your fitness is already sort of kind of, you know, well there's still opportunity for improvement and that sort of thing but...

Dr. Lee:
And that's one of the main messages I want to communicate today. You need to find your people. You need to find your peeps. You need to find the place where you feel comfortable and that you have alignment with their learning and teaching culture and where you feel most comfortable with your own self. And that means finding a unique but also authentic version of yourself, the best version of yourself that you can present on interview day.

Ryan Sorensen:
Dr Lee, the first time I met you was actually when you were presenting on building your brand, which was just like what you're talking about, presenting your own unique self, your own unique brand. Could you describe for our listeners what you mean by building your brand?

Dr. Lee:
So your listeners probably are familiar with corporate brands. So when I say the word Nike, for example, which actually means victory, it's the Greek goddess of victory, they are trying to communicate that brand. And they often have a slogan like Nike's happens to be, just do it right? And so they're trying to convey that as their brand, or a company like FedEx, which is trying to communicate if it actually has to be there overnight, absolutely positively, you know, you can trust this. And so for the corporate world, brands are a promise, a promise, and an expectation that they will meet a goal or an objective or some product brand that they're trying to sell. But for people, your promise too. So when you come to the interview, you're bringing your brand, and that brand is your promise, your promise that you will do your best, that you will be a success, and that you will represent this program in the future in the best possible light. And so your brand is your own. And Oscar Wilde would say, "you must be yourself, because everybody else is taken" and that is the most important quality of the brand, authenticity. It has to be your own. And as an interviewer, I'm looking for inauthenticity, and I can detect who's not genuine, who's not sincere, who's just saying the words, but actually doesn't believe in what they're selling. And you have to believe it. And in order to believe it, it has to be true.

Gianmarco Calderara:
Let's say, you know, an applicant just has no idea what their brand is, right? Or just for whatever reason, they're having a hard time kind of pinpointing, you know, what they want their message to be to an interviewer, what advice would you give that applicant or some steps you can take to really hone in on what your brand is going to be?

Dr. Lee:
Yeah, I think a lot of your listeners probably this whole brand concept is a novel concept to them. They're used to presenting their CV, which is usually just a laundry list of activities and extracurricular things, and it's just, a list, and because that's gotten you where you are, you think that's the next step also. But this is a totally different ball game when you make the change from medical school, where there's 200 people in your class to residency, where there might be only four or six and so that means you have to stand out without sticking out. And so creating a brand requires strategic, intentional, and deliberate crafting of the brand. And all good brands start with a core. And so for our hospital, we call those the I care values, integrity, compassion, accountability, respect, and excellence. And so everybody's brand has to start with that as the foundation. What I mean by building on your brand is taking those foundational elements which, of course, are given, in fact, to be a good doctor and a good ophthalmologist, and making it your own. And one of the things that building a brand means is searching for the thing that makes you, you. I always say your brand should be recognizable instantly by your mom or your best friend. It should be that kind of obvious, and we don't want to rehash the core elements of intelligence, team player, and communication. Those are all in your CV. What you're trying to show the interviewer and the faculty that are going to be with you is that you offer something new, novel, unique, and whether that's your hobby or your outside interest, or whatever track you're on. And so one of the questions I always ask applicants when they come to me about their brand is, are you on a track? Because if you're on a track that already establishes the core elements that you're going to build on. So typical tracks, and therefore typical brands include leadership, advocacy, care of the underserved, resolving health care disparities, and looking at inequities in the health care system. From an access standpoint, there are whole different arenas where tracks make it just so much easier for you to have a brand. Some of the brands are very scientific, space medicine or genetics, but even within those scientific tracks, you have to develop your own passion and enthusiasm for something within that track that makes you stand out.

Gianmarco Calderara:
Okay. And when you say track, are you talking about, like, formal, like pathways, programs, that sort of thing?

Dr. Lee:
Yeah. So some medical schools, including Baylor College Medicine, make it so easy because they just give you the track, but many medical schools have no track at all, so they just have to make their own track. But in order to make their own track, they have to at least kind of have an idea of what that track looks like. And so the common domains are leadership, advocacy, and care of the underserved. These are kind of common ones, and then less common ones are like community service, diversity, equity, and inclusiveness. These are the kinds of tracks that you can make on your own without a formal track.

Ryan Sorensen:
I hate to put both of you on the spot, but what if I give you some of some interesting things Gianni's done, and you create a brand for him?

Gianmarco Calderara:
Oh my gosh, it's gonna be huge for me.

Ryan Sorensen:
So we talked earlier about Gianni was a participant on American Idol, and he got to Hollywood, which I remember was really exciting.

Gianmarco Calderara:
Ryan and I also went to high school together.

Ryan Sorensen:
Yeah. So we’ve known each other for a long time. Gianni has also done a lot of research. He's interested in radiology. He's done a lot of work with the inmates at the jail here.
Anything else you want to add?

Gianmarco Calderara:
No, I swam for a long time too, but yeah, that's it.

Dr. Lee:
So even though those are unique for Gianni and obviously are interesting and exciting kinds of things, so you've already got what we would call a hook. And every great song and every great movie has to have a hook, and so you've already got your hook, which is you are demonstrating creativity. You're pattern-oriented and visually oriented because of your interest in radiology and music itself has a science to it and an art. So ophthalmology and really all specialties in medicine are both science and art. So trying to show that to an interviewer with your activities is part of brand development. And so when you have activities like music and art, which have both the creative side, especially if you can say there's a science side to it, and you can elaborate and articulate that science side that shows that you can become a successful and innovative ophthalmologist or radiologist or whatever you end up choosing. And so you're using your extracurricular activities to showcase things that are not evident in your CV. And so when you're building that kind of brand, and then you have this side track serving 
underserved and vulnerable communities, and you would incorporate the brand in every opportunity there as well. So for example, for music, if you are if you're taking care of patients who are prisoners or vulnerable populations, music is a binding force and allows you to have a commonality with people across all cultures and across all socioeconomic categories, and so using that music piece in your everyday activities to bond with people is a unique offering. And so that's what you're trying to do with your brand development. Show that your activities are not just cool, that your activities are going to make you a better doctor, have made you a better person, and will make you proud to have been in this program, that that is what I'm looking for. So yeah, I think that's a great start, Gianni, and it forms a great brand, and you've got a lot of things going for you because everybody has played one of the following instruments, guitar, piano, cello, violin, everybody's gone on one of the following rotations, homes, clinics, St Vincent clinic, some volunteer clinic, everybody's been to one of the following countries, Haiti, Madagascar, wherever. And that's by design, right? It's a checklist system. So if you have the opportunity to show something novel like I was on American Idol, that is going to resonate and make you memorable, authentic, and unique, and that is what you're going for, and that's what I'm looking for.

Ryan Sorensen:
I think you have a great knack for being able to put all that together. I think you really described literally what Gianni is. That's what I see as his classmate. But I think we were writing personal statements yesterday, and we were both struggling, trying to put it into words. So we really appreciate you showing us how you do that well.

Dr. Lee:
I think that is the key. That's the reason to come to me. I cannot make your brand. I just make your brand better. I'm your sales and marketing division. I'm your Public Relations Division. You're the product. I can't make the product better, but I can make the sales pitch better, and we have to make it a bite-sized brand. We have to sell in one or two words, and what we're going for is what Ryan alluded to. He's known you since high school, and so if we articulate the brand without ever saying your name, Ryan could literally say that's my friend Gianni, right, for sure, and that's what you're going for.

Ryan Sorensen:
Over the years of reading residency applications, are there some brands that you remember that really stick out to you?

Dr. Lee:
Yeah, so the best brands are ones that incorporate the core values and show rather than say passion and enthusiasm. Enzo Ferrari said passion cannot be stated. It can only be lived. And I truly believe that your chance to showcase your passion is not by saying you're passionate and enthusiastic about ophthalmology. It's by showing your passion and enthusiasm for ophthalmology, and you have to show that same level of passion in your other activities. So it's better to be the leader of two things than the member of 10 things. It's better to have one thing that you took to completion on your own than be the participating member in 10 things, the worst brands are ones that are just rehashes of the CV. We have read your curriculum vitae, and we have looked at your resume. You don't have to rehash all your activities. Your interview is your chance to make a sales pitch, and it has to be short, and it has to be clear, and it has to be you, authentic, you. And that's what I mean by being able to articulate your brand. You have to show me the passion, you have to show me the enthusiasm. And that's what auditions are for. And in the creative world. You know, this is, is true. You can't just look at people's CVs and say, okay, they would be great for this part. You have to have them come in and read for that part. And you're reading for the part when you come. And if you're just straight up reading your CV, you're not going to get the part.

Gianmarco Calderara:
So it sounds like, you know, being authentic. It really starts with a personal statement, and then, you know, kind of extends to the interview, I guess. How would you go about making sure that those two things are in agreement with one another? And obviously, if you're being authentic, that makes it a lot easier. But kind of when you're going to your personal statement for the first time, you know blank piece of paper, kind of what are the things that you're thinking of to first put down, or kind of structuring that at the towards the beginning process of it.

Dr. Lee:
Yeah, so you should really be writing with the end in mind. You need to have a beginning, a middle, and an end. But really you have to have a punchline at the end that incorporates and sells your brand, and ideally, you would Telegraph that that's going to be the end. It’s in your interview by saying words like "the most important thing about that experience was," and "what I learned from that was," and then you're going to hit them with the punchline. Every brand has to have a punchline. And so if your brand is innovation and creativity, then we're going to use that word at the beginning, the middle, and the end. We want to reinforce the concept three times. Here's what I am. Here's the proof that I'm that. And let me tell you again who I am, because at the end of the personal statement, you want the reader to say in one word or two words, that's what this is. And many, many brands are like this. So if I just say Mercedes, for instance, Mercedes is luxury. The best or nothing, that's kind of what their brand is. If you look at a company like BMW, which is looking at the exact same demographic in terms of price point and who they're appealing to, they're not trying to be that they're trying to be driving is a pleasure, the ultimate driving machine. They're trying to sell that driving itself is the goal. And if you're going to do that, and if you believe this, then our vehicle is the one to take you there. All sports cars are fast. Lamborghini, Ferrari, and McLarens are all fast, but they're not trying to say they're fast. Everybody knows they're fast. What they are trying to sell is different brands for different people, even though they're trying to reach the same demographic. And that's this application process. Everybody's smart, everybody's a team player. Everybody has passion and enthusiasm for ophthalmology. That will not be a differentiating feature, you must find your niche, and you must sell that niche, and that is the goal of the personal statement.

Gianmarco Calderara:
Actually, I really like the analogy of, like the sports cars, kind of like comparing that to, like intelligence in medicine. I think that's a really, really solid analogy.

Ryan Sorensen:
Yeah, I think when I was on rotation with you, you said when you interview, they're not going to remember your name, but they're going to remember a future astronaut or Olympic trial swimmer or American Idol participant, and that's how they're going to refer about you for the whole application cycle as they talk with other people that have read your personal statement and interviewed you. I didn't realize that, and I thought that was very insightful. So I just thought I would, I would share that

Dr. Lee:
No, that is exactly the message your listeners need to hear. You're trying to use whatever you have, whether it's American Idol or Olympic swimmer, to make a memorable connection to your brand. You, it's your job to explain how being on American Idol makes you a better applicant. The American Idol thing is just to get them to remember you because they can't remember your name. And Neil Gaiman would say that human beings are hardwired for storytelling. We are storytelling creatures, and we're story-listening creatures. And even in medicine, we learn better from case reports. We learn better from presentations of cases. And if you've gone to lectures, you know that the best lectures start with a case report. They want you to connect with a person, a personal story. And that's what I mean by having your own authentic personal voice. You want your story to resonate with that person, and you want them to remember the story the hook, and make that connection to your name, and then say this. And this is the kind of person we want in our program, because when we go to the other room, we're looking through the names, and you want the person to not be judging you anymore. You want that person to be advocating for you in the other room. That's your goal, turning this person from a judge to an advocate.

Gianmarco Calderara:
I’ve got a lot of work to do on my personal statement when I get home.

Ryan Sorensen:
We've still got some time. I was just gonna say we've kind of touched on our personal statement quite a bit. I was wondering if it's okay if we went on to talk a little bit about interviewing. The first question I want to ask has to do with one of your famous quotes, don't let amygdala grab you. Can you explain this and explain why it's important for when you're interviewing?

Dr. Lee:
Yeah. So as your listeners probably know, the amygdala is part of your limbic system, and that's the emotional part of your brain. It's really deep inside your brain because it's that old. So the older parts of your brain, like your brain stem, evolved from lower animals. Cortex only comes later, and so deep inside all of us is the amygdala and this limbic system. It's right next to your memory, the hippocampus, and your temporal lobe. On purpose. And the reason is you need to remember the cave where the saber tooth tiger almost ate you. You need to know which plant almost killed you when you ate it, and which plant saved your brother, Tor when he was sick. You need to know what that plant looked like. And so you're making an emotional connection with the amygdala. Unfortunately, it turns into fight or flight, sympathetic or fear, and it's a good thing. You want to remember what you're afraid of, and so what I mean by don't let the amygdala grab you is that. We want to use that emotional connection to memory to make the person who's interviewing you have an emotional person-to-person connection that will make you memorable, but not with fear, love, and with like. Amazingly, the amygdala does that too. When you meet the person you're going to be with for the rest of your life, you feel it. You feel it in your sympathetics. You feel it in your stomach. You feel it in your sweating and your heart rate, it's like a core response, a sympathetic autonomic response that you call love, but I call amygdala, and we cannot let the amygdala grab us. What that means is amygdala can make you want to run away. Amygdala can make you shy away from challenges, and that's fear. And when people are brave and are courageous, they're not, not afraid, they're afraid, but that is not courage. Courage is the realization that there are things more important than fear, and that is what you're striving for. When I mean by control your amygdala, I mean, yes, you're afraid, but push through, keep going, and then you will find that you can control amygdala to your advantage, and that creates memories, and that creates memorability in the listener, and that is what you're trying to achieve. The amygdala is a very dangerous thing. Amygdala, in Greek, it means almond, and so that little nut, don't let that little nut control you. You have to control the little nut because if you let the little nut control you, you'll go nuts. And so you must learn control, and that is what I mean by amygdala.

Ryan Sorensen
Thank you so much for explaining that.

Gianmarco Calderara:
As we kind of approach interview, you know, season. What are some of the things that you'd recommend applicants to do to prepare for, you know, an interview, and really for, I guess, a lot of us, the last time we interviewed, you know, we really had one big interview for med school, you know, a couple of them, and then, you know, the next one's residency. How do we go about practicing or preparing for it?

Dr. Lee:
Yeah, so ideally, you'd be already working on this prospectively from the start, by keeping a diary of every single thing you've ever done in your whole life. Because you're collecting vignettes, you're going to choose 20 and hone it down to 10, your 10 best adventures. And you're going to use those short vignettes to propel your brand because there are very few questions that can be asked of you. They cover very specific domains, leadership, communication, conflict resolution, a failure scenario, a strength slash weakness, dealing with an ethical issue, overcoming a challenge or a barrier. There are just very few behavior-based scenarios that interviewers can ask you. So, it usually comes to you like a behavior-based question. “Tell me a time when you had to take on a leadership role. Tell me about a time you failed and what you did about it. Tell me about the greatest obstacle you've had to overcome in these are very standard questions.” And so, because we know what the questions are, you can have the answers prepared in advance. And what you're trying to do with the answers is not make them rote. They still have to be spontaneous. But what you're trying to do is have structure, a beginning, a middle, and an end, and you'll end with “and the thing I learned from that experience was that” insert the punchline, “that sometimes being a leader means putting yourself last”, or whatever your punchline is. And it's really important that you practice these things because the interviews have all gone to Zoom. And so as opposed to a face-to-face interaction where you have body language and you have tone, you lose all of those social cues on Zoom, and so it's awkward to do this, and so you have to practice, weirdly, your answers on zoom with a trusted colleague or friend, and then you'll do the same for them. Then you'll deconstruct all the answers, and you'll say when you know the beginning was good here, but we didn't have appropriate rising exposition, and we didn't have a good conclusion. And you have to be prepared for standardized questions as well. Standardized questions have standard answers, and so that means if a question comes to you like a witnessed ethical scenario, you have to use the standard format, which is justice, beneficence, nonmaleficence, and autonomy. If it's giving bad news, you would use some sort of protocol, like spikes, you know, setting the proper private encounter scenario, inviting the person to participate, assessing their knowledge, learning their perception, using empathy, and having a solution. And if it's dealing with a problem patient or an angry patient, you can use whatever structure you're going to use, but you have to have a structure because those standard answers are graded, and so programs that use standardized questions have a scoring rubric, and if you don't have a structure, it won't come out right. The other thing you have to practice is conversational tone and contact. It's very tempting to end in a conversational manner because you don't want to look like overly formal but in interview settings, you have to have a beginning, middle, and end. So, the most common ending that we see on our side is, “Yeah, that's what happened,” or “Yeah, I really enjoyed that.” That, “yeah, that's what happened,” Is a common way to end sentences in conversation, but it's not a good ending for delivering a punchline and showcasing your brand. We'd rather have it end “and you know, the best part of that experience was,” or “the most important thing about that activity was” so that the learner listens, and the listener understands that you're about to end with the punchline, and here it comes, and then you stop, then you won't end with the blah, yeah, that's what I did.

Ryan Sorensen:
Thanks. That was really insightful. You mentioned that the interviews have gone to Zoom. What's some advice you have? Besides, you mentioned practicing. What other advice do you have for doing well on Zoom?

Dr. Lee:
So we do a mock for all our candidates right before their first interview. The first thing we're going to be assessing is lighting, volume, your microphone, and whether you're on mute or not. On Zoom sometimes the setting is set to mute all participants when they enter, which means you think you're entering unmuted, but it's muted and then so the temptation is just to start talking, but you need to make sure that they haven't set the zoom to mute on entry, which is a common setting, and you have to have a Duchenne smile when you enter. A Duchenne smile is a genuine smile. It's genuine because it's not only your mouth but also your eyes. And some people call this a smize. It's like smiling with your eyes. In fact, you can identify a Duchenne smile even without the mouth. You can literally be wearing a mask, and you can tell if someone is legit. And because Zoom doesn't allow you the small talk phase and getting into the room and shaking a hand, as soon as you enter the room, you have to have the Duchenne smile ready to go, and that means you should be thinking about something that pleases you or amuses you, or makes you happy or brings you joy right before you enter into the Zoom. So as soon as the camera comes on, joy, joy in your head, but also joy in your smiles, which is the Duchenne smile. If you don't do it, a fake smile will have to come out. The fake smile, you know, as cheese. Okay, smile, everybody, cheese. The cheese smile is cheesy and is easily detectable. And I don't want you to use that. I want you to have a Duchenne genuine smile as soon as you hit the window. And I don't want to say hey, you are on mute. So those are the two things you have to do. You should also be hardwired, not using the wireless because you don't know if your roommates are going to be watching Zoom, Netflix, or whatever they're doing, they might suck up all your bandwidth. You should have a bland, plain background. Don't put anything back there that's going to be distracting, and don't let the conversation low. Conversations are back and forth, just like this podcast, you want to make sure you have adequate flow back and forth and make sure your answer is short. So each of these vignettes has to be only about one to two minutes. So no matter what question they have, you better get the answer in two minutes. But you have your talking points and they're ready to go, so no matter what question they ask you, you will adapt the talking point to that question, so that you get your points across, your brand must come out no matter what 10 questions they ask you, it's still about you and your brand.

Gianmarco Calderara:
Got it. Another thing, I don't know if you mentioned lighting in that response, I might have just missed that. But what kind of lighting? Sorry, if you could revisit that again?

Dr. Lee:
Yeah. So a lot of people use those ring lights, which produce diffuse background lighting that illuminates you equally. The worst ones are when it's the lighting is changing in the background, and so that means the lighting is changing on you. And if those lighting conditions are dependent on the window, then you're going to be at the mercy of the weather. So it's just way better to be indoors, with no window diffuse lighting. You don't necessarily have to do the ring light thing, but you have to have a diffuse lighting that showcases your face and your body in a diffuse illumination that is not going to be subject to the whims of the weather.

Ryan Sorensen:
Got it. How do you feel about the virtual background? Do you like it or no?

Dr. Lee:
No, it's always better just to have authenticity. Virtual backgrounds already are projecting inauthenticity, and as you know, at the edges of virtual backgrounds sometimes it drops out, and so it makes it look weird. And so it's just better to have a real background that's bland and white, and then you're already projecting authenticity. White. It's neutral. There's no way they can judge you on it, if you pick hot pink, it says something about you. If you pick red, it says something about you. And maybe that's not what you want to be communicating. So just bland. So it's about you, not about your background.

Gianmarco Calderara:
What sort of mistakes are you seeing applicants, you kind of alluded to this earlier, are you seeing interviewees make consistently that really kind of just like stands out to you, that, you know, something that's happening, you know over and over again.

Dr. Lee:
Yeah, the most common mistake is being late. Be early if you can, most of the places they let you in from a waiting room. If you're late, that's already a bad thing. No matter what the program says the social, it matters. And if you can't go to the social, don't say you didn't go. Say I couldn't go today because I had another interview, but I'm going to go to the next interview cycle social because you actually don't have to be synchronous to your interview anymore. You can go to the social even if it's not your cohort, because if you skip it, it says something about you. Don't misspell ophthalmology. It's super important that you use the spell check on ophthalmology for your whole application. The reason is, there are 500 applications, so that first pass is just trying to get rid of people using negative criteria. It is negative criteria. Who didn't get the score, who didn't go to a top 25 medical school. They're just excluding people based on negative criteria, rather than what we should be concentrating on, which is positive criteria based on your brand. One of the worst answers that I hear all the time is “That's a really good question. Can I think about it?” When you say that, “that's a really good question. Can I think about it?” What it really means is you're not prepared. How could there be a question you're prepared for? We gave you all the questions. So you have to have your questions ready, and that means having the vignettes in advance. The other thing that's super, super common is when asked, “Why are you here? Why are you interviewing at our program?” The truth is, you applied to 80 programs, you got 15 interviews, and this was one of them, that is the truth. You cannot say that truth. Everybody is pretending like that's not the truth, even though it is. And therefore you can't say that answer. You must go in advance to their website and find what aligns with your brand. Best, you must have both a personal and a professional reason for sitting there. So when they ask you, why are you visiting us here in insert wherever you can say authentically that you have a friend, cousin, Aunt, you're staying with that person. You came one day earlier, two years ago, or whatever. To look at the town you're familiar with. A personal reason for being there and a professional reason. “On your website, I noticed that you have a very integrated advocacy program for care of the underserved in the prison population or in this Hispanic, Spanish-speaking population only.” That's what I'm interested in, or “I'm really interested in the science of music. I can think of no better city than” insert their city, Los Angeles, New York. “And yesterday I was in town and I saw a jazz band, and I'm really into the science of jazz.” And if they're interested in what you just said, they will reciprocate by saying this. “Tell me more about that.” That's what you're trying to get them to say. “Tell me more about”. If it's just question, answer, question, answer, question, answer. That interview is actually not going very well. And what we'd really like to have them say is, “Oh, I know we're going over here, but let me just tell you one more thing about our program.” Now you know that they have switched to the advocacy mode. They're going into recruitment mode. If however, you hear these words, “Well, you know, I think we're ending a little bit early here. I'm just going to let you get to your next interview early.” That is a very bad sign. You want them to use up all the time, and ideally, they will be spending the last minute recruiting you. That means you did your job. Many applicants tell me, when I ask them “How did it go”, they don't know. They say, “Well, I don't know. Dr Lee, I think it went good,” like no, you should know. Okay, you should know at the end whether they were on the recruitment road or, “Well, look at the time. You can go to your next interview early.” You should know the difference between those two answers.

Ryan Sorensen:
Well, I think we've asked almost all our questions.

Gianmarco Calderara:
I had, I had one more that I just thought of. I know this is kind of a newer topic over recent years. This kind of goes back to the personal statements, but I just thought it'd be interesting to get your take on kind of the implementation now, like AI and everybody having chat GPT. I guess, is there any place in that process where using AI is helpful, or should applicants totally stay away from it? Or kind of, what are your thoughts on that now that that's a tool that is kind of readily available?

Dr. Lee:
So AI is a powerful tool for helping you get started. I think a lot of programs are going to ask you if you used AI to make your statement, so there's going to be some little bit of implicit bias there if you use it. I personally don't have any objection to it. To get started, what you're trying to do, however, is have authenticity, and authenticity cannot come from AI. I personally want AI to do my dishes and take away mundane tasks from my job. I don't want AI to make my music or my art. I want AI to take away the mundane things so that I can do music and art. Once you start letting AI do the music and art, that's the dangerous part, AI can do music and art, but you can kind of tell that it's inauthentic, because really, all of these are large language models that are just predicting what the next word is going to be based on words that were already given in a collective database that has gigabytes of data, but it's really just predicting what someone else has said, and therefore what it thinks it should say in response to a query. And to me, that's not what it's for. It's for getting started, for building a framework. I'm fine with that, but your authentic voice has to come out, and AI cannot deliver that.

Ryan Sorensen:
Just a follow-up question on that. How do you feel about for example, if you're writing your personal statement, and like you said, you tell the AI what your brand is, you put in your personal statement, and you ask for feedback to see if that brand is represented?

Dr. Lee:
I personally am totally fine with that, because you're using it to generate ideas, and then you will make those ideas your own. I'm matching it to what's authentic. I'm totally okay with that, just like I'm gonna tell you with using a dictionary or a thesaurus, that's what it's for. The thesaurus doesn't write your statement, the dictionary doesn't write your statement, and neither should AI, but it can give you ideas. I'd like to use a different word here for passion and enthusiasm than keep writing this word. Okay, thesaurus. I'm fine with that.

Gianmarco Calderara:
Okay, cool. All right. Well, I think that's all the questions that we have. Thank you so much for taking the time to come and talk to us. Was great hearing about all this. I think it's gonna be very helpful in the coming months.

Dr. Lee:
Thanks for having me.

Ryan Sorensen:
Thank you so much. All right. Thanks.

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

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

Transcript

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

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

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

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

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

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

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

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

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

Gianni Calderara:
And how did you decide on medicine?

Dr. Gordon
Medicine as a field?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

There is a National Human Trafficking Hotline.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Gordon:
Oh, maybe something less distressing.

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

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

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

Gianni Calderara:
Sounds good.

Dr. Gordon:
Five stars for sure.

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

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

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

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

Transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Agrawal:
Yeah, absolutely.

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

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

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

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

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

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

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

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

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

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

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

Race Schaeffer:
I have. 

Dr. Agrawal:
Okay, good.

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

Dr. Agrawal:
Okay.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Race Schaeffer:
Right on I was recently recommended scrubs

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Transcript

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

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

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

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

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

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

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

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

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

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

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

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

Gianni:
Nice, I also played water polo.

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

Aaron:
Is water polo really contact heavy?

Gianni:
It can be.

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

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

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

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

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

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

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

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

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

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

Dr. Lindquist:
Exactly.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Lindquist:
Exactly.

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

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

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

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

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

Dr. Lindquist:
Thank you.

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

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

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

Transcript

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Eileen: And what's your email first?

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

Eileen: And spell please…

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

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

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

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

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

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

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

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

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

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

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

Transcript

[Intro melody into roundtable discussion.] 

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

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

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

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

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

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

[Transition melody]

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

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

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

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

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

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

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

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

Dr. Detti: It's very exciting. 

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

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

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

Dr. Detti: Right

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

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

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

Dr. Detti: That is correct. 

Madeline: Okay. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Detti: Well, thank you.

[Outro melody]

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

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

Transcript

[Intro Melody]

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

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

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

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

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

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

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

Juan: Implanting electrodes into people’s brains.

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

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

[Interlude Melody]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Outro Melody]

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

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

Transcript

Intro Melody

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

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

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

Trung: All right! And uhm… 

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

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

Juan Carlos: Yeah! 

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

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

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

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

Trung: Yeah, let's get into it. 

Juan Carlos: All right. Sweet! 

Interlude Melody

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Juan Carlos:…that, yeah, go ahead. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Outro Melody

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

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

Transcript

[Intro melody into roundtable discussion.]

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

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

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

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

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

Delia: Yeah

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

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

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

Delia: Let's get into it. 

Juan Carlos: Cool. 

[Interlude melody]

Dr. Hull: Hi, everybody. 

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

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

(All laugh)

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

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

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

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

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

Delia: Just that insatiable curiosity, I guess? 

Dr. Hull: Yeah. 

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

Dr. Hull: Yeah. 

Delia: Yeah. 

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

Juan Carlos: Sounds like a very powerful motivator. 

Dr. Hull: Yeah.

Juan Carlos: To pursue something. 

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

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

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

Dr. Hull: It is! It is.

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

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

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

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

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

(All Laugh)

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

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

(All chuckle)

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

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

Dr. Hull: Right.

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

Dr. Hull: Mhm 

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

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

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

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

Delia: It's terrifying. 

(All Laugh)

Dr. Hull: It is. It is terrifying. 

Delia: An argument for screen time limits. 

Juan Carlos: Yeah. 

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

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

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

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

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

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

Dr. Hull: Yeah, it is another level. 

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

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

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

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

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

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

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

Juan Carlos: Yeah. 

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

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

Juan Carlos: Different impact. 

Dr. Hull: Mhm. 

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

Dr. Hull: Joy rounds 

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

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

Juan Carlos: Yeah, the small victories 

Dr. Hull: The small victories.

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

Dr. Hull: But dinner’s okay.

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

(All laugh) 

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

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

Delia: I love it.

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

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

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

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

Dr. Hull: Yes. Yeah, definitely. 

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

Dr. Hull: Right. 

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

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

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

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

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

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

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

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

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

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

Delia: Do you have any other questions? 

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

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

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

Dr. Hull: It's perspective. 

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

Dr. Hull: For aspiring neurologists. 

(All Laugh)

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

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

Dr. Hull: Yeah. 

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

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

Delia: Thank you so much for taking the time. 

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

[Outro melody.]

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

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

Transcript

[Intro melody into roundtable discussion.]

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

Emily: I am your other host, Emily Xiao. 

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

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

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

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

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

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

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

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

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

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

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

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

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

Emily: Yeah, let’s get into it. 

[Interlude Melody]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Mehta: Yeah

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

Dr. Mehta: Yeah –(laughs)–

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

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

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

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

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

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

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

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

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

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

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

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

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

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

All: –(laughs)–

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

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

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

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

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

[Outro melody]

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

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

Transcript

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

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

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

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

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

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

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

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

Juan Carlos Ramirez
Oh got you.

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

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

Madeline Graham
And topical too… oh sorry…

Juan Carlos Ramirez
Go ahead.

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

Juan Carlos Ramirez
Yeah.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Juan Carlos Ramirez
Agreed!

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

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

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

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

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

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

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

Dr. Montealegre
No.

Juan Carlos Ramirez
No I am just kidding.

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

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

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

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

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

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

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

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

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

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

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

Dr. Montealegre
Absolutely!

Madeline Graham
Yeah.

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

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

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

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

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

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

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

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

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

Juan Carlos Ramirez
Absolutely!

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

Madeline Graham
Thank you so much again.

Dr. Montealegre
Thank you so much.

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

Dr. Montealegre
Wonderful! Best wishes

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

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

Transcript

[Intro Melody] 

Juan Carlos: Welcome everyone, to the Baylor College of Medicine Resonance podcast. My name is Juan Carlos Ramirez. I am one of your hosts. 

Alice: And my name is Alice Wen, and I'm also a co-host for this episode. 

Juan Carlos: And Alice is also our, the lead writer for this episode. And today, we're going to talk to Dr. Carolyn Smith, as we will discuss her career path as a scientist, as well as her time as dean of The Graduate School of Biomedical Sciences here at Baylor. We will also highlight her motivations for dedicating her time to graduate education, her goals as Dean, the challenges that covid-19 has posed to The Graduate School, curriculum and rotation schedules, with ongoing student research, and her vision for the future of The Graduate School of Biomedical Sciences.  

Juan Carlos: So, for those of you who may not know, Dr. Smith serves at Baylor as a faculty member in the molecular and cellular biology, Urology, and she's also a member of the Dan L. Duncan Comprehensive Cancer Center. She's the director of the Tissue Culture Core and Dean of The Graduate School of Biomedical Sciences. So, she does wear many hats. She obtained her Ph.D. from the University of Western Ontario and completed her post-doctoral training here at Baylor College of Medicine before, joining the department of molecular and cellular biology as a faculty member. She has been involved in graduate school education, first, as associate director of the translational, biology, and molecular medicine graduate program.  

Juan Carlos: She followed roles in The Graduate School of Biomedical Sciences as assistant Dean for curriculum, senior associate Dean for graduate education and Academic Program development, and now interim dean. 

Alice:  Correction: She is now Dean officially dean.  

Juan Carlos: She is officially Dean.  

Alice: Yes, it has changed since I wrote. Yeah. 

Juan Carlos: And she is interested in finding ways to enhance the effectiveness of our graduate program by supporting the professional development of our own students and postdoctoral fellows. We feel very blessed and we're also very excited to have her on the show, but I will ask. I mean, it's very obvious. Why you chose to have Dr. Smith on our show today. Is there any reason that more so compelled you? Is it her education? Is it her career path? Is it sort of, her life story? 

Alice: I think a combination of things. First of all, I think her role as interim Dean and now dean of the graduate school played a huge factor in my interest in interviewing her just from a first-hand account. Our programs are, first of all, being restructured to face the ever-changing landscape of Science and to prepare future students for careers in a wide array of different fields. And secondly, I think, obviously, her research background is quite impressive as well. She still runs a lab acting as dean of graduate school. So, I think it I think it's something to be admired, and something that hopefully we will gain a little bit more insight into all the qualities she has balancing that science with her administrative goals, and yeah, I think she's a perfect candidate to interview for a podcast focus on highlighting extraordinary leaders at Baylor.  

Juan Carlos: I concur I completely agree with you and I just want to preface this, I guess, for our listeners, and say that her story is very inspiring. Never give up when someone tells you that, that may be the science isn't cut out for you. This is more motivation to persevere and push forward and one day become the dean of The Graduate School of Biomedical Sciences at a top institution. So, without further ado, let's talk to Dr. Smith.  

[Interlude melody] 

Alice: We're very excited to have you on the show. Dr. Smith. Could you tell us a little bit about your career background and science, what are your interests, and where did you train?  

Dr. Smith: Sure, happy to do that. So, I got interested in science from a very early age. Science was one of my favorite classes. I can remember going back to middle school, but that was really where I had the best experiences in class. I really liked interacting with my science teachers when I was in Middle School, and I was also fortunate to have a great uncle who when he retired from the military, decided to spend his time studying science as a retiree, and he was really great for me. He would give me books and he would have conversations with me when I was pretty young kid about science and some really kind of interesting, and, you know, maybe kind of far-out ideas, but it really opened my mind to thinking about how fun science was and how it led us really think about interesting things. So, at one point early early, when I was very small, I thought I wanted to be a pediatrician but once I got into middle school and high school, I just got so attracted into science and the idea of being able to solve puzzles, that that's really where I gravitated. I did my undergraduate degree at the University of Toronto in Canada in Biochemistry and was attracted to that because it provided me some tools to start understanding how life works and I thought that would be a pretty good way to start my education and was really fortunate to be able to get research experience. Really starting for my first year, part of that arose from the circumstances of my family. And while I was born in Canada and I lived there until I was 16, my family was moved because of my father's job into the United States when I was a junior in high school. I came into the U.S I was living on as a derivative of his Visa. So, I couldn't work as a high school student and so my parents found this summer research program at the University of Iowa, and as a junior, the summer, after my junior year in the summer after my senior year in high school. I was able to go to Iowa City and work on some research projects on amino acid transport in the small intestine. And so, really way before I should have been in a research lab doing research. That's what I got to do. So, when I started my undergraduate degree in Canada, and yes, I left Iowa to go pack to Canada, to do that degree, had a first-year biology teacher who needed a lab assistant and I wanted a job to make some money and I put up my hand and he, his main collaborator happened to I work at the University of Iowa. And so, when I said, I had been there for two summers. He thought that was Karma. And I got the job as opposed to probably 50 other people who also wanted the job. That job was looking at reproduction in insects. So, I spent four years of my undergraduate degree as a side job raising colonies of cockroaches and Locusts and then studying their reproduction. So, the lab was trying to focus on understanding that and how you could intervene in that as a method of pest control, ultimately would be the long-term application. So, I did that all the way through and then as I got into my senior year of biochemistry, I needed a research project for my senior thesis and this was quite a long time ago. So, I was working with one of the labs that had cloned the large subunit of RNA polymerase 2. Now that wouldn't be a big deal, but back then working with a gene for such a large protein was enormously challenging because handling large pieces of DNA just was not something that the technology was well-suited for at that time and that was in some ways, a very important experience for me because I did actually do all that. Well, at the cloning, it was hard, didn't have tools, didn't have kids had a lot of failures. Layers. And I remember the mentor at that point. I'm kind of suggesting to me that maybe I wasn't cut out for Science, and the kind of one of the key things for me at that point was I was really determined to prove him wrong. And so not that I made huge progress that year, but I did and I think that was a good lesson for me, in terms of developing a little bit of a hard head so that when things don't work for you in a while, when you have problems come up that you just sort of decide you're going to get through them. Whether it takes four times or you know, 25 times to get the experiments to work properly. 

Dr. Smith: Throughout my time, as an undergraduate. I got interested in in reproduction. So, the insects were part of that. But the insect work we were doing was actually with insect hormones that control reproduction. And I did want to move more into the area of mammalian biology. And so, I decided that I really wanted to work in the area of reproductive hormones, steroids in particular were quite interesting to me. And so, at that point, I had already met the person who would become my husband. And so, I had certain geographical constraints that I was wanting to live with. So, I was only looking at universities in Canada to do my graduate work. And so, I did go from Toronto to a city of about couple hours West of there to London, Ontario. And I did my Ph.D. there and I did my work on the proteins that are in the plasma that transport sex steroids. So primarily for me corticosteroid binding globulin, so that transports glucocorticoids and that was a great experience.  

Dr. Smith: I had the fortune of joining a lab where the faculty member had just come to the university and they were setting up their lab. And so, I had the chance to see how you set up a lab, how you write initial grants, how you get everything going, and because there weren't many people in a lab. Even as a beginning graduate student, I got exposed to a lot of different  
aspects of how you set up and run a lab, and as well, it was a really productive time. It was when cloning and sequencing were just getting going as major technologies – poured, probably hundreds, but it feels like millions of sequencing gels, and had to make our own sequencing reactions. It was really a time of trying to figure things out from first principles, but it was a great experience. We got lots of work done, lots of papers published, and because I had that chance to really see how things work as not. Certainly not as a PI, but someone working very closely on a regular basis with their PI. I got a great experience and a lot of training, not only in the science, but how you sort of think about conducting science at a laboratory level.  

Dr. Smith: At that point, I really wanted to continue my training and I was certain that I wanted to continue my career in studying how sex steroids worked. And so, I wanted to move from setting how they are transported in the circulation to how they actually get in a cell and what they do. And because of that, I was looking at some of the top labs in the world for who was studying, sex steroids, and the biology of them, and, of course, was very interested in the work that was being done by Bert O'Malley and Bill Schrader. I had read a paper there's as, in a second-year undergraduate class and it was a paper. They had published in Scientific American, and I just thought it was the coolest thing. So, by the time I'm finished my Ph.D. And I thought I had actually had the opportunity to maybe come to a lab like that I was really thrilled. So, I came to Baylor as a postdoc and worked in their lab and that's, that's sort of the early trajectory of sort of just being interested in science and then sort of finding out that that area that I was interested in was really related to steroids and how they work. So, it's been a great time. I trained here at Baylor, became a faculty member, and I'm still here. So, it's been a great place to be.  

Alice: Really cool! That's very, very interesting that you moved from insects to mammalian systems and then specifically homed in on reproductive hormones and their effects on gene expression. Can you tell us a little bit about what you hope your research could accomplish maybe in the fields of Health Care and patient populations? 

Dr. Smith: Sure. You know, what, as I, when I came to Baylor, I wanted to work on sort of unique ways that steroids worked. And I had some chances as a postdoctoral fellow to look at non-traditional mechanisms of action of steroid receptors and how they could work without actually binding to steroids as part of components of cell signaling Pathways. And that work led into a fundamental question that was really difficult to understand back when we started this. And that is how there are classes of drugs that will bind to steroid receptors and can sometimes turn them on and sometimes turn them off and their ability to turn on or turn off the actions of the steroid receptors was dependent on the cell environment they were in. So, it was a great way to bring together my interest and how receptors could work without ligands as components of signaling pathways to marry that with the idea that steroids with some types of ligands for them, could behave either as stimulators of transcription or inhibitors of transcription. And so, bringing that together, we, in conjunction with Dr. O'Malley as a postdoctoral mentor and then as I launched my own laboratory, we spent a lot of time trying to understand the relationship between Signaling Pathways ligands and these mixed responses. And that turned out to be really quite important in terms of, thinking of drugs, like tamoxifen that had been really widely used for breast cancer. And the reason for that was, you know, tamoxifen was used really widely. It was often very, very effective and then when would develop resistance to the drug and tumors would start to grow again and not only with tumor start to grow in face of the tamoxifen, but the tamoxifen became a stimulator of growth. So in in the context of people and treatment for a, you know, really terrible disease – we were seeing the same thing that we could do in cell model systems either it could stimulate a response or it can inhibit response. And so, it got us interested again in thinking about the differences that occur within tumors that sort of change that interpretation. So it's led to the concept of selective modulators for steroid receptors in particular, the work we did really establish the field that there are selective estrogen receptor modulators. And that was really the first concept for steroid receptors that there could be these dual regulators of their activity and it allowed not only folks in the estrogen receptor fields to think about this but also as we've gone on it, Now, expanded it to the Androgen receptor field, the glucocorticoid receptor field, and progesterone receptor field. Where we know in all of those there are abilities to really dial with more sensitivity or more specificity than we thought possible Agonist versus antagonist actions. So, that's one of the things I think that, you know, I really was pleased to be part of it really helped launch that field and I think it's a, it's been a really great that's emerged into thinking, more about how estrogens contribute in different ways, to development of breast cancer. And so, that's an area where I think we still have lots of things to sort out in terms of estrogen and risk profiles for breast cancer. It's pretty easy for many many folks, to think of it as estrogen is bad, with respect to breast cancer, but there's actually interesting data that suggest much more complex than that. Again, I think we're going to be thinking about receptors in context of their environment, different cell types, different stages of development and different responses. That's where I think there's lots of future within the steroid receptor field.

Alice: Really cool. I also wanted to ask you about your position as dean of the graduate school at Baylor. What sparked you to, I think, pursue that position? And what do you hope to accomplish in your time as dean?  

Dr. Smith: Thank you for the question. And so, as a faculty member here within the college. I like many, many other faculty, was interested in mentoring students and being involved with my graduate program. And so that really wasn't very different from a lot of other people here. I got interested in getting more involved in education from an administrative perspective. When the college was thinking about how to set up a new graduate program. And the idea on this was to try and blend together the idea that we have, we trained basic scientists and we trained clinicians, and we trained clinical scientists, but you hear a lot about the gap between basic research and clinical research. And so, there was a group thinking about how to bridge that gap and my department chair, who was Bert. O'Malley suggested, I might like to participate in that group, and it fit in really nicely with my research work because we were thinking about tamoxifen and breast cancer and how to understand changes in how patients with breast cancer responded to the drug. And that was really an area where there were lots of clinical people thinking about it and basic, scientists thinking about it. We were trying to figure out how to pull those things together. So, I got involved in this group. It ultimately led to the formation of the translational biology and molecular medicine graduate program. And so, I was very involved in that program for a number of years as an associate director and help establish that program along with the directors at the time. And so that was one aspect that really kind of got me a little bit more involved in administration and then shortly after that the college was going up for accreditation by the southern association of colleges and commission on colleges and they needed, we needed to have a plan for bringing new training to students at the college. And we thought maybe translational medicine and translational science might be something that would be different. And so, I ended up leading the, at that time the quality enhancement program, so initiating a couple of programs at the college and that got me very interested in administration at education and from there it just grew got involved versus assistant Dean for curriculum, and then that's evolved to the position I have today. So, it really came out of my science and trying to figure out how we create programs to train graduate students and medical students to have more awareness and skills in the area of translational medicine.  

Alice: So because covid-19 has kind of changed the entire landscape of what education looks like and say it same is true for all aspects of Education from K to 12 to college. Obviously, it's heavily impacted graduate students as well. What are some of the major challenges that you have had to overcome is Dean during this time? And how do you foresee that any of the changes just might change the entire future of graduate programs or curve? 

Dr. Smith: It is clearly changed a great many things when it started last March in 2020, we were just coming into the end of our big push for recruiting in new students for the folks that would matriculated in August of 2020. And so, in many ways the timing of the start of the pandemic was as about as good as it could have been. We had finished our in-person interviews with students. And so, we could finish up recruitment through regular email and typical virtual types of communication. And our first-year students were in their fourth term. So, they were already pretty comfortable with how things work at the college and their faculty and things like that. So, we certainly have had to learn since that time how to do all of our classes remotely. And so, this has been, I think, a big learning experience for the faculty where they've had to learn how to use zoom. I mean everyone's had to learn how to do Zoom but teaching on zoom is a little different, especially if you wanted to have small group activities and things like that. So, we've had to do a lot of things to learn in that area. In some ways, it's been really great. I think we've had many faculty comment that they're actually having better discussions with students because it feels like you're talking to someone right in front of you. It's not like a big room where there's someone in the back, and you can't really see them. And so, in a lot of ways it can feel a lot more personal and so you do get more discussion and people are traveling less. And so, I think in many ways that has been a positive on the overall education programs. We have brilliant faculty here at Baylor that are in high demand, it often means many of them are gone for a large portion of time. That's just not the case now. So, in some ways it's really been a positive. If one wants to say, there's any positive coming out of the pandemic, but that's been great. I think having more of that interaction between students and faculty because you feel like you're talking right with them face-to-face. Those have been great things coming out. On the negative side of things, it does take more time to prepare classes. And, you know, there are always technological glitches. And so, we know sometimes that's just not very satisfying for students. We know it's not satisfying for faculty. So, you know, some of those things, I'm sure will be glad when we don't have to always rely on a computer screen when someone has a nice quiet room to be able to participate in a class and the delay and the disruption in the research certainly was a huge, huge event, you know, you really couldn't have imagined in any other context other than a something like a pandemic, the idea that you would sort of walk out of the lab one day and might not get back in for a couple of months. And that's really extraordinary, you know, a lot of experiments take enormous amounts of time and very careful work to get them set up. So that you can get a model system or an experimental system where you can collect good data. And for anyone who either had that up and running or was just on the verge or even really just starting in the lab and trying to figure out how they were going to set up their experiments that time away from the lab was really, really very disruptive. So that certainly is going to be a factor. Now we hoped and certainly encourage students and faculty to you know, make lemonade out of the lemon that we were all served up and and use that time to read and plan and analyze data that you had. So I'm hopeful that for, you know, many of us students faculty postdocs that, that was sort of some forced time to think about projects and, you know, develop some new ideas and maybe connect with people and experiments, you could do, once we get back to the lab. And snow where we are, where we are at this point and students are now doing all their classes remotely. We hold them for the most part. I think they go fairly. Well, I certainly think people would love to get back together though, and there's smaller groups and be able to present their data and you know, stand up in front of a crowd and sort of talk about the things that they're most passionate about. But I think you know, we've tried as well as you know, everyone at the college to make the best of it. So, there will be things we take away that we think of finally and those that will be happier over.  

Alice: Um. We’re all looking forward to the day when we can get back to in-person event, but I think we've been quite resilient throughout this entire situation. So I’m really very grateful for Baylor's programs and the support the day offer too.  

Dr. Smith: Well, I would say, I have just been so impressed with everyone and their response, and really, their resilience, and the ability to create new things. Things even better than we had before. So it's been really fantastic to be part of such a creative and innovative community.  

Alice: So, thinking of creating new things. Actually, I wanted to ask you. So, I know the Baylor graduate program has been undergoing a program restructuring. And for the past couple of years. Can you tell us what motivated The Graduate School to pursue such a move and what they hope to accomplish with this restructuring? 

Dr. Smith: Sure. So, the restructuring was something that we had been thinking about a number of people that had been thinking about for two or three years before we began to really start seriously planning on it and that thinking was motivated by the reality of science changing over time. Right? So, if you think about how medical schools and basic science departments in medical schools were set up, they were really established so you have an Immunology department, so you'd have immunologists who could teach Immunology to medical students and if you go back in science, you know, immunologist had a whole set of techniques that they use to do their work and biochemists had a whole set of techniques that they use to do their work and geneticists and so on but science has changed and evolved so much in the last, you know, latter third of the 1900s and it, you know, it just keeps accelerating and and as we looked at how graduate programs were set up and we looked at the faculty and we looked at what people were doing you suddenly realize that the techniques that geneticists use were the same that biochemistry people were using and, and people in cell biology department were using, we are sharing so much. And we're so dependent and utilize each other's resources that some of those divisions didn't make sense. So that was one component of it. We didn't actually realize it, but if you looked at the underlying data, if you had students in a genetics program, only half of them were in the genetics department, the rest of them were spread out. Out across the college. So, we thought perhaps we might start thinking about science more, as areas of scientific interest that were broader than departments. So that was part of it and of the programs that emerged from the restructuring. We certainly have several that really are very Broad and touch, really largely across many, many areas of science and research and partners with a college. So that was one part of it. The second part is we had realized, as we had gone from, the more traditional department, based systems and to biology that was much more transdisciplinary and inclusive across departments that some programs have gotten very small and some programs had gotten very big and one of the things we know to in that was that if you were a student in a large program, your experience could be quite different from your experience as a student in a small program. So, you might have fewer people to interact with. Maybe if you are faculty, that could serve on committees, do our research opportunities, and we really wanted to try and get rid of those extremes of very large departments, and very small departments, and try and create an environment where students had a much more equal opportunity to access resources, regardless of which program they joined. And then the thing we wanted to do was to try and align these areas of programs and their research with research strengths at the college. So we wanted to be able to offer robust mentoring experiences, coursework, technological and experimental support in areas where the college had a lot of depth and present that to a candidate. So that when they would come in, they have a really great experience with not necessarily the work of having to create entirely that experience for themselves and there is some value in doing that. But it shouldn’t always have to be, feel like like you're starting from scratch to do that. So those things kind of came together and we're part of the prompt for us to start the transformation and then as we started doing that, we got: Well, if we're going to look at changes in programs, let's really take a look at all the key things that we do as academic milestones and Ph.D. training and see if that's the way we want to keep doing them or if we want to take this opportunity to change them. And so, we changed a lot of the curriculum again to kind of reflect on the idea that there's a lot common between all the disciplines and we wanted to make sure that our students coming into programs had a common tool box of vocabulary and understanding of experiments and scientific principles. And that led to the creation of our foundational courses. We have a more unified view on what should happen in a qualifying exam, which is one of the key steps before students admitted to candidacy. We wanted to make sure that the graduation requirements were comparable across all the programs. So we did all of that work. Lots and lots of students and faculty continue to contribute to discussions that took place over the course of an entire year. And we came out, I think with some really great ideas and built on the experiments of our prior graduate programs where you know, programs had huge successes and some areas. And so we thought yeah. Include those in the new programs and areas where programs that this didn't work quite well. We had lots of discussions and we were able to kind of find best Solutions or what we thought and hope will become great solutions for us as we move forward. We sort of drew upon this. So I think it was a really collaborative process where we try to take. Take all the good stuff. We had learned as individual programs in the past and put them together and new programs to go forward. 

Alice: Oh, and we only have a few minutes left, but I want to ask you, obviously, I hopefully you'll have a very long and successful career from here out. But what do you hope to be your legacy as both a scientist and as dean of graduate school?  

Dr. Smith: Hey, that's a really interesting question. I hope that my legacy builds on, you know, my work as a scientist and understanding of what we need to do and have in place to do great science and then taking that and translating that into educational programs, that help students be able to do that for themselves to have available to them resources but understand how they can work within their programs and the departments to do the best science possible. And not only be trained well as scientists, but to be trained and have opportunities to develop professionally. And so, I really like, and hope that what I accomplished at my time here at Baylor is to create an environment where people can come in and do the best science they possibly can and do the training and be able to get access to resources that lets them develop to be the best individuals that they can in terms of their own professional goals. So, I really love the idea that Ph.D. training has evolved so that people can come in learn to be really strong critical thinkers, do the science that they're most interested in and then they have opportunities to develop the skills and make contacts that lets them move into the career of their choice. We used to think about training Ph.D. candidates as the next generation of faculty. And while that still is very very important, and we absolutely are committed to doing that. One of the things I really love in my current job as every year, looking at where our graduates go in terms of their employment. And I am really continually amazed to see where people go. That gives me really a tremendous sense of satisfaction that the graduate programs here, the research environment we have here. Is such that people can come do science. They're passionate about it. And then go do really great things after that. So, I hope we are taking the Baylor concepts of, you know, great science, collegiality critical thinking and really dispersing that throughout the country and throughout the world. And if that's what we accomplish, I'll be really pleased with that.  

Alice: And one last thing is there any advice that you would like to give to budding scientists for me, maybe an undergraduate or even earlier on in their training?  

Dr. Smith: Um. So, I think you know, science is a is a huge amount of fun, right? You can find, you can develop your own questions. You can develop your own way to address questions. And you can really explore. And so, it's great because you're not constrained to specific things that you necessarily have to do to be able to advance as a scientist. So, in terms of advice, for younger people coming into science, this is a great place, use your creativity, use your curiosity, nurture, those things, and then balance that with some hard work and the curiosity and the hard work generally go really well together. You can ask questions and you have the intent and the desire to address those questions and get to answers. And that kind of brings it around to a really nice conclusion. But as in many things, life and training as a scientist is not all about work. So always make sure you balance that off. Find those things that are fun that are important to feed your inner soul and keep you energized and, you know, just excited to get up every day for many people. I hope getting up every day means coming in and doing some science and then having some fun time afterwards, but keeping those keeping that creativity going and  not being discouraged and and keeping going I think is a great way to go.  

Alice: So that concludes my interview. Juan do you have any other questions? Well, thank you for the questions. They were great.  

Juan Carlos: And as always, thank you for your time and for inspiring us all and encouraging budding scientists out there and even those who are going through tough times and looking at you as an example of perseverance, and hanging in there and one day they will be leaders in science as well.  

Dr. Smith: Yeah, absolutely. I know all of our students can. Thank you very much for having me. It was really great.  

Alice: Thank you for coming.  

Dr. Smith: Thanks. 

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

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

Transcript

[Intro Melody]

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

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

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

[Interlude Melody]

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

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

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

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

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

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

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

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

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

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

Dr. Yau: Yes. Yep!

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

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

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

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

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

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

Dr. Yau: Great. Thanks.

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

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

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

Kiara: Nice!

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

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

Erik: Okay.

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

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

Kiara: Sorry!

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

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

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

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

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

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

Dr. Yau: Right.

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

Dr. Yau: Yes, for sure.

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

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

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

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

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

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

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

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

Kiara: And…

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

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

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

Kiara: And, do they feel pain?

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

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

Dr. Yau: Right.

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

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

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

Dr. Yau: That's right.

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

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

Erik: Right.

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

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

Dr. Yau: Oh no.

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

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

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

Kiara: Without any proprioceptive input, right?

Dr. Yau: Yeah.

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

Dr. Yau: Right. So, uh…

Erik: We ask the hard questions here.

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

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

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

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

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

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

Erik: Yeah. Like a map?

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

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

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

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

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

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

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

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

[All laugh.]

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

Dr. Yau: Yeah, right. Yep.

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

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

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

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

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

Kiara: Right.

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

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

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

Kiara: [Laughs] Sorry.

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

Kiara: How you perceive, right?

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

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

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

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

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

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

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

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

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

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

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

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

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

Erik: Okay.

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

Erik: Oh. Okay, right. Gotcha.

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

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

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

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

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

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

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

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

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

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

Erik: Same. Same.

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

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

Dr. Yau:  Sure!

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

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

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

Erik: Yeah, thank you.

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

Kiara: You too. Have a good night.

[Outro Melody]

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

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

Transcript

[Intro melody].

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

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

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

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

Juan: That's so cool. So, professor, Dr. Lehnhardt, has a lot of interesting skills and professional interests, of which include emergency medicine, as we mentioned before, extreme environmental medicine, aerospace medicine, wilderness medicine--he does teach in the wilderness medicine elective, Emergency Medical Services, and medical education.

Juan: The NASA human research program of, which he's a lead and an element scientist focuses on enhancing the health and performance of humans in spaceflight in preparation for an ultimate voyage to Mars.

Eileen: Which is crazy. I can imagine that involves a lot. The main five things that they focus on are International Space Station research and operations integration, space radiation, human health countermeasures, exploration medical capability, and human factors and behavioral performance. Seems like it covers a lot of ground there.

Juan: Yeah, lots--perhaps, lots of moving parts and something that I can only imagine is insanely complicated. I mean, medicine alone is already complicated.

Eileen: Yeah, definitely.

Juan: Yeah, when physics is a factor, you're just like, "oh my God."

Eileen: Yeah, I took the bare minimum of physics that I needed for medical school. So I am very impressed by people who are at that level. I think, I think it'll be really interesting to hear Dr. Lehnhardt talk about all of those things. And I know you also, you took one of his classes, is that right?

Juan: Yeah, I did. And just it's the human space exploration in medicine or some variation of that. But there are, you know, two electives and you take one which is pretty, pretty vague and a lot of old NASA scientists and Baylor faculty who also have a joint appointment at NASA. And also some physician astronauts, too, that just come to class and they share about, you know, their work and what they're doing, sort of cutting-edge research. And there's the second part, the second elective really dives in pretty, pretty detailed--and that's how I sort of came across Dr. Lehnhardt's work, a little more in depth. There is a Space Medicine Interest Group here at Baylor that kind of introduces people who aren't in the space medicine track, which--there is a space medicine track. It's just so interesting to see this other side of healthcare from a very outside the box perspective, you know, it's like "How do we solve problems with, you know, health problems here on Earth? Okay. Great. You know, those are challenging. Now, how do we do that in space with limited everything?" I can imagine how, you know that task being so--it's so demanding, you know, because essentially you're trying to create or come up with the Swiss army knife for, you know, for space travel. You know, how do you maximize, you know, efficiency and safety with so little?  

Eileen: There are so many challenges inherent in that--not to mention the fact that most of your astronauts are probably not also going to be physicians. So then you're dealing with limited space and limited personnel. I think it'll be really interesting to hear Dr. Lehnhardt talk about how to address some of these challenges and I know that he is a great teacher, so I'm excited to hear him explain some of these concepts for us.

Juan: Yeah, sort of give us an inside look at what it takes, really plan for these inherently complicated and dangerous things.

Eileen: We're really lucky here at Baylor to have these opportunities to get to work with doctors like Dr. Lehnhardt and to be right next to NASA and have this space medicine exploration track. I think it's a pretty unique opportunity.

Juan: Yeah. For sure. And for Baylor students and non Baylor, students, non-medical students, and just anyone interested in cool science and being on that leading end, I think you're really going to enjoy, as well as I am, right here about Dr. Lehnhardt work and how it can impact all of our lives in a very positive way, and inspire the next generation.

Eileen: Let's get started.

Juan: Cool. Let's go to the episode because we've talked too long already and let's talk to Dr. Lehnhardt.

[Interlude melody].

Juan: And we are here with the Baylor College of Medicine Resonance podcast and we are now joined by Dr. Lehnhardt. Please welcome Dr. Lehnhardt.

Dr. Lehnhardt: Thank you, pleasure to be here.

Eileen: Very glad to have you. I'm Eileen. I'm another one of the writers and producers for the Baylor College of Medicine podcast.

Juan: Yeah, and as we've mentioned in the roundtable, today we're going to discuss Dr. Lehnhardt's role in engineering human spaceflight exploration medical capabilities.

Juan: And if you are not a space nerd, like we are, and you haven't heard about all the cool things that the NASA is preparing to do, Dr. Lehnhardt's spearheading the element, NASA's human research program and he's here to share with us all about what he's doing. But if you haven't heard of Dr. Lehnhardt--could you take this time, Dr. Lehnhardt, to tell us a little bit about your background? What motivated you to pursue a career in medicine and human spaceflight?

Dr. Lehnhardt:  So it's a--it's a long story. So I will start at the beginning but I won't go too long. So if it's not evident yet from my accent, I'm originally from Canada. And as a small kid growing up in Canada, I had a passion for spaceflight. And I was really enamored by the space shuttle and all the different missions that NASA was doing and the Canadian Space Agency--there is a Canadian Space Agency and it's, it's kind of small compared to NASA, but they like to say that they punch above their weight. So they, they are very active in the space world. The Canadian Space Agency had astronauts and I always thought that would be really an amazing opportunity to be an astronaut and that was something that was a big interest to me, but I had no idea how to get there and how to even pursue it.

Dr. Lehnhardt:  So when I was a kid growing up, my favorite fields were in the biological sciences. And so I had thought about medicine and one of my guidance counselors at the time in high school said, "Why don't you look at the profiles of Canadian astronauts and see what they did? And then maybe you can do human spaceflight stuff." And one of the Canadian astronauts was a guy named Dave Williams and he was an emergency physician and I thought cool, I'll be an emergency physician and maybe I can go to space.

Dr. Lehnhardt:  So, my initial thoughts were not exactly well thought out, they weren't terribly mature, but they got me on the right path. And so I did all of my undergraduate training and medical training in Canada at the University of Guelph first, and then at the University of Western Ontario. And then I did an emergency medicine residency, which in Canada is a five-year residency and one of the opportunities I had during my residency was to spend some of my elective time focusing on an area that was of particular interest to me. And for so for me, that was space medicine, but to broaden it a little bit more, it was about the medicine of extreme environments and how we provide medical care in extreme environments. And so during my residency, I got to spend time learning about aviation medicine, about diving medicine, about military medicine, and about space medicine. And I just loved all of it. And so I eventually tried to steer my career towards "How do I become involved in the medicine of extreme environments?" And so I ended up here at Baylor as a faculty member in the Center for Space Medicine. And I now work at NASA as the element scientist, which is the lead scientist for exploration medical capability. And our job in exploration medical capability: we are a part of the NASA Human Research Program and we focus on the design of medical systems for space exploration. So now I get to take that passion that I've had about space and about medicine and space and I get to try and come up with the systems or help to come up with the systems that astronauts are going to use when we go to the moon and Mars to take care of each other.

Juan: It's a very compelling story and I think it's only the abbreviated version, but from sort of your spoken words and your passion and your background and career track, you seem to have pick up the picked up an impressive, an extensive list of accomplishments in the realm of extreme medicine, as you just highlighted, and space-related activities. But I think--is Physician Astronaut still on the--your professional bucket list? I--I'm guilty to ask, but I feel like there's a lot left in the tank of for Dr. Lehnhardt.

Dr. Lehnhardt: Yeah, don't feel bad about asking. I tell everyone I meet that I want to be an astronaut. I'm not, I'm not shy about that. So I would personally love to do that still and it's still something that I will apply for and continue to try and do for as long as I can. And then maybe eventually if no one else will pay for me to go to space, maybe I'll figure out a way to pay for myself to go to space. So commercial human spaceflight is starting to come online soon and there's a number of different companies now that are looking to fly people to space. But ultimately, yes, I think that my, my goal would be to be the doctor in space that's taking care of the other astronauts. But if I get to--if all I get to do is stay on the ground and help NASA to do that, I would consider that to be extremely fulfilling.

Juan: Which is also no minor accomplishment. But you mentioned your lead role as a lead scientist and element scientist. Could you explain to our audience what an element scientist is, and sort of what your role… what your… how does your work on a day-to-day or if you could provide a detailed description of how you integrate the exploratory medical capability element medicine and engineering.

Dr. Lehnhardt: It's a, it's a really fascinating area because my background is not in engineering. And… but yet I get to work every day with scientists and engineers and clinicians who are trying to tackle this really hard problem of, how are we going to take care of people in space when we can't come home again? So, the example we always use is the mission to Mars. And if you think about the mission to Mars, we're going to have a spacecraft that's going to be pretty small. What you see on the science fiction movies like The Martian, of this enormous spacecraft where everyone has tons of room and they can all float around really easily.

Juan: --Hermes--

Dr. Lehnhardt: That, that may be the future, but it's not where we are today. And so our plans for Mars are going to be a small spacecraft and a small crew and they're going to have a very long trip to Mars. It's going to be anywhere from six to nine months just to get there. And once you start going to Mars, you can't just stop and turn around and come home again. So, what we have to do from a medical perspective is we really have to think about, can we predict the number of, can we predict the number of conditions or the types of conditions that are going to occur from a medical perspective? And can we make sure that we have all of the stuff on board to diagnose and treat and manage those conditions? And can we predict that so far in advance that we can plan the entire mission? So that we have, not only the stuff, but the people on board, who can execute the tasks and use the stuff so that we have real capabilities.

Dr. Lehnhardt:  And it would be like, for example, saying that you are going to have all of the supplies and all of the staff, you need to run an emergency department. You'd have no capability to change your people, get new equipment or change your equipment, and you'd have to run for months and months at a time without any additional stuff. And so it's a, it's an extremely complicated problem. But in essence, from a, from a mathematics perspective, it's what we call the "backpack problem," which is the--you have a limited amount of space or resources you can have; how do you select the highest yield things? And so my team that I work with, I provide them with leadership and guidance from a scientific perspective and they do the work of designing the systems and trying to predict the conditions that are going to occur so that we can make sure that we have all the right stuff when we go and we have all the right skills on board to take care of everyone for these really long missions.

Eileen: Well, I can imagine, I can imagine that even just trying to run an emergency department on Earth would be very challenging if you couldn't change any of your equipment or any of your people, but I'm sure there are also extra health challenges that come with working in space. Is there any particular health risk that's more critical than others on a long-term space, space flight? And what do you do to mitigate these risks?

Dr. Lehnhardt: It's a, it's a complex problem because there are a number of hazards of space flight that we have to take into account. And they include things like the lack of gravity, the high radiation environment of space, the isolation and confined nature of a spacecraft, the distance from Earth, all of these things are the are the hazards or the types of hazards that we face.

Dr. Lehnhardt:  Everyone's got their own personal favorites that they are most concerned about. The ones that my group focuses most on are related to the distance from Earth challenge, which comes with the inability to return home--so no evacuation, the inability to resupply due to the distance and the time, and then the lack of communications with the ground. And so as you go further and further away from Earth, you no longer have real-time communication. So you can imagine trying to have the conversation we're having right now if after I said something, I had to wait 10 minutes to hear you say something. And then you had to wait 10 minutes to hear me say something. It becomes a very long and boring conversation very quickly. So the, the distance from Earth hazard is the one that that we focus on the most in exploration medical capability because it's related to our system design problem. But all of the hazards work together. So, for example, some of my colleagues in the Human Research Program focus on the synergy between the low gravity environment and the high radiation environment, and the effects that those may have on the human brain in the way that people think and execute tasks. And so, we have other colleagues in our group, in our program, who focus on the counter measures that people need in terms of nutrition and exercise to stay healthy and productive during their missions.

Dr. Lehnhardt:  And one of the biggest problems that we have is that when you look at each of these problems in isolation or each of these risks or challenges in isolation, you might come up with a great solution that works for that one thing. But can I take all of those individual solutions and can I fit them all together or integrate them all together into a small spacecraft that has limited mass and volume? And so it's the actual integration of all of these things that is where the rubber hits the road, so to speak. And that's where the biggest challenge is. How do we define what the, the highest yield stuff is to take with us? And how do we make sure that we manage as many problems as we can, given our resource constraints? And so the example that I use a lot is sometimes it--when you're designing something like a spacecraft, the designers of the spacecraft will come back to you and say, "I can't possibly fit all the stuff you want me to take. Show me what you're going to get rid of." And then we suddenly have this whole thing where everyone's fighting about their favorite thing and what they believe they need to have to manage their individual problem. But we really need to be able to do is take a systems look at everything and say "what is the thing here that gets me the least bang for my buck?" And that's probably the thing that's going to come out of the system.

Dr. Lehnhardt:  And so a lot of the work that that my team does and the work of the human research program is not only trying to identify and characterize the risks and come up with countermeasures or solutions to those risks, but it's also integrating all of those things together into one comprehensive system and figuring out how we're going to fit it all on this small spacecraft that's gonna go to Mars.

Juan: Wow, it's very complicated. As students of Baylor College of Medicine, we have the luxury of taking space medicine electives. And I took the elective this last, this last term, and I--you spoke about essentially what you just said and a term called "trade space analysis" and this involves, you know, the integration of all systems, right, basically systems engineering to--for risk mitigation. And that largely involves devices or technology. That--my question is, sort of, to what extent do you incorporate soft skills and do that risk mitigation? So, you know, sending an emergency physician and Mar--to Mars or not. Does that play a heavy role in that trade space analysis?

Dr. Lehnhardt: It does, and trade space analysis is really about helping us to try and come up with the optimized solution to a given problem. And one of the challenges that we have seen is that in many cases, there's a belief that if we if we fly a laryngoscope, that someone can intubate someone in space. And that's a not an unreasonable belief if you're flying a physician. But if you're flying a non-physician or someone who's had minimal training and how to do that, we know that that is a difficult skill. And one that we spend a lot of time learning before we actually practice it on patients. And so the need to incorporate what we were referring to as the knowledge skills and abilities into our capabilities matrix for this system is very important. So our goal is to not only identify the stuff that we would need to take, but also the skill set needed to make that capability real. The example I'll give you is: one requirement you may have for a medical system is that the medical system has to be able to provide intravenous fluid resuscitation. Well in order to do that, we need to have not only the bags of saline and the IV's and the lines and all this kind of stuff, we need to have a person on board who has the necessary training to do that task or—maybe and/or--we need to also be able to help refresh the skills of that person in doing that task or maybe even teach it to them for the first time. So to keep this example going, if the person on board who normally takes care of, everybody is a doctor, but the doctor is the person who gets sick, then one of their crew members, one of the other astronauts is going to have to be able to place the IV in that doctor. And as a result, they may have to learn how to do that on the fly. So we may have software that we could use on board that the astronauts would be able to do just-in-time training. They'd basically be watching a YouTube video, for lack of a better term, and figuring out how to put an IV in--and then they put an IV into their colleague because that, because they would have to do that. So, the skills were important, the ability to maintain the skills are important, the ability to teach new skills on the fly are important, as well as the training that we do before they go. So, how can we best prepare them on the ground to be able to execute those skills in that environment?

Dr. Lehnhardt:  So ultimately a system design, the system has to include the operators of the system and those, those people are going to be essential in executing the tasks that make the capabilities real. Having a laryngoscope that no one can use does not mean you have the ability to do airway management as a capability on a spacecraft.

Juan: It also reminds me of what you had mentioned during your course is that dilemma of taking an AED--you know, how often do AEDs get used? I mean astronauts are relatively healthy but you just never know. It seems like a lot of pros and cons to "Do we need it? Do we not need it? Can this person do it?" So and it also sounds like, from what you were saying, is that cross-training is becoming a very important thing. I know NASA trains them in like first aid and I'm not sure what the extent of basic capabilities, but there will likely be some continuous training en route and back, I assume.

Dr. Lehnhardt: Very much so, and when you think about the size of a crew to Mars, so, right now, some of the mission designs that people are looking at are four crew members, maybe six crew members. There's an awful lot of skills and knowledge that have to be available to those folks on board and it's either got to be in their brains or it's got to be in their computer systems that they can access or in their checklists in a way they can access it in a very rapid manner. And they have to be familiar with all those protocols and all those procedures and they have to be able to do all of those tasks. Just in that small number of people.

Dr. Lehnhardt:  So, the astronauts of today and the astronauts of tomorrow, are absolutely cross-trained and will be cross-trained in lots of different areas. They will have many different opportunities for refresher training and just-in-time training during these long missions. And some of that frankly might actually end up being really valuable to them because one of the arguments are one of the, the points we've heard from some of the astronauts is there's actually a reasonably good chance on the way to Mars that you would get bored. Because it's not like there's actually that much to do every day on the spacecraft. So, so that ability to learn new skills, to cross-train to run simulations and practice using different skills--those may actually end up becoming kind of fun activities or we can design them in ways that they're more entertaining and fun activities than they might have otherwise been. Because it might, in that sense, be multi-purpose. It helps with their isolation and confinement because they are they're learning something new and interesting. But it also makes sure that their, their skills are up to speed for when they need to execute them either in an emergency or some other contingency.

Juan: Right,  so it sounds like there would consistently remain engaged and it's probably good psychologically, as well. I just can't blend it to words of "astronaut" and "bored" together. I don't, I don't think they go. But, yeah, very good point, and it just seems like on, on that path that this, of not being bored in the psychological aspect--does that, is that taken into account during your risk mitigation and planning? Or is that just there's another piece of the pie that needs to be solved?"

Dr. Lehnhardt: The, the psychological countermeasures that are being considered in the Human Research Program have to do a lot with the selection of the of the right people for these kinds of missions. And, and so there's a, there's a phrase or a term that gets used a lot, which is "the exploration mindset" or "the exploration skill set." And that's people who don't become bored easily. People who don't have problems being in small groups, and living with small groups of people for extended periods of time. People who are very collegial and easy to get along with. Those kind of expeditionary skills are very important and so we have to make sure we select the right people to go. Then we have to train them appropriately and part of that training is how to deal with the psychological challenges of isolation, and confinement, and being in an environment, where frankly, everything around you is trying to kill you.

Dr. Lehnhardt:  You have to be, you have to have to be able and be prepared to deal with that and to face it during the mission. But then there's lots of research going on into, during the mission how can we give them extra things that will assist their mindset? And so, it may be simple things, like yoga and meditation type exercises. They're all kinds of advanced technologies that we're looking at to, with things like virtual reality. On the space station today, the astronauts have really good communications with the ground, so they get to speak with their friends and family on a regular basis. How can we make sure that they can maintain some communications with their friends and family? Even when they're really far away. All of these different things are the mitigation strategies for dealing with the psychological challenges of space exploration and all of those have to be incorporated into our broader systems. So, if we develop a system that requires virtual reality for psychological challenges, then I can use the same virtual reality system for medical training, or I can use the same virtual reality system for some kind of maintenance on a piece of equipment that breaks inside the spacecraft.

Dr. Lehnhardt:  There's lots of different ways to blend and meld together the different types of capabilities and countermeasures that we develop for psychological issues, for medical issues, for lots of different, what we call crew, health and performance challenges.

Eileen: It sounds like everyone on the team is wearing a lot of hats. We've got astronauts now getting medical and yoga training. I think it's really interesting to consider how people fulfill these different roles. You mentioned earlier that you don't really have a background in engineering, so I was just wondering what it was like for you when you really started working with a lot of engineers? How you got into that mindset and how your work is really able to synergize between the two different disciplines?

Dr. Lehnhardt: It's a, it's been a really great experience for me, learning how to work with all these different folks and be truly interdisciplinary. And looking back on it now, if I could go back to myself when I was a kid and say, maybe you should go be an engineer, maybe I would have done that. That seems like it would have been a cool job as well. But one of the things I realized very quickly in my work, was that the doctors and the engineers typically approach problems in a different way. And so I realized that one of my tasks as the as the lead scientist for the group was to try and make sure that I could understand both sides and how they approach problems differently and find the commonalities between them so we could build a bridge between the engineering side and the medical side.

Dr. Lehnhardt:  And so where that I think is, particularly interesting, is, is that mindset for how they approach problems. And from a physician's perspective, especially in the emergency department, when I see a patient and they have chest pain, the first thing I do is I think of all the terrible things that could be happening to them. And my job is to figure out that they don't have any of those terrible things. And the engineering position is: what is the most likely cause of the chest pain?

Dr. Lehnhardt:  And the most likely cause of the chest pain is not one of the terrible things, because the most terrible things don't happen that often. So the engineers approach a problem from the likelihood and consequence associated with that condition, or that problem, whereas the physician side of me is the "come up with a differential diagnosis, identify the worst things on it, and then rule all of those out." And so what I've actually found in myself is that my practice in medicine now uses a little bit of both. I still think about the worst case scenario, but I also think about, more about what's most common and most likely. And so I'm actually using that bridge, if you will between engineering and medicine in my own daily practice in emergency medicine. But by understanding where each of the different groups is coming from, you start to be able to understand how you can help them to communicate better with each other.

Dr. Lehnhardt:  And one of the things we realized is that the medical community communicates in terms of what the worst possible outcome could be, the engineering community says, but how often does that actually happen? And do I need to design or build an entire system just to deal with something that may never occur? And what we have to do is find that happy medium between the two where we can get to what I'll refer to as an acceptable risk profile for any given condition. So maybe I can't rule out the worst possible things because I don't have all of those capabilities on the spacecraft. But at the very least, I should be able to identify the highest likelihood conditions and manage all of those to a reasonable point.

Dr. Lehnhardt:  And so it's that, finding that consensus position and being able to back it up with a rationale and the evidence that justifies the need for it, allows the engineers to then say, okay, I hear what you're saying. I understand why you need it. We're going to go and build it for you.

Juan: Sounds like a fine line to navigate, especially given time constraints.

Juan: If, if you will, what is one of the, like, the coolest projects, you were able to work with engineers and---lately? Or to date?

Dr. Lehnhardt: So I think that the, the most---What I'll say one of the, one of the really rewarding projects that I worked on, is one that we call autonomous medical officer support software and and what that is, is a software capability that allowed us to take astronauts, who had never performed a particular complicated medical procedure before, and we could use this software to guide them through how to do this procedure from beginning to end. And while we were doing that, we didn't allow anyone on the ground to talk to them.

Juan: Wow.

Dr. Lehnhardt: And what we were trying to demonstrate was that we could--and that's where the word autonomous comes from--in an autonomous fashion, we could help non-physician astronauts to perform medical procedures without any support from mission control. And that's really important when we start talking about the types of communication delays that we're going to see on the way to Mars. We need them to be more self-sufficient and what we're calling Earth-independent. And so this ability, this software, what we did was---one procedure that we wanted to be able to have astronauts to do, was we wanted them to be able to do ultrasounds for the kidneys and bladder. And the reason we wanted them to do that is because one of the problems, some of the problems we occur and see in spaceflight are related to either urinary retention or kidney stones. And so, we had to be able to know that the that an astronaut could perform one of those tests without the ground having to tell them "move your probe 3 centimeters to the left." We had to have them be able to learn how to do the task. And so they open up the software, they turn on the ultrasound, they follow all the procedures and they got a bunch of really good kidney and bladder ultrasound images, which they could then transmit to the ground for someone on the ground to read and interpret. And they did all of that on their own without any prior training or knowledge of how to do it.

Dr. Lehnhardt:  And so to me, that is the, it's one of the first real demonstrations that we've ever seen in spaceflight of astronauts performing complex medical procedures on their own, in the way that we would see it when they go to Mars. And so that to me was very rewarding.

Eileen: That's, that's pretty crazy and difficult to imagine, but very impressive. I'm wondering how you see that technology affecting us here on Earth. It seems like people who are in other extreme environments could also use similar types of strategies.

Dr. Lehnhardt: That is the, the ultimate goal, is to--we want to take stuff on Earth and use it in space and we want to take stuff in space and use it on Earth. And so, the application of a lot of the work that my team does on, on exploration medical capability has a lot of different applications on the ground in remote environments or in austere environments. And so you're absolutely right. It's, it's easy to imagine a world now where some would be able to have software on their phone or on their tablet, have a portable ultrasound device that they could take almost anywhere in the world and they would be able to use that software to guide them through how to perform any reasonable type of ultrasound exam in a fashion that would allow them to take care of that person or diagnose that condition in that environment.

Dr. Lehnhardt:  So I would love to see applications where you could start deploying software like this into all sorts of different environments, where--if they have access to all the experts then, great use them--but when they don't and they're on their own, we should be able to help people take better care of themselves, anywhere in the world.

Juan: Wow, that's very interesting. I've tried to keep up with technologies that NASA creates and how they're implemented on the ground. You mentioned earlier the virtual stuff, being able to teach someone virtually, I could possibly see that being translated during these sort of difficult times where everyone segregated. And, you know, we are medical students and we, we had to reduce our clinical time or clinical exposure because of these things. And I could see that possibly being I think where, well, we can teach who virtually and, and it won't be just like a like a "sign in to zoom" kind of thing. So it'll be like a very hands-on virtual experience. Thank you for sharing that.

Juan: So as sort of, as a way to conclude this, this awesome interview and we hate it to end, but we wanted to get… so a very inspirational tone for those who haven't already been inspired. What advice would you have to, sort of, dreamers out there who aspire to one day, do what you do? And may one day, one day want to set foot on sort of a celestial body--moon, or Mars, or beyond?

Dr. Lehnhardt: I think the advice that I always try to share is that the, there's lots of different niches in medicine and there's many different ways for people to find the area that they are most interested in. And for me, my niche is fairly specialized and, and not something that a lot of people do. And when I was going through medical school and residency in Canada, one of the, when I would tell people that my interest was, was space medicine, I got a lot of blank stares from people. Or, they would tell me that "you can't do that" or, or "why would you do that; why don't you just go be a cardiologist?" And, and I had to try and explain to people that what I was trying to do was to bring together different areas of interest, or passions, that I had in a way that I thought was going to be fulfilling. And that was a little bit out of the norm, I think, for a lot of the people that I was talking to. And so they couldn't see a world where I would get to do that. And frankly, neither could I. But at the time, I just knew that I--this is an area I wanted to pursue. I knew that it existed and that other people did it and I was going to find a way. And so that's my general advice to people in, if---regardless of what the niche is, or the thing that you're interested in, find other people out there who share that passion with you and then figure out how to do it.

Dr. Lehnhardt:  And so, for me, what I did is I literally sent a cold email to a doctor who worked for the Canadian space agency and I said, "I think I kind of want to be you someday, can you help me do that?" And he did. And he was my first kind of foray into the world of aviation medicine and diving medicine and space medicine, and that's what started all of this.

Dr. Lehnhardt:  And so, finding those people who can help you is really important. The other part of it, though, is finding the other people who are, who are your peers, who are like you and want to do similar things. And for me, where that was, was I had talked to some of my mentors and done a number of different training opportunities that I could find in, in aerospace medicine. And when I'd exhausted those, one of them said, "why don't you go to the International Space University?" And I was like, "That sounds fake. What is that?" And I've discovered that it's totally not fake and I went and it was great. And what it was, was there was an opportunity for me to learn all the stuff about space that I didn't know because I've been focused solely on the medicine in space and I got to see the broader, the broader community, if you will, of people who are interested in human spaceflight. And that helped me to find all of these peers and fellow space nerds, if you will, who I could commiserate with and share my passion with. So I didn't---the mentors were really important in helping me to find the opportunities to do the things I wanted to do. But my people, if you will, the space people, were the ones who helped me to really discover my passion and keep it going and to seek it out.

Dr. Lehnhardt:  And it was after that opportunity, that I started to truly try to pursue space medicine as part of my career. So the---people might tell you that what you want to do is a little bit different, but if you find the right people to help you along the way and the right people to share your passion, that's going to go a long way towards driving you to where you want to be.

Dr. Lehnhardt:  The last thing I'll say on that though is, I could have never imagined in a million years doing this job for NASA. It was inconceivable to me. So if someone had said to me 10 years ago, "Where do you think you're going to end up?" I would have been completely wrong. So the last piece of advice I would give is always seek out opportunities and in a lot of cases, try to find a way to say yes instead of saying no.

Dr. Lehnhardt:  And for me, when someone came to and said, "Hey, there's this job at Nasa. You should apply for it." I could have simply said, "Oh no, that's---I couldn't possibly do that. I won't. I won't get it." Instead, it was like, maybe I should give this a shot and put my name in and see what I can do. And, and thankfully, I was successful. So, the the willingness to stick your neck out there and, and be rejected is a big part of trying to figure out here you want to go. And just to bring this whole thing full circle, lots of people who apply to be astronauts are rejected over and over and over again and they keep coming back. So you can't be scared of that rejection if you want to get to a to a truly unique position.

Juan: Absolutely. I give you agree with you wholeheartedly and you're just, you know, further convincing all of us that---that we hope that you continue to apply, because you've shown the resilience and you're not giving up, and you're doing all the work. And then one day it'll be like, we interviewed Dr. Lehnhardt and now he's in Mars and we're going to try to get a second interview with the 20 minute delay. But thank you so much for sharing. I think it's very inspirational, very informational. And I think our listeners will really appreciate it.

Eileen, do you have any other questions?

Eileen: Yeah, I just, I wanted to say thank you to Dr. Lehnhardt. It's been so valuable considering how we can blend different styles of thinking, giving us sort of a new perspective on things. I did have one final question. I know you were just saying that you can't necessarily predict the future and probably would have been wrong 10 years ago—yet, I'm still going to go ahead and ask you, where do you think space travel and human spaceflight will be in the next 20, 30 years?

Dr. Lehnhardt: 20, 30 years is a long time so that's a, it's a, it's anybody's guess. If you had asked anyone 10 years ago, if we could land rockets they would have said that you were crazy. And now we are landing rockets like once a month. So, it truly is amazing to me that, the pace of technology change. However, the rate-limiting step in all of this isn't necessarily the technology as much as it is the, the humans. We are the rate-limiting step for a lot of these missions.

Dr. Lehnhardt:  And even the mission of Mars is a great example. If we really wanted to build a rocket today, that could go to Mars and take people there, we could probably do it. Can we keep them alive and healthy and productive for the entire mission? That's where I'm not so sure. And so, the focus that we have on technology right now is fantastic. But the, the shifting of that focus towards the health and performance of the people is critical.

Dr. Lehnhardt:  And so, the--what I hope to see, and what NASA is trying to do is, is a mission to Mars in the, in the 2030s that is in the commonly referred to as "the Mars vicinity," meaning the first mission to Mars may not land on Mars, because landing on Mars is actually super hard and we don't really know how to do it yet from a technology perspective. But can we send people into deep space? Can they live in deep space for long periods of time? Can they be healthy and productive while they do it? That's the most important thing for us to determine. And then we can keep going further and further after that. So, I would love to see humans in the Mars vicinity in the 2030s, healthy and happy and productive.

Juan: Same here.

Eileen: Spoken like a true space lover and doctor.

Juan: Well, thanks again, Dr. Lehnhardt. Just one more, add--sort of an admin question for our listeners: if they want to get a hold of you or seek more of your information, is there a website or an email that you could point them to? Or a perhaps a website?

Dr. Lehnhardt: Sure. So my---I'm on the Baylor faculty pages, so you can generally find me there. I'm on Twitter as "Aerospace doctor," so "Aerospace" and then "DR." So you can always, I always post space and, and health stuff on there. And then lastly, my NASA email and my Baylor email are both public. So it's my first name (K-R-I-S) dot last name (L-E-H-N-H-A-R-D-T) at nasa.gov.

Juan: Wonderful, thank you so much. Well there you have it. Please feel free to reach out to--if you'd like to pursue your dreams. And we really appreciate your time.

Eileen: Thank you so much. You know, this is a busy time for everyone. It was really wonderful to get the chance to talk to you.

Dr. Lehnhardt: It's been a pleasure. Thanks a lot.

Juan: Thank you.

Eileen: Bye.

[Outro melody].

iTunes | Spotify | Google Play | Stitcher | Length: 39 minutes | Published: Sept. 15, 2021

Dr. Margaret Goodell discusses her research interests and career path through the years. We ask her about how she foresees her research on hematopoietic stem cell differentiation may impact future patient care. She also discusses what she thinks comprises good science and advice she has for aspiring researchers. 

Transcript

Alice: Hi everyone. We're welcoming Dr. Margaret Goodell to our podcast today and we're really excited to have her. She's been a pioneer and a leader, in multiple fields, in research at Baylor. And without further ado, let's jump right into it. So Dr. Goodell, well, happy to have you on our show today, can you tell us a little bit more about yourself and how your research interests have evolved over time?

Dr. Goodell: Well, thanks for having me. It's really a pleasure to be here and talk to you and the broader audience that's out there. So I've been at Baylor for about 20 years and before that I did my Ph.D. in England and my postdoc in Boston. And even though I did my Ph.D. in England, I actually grew up in the Midwest and so I was able to move around a lot during my sort of upbringing and training in science. I started out in my Ph.D. actually being interested in stem cells. In those days, I was working on embryonic stem cells and I remember having to persuade my thesis committee why they were of any value, because nobody really had worked on them and nobody really knew very much about them. And I said, well, they have all this potential and you could use them to make a new mouse and all of this stuff, and they didn't really get it for a while. But then obviously it became very popular (embryonic stem cells did). And then I decided on my postdoc to work on hematopoietic stem cells and that really launched the line of investigation that I've been doing ever since.

So when I came to Baylor, I had the view of really studying the fundamental mechanisms that regulate hematopoietic stem cells, that really regenerate all of your blood cells continuously throughout life. And even then stem cells were not really a buzzword, they were something I thought had a lot of potential, I was interested in how things regenerate, and how it's essentially a program of development that is ongoing even when you're adults. So it's a special window into that developmental process, which I thought was very fascinating, but it wasn't a very popular field either in hematopoiesis or anything else. Although, there were pockets of people that were interested in regeneration of skin or liver or muscle. And so there were people that were interested in stem cells. But really it was a few discoveries about embryonic stem cells and induced pluripotential stem cells that galvanized the whole field, and really captured all of the work going on in stem cell biology that was going on at the time. And I was already maybe five years into my faculty position here when that really happened. So I got to really ride this wave of excitement in the field. So that was fortuitous. And I guess that's one of my lessons for the audience, which is that you have to choose something you're excited about and decide to work on it and be determined even if it's not really popular at that moment because you don't know, you know, it could be something that becomes really popular and you might be able to contribute to the growth of that field, which I feel that I did and my work did, and I also benefited from all the other external interest that was going on at the time. I guess I would say it was a lucky break that I was interested in that and then it all came to fruition because of a lot of other events that we're going on at the same time.

Snigdha: I was wondering if there was like anything in particular that sparked your interest and stuff?

Dr. Goodell: So I don't really recall a moment where I decided what was interesting about them. When I was doing my, when I was ending my Ph.D., it was the time of increasing interest in the concept of gene therapy, and gene therapy has obviously had its real ups and downs; and really the people who were interested in stem cells were from the gene therapy field because they viewed stem cells as the vehicle for it. Because if you could modify a stem cell then you could make any therapy more permanent. If you could re0implant them into the body. So my interest
was more basic and more fundamental, but I ended up going to a gene therapy lab as a postdoc because that was where you had to go if you wanted to study something like stem cells, that's how unpopular the field was at the time.

Snigdha: So the next question I wanted to ask was, did you have any role models or early influences in life that pushed you to go into science?

Dr. Goodell: I really didn't come from a scientific family or anything and you know there wasn't really anybody around me who was interested, but I think I showed early interest in it and I had a grandmother who was always sort of trying to identify things in us, in me and my sisters that we were interested in and would send us books. The days of books, you know, you could read a book when you were 7 years old or 10 years old, instead of going to the internet. And I think I really enjoyed that literature and it kind of got me hooked. And so by the time I was finishing high school I knew I wanted to do something in science. I didn't really know, I was interested in astrophysics, as well as biology and ended up going into biology. But it was kind of unformulated, just that I really enjoyed science. I think it was the inquiring nature of it, wanting to understand how things work.

So my undergraduate degree was kind of unusual. I started out as an undergraduate in a small liberal arts college in Connecticut and then I decided to do a semester abroad in England in London at Imperial College of Science and Technology. And the way that the British education system works, they put you into the extreme end of sort of research if you're in science very early on. And so when I got there, which would have been my junior year abroad or my first semester of my junior year abroad, I was actually starting to read scientific literature already; which, if I had been back at in Connecticut I still would have been reading textbooks. And so once I got into scientific literature and really started reading things in depth, I got super excited and then that summer I stayed for a year instead of a semester, and then I worked in a lab at summer and then basically have been working in the lab ever since.

So, for me what really cemented? It was not just reading science the way that we're taught it, you know, in undergraduate classes in college which I actually found kind of dry but it was understanding how it works. How research works from the laboratory perspective. Not just getting in the lab but really being able to read the papers and understanding how the discoveries went. What got me super excited, this seems like ancient literature to you guys, but I did a big section when I was in England on regulation of bacterial gene expression. And it's kind of a very simple system, it was like Lambda phage and how Lambda regulates its gene expression and how different bacterial genes are regulated. But it was just super exciting at the time and I read the whole series of literature about how these discoveries were made. And so for me, it was also kind of insight into how a series of studies lead to a greater understanding about a biological system. And so being able to put that all together, that was kind of the magic for me.

So that's a great question too. So I was finishing my postdoc and I started to go on the job market and I cast a wide net. I find when I'm trying to recruit people a lot of people have very clear preconceived notions about where they should go for their job, which as a general piece of advice, I think that's kind of a mistake because you really, there's not that many academic jobs in any given time, you really have to go where you're going to get the best opportunity, meaning a good starter package and a good environment, the combination of those two things. But I didn't have any preconceived notion having grown up in the Midwest, you know, having been trained partly on the East Coast, lived in England for a while. I sort of just was able to look at anything and when I looked at a number of places, it really helped me prioritize. What was going to be important in an environment. So I don't think I really had a good sense of what was going to make a good scientific environment at that time when I when I started looking for a job, but it was really through the process that I understood that better. And in the end it came down to two top choices. I had another fantastic offer from a place which I won't mention. But you would say is ranked extremely highly. And what it came down to for me, in fact that other place offered me a little bit more money, a little bit better start up package, etc., but I thought that the mentorship that I would get here at Baylor was, was going to be better. It was a gut feeling on the basis of the people that I would be working with and I think that was absolutely the right decision. I've never looked back, and even realizing that that was the right decision and the mentorship that I did get has allowed me to sort of use that as a guiding principle in my own behaviors going forward. So I try to be a great mentor. I try to recognize great mentors and really utilize those principles in my whole professional life.

Snigdha: So were there any particular challenges or obstacles you faced as a young scientist that influenced your career path? And if so, how are you able to overcome or adapt?

Dr. Goodell: You know there's always a lot of challenges. There's a lot of grant rejection, there's a lot of paper rejections. I actually just tweeted about this a couple of nights ago because I was counseling one of my students who got a grant, her training award rejected, brutally rejected, there was some not very nice comments on it. I just saw this is not necessary, sometimes reviewers are really just not very nice. On the other hand, I thought well this is a great training opportunity because this is really how it works in the real world and you have to be resilient.  And a lot of PIs we joke about this all the time that it does take a lot of resilience and being determined that this is what you really want to do, that you're doing the right science. I remember a grant that I had that I considered — the work that I'm doing now is still stem cell biology, but we started working on this one gene called DNMT3A. It's a DNA methyltransferase. And when we sort of stumbled upon this and really started working on it, I realized that it was super important and now I feel that it's probably some of my best scientific work, the whole body of work that has evolved from that discovery is really what I think is some of my finest work. But I could not get a grant on it. I submitted an R01 four times. And every time I was absolutely brutalized by the reviewers and they said, "oh, there's work that's premature", "it's not very clear that's supported" and etc. It took publications from other labs in the field to show that the work was, in fact, incredibly important. Again, this was another example of sort of a serendipity and being in the right place the right time and working on something before it became really popular. And all of a sudden this became one of the most popular genes in the field. And all of a sudden, I didn't have any trouble raising money for it anymore. So, it's, it seems kind of sad, but I knew that it was important. I knew that this was the right Gene to work on and that these were the right experiments to do. And so I was able to dig in and keep working on it. That whole discovery was really about 10 years ago. So really mid-career. But you know, you're still continuously having to overcome those kinds of challenges, I would say.

I would say it a completely different challenge, though, is in a way more interesting. Which is, what are you going to work on? And how does that evolve over time? And I've thought about that a lot because there have been other lines of research that I've been really excited about and then decided for one or another reason not to continue working on that because at any given time you only have so many resources. You only have so many people and you really just can't do everything. And so this DNMT3A project is a great example because we had just had a Nature paper in a different area of interferon signaling and its impact on stem cells that I realized was also really a great area. And I was determined to write another grant on that and keep working on that. But this DNMT3A project started happening and I just didn't have enough resources, people or money, to work on both of these big, big projects. So I sort of put all my chips onto this other thing. So, it's sort of made me realize that sometimes these choices are a little bit like gambling or playing cards, you know, it's the Kenny Rogers song, you gotta know when to hold 'em and know when to fold 'em and you have to make choices. They're not always going to be the right choices but you, you have to sort of put your chips on, you know, this particular hand that you've got at the moment. Or you have to say, well, I know this is cool work, but I can't get anybody else to think it's great, I can't get the paper published where I'd like it to be because these reviewers just don't get it, whatever, whatever. And, and then you just have to move on sometimes and work on something else and maybe that area will be more ripe another time. I think you really have to evolve as a scientist. You have to allow your work to evolve, you can't think "I'm going to work on the same protein for my whole life", unless it's a really fabulous protein. It's important to evolve but yet that decision is a hard decision every time you have to face it, right? Am I going to go in this new direction? Am I going to get funded in this new direction? Should I stick with what I know? And people know me for stem cells, they've known me for that forever, will I ever get funded for this? This DNA methylation thing? I don't know, but you have to, I guess, you have to have the courage of your convictions and be willing to be courageous and do something else. Even if that means to give up something else, it's also potentially very fruitful.

Erik: Actually can I ask a follow-up on that? Really, as a PI, a lot of what you're doing is sort of managing other people. Would you say that's a correct statement?

Dr. Goodell: Absolutely, and you're really not trained for that at all. You might have had an undergraduate working for you or something like that but you're not trained to run a team of 10 or 20 trainees and staff.

Erik: So I guess my question is, how did you learn how to manage? Where do you think you picked up the skills? Because you run a very successful lab, I mean, by every measure. So, I think that would be great for our listeners to hear because I think it's something everybody should be thinking about.

Dr. Goodell: I don't think I necessarily did a great job in the beginning and I didn't really have any courses or anything like that and there is a lot more emphasis now on training us to be good mentors. And I think that's a wonderful thing and hopefully all of you, when you're in the position, will take advantage of that. So how did I learn to do it? I learned from my other mentors. So I learned from the guy who hired me who was my chair, basically. I learned from looking, watching other labs either do things I didn't think were the right way to handle it, or were the right way to handle it. And I also realized that there was more help available than I realized at first. So, for example, when I did have personnel problems, there are people whose job it is at Baylor and all professional institutions to help you deal with problems; and they have strategies, they have other places to go to. I've done everything in my career, including you know, encouraging people that I knew to seek help for mental health concerns, you know? And I mean, that's something that isn't really discussed. But there are great resources for that. People might have had other issues going on. And so once you kind of get into it, you realize that even if you don't feel like you're a good manager, that there's a lot of help to be found if you seek it. So, that's one thing. And then I guess the other thing is again, kind of returning to first principle – it sounds kind of silly, it's like that Kindergarten book, right? It comes down to treating people the way that you would want to be treated yourself. And once you really incorporate that into your philosophy, I think it makes a lot of difference. And even when you get frustrated with people, you have to think, well, I'm frustrated, maybe they're not working hard enough in the lab or whatever. But why is that, is there something going on with their life that they're not telling me? Maybe their grandmother died or maybe they really don't like the project and this isn't the right lab for them. Maybe the technician needs a different kind of a job because she's just not motivated in science anymore and yet she hasn't figured that out. So once you really put that as your sort of guiding principle – that you really have to treat everybody as you would want to be treated, that's your North Star. And I think that has helped me be a good mentor both in my lab and in dealing with some people now that I'm a chair of a department, I feel the same way.

Erik: Well, thank you, I think that's great for people to hear something.

Alice: Our last question that we were hoping that you could answer, is a little bit more science- heavy. How does your knowledge, our knowledge of how stem cells differentiate, how do you foresee that impacting the future of patient care?

Dr. Goodell: That's a great question, the stem cell field definitely exploded because of the promise of stem cells for various kinds of therapy and I still think we're getting there. It is taking a long time and it will continue to take a lot longer, but I think the impact is many-fold. From a very basic science perspective, understanding the mechanisms of how stem cells differentiate has given us insights into other things. So, for example, in cancer, because many cancers are fundamentally – at least cancers of the blood, hematologic cancers – are thought to be a combination of both a block in differentiation as well as something that drives those cells to proliferate inappropriately. And that you really have to have both of these sides going on at the same time in order to cause a leukemia. And so this gene that I studied now, DNMT3A, that's really important and its major role is to permit efficient differentiation of stem cells and so it seemed to be really an interesting gene for regulating stem cells. But once we discovered that it was also important in cancer because it's frequently mutated in cancer, that gave us really fundamental insights. Now it turns out it's a tumor suppressor so it's not very easy just to kind of fix it to cure your cancer. But, nonetheless, it's given us a lot of insight into how these particular malignancies arise and to think about how one could effect that change with drugs or other approaches for cancer treatment. So, yes, one point is that stem cell research can help in areas outside of just regenerative medicine, because it's giving insight into normal development and also cancer. In terms of regeneration I do think we are getting closer to, let's say, the long-term goal of tissue replacement in certain circumstances and there are better and better protocols for taking embryonic stem cells and differentiating them down towards specific lineages. Lots of work in neuroscience to do that and you can get fairly pure cultures of certain neurogenic lineages. It's kind of hard to just implant them by injecting them into a brain right now but we might really get to that point where you could use some of these cells and sort of patch a tissue in a way. So it's still a process but there's a lot of research in the field, a lot of excitement and I think we're getting there, there really will be a great tool. Stem cells will be, in general, a great tool for regenerative medicine and for therapeutic purposes.

Alice: I think it's really fascinating. Actually, I'm not so familiar with the history of stem cell therapy and stem cell research, but I believe it has been decades since the discovery of differentiation from fibroblasts. Is that correct? And since then, can you describe some of the progress that the field has made and what are some of the biggest challenges to bringing it to patient care?

Dr. Goodell: So I would say there's a few times in your scientific career where you'll see something come along that shocks you as an investigator. You're reading this paper and it's like "oh my gosh I can't ever imagine that that happened" and IPS cells were one of those. PCR was one of those revolutions, absolutely revolutionizing things. In fact it was kind of thing where people thought "well, that's so obvious, I should have thought of it myself" when PCR was developed but nobody had. And obviously it really transformed everything you do. And I think CRISPR is another example of something that most of us could never have envisioned, and it comes along and just like wildfire just transforms virtually everything that all of us are doing in the lab all the time. So IPS cells was like that for the stem cell field for sure. But in the very beginning, they were virtually impossible to harness. People didn't really understand how they were made. Could you make them from any cell? Could you make it from an adult skin cell, a skin cell from a baby? Could you make it from a hepatocyte, a blood cell? People were just sort of trying everything. They were then trying different genes. Well, you know, these four genes could do it, but could you use a micro RNA or could you use a combination of three genes in a drug? And then really what is this the process, is it an epigenetic process that resets it. And does it really reset it back to completely normal or only partly normal? So, all of these questions were really the focus I would say in the first 5, 6, almost 10 years really trying to understand how that works. And now the field is really maturing and focused more on, OK, now let's make something really productive out of them. Can we not only make a cardiomyocyte, but what does that cardiomyocyte do in terms of its normal function? Mostly still, when you differentiate embryonic stem cells, you get something that resembles a differentiated cell that would come out of a newborn or even a fetus. So it's not really something that you can use to replace in an adult because actually the function of those cells is a little bit different so people are still trying to overcome that gap, how far can you take them. But it's evolving all the time.

One of the other really exciting developments in the field was realizing that under certain conditions you could put embryonic stem cells and a few other things in the media and you could actually get these self-organizing bodies, something that looks like a little eye that you can develop completely artificially, these eye cups.

Erik: I had a question if there's time, I want to respect your time, but I had a tag-along question about your research. So DNMT3A. So obviously I've already shown, I'm not an expert on it, but I was just wondering if I'm understanding it correctly, if you could expand on it because I think it's really cool. So it basically helps in stabilizing – it's only in the nucleosome. Is that correct? First off?

Dr. Goodell: It's in the nucleus and what it does is it puts DNA methylation all over your DNA. And DNA methylation is just a mark that helps regulate the gene expression. And what it does is it puts it in very specific places and we still don't really understand how it knows where to go and when to go. And if you don't have it there, the way that we think about it is that the methylation in general, as a very broad brush stroke, is important for shutting down the expression of genes. So a very simple way to think of the purpose of this DNMT3A protein is that it's very high in the stem cell. And then as soon as the stem cells is told to differentiate, it has to go and shut down the stem cell program, and if you don't shut down the stem cell program, you can sort of get a little bit of differentiation. So, it'll start to go down that let's say the red blood cell lineage and make red blood cells. But it still thinks that it's kind of a stem cell and it gets confused. And then that's probably why if you don't have DNMT3A those cells are then more easily transformed down a malignant lineage because they're trying to be something, but they're also thinking that they are a stem cell that continues to proliferate.

Erik: Okay. Okay. And so was I understanding correctly that it also is thought to maybe have some function in like the phase of DNA within the nucleus? I think that's what I was starting to read about that I thought was really interesting, and maybe that's how people are thinking it might be affecting expression levels as well and whatnot?

Dr. Goodell: That is possible. We do think that, so, one of the papers that we published recently, we showed that there are large regions in the genome that have little or no DNA methylation. So, I would say that, first of all, almost all your DNA has a ton of DNA methylation it's just covered with it as a mark, okay? Just like peanut butter on your bread, whatever. It's just like all over it. And yet there are these little pockets that don't have very much methylation and those are important regulatory sites and DNMT3A is definitely important for changing that state. So making sure that there's the peanut butter over all those little holes. But what we found, this is another example, actually, of sort of following the research, even though it's not strictly related – we started looking at DNA methylation in general. Where is it in the genome? What is it doing? How is it regulating things? So, in a way it's a little bit tangential to what DNMT3A specifically is doing, is asking what DNA methylation is doing. So, when we looked really closely we saw not just these tiny pockets that lacked DNA methylation but large tracts of DNA that lacked it. And I'm talking about 10 KB or 20 KB which are really large chunks of the genome that don't have DNA methylation that, before our paper, nobody knew that these large tracts existed. That paper was a few years ago. And so, then we thought, well what are these large tracts for? We call them canyons because they're like Grand Canyons, like really big and they have a little river in them, there's always a gene in them. So it's kind of a nice analogy and so we kept thinking hat are they doing? What are they doing? And we think those canyons are there for a number of reasons, but in our recent paper, we showed that they are sites of 3D chromatin interactions. And that several of these can be interacting together. Sort of like the center of a flower that these pieces of DNA are all coming together and sort of locking together around these big tracts of low methylation. And we suggested it might be a phase transition type of event that's also got polycomb proteins and other things involved in it. That was our observation and that's an area I would love to go into in the future as well.

Erik: No, I think that's amazing. I think that's a really novel and cool way of thinking about it. When I was reading I was like well, that makes a lot of sense when you think about it, kind of manipulating the phase like that to be regulatory. But I guess you're not even speculating about regulation, but are you? I don't know.

Dr. Goodell: We do, we actually think – so those canyons exist in two states and I'll give you another one of my crazy analogies in a second, but the canyons exist either in an off state or in an on state, and the ones that are involved in these really long-distance, 3D genome interactions, which are megabases apart – so it's like multiple megabases, which is also like a scale that wasn't envisioned before – it's the canyons that are involved in those really long-distance interactions are the ones that are in the off state and not the ones that are in the on state and it's not random. So, it does seem, I'll give you my other analogy of these canyons and what DNA methylation might be doing. Again I was thinking a lot about DNA methylation as a mark and how important is it and it's even interesting to think about where it came to be evolutionarily and how it's used in different organisms and things like that. And when I really thought about these canyons, what I kind of realized is that the genes that are in these canyons – I mentioned that there's like a river in them – and if you look at what those genes are, they're always the most important genes in the genome. There's a gene called PAX6 which is critical for eye development. If you knock out PAX6, you won't get any eyes. Okay, so PAX6 is one, it has its own special, little canyon. It's just sitting there all alone, protected in this big void of DNA methylation. Almost all the Hox genes, which are involved in embryonic development, have their own little canyon. Many other transcription factors that are really important regulators have their own canyon. So I was really realizing these are all really special things. And in fact when you want to turn on one of those important genes, you turn it on like gangbusters, right? Everything gets turned on and all the transcription factors are landing there at once. And they're turning it on and then later, it has to be turned off.

So I was probably on one of my flights – now we're not flying anymore, because COVID – but I started thinking of these canyons. When they're on they're like the busiest airport on the planet. So it's like JFK Airport in New York, or our Houston airport is a pretty busy airport too, or O'Hare in Chicago used to be the busiest airport, and when it's daylight time that is the busiest airport. But when the Earth rotates and that's out of the sun there's not very many plans are landing in Chicago O'Hare anymore at 3 o'clock in the morning, right? Really not very many and so that airport is shut down. So I started thinking about these canyons as sort of permitting, basically, the runways and that the methylation around it is the structure that allows that runway to have the lights  bright on when the planes are landing and the lights off when they're not landing. And so it's kind of the infrastructure around it. It might not be the landing pad itself, but these are structures in the genome that are really allowing everything to be landing at once when it needs to be on, you know, everything is going. But when needs to be off, everything is off. And it's sort of a big structure, that only the biggest airports, the biggest cities, the most important cities are allowed to have one of those special canyons of special genes.

Alice: I'm really tempted to ask this question now. I think we have a tiny bit of more time, so I'm going to ask two subparts in the same question. One, are there any other regulators that behave, as far as, you know, like DNMT3A. And two, have you guys considered looking at any other lineages besides hematopoietic stem cells.

Dr. Goodell: Great questions. So there's no other gene that really acts exactly like DNMT3A, that is so special for – at least in the hematopoietic lineage – for the stem cell and has such a clean function. However, there are other genes that have semi-overlapping behaviors, and so one of them called TET2 and its purpose is to remove the DNA methylation that DNMT3A and other proteins put down. So it's interesting, it's the opposite side of the coin and when you knock it out it has a overlapping phenotype to DNMT3A. So it has a similar role in cancer and it has a related role in regulating stem cells too, even though it kind of has the opposite molecular or biochemical function. It removes methylation instead of putting it on, it has a similar outcome in terms of what it does for the stem cells.

Alice: So as you were mentioning, it's a regulator for a lot of different important genes in different lineages. So I was wondering, is there a potential, do you think, for it to be heavily involved in many processes throughout the body?

Dr. Goodell: So we know that it's also involved in differentiation of embryonic stem cells. In fact that's one of the places its role in differentiation was first discovered, and we have suspected that it plays a role in some other lineages. But that hasn't been looked at that carefully for a number of reasons. There is evidence from some other labs that it may play a role in skin differentiation as well. It certainly may play some other roles but that's another area that would be worth looking at in more detail.

Snigdha: It was really great to hear from you about your research and I really love your analogy – the flower one, and the airport one, those ones will probably stick for a while. But yeah, it's really exciting to hear about your research and your career path. Did you have any final words of advice for students who are looking to start their own research years?

Dr. Goodell: I would say research is really fun and it's forever varied and that's really one of the privileges of working in this area. During the pandemic shut down that we're in right now, some readers may be listening to this in the future and not be in that any longer. But that's where, you know, we're recording this in the middle of our pandemic. I think a lot of people have asked whether they're happy in their jobs, whether this is something that they really want to be doing long-term. I feel we're very fortunate, in research, the pandemic has actually pointed out exactly how important research is and has offered many new opportunities for really great questions that should be addressed outside of stem cell biology as well. I think as a career it offers a lot of flexibility, it offers constant change, you always have new people coming in your lab, you always have new people to work with. There's always new exciting ideas. You're able to evolve your research, you're running your own little business. It's your own little business. And as long as you can continue to raise money for it, you can keep producing your products and your products are your papers that you sell to the community and you try to get the journals to publish. So it's very satisfying in that sense, as a career. Also, I have three children and I've had to manage that through being a PI. I started my family after I had been a professor here for a couple of years, and now my oldest is at college. So it also offers a lot of flexibility and I think that's great and research, you know, it's not really a 9 to 5 job. Unfortunately, it's like an all-time job. I'm always thinking about it. I'm often on my email at strange times the day and night, but it also means that I don't have to be in at 8:00 a.m. every day and I have flexibility. And that has helped manage having a family and that flexibility has been nice, you know, during the COVID era and things like that. So I would say it's really a privilege. It's a great career and it's a lot of fun if you don't get too down when you have the few setbacks that you have, you just have to keep plowing forward.

Snigdha: It's really awesome to hear from you. We really appreciate you taking the time out of your busy schedule. You know, you have a lot going on especially right now during the pandemic. But again, thank you so much. It was amazing to be able to interview you for this.  

Dr. Goodell: Well thank you all for having me. You had great questions and it's a fun opportunity to talk about some of these things that I think about, don't really talk about very often.

iTunes | Spotify | Google Play | Stitcher | Length: 46 minutes | Published: Aug. 26, 2021

Dr. Richard Hamill will discuss his journey from teaching, to being the residency director of internal medicine at BCM. We’ll ask him about his experience teaching, his work, and his views of how medicine has and will continue to evolve.

Transcript

Erik: So anyway now the bureaucracy is out of the way if you have any questions for us - If not, I've already hit recording on our end and I'm recording video and audio. But the video will not be a part of it.

Hamill: All right

Jason: So what was your career journey? I guess as a doctor

Hamill: As a physi-?

Jason: As a physician, as a teacher, as a - yeah - as a residency director, like what was that Journey?

Hamill: Well, so I went to medical school at Wayne State University in Detroit and then I stayed there and did my training as a resident and I ended up being a chief medical resident there. So I got the opportunity to teach for that year, which I really enjoyed and then I went off did my fellowship in infectious disease at University of Wisconsin and I actually did three years. Normally the fellowship would be too but I did three there. The third year was mostly in the lab. I did have the opportunity to do some teaching there. I taught, for instance, the endocarditis block, you know, our lecture for the medical students and micro, so I got to do it there. And I actually - one of the kind of memorable Grand rounds I did, there was the – I took care of the first patient with HIV in the state of Wisconsin. And he was a patient who was admitted to the VA there. And so, I gave Grand rounds, the first Grand rounds on AIDS at the University of Wisconsin. So, you know, I thought that was kind of cool. I still have the handout from that.

Hamill: Then I came to Houston in 1985 Dr. Musher actually, you know, interviewed me for the job and I heard that was kind of memorable because that he picked me up. I had never met him before, you know, and he picked me up at this dumpy Hotel on Holcombe and his big blue Chevy. I don't know if you guys have seen that Chevy convertible that he drives – an old Chevy with a white convertible – he still has – 1950 something. You know, I like the people, Dr. young, Dr. Musher I met at the time. Kind of my wife and I wanted to change so I came here. I told her when we came down and be five years here and we've been here now thirty, you know, so we liked it here. You know initially when the reason I came to the VA was that when I first started, the VA was a nice opportunity because you could see patients, you could teach, you could do your research, and nobody really bothered you, you know. And back then, you know, things weren't near as strict as they are now, in terms of, you know, you didn't have to round every day without staff and those types of things. But I did enjoy teaching and I, you know, I tended Morning Report quite frequently then, and I spent three years as the associate chief of the medical service while I was at the VA and I was, for a long time, the chairman of the curriculum subcommittee, for the Residency program. And then in 2006, the person who is charge of the Residency program ahead of me, Dr. Levy decided he wanted to go over the dark side and join the law profession (he'd been going to law school at night). And so, I was put in charge as chairman of the recruitment committee for that position. But then Dr. Greenberg was the acting chair of the medicine at the time. And I told him well, you know, I sort of would like to apply for the job so he made me step down as chairman the committee ultimately I was chosen to run the residency program. You know, I'm glad I did it. I had been involved prior to that with a group called the mycosis study group. And so, we did a lot of studies for fungal diseases. And at the time, you know, this was early on in the HIV era, we saw a lot of patients in Houston with cryptococcus, histoplasma, and HIV. So we were one of the highest enrolling centers in the country and a lot of different studies particularly for cryptococcal disease but you know as therapy started coming out for HIV and stuff, those patients became fewer. And so it became much harder to do those studies and things. I think the transition to the educational program was kind of a natural one for me. I still get, you know, to do my fungal things and still get to participate. People still call me for all the complicated fungal infections – I mean, I got an email yesterday from one of our former trainees who has a patient over at MD Anderson, who had some questions about, so I still get to do that. But I also get to teach and kind of run The Residency program too.

Erik: Well, I'm curious because, I actually went to Wisconsin for undergrad and I'm from Illinois, so also from the Midwest and I'm always kind of interested to hear what attracted you to, you know, the VA and then Baylor specifically that, you know, you felt like maybe you - I don't know if there's anything you felt like you couldn't find in the Midwest or elsewhere on the coast or something.

Hamill: Well, you know, we liked Wisconsin; Madison was a nice place to live. No, my wife is still mad at me for leaving there; she thought it was Heaven on Earth, you know, because she had grown up in Detroit, her dad was a fireman in Detroit. She had grown up in Detroit, so leaving, Detroit was like, great for her. But, you know, because of Wisconsin was so nice, people wanted to stay there, and there were no jobs. A lot of the guys who had finished the fellowship program ahead of me were working in ER's and stuff because they couldn't get an ID job

Erik: Really?

Hamill: Yeah. And you know Madison is kind of a small city, you know. It's not like Houston is and it's not a very diverse city, right?

Erik: Definitely

Hamill: And so, you know, I think just Houston offered a lot more opportunity for my career and Madison did at the time. And that was borne out, I think about by my career trajectory. I couldn't have done the type of research I did at a lot of other places with the support I had here, and the diversity of the patient population that we had here. Very few places in the country have that, and even the ones that do – I don't think everything's not as concentrated together as it is here. So it makes, you know, getting around pretty easy and it makes life pretty easy because you don't have to, you know, run all over town. The other thing about Houston the medical center which I think is kind of unique is the fact that you can live so close by. I still still living a pretty nice part of town in a lot of major medical centers, you can't do that. So for the first four years I lived here, I actually rode my bike to work every day because I only lived a few miles away. And I'd still I have a ten-year-old car that only has 48 thousand miles on it because I hardly drive

Erik: Even in the heat you'd bike in, huh?

Hamill: Well, back then – Houston wasn't as bike friendly back then. So the reason I quit was I actually got hit by a car.

Erik: Oh my goodness. Oh my sorry to hear that.

Hamill: But, so there are a lot of opportunities here to do research. You know, the Infectious Disease section I think a Baylor is always been very strong, you know, and good colleagues at the Infectious Disease community here in Houston is good. It's very collegial, maybe a little unlike Cardiology or something.

Erik: Gotcha
Jason: Sure, yeah, what was one of your most difficult patient cases

Hamill: Couple different things – I think one of the disease's I think that's really difficult to manage is coccidioidomycosis. And I have a patient actually, I'm following in the clinic right now, I think is was one of the most difficult ones I've had. He's a young man who had been diagnosed with cocci when he was in the service in California, about three or four years ago, and at that time, he had pulmonary disease, CNS disease, cervical spinal disease, thoracic spinal disease, and he had to have thoracic surgery, spinal surgery, and was treated in California. And then he came here and he been off medicines for a while and he relapsed. And when he got here, he had exacerbation of his cervical disease and he developed hydrocephalus. And so he had to have a surgery for his hydrocephalus and we treated him with high-dose fluconazole which is sort of the guideline directed therapy for his meningitis. Well, he was on 1200 milligrams a day and all his hair fell out, and he got upset from that. So that's one of the side effects of fluconazole. And you know, I have some friends out in the Arizona, who deal with a lot of this. I talked to them and ultimately we started him on posaconazole, and so far he's been doing pretty well on Posaconazole. But, you know this is a difficult disease to treat will never be able to cure him with the present drugs and he's got to be diligent about making sure he takes his drugs. So that's a tough one to treat.

Erik: So is the main reason that it's tough just because we have better azoles and antifungals to treat the other diseases where it's just not there?

Hamill: Well, yeah, just the ones that the ones we have just aren't effective for cocci. I mean, so far right now, cocci meningitis is considered an incurable disease and it's complicated even in patients who you can manage them, you know, you never cure their CNS disease. So there are still at risk down the road for hydrocephalus. I've had three patients now who I follow – we don't see a lot of cocci here, but I've had three patients of the few we've seen who've required shunting or some other Neurosurgical procedure for management of the hydrocephalus because it's such a common complication. So it makes it difficult to manage. And it's a very humbling disease. And then some of our HIV patients early on in the HIV era – it was very depressing, you know? And because we didn't have great drugs for these patients. If we had the drugs available back then – if we had the drugs we have now back then, we would have done a lot better with HIV because they took their medicines, you know. Early in the HIV era, we didn't have a lot of knowledge about the pharmacokinetics, for instance, of AZT. When that one that was our first drug available patients would wake up every four hours at night to take their medicine because we thought the half-life was short, you know. And they did it, they set their clocks. They got up at every 4 hours at night to take it and they did fine. But then they got after 20 to 40 weeks, they all got resistant, and we just bounced from drug to drug to drug like that. But ultimately, we had nothing to offer them. So it wasn't until we could get combination therapy and we could actually start curing these. And I have two patients right now – or one, at least (I had two and then one died last year). But back in 1996, we got combination, they were on their death beds, but both of them – they were alive for years afterwards after we were able to get the protease inhibitors.

Erik: When you talk about HIV gets me to think, because I mean I know you said that you were in your fellowship when HIV was kind of first being realized and coming into the scene so I guess it probably didn't get you to go an infectious disease because you're already doing it. But did you feel like that sort of endemic caused more people to go into infectious disease? And I'm asking this question because of COVID, I'm wondering if we're going to see a bunch of people who want to be infectious disease doctors because you know it's everybody's you know it's the thing sort of to learn more about and treat.

Hamill: Yeah, you know I think it probably was. It's what's interesting – we had the graduation virtual graduation for our ID fellows the other night, and Dr. Fauci actually had put together a video for all the graduating ID fellows in the country. And so they showed it at our virtual graduation the other night and he brought up an incident that happened back in the early 80s. Dr. Petersdorf, who was at the University of Washington and was a very well-known ID doc then, had given an address at the Infectious Disease society meeting saying that there were too many ID doctors back then, and that they'd all be culturing themselves and treating them because there were just too many of us. Well, I mean that was literally in the doorstep of HIV. Then since then, you know, we've got leaked layers disease, we've got SARS and we've got MERS, we've got covid. And you know all these new diseases that people wouldn't imagine back antibiotic resistance and infection control is tough, global health. So I think, yeah, I think probably HIV did have an impetus for people to go into ID back then because a lot more people; we have a lot more women have now too, you know, which I think is one of the nice things about the field because I think – we graduated six fellows this year and all of them were women. So I think it's been a nice opportunity for women, unlike some sub-specialties, like Cardiology which are very heavily male dominated, you know, ID's allowed women to come in.

Erik: They're going to think you're coming at – you have a vendetta against cardiologists. I'm just joking.

Hamill: It's not as interesting of a subspecialty as ID.

Jason: We both remember – I mean, we're one of the few students who actually attended the lectures. I did want to ask though, why is it that you still put up with teaching us medical students?

Hamill: Well I wondered – I got the evaluations yesterday actually from the last, you know, the last group actually. You know most of them were recorded from the year before – I only gave 2 in person. And, several times over the course of the years that I've given these lectures, the students complain about the TV lecture. Because they say that, what I tell them, they don't believe – they don't believe it. And what I tell them is has to do with BCG vaccination, you know? And the public health response to that and what I tell them is what's in the guidelines, but they don't like it because they think it's discriminatory. And I got one of the, one of the evaluations yesterday, said, well, what he said, was, what's not in their ID first aid book, or whatever the dumbed down version of the book reviews. Well, I'm sorry but it's not the public health response, you know BCG is pretty well laid out, you know you ignore the BCG status when you do PPD testing, or when you do T-spot testing nowadays. That's the way it's supposed to be done, but these books and their thought is well that's discriminatory. Well, it's not and it kind of – it's a little bit irksome right when the students are bellyaching about that when they don't really know the data. And then the other comment that they got this time was, well, I was teaching them stuff that only ID fellas need to know. So, I'm teaching them the ID that they're going to see when they get in the clinic. Because if I teach them, they will be seeing it and they don't know because they haven't been the clinics yet, but you guys have now or you will be you will see these things. So that's the one thing that bothers me about it. I do miss not interacting with the students in class – I like that better? I don't, I don't like giving Zoom lectures because it's fun to interact with students so that's why I do it. And I'd like to round on the ward still, you know, a lot of program directors around the country don't round because they don't have time to do it. But I don't like that because you don't get to interact with students. And you know, I like clinical medicine, so I want to continue that, and I think I have something to impart to you. There's, you know, there's been this movement for hospitalists to do all the rounding in medicine now in general medicine. The man who actually got me interested in joining the mycosis study group used to be the chief chair, chief of general medicine over at UT. He was actually a pulmonologist Jorge Cirrosi. He wrote an editorial in annals of internal medicine a few years ago because he still rounded on general medicine and he was 70 something. We still have something to offer, we have some insights, you know, we may not be able to get the patient out of the hospital as quick as maybe a hospitalist does, or something, but I think we have some history and some insights and like this, you know, that that we can give you guys that they may be beneficial in an approach to Medicine still, because we've seen a lot more than you guys have.

Erik: Definitely, definitely. I didn't realize that there was a move for hospitalist to do all the –  most of the rounding.

Hamill: Oh yeah,  and that's the way it is at a lot of places. You know if you but I mean, if you look at who's running a been table now, it's mostly the hospitalists. Dr. Greenberg and I were the only ID people, I think, now who rounded on general medicine there. Several of the Endocrinologist did, and I think one or two of the nephrologists. But mostly, that's all it is. And at the VA, you have more of the subspecialists, but there are moving away from that as well. But that's nationally, that's the trend. But I enjoy it and I think we still have something to add.

Erik: And I think Jason, correct me if I'm wrong, but were you also trying to ask about like the fact that the years, because when Jason was saying he attended all and I attended most I did watch them all, you know in some manner, but some of them I did stream. And I think we're also curious just to know as somebody who's been teaching a long time and has seen streaming become more of a thing, like, do you like that, or are you indifferent or do you despise it?

Hamill: Well, I don't despise it but I, you know, I like I said, I enjoy interacting with the students. I'd rather they'd be there than often in the Netherlands, you know. You know, when I went to medical school, I had a big class (there were 256 of us). Most of us went to class, but not everybody did; we had a scribe service back then that you could pay for. We all paid for it just to augment our notes, but most of us went, but I went to socialize with my friends, you know. The way our medical school is set up, we had a we were broken up into 16 person labs, you know and so, you know, that was your social unit. I mean we had potluck dinners, and picnics, and we went on vacations together and stuff, you know, that's why I went to, that's why I went to classes. But yeah, I don't, you know – you sit at home and you look at zoomed all day long, I mean I hate it right now. Excuse my language, ha ha, I hate this. Yeah, everything Zoom right now. I am sitting up here in my office. I come here every day, our house is under construction right now, you know, so I can't stay at home. My office is a mess and stuff, so I got I come up to work, well several days. I'm the only one up here, you know, and it's lonely. And that's not the way medicine should be.

Jason: For sure. I definitely feel that the like I went to class mostly to see people.

Erik: Yeah, yeah.

Hamill; And I think it's helpful too because, you know, you can ask questions and people come up afterwards and stuff to talk, you know.

Jason: It doesn't take like a, you know, six emails to get one question and you can just ask it and, you know.

Hamill: So I miss that.

Jason: Yeah, for sure. I guess, I was wondering how is it different from teaching like us medical students compared to residents? Is it different is it not different? It's a little different because, you know, there's a different level of sophistication. But you know, I've had medical students who are phenomenal or better than the residents, you know, so it's not a hard and fast rule when I round on infectious disease service I do like to have a fellow on the service with me because you can talk about a little bit more sophisticated topic, you know. And so for me, that's good because then they challenge you a little bit, but on the whole I think, the way I do rounds, it's good because I think we can address certain aspects of different patients at different levels, right? And so, it's always good to make us think about the basics, but you can get a little more sophisticated. You know, there's, you know, there's that RIME acronym, they, you know, you guys are familiar with RIME

Erik: I don't think so.

Hamill: Okay, so theoretically, that's how we should be, evaluating you guys, putting you on the RIME scale. R is reporter, I is interpreter, M is manager, and E is – I don't know teacher or explainer or something like that. So yeah, as a first, you know, when you're on your first clinical rotation as a medical student, you guys are pretty much reporting what you find. It's very satisfying to me to see a student start to be able to interpret the values and certainly manage it, you know. They tell me the patient has hyperkalemia, they know to give kayexalate, and insulin and glucose and what have you.

Jason: We talked about fungi, I guess a lot in the lectures too, so why are fungi your favorite class of microorganism?

Hamill: Well, because they call cause cool diseases, right? So, you know, right now, a lot of the stuff, there's a lot of stuff out there about COVID, you know. But, I find it boring because, you know, I mean, I know there's a lot of things that can happen to patients with COVID, you know. I mean, besides having respiratory things, they have GI things, they have hematologic things, they have thromboses, blah blah blah. But I don't know; they don't have these weird skin lesions like people with fungi get, you know. And they don't have all these weird manifestations. And there's not cool epidemiology like there is with fungi, right? The epidemiology is really neat. The other reason I like it is because nobody else does. So, I can see myself as an expert so people will come to me with questions because you know I've dealt with it and that's where my expertise is and stuff. You know, and it's kind of cool that, you know, you see these diseases that have weird manifestation and they are – sometimes they can be very difficult to manage. And I think we don't – sometimes people, I don't think look at the little bit deeper into these diseases. For instance with cocci now, I think it's becoming pretty clear with cocci that if somebody has a very bad cocci infection that there's something wrong with their immune system, and people don't think that way. They think well, he's got bad cocci and we got to treat it. But I think we're finding now more and more that there's something wrong with their immune system. So actually, in the New England Journal of Medicine last week, they had a case description of a child who had disseminated cocci and had a bad infection and it turned out they ended up treating the patient with some of these immune modulating drugs, as well as interferon gamma, and the kid actually did very well. And then they genetically, they looked at him and he had truncation of a gene that allowed for – that caused the decrease in the interferon gamma production. We don't look as carefully into those things as we should in those patients. So I think anybody that has disseminated cryptococcosis, histoplasmosis, coccidioidomycosis, who doesn't have something obvious – we should, we probably ought to be investigating them because they probably do have something wrong with them. A lot more sophisticated than we can usually get.

Jason: Yeah, so fungi, pretty cool.

Hamill: Yeah, they are.

Jason: Yeah, kind of different. No, definitely – I when I was learning it I definitely felt like the clinical manifestations are like, very different from like bacteria. I feel like bacteria were like, very like, clear. Like a lot more clear out of in, like, a picture of what, what they did, but fungi really were like kind of all over the place with clinical manifestation

Hamill: But I think you know, a lot of times if you take a good epidemiologic history and patient you sometimes get some clues, or look at their underlying illnesses.

Jason: Hmm do you have a favorite fungus? We've talked about cocci a lot.

Hamill: Like yeah, I like cryptococcus. I think is probably my favorite. I mean if you can if you effectively treat somebody with cryptococcus you can help them a lot. It's probably not the most interesting in terms of its clinical manifestations but it's the most satisfying to treat sometimes

Jason: And then, okay, the next question I have is kind of fun one: as a residency director for like so many years, how have you seen students suck up to you?

Hamill: I don't know. I don't think they suck up a lot. Occasionally there will be a student though you know who want to talk, come in and talk you know, more than the typical. It's clear they want to stick around or something, but it doesn't happen too much.

Jason: Okay. Okay, cool. I mean it's like I feel like I've a lot of times, like, especially during lecture like okay, like no one really liked knows like your title or whatever, like, during lecture and be like, oh yeah, like, by the way, like Dr. Hamill is like the residency director and then they're like, oh like now he's like actually listen to him and I was like – what the, like why would you not listen, you know, why won't you listen to him before?

Hamill: That's right.

Jason: Why don't you attend his lecture, like you know, a six of the classes is attending his lecture? I don't really get it but it's fine.

Hamill: Does that give me more credibility or something?

Jason: I don't know. I don't know, it's fine.  Anyway, that's just a fun question. I guess after practicing, like medicine and teaching for so many years, what do you say is the most rewarding part of your job, either the medicine or the teaching?

Hamill: You know, I think just seeing how you guys mature over the years, you know? I mean, I've seen a lot of students come and go now and a lot of residents going go, and I always get sad, you know. We had our graduation two weeks ago for the residents, you know. We see them; unfortunately, we didn't this year, but most years we see them packed into a room on the first day, you know. They sort of have this deer in the headlight, look, you know, there's nowhere to go. But, you know, I usually round at Ben Taub in the end April-May, you know, of each year. And when I have a third-year resident running a ward team then, it's very satisfying to see how well they've done. You know, I would trust most of them implicitly with my life, you know, because they've done a great job and I think that's the most satisfying thing to see them come very raw and over just three years, you know, work very hard, work with a lot of camaraderie with a group, you know, and become just very, very competent physicians. That that to me is tremendous. We put out a lot of good physicians. Then to see them go on, you know, a lot of, you know, my residence now are, you know, they're faculty here and stuff, to see them being successful and stuff like that, you know, it's just very satisfying.

Jason: I mean, there they literally is a new class of interns, they're starting like what next Wednesday, right?

Hamill: They start Friday, but they're here now.

Jason: They're here right now?

Hamill: And just before you got on, I was just finishing up our bootcamp online. But we had a camp today with them. Yeah, I met him all, we had a drive-through in front of the McNair building on Thursday and Friday for them to pick up their white coats, and so they're all in town and a next Friday I think they start.

Jason: So they have the same look, the headlight.

Hamill: Yeah, yeah, although you can't see them all in one room.

Erik: Has COVID changed anything about how like it's going to be structured or is it going to be pretty much the same way?

Hamill: Well, you know, I mean, it has changed the orientation completely, right? Everything is online now. We had our orientation yesterday morning, it was all online. All the Baylor, orientation's online. Except for you know we have to do a donning and doffing gown thing for them, you know? And we certainly are doing the n95 Mask fitting now. And yeah, you know we have to have them socially kind of separated in the team rooms and stuff, which to me is unfortunate because you guys have been through medicine, right? I mean, you know how it is when you're in a team room, you sort of through osmosis you pick up things, right? A little things you know, how you put this order in? What is this low potassium mean? What is it? And we don't we're not going to have that because kids are going to be scattered around a little bit more, so I think it's going to be detrimental to their education. So I do really hope that we get through this thing pretty fast. Actually, myself and Amy Angler. I don't know if you guys know Amy, she just graduated from the medical school. She's gonna be one of our interns. She and I were interviewed yesterday by a woman from the Houston Chronicle. There's going to be an article in the chronicle I think this week or next week about the interns starting in this era. Look for that.

Jason: So I guess, what has been like the least rewarding part of the most frustrating part of your job?

Hamill: Well, I think the amount of paperwork over the years, and the amount of regulatory things that have occurred, you know. I feel bad for the residents because we're just – we're always hitting them up with, you know, you got to do this training and that training and stuff that they never had to do in the past. This year was particularly bad because, you know, three of the four hospitals that they train at all had CMS things. And so they had to do a tremendous amount of training that really was duplicative but all three hospitals required it, right? And so they had to do it on multiple occasions for all. Plus you know, they have ACGME surveys, and they got to do duty hours. They have to do training on compliance and they got to do ethics training and human research, and HIPAA, and I mean, there's just a huge amount of training that they didn't have to do before. For all this training, they could be taking care of patients, and they could be getting so much more out of it. So that bothers me and then all the paperwork, that's involved nowadays. The other aspect I don't like, is that just in case there are disciplinary problems, you know. We don't have many of those, fortunately, but we do have some remediation issues occasionally with residents and that's very unpleasant because as a whole these kids are pretty good and yeah but sometimes people just can't put two and two together, you know. Yeah that's just not satisfying.

Erik: Well I've heard a lot of – we've interviewed quite a few people who have sort of been around long enough to see the paperwork build up and have said, similar things. But I've also talked to some people who have said, you know, doctors have always had a lot of paperwork to do it just you just used to handwrite it. Are you talking specifically about like EMR stuff? Or - because like notes in general, you've had to take since the beginning, right?

Hamill: I think the paperwork burden is more the regulatory documents.

Erik: Gotcha.

Hamill: So, when I trained, obviously all the records were handwritten. I don't think that was optimal. The hospital where I did my residency at the time, had the largest inpatient oncology population in the country, bigger than MD Anderson. And so we would see patients, that would have a chart about 2 feet high.

Erik: Wow.

Hamill: And you had to go through the chart every time these patients were admitted and calculate how much doxorubicin they had gotten, so we'd stayed below the 250 milligrams per meter squared, you know. So you might spend hours going through the pages of this chart, trying to find that. Well, the EMR certainly facilitated that type of stuff. But on the other hand, it's taken people away from the patients and patient's rooms because they're sitting in front of computer because there's so much a data available there that they sit there and get it all, instead of being with a patient. I think that's the major thing that that I don't like about the EMR and that's been commented on. You know we had Robert Wachter or who's the chair at UCSF and he wrote that book, the digital doctor. It's a good book but one the pictures he has in there, one that the daughter of one of his patients had drawn his back is to the patient looking at the record, you know. I mean that's been an unsatisfying component of this medicine these days.

Erik: Definitely.

Jason: Even as a med student, I feel like I can just be, like, in the mornings, I'm like, I can be in front of the computer, like the entire morning up till it rounds and like, forget to see the patient. I have to like, time myself, like, okay, I just could spend like 20 minutes and then anything that I don't get in the 20 minutes, I just going to see the patient and then I can come back to, it's fine. I don't have to get like every single little thing. But yeah, that's definitely something that I've noticed, like even for me like oh my gosh, is like so much stuff in the morning. There's all these new labs like all these new all these new tests.

Hamill: You know, some of the residents couple years ago, it applied for one of these ACGME grants, back to the bedside grants, and had developed this program to, you know, interview patients about things other than their medical issue, you know, where they live, how they grew up. If they were a veteran where they would Branch the service they were in and do they see combat or something. But that's sort of been curtailed now because of this COVID thing because you can't get everybody in the room now, to listen to those stories, you know. Which is unfortunate because that program was highly liked by the residents. It's unfortunate that this whole issue is sort of taking us away from the bedside again. We want to minimize our exposure to these patients. I had an attending when I was on a fourth-year student for infectious diseases. He was a world-renowned infectious disease expert, but he was a jerk. But one of the things he told us was you never sit on the patient's bed and you never touch patient except to examine them. Subsequently he went all over the off, the dark end to the dark side. It's one of those people that gave a massive infusions of vitamin B12 and you know chronic fatigue syndrome blah blah blah stuff, but he was just wrong, you know, you touch patients, she said in their bed, you talk with him. That's how you connect with your patient.

Jason: I remember – it was during one of your lecture, you had said this kind of like – I don't know, it was in response to a question and you said almost subconsciously, like, "sometimes it's nice to touch your patients". I forgot what the response – what the context was. I just remember you saying that? And yeah, I yeah, I definitely remember that though.

Erik: There was – I actually saw lecture of, I think it was another physician from UCSF doing like a TED talk about sort of the healing touch of like just even just like a pat on the shoulder or like, you know, just human contact.

Hamill: Yeah.

Jason: Especially now during covid, especially the patients who have covid. It's like I feel like I'm sure like nobody touches them; we're gowned up and like have goggles and like

Erik: can't see their loved ones.

Jason: Yeah, can't see their loved ones.

Hamill: It's like they're lepers right?

Erik: Last question or last two.

Jason: Yeah, maybe like last question. I guess how have you seen medicine change over time?

Erik: We've already talked about EMR. But yeah, but any others?

Hamill: I think part of it is, you know, like the hospitalist movement. I mean there's good and bad for the hospitalist movement. It clearly is more organized and stuff, but there is too much of a push nowadays to get patients in and out of the hospitals. You know, I remember, when I was a resident, you know, we rotated through the VA to, you know, and back then, the patient in the hospitals were in big ward's, you know. You didn't have individual rooms and so you might have 20, 24 patients in a room. Well, at the VA, you know, these guys were all vets, you know? And a lot of more World War Two vets. So they'd sit around telling War Stories all day long and they never wanted to leave the hospital? They didn't want to be discharged and they stayed around for months and months, you know. But, you got to see the natural history of disease to, right? You got to see things work out. Nowadays patients are kicked out of the hospital so quickly that you don't get to see the stuff. So five, six, seven years ago, I was running on general medicine in July and we admitted a young man from Kingwood who had a family normal guy, you know? But he was admitted with aseptic meningitis, he wasn't real ill, you know, we thought maybe it was West Nile, but all the testing came back negative as he was being discharged. I asked the house staff will get a typhus antibody on him. Well they didn't and he got discharged and he was supposed to come see me a couple months later, he never did, but this was July, he showed up in January. He was fine, but I got a typhus antibody then. Well, his IgG tighter was off the wall. So the house staff and students, never knew that, right? Because I didn't remember who they all were and stuff. And yet I found out what that guy had, you know, and it helped me because down the road, I've seen more patients like that. So five, six years ago, we had one of the guys who's head of General medicine that you at San Francisco VA, who's Gupreet Dhaliwal. And if you guys get a chance, you should Google him and see some of the stuff he's written. But he came as the visiting Professor Chief residents at the end of the year, we get to invite a visiting professor. And he was the visiting Professor, so his lecture was from good to great. And we talked about was what you guys need to do, is you need to keep a list of all the patients, you see, then periodically go back in the record and find out what happened to them because you certainly don't know when they leave the hospital and when you find out about that then that's what makes you great. Because you found out you seen what happened to your, either to your therapeutic intervention, or your diagnostic things and that's what that case sort of demonstrated to me. So that's been I think one of the major problems with medicine and DRGs and stuff like that trying to get patients out of the hospital and not being able to see what happened to them. Unless you make a real concerted effort to do. Then if you make that effort, you're going to learn a lot more.

Erik: That's pretty interesting. I didn't think about that, the longitudinal course of patients, you really miss out on it.

Jason: Literally one of the patients that we have right now, we suspecting like an autoimmune cause, but everything's being done outpatient. We're trying to get her out.

Hamill: Yeah.

Jason: In the clinic and everything's been done outpatient. I'm like, I really want to know – she's got like elevated ESR; that's the one test that's come back already. Everything else like we're just we're going to discharge her and then follow up. You know she's gonna have to follow up outpatient. I'm like I am dying to know like what she has actually.

Hamill: Well that's why you got to write down her name, medical record number and then find out what happened to her because then you'll learn something.

Jason: Yeah, yeah

Hamill: Either you're on the wrong track or you were on the right track.

Jason: I guess, last question. So what do you see in the future of medicine?

Hamill: Well, you know, I don't think, I think there will be more of a telemedicine impact on medicine, but I don't think it will be to the extent that it is now. I mean, I think we'll come up with a vaccine for this COVID thing, or treatment or both. And I and so we'll get through this. There may be other pandemics in the future. But I think what this has taught us is that we can respond pretty quickly and that the scientific Community can come up with treatments and stuff like that, so, I mean this will be short lived. But telemedicine, I think we'll have a more impact. I think we will unfortunately probably move more and more away from the bedside, less into inpatient medicine, more to outpatient medicine because we can do so much more as an outpatient work people off. I'm hoping that people will still see the intellectual challenge in medicine and not, you know, not get too cookbook-y about it because sometimes we seem to see that. But I still want people to enjoy it. You know, like I do. I'd like to see the regulatory environment not get so burdensome so doctors don't want to practice. Because you know, I mean I've enjoyed my career, and I want young guys like you guys to enjoy your career, and I don't want to have people make it so burdensome or so difficult that it's like a job and not a, you know, a hobby or something.

Jason: That is the dream for the job to be something that we really love and really enjoy.

Hamill: But I think you can do that, I mean. But you got to you got to take an effort to make it what it is.

Jason: Definitely, definitely.

Erik: Well yeah. And I mean do your point of what you said earlier about how you you like teaching because you think you have a lot to kind of teach us who have not seen nearly as many things as you, I think that's absolutely true and that's one of the reasons we were really happy when you decided to be interviewed by us, we really appreciate and we do think you have a lot that we can learn from. So we really appreciate your time, we know that you are busy, so thank you.

Jason: Appreciate you teaching us also all about the even the diabetic feet. Yeah. And we're not just saying that because you're the residency director, okay.

Hamill: You know I tore this thing out today. Can you see that? Oh drinks. Yeah. Oh man you got we have two new faculty members starting at the VA in July. Two of our fellows and ID section and I want one of them to get interested in diabetic feet. As they're saying here, you know, in the last 20 years, there's been no change in Canada, absolutely no change in the incident to diabetic amputations for diabetic feet. Whereas other things, you know, have improved a lot, so we need some work on diabetic feet.

Jason: Yeah, some new innovation. Yeah, yeah, alrighty. Well yeah, thank you so much once again.

Erik: Yeah. Thank you.

Hamill: Have a good day.

iTunes | Spotify | Google Play | Stitcher | Length: 40 minutes | Published: June 30, 2021

Dr. Joanna Fields-Gilmore discusses her work as a family medicine doctor and training in the Compassion and the Art of Medicine Elective.

Transcript

[Music] 

Erik: And we're here.

Juan: Yes we are.

Erik: This is the Baylor College of Medicine Resonance Podcast. I am one of your hosts, Erik Anderson.

Juan: I am another host, Juan Carlos Ramirez.

Karl: And my name is Karl Lundin. I was the writer for this episode.

Erik: Yeah and so today we're going to be talking with Dr. Fields-Gilmore about her experience as a family medicine practitioner and Karl

Karl: So yes, we are going to be talking today to Dr. Joanna Fields-Gilmore, one of the wonderful faculty members we have here at Baylor College of Medicine. Dr. Fields-Gilmore is a family medicine specialist. Family medicine is a very important field; when people think of the classic community doctor, that's a family medicine doctor. They do it all: they take care of adults, they take care of kids, they take care of pregnant ladies and babies and all that stuff so really kind of the jack of all trades type doctor. So it’ll be cool, we'll get a chance to talk to her and get some sort of insight into that particular field of medicine and what it's like to be kind of integrated in the community as a physician. We'll also get to know Dr. Fields-Gilmore more personally, kind of hear about some of her background and what brought her to Baylor which will be really cool stuff. And we'll also get to hear about the course that she recently took on as the director of which is Compassion and the Art of Medicine. It's a really cool elective course offered to first-year medical students in the fall every year, and then also second-year medical students kind of come in as sort of small group facilitators for the class. So it's kind of a fun time.

Juan: It’s a great course. I took it actually. It's more a lot along the lines of just understanding people a little more. It's not just like their illness, systemic issues you know just problems that are going on in the world that affect people's health even here in Harris County. I remember some of the speakers that came over to talk to us like directors of homeless shelters and stuff like that. It's really good, kind of like an eye-opening experience too and I think you take a lot away from that. It’s a big slice of humble pie too.

Karl: Yeah. I think it kind of once again gets to sort of a part of our medical education that we sometimes don't think of; you know a lot of it is focused on book knowledge, on learning these various scientific and medical facts and problem solving skills and all that is very important to the practice of medicine, but another important thing about medical practice is the relationship you can build with your patients and with the community and how you can really learn from your patient how to best care for your patient. And so Compassion and the Art of Medicine was really, I also took the course, really valuable in sort of offering a chance for us to expand our perspective and develop some of those compassion and empathy skills. Because when you have a patient come into the room and you talk to them, they're bringing a whole lot of experiences of life with them and it's important for you to be able to reach out and try to learn and understand that patient so that you can best treat them and best manage their care. And we're going to get into her vision for the course, kind of what the course is all about and some of the cool stuff involved around that too. So it should be a good conversation.

Erik: Yeah, yeah definitely. Well, without further ado, Dr. Fields-Gilmore.

Karl: Well Dr. Fields-Gilmore, thank you for joining us for the podcast today. We appreciate you working through some technical issues because we are actually recording this, for those of you that don't know, during the Covid 19 sort of social isolation period of time, so we're having to do this virtually. But we appreciate you joining us today.

Dr. Fields-Gilmore: Thank you for having me.

Karl: We're glad to have you. So we thought we would just start off by asking you to tell us a little bit about your background, your education, where you grew up, all that sort of stuff.

Dr. Fields-Gilmore: Well I'm a native Houstonian. I was born and reared in Houston, and then I went off to Nacogdoches, Texas to do my first stint of college. So I got my bachelor's there and then in Indianapolis, Indiana for the for my second graduate degree and medical degree and then off to California for residency training. So I've been a couple of places. I've also been to Africa, did some work there while I was a fourth-year med student and also with one of the professors that I worked with when I was doing one of my graduate degrees. And my experience after residency, I was a national health corps scholar and in that experience you have to do four years of service time and no, they don't pay any student loans while you're doing that service time, which I'm doing in rural areas. And so I was in Laredo, Texas, which is right across the street from Nuevo Laredo, and if you know anything about that and the drug cartels and those kinds of things that were going on. Just a really interesting experience so far, because everything has been with underserved but just a lot of different areas and a lot of different regions that I've worked in. So it's been interesting.

Karl: Yeah, it sounds like you had a lot of different experiences in a lot of different places. Sounds kind of cool, you know lots of opportunities. Just out of curiosity, how long were you in Africa and what were you doing there more specifically?

Dr. Fields-Gilmore: So at Indiana University School of Medicine you had the opportunity to go to Kenya to do some work. And for me, I did not end up going to the traditional place that they go to in Kenya for Indiana University School of Medicine. I ended up doing missionary work so I ended up doing an Africa inland mission and I was in Kajabe. So Kajabe is an hour outside of Nairobi up in the mountains, and I went there right after they had their internal unrest. It was kind of like a civil war, if you will, where the largest group the Kikuyu was warring with the another group because of the election that they just had. This was in 2000, between 2008 and 2009. And so I went there right after they had that. It was kind of iffy whether or not I was going to be able to go because it was so dangerous. And so that was a different experience because the people that we saw were people who were coming in from having been internally displaced: what you would call refugees but they called them “internally displaced people” while I was there. And I went and we gave medical care to the people in the internally displaced camps, but they also made their way up to the mission hospital that I was a student physician at.

Karl: Wow. How do you feel like that kind of informed your subsequent experiences in your practice as a doctor?

Dr. Fields-Gilmore: You know, I'm going to tell you when you are a fourth year medical student you’re, I mean throughout your whole experience, even now I'm an attending I've been out of residency for a while and I didn't, you know, I've been working for a while and you still don't know everything. So when you're up for the amazing… it's scary, it's exciting, it can be fun and if you go to a different country and you get some down time you're able to explore. You get to know a different culture; hopefully you learn a little bit of the language, but when it comes to the medicine you're a fourth year med student and you know, you have a lot more responsibility in that situation than you do when you're here doing your clinicals in America. 

Erik: I'm curious, what ended up making you want to come back to Texas eventually? Or did you always want to come back to Texas?

Dr. Fields-Gilmore: You know, I had no plans to come back to Texas. I was going to stay in California. I came back because of family. I helped my family: we had some illnesses and some people passing away, and I came back to help my mom and ended up staying here for a whole lot of reasons that had nothing to do with wanting to stay for medicine. So I'm here. I mean I just bought a house.

Erik: So was there anything particular about Baylor that made you want to come and become a faculty here?

Dr. Fields-Gilmore: I'm going to tell you this: I have always wanted to be in the Baylor family. I wanted to go to Baylor's undergrad, I wanted to go to Baylor for med school, and I wanted to do residency at Baylor. So when I was finishing up my service as a national health corps scholar, I was looking around and I had an opportunity to be a partner for a clinic, which is scary in and of itself because you got to put a bunch of money in. You have to decide whether or not, you know, do you think this clinic is going to thrive or die? You know, lifestyle. So lots of decisions and Baylor looked like they had an opening, so I said, “Ha ha ha ha, I'm gonna try,” because I hadn't been accepted by Baylor up until now so I was like, “Ah, this is just, you know, a formality; I'm just gonna fill this out.” And I went for the interview and everything and actually I had got no emails that they picked another candidate. And so I said, “Okay, well well…” And me being the kind of person I am, I always want to know well if I didn't get that position then I want to know what would make my application stronger. And I think that this is something that anybody can learn from: if you don't get it the first time, then find out what makes you a stronger candidate so that if you want to try again then you can try again right. So you need to do more volunteer work, you need to do this that and the other… And I emailed and I got the email back and it said, “Oh no we wanted you! You got the email on mistake! We want you to start.” And I said, “Wow! I've got the job!” And so all the other, if I had at least two or three other opportunities, I said, “Okay, I'm going to go with Baylor because I'd always wanted to be a part of that. 

Karl: Oh that's very nice, that's very nice. In terms of the field you chose: you're a family medicine doctor right which we were just wondering first of all, what interested you in family medicine? And then what do you feel some of the unique opportunities you have and challenges in that field? Because it's kind of like, I'd say personally for me, my perception of family medicine is you are the closest interacting with the community as a whole. 

Dr. Fields-Gilmore: So I have a master's in public health, and I earned my master's in science and my master's in public health. I earned it before medical school. So when I got to medical school, I was older; I was non-traditional because I had two math degrees prior to that and worked and everything before that. I love public health! Absolutely hands down, a lot of public health and programming was my area, and I just really enjoyed it. And so for me, as I was going to medical school I knew that I wanted to do something that kept me involved with the community, okay, and would allow me to have that interaction with the community. So family medicine was one of those, one of the three or four on my list of what I wanted to do as far as matching was concerned. And so my because my personal mission statement was to serve the underserved and affect positive change in any community in which I served, so that's where I wanted to be because I wanted to continue to be able to do the public health things, do a program right, and try to make some mass changes. Not just one-on-one change, but do some programming and things that would hopefully help a whole community.

Karl: Yeah so do you feel like, what are some of the more unique opportunities or kind of the unique aspects of a family medicine doctor's position that allow them to do that in the community?

Dr. Fields-Gilmore: So over the years, because I'm not just going to focus on the Baylor experience, it has been helpful when you're, when physicians, especially family medicine and internal medicine, when they're able to do different types of programs that meet the needs of the community. So if you go into a community and you see that there's a lot of one type of disease, and it may be some lack of education knowledge or access to a resource. And if you can improve upon that to then improve that area, then that's what makes the job as exciting. To wake up in the morning and to continue to do, you know. And so that's a positive aspect of family medicine is being able to have that. With Baylor it's quality improvement projects, it's working with the students, and when the students have projects to work on with the community residents as well. So that is what the opportunity is, and that's what makes it good. 

Erik: It used to be more of a tradition to have actually in-house visits from physicians, and I could see, you know, where you'd actually go into people's homes and see them rather than coming to the clinic. As a family medicine physician, is that something that you would want to see come back, or do or do you think the current way that we do things where, you know, people come to us is the best way to do it?

Dr. Fields-Gilmore: I think that having a mixed bag is good. So when I was in medical school, there was one doctor… What’s her name? It was doctor… Obeime! Mercy Obeime, and she's big time in Indianapolis. I worked under her and shadowed her and was a student of hers for a long time, and she had an, I don't know what her position was… She was a medical director and a bunch of other titles and stuff. But she had the doctor's bag, she had an old school doctor's bag, and one of the things that she did amongst all the other things that she did was she went to people's homes. And so she had a clinic, she had her own clinic, it was thriving, she had mid-levels and she had another physician who worked with her. She was affiliated with the hospital; like I said, she was a medical director, she did a bunch of volunteer type of programming, she even had a foundation, they would go to Africa. So she had a lot of stuff going on and she did some home visits. When I was training in residency, we did home visits. So I think that them coming to the clinic is good because you have a more controlled environment and it's safer actually, because sometimes you never know what you're gonna walk into. But also going to see where someone lives, because we did that and I think… I can't remember… I think we did a home visit in medical school, but I know we did it in residency, especially for our diabetic patients; we went to their homes, we looked in refrigerators, you know. We did their foot exam there, we did all of that. So it's something that is done, you know. It can be done.

Erik: Well that's good to hear, and the fact that you were doing it, I guess maybe I just don't understand it enough; it seems to me that it's always just clinic visits and the home visit is being phased out, but maybe it's not. Would you say that it's not actually as gone as maybe like, for instance, I might think?

Dr. Fields-Gilmore: I think that because you're at an institution right now, the area where you are in your training, you're not seeing it then it doesn't seem like it exists. But you got to remember that you have a whole life ahead of you in this, and you will see a lot of different things you know like, “Oh they never did that there, but they do that here.” And now you know I tell people I switched around a lot. I didn't stay in one spot, and I know some people there they are successful when they go from undergrad to medical school to residency and they stay in one spot. If you can move around and if it's good for you and if it's successful and it makes you know, your curriculum vitae look good and all that, move around because you're going to have different experiences. And I think that that's it.

Erik: Yeah actually Karl and I both took a number of years off, so I think we both agree a lot with that sentiment.

Karl: Definitely. So a little bit of a change of topic, but one of the reasons I reached out to you to schedule this interview is because I actually took your Compassion and the Art of Medicine course my first year in med school, and I enjoyed it a lot. I understand you recently took over that, and we were just interested to ask you some things about that. Like what interested you in the course?

Dr. Fields-Gilmore: So I applied for the course because I had done the Healer's Art with Dr. Michelle Barrett, and she's a UT physician pediatrician, but the healer's art course has both Baylor and UT students. And you know what you guys experience in residency, in medical school is completely, completely different than what we experienced. We experienced a lot of the things that you guys now are able to report on; if somebody does something you can anonymously report. And so we endured that. And so when I was invited to do Healers Art, I was like, “Wow, they have something where you can actually just, you know, get some things off of your chest and you're not gonna get in trouble for it,” and I could be a facilitator for that. And I was actually really scared to be a faculty facilitator, but it ended up being wonderful. So then when I saw the Compassion and the Art of Medicine course director position opened up, I was like, “I could probably do that,” and I was chosen. So that's what made me do it, because this type of thing, it was not even in the stratosphere of the universe for medical schools to be thinking about how people, how the physicians feel, how they're training trainers. They didn't get somebody to ask you how you felt; you get up and you go to go do what you got to do and, you know, make sure you get your grades. Nobody asked you how you felt and how did it feel when somebody that, you know, as a student you cared for died or something. Nobody. Yeah you just kept going, and so I was like, “This is awesome that Baylor's doing this.” I just was really excited about the fact that this was being offered to the students because it wasn't offered for when I was training.

Erik: And do you want to explain what it is just in case there are people that are listening, or either one of you I guess. Just a brief synopsis.

Dr. Fields-Gilmore: Karl, you do it.

Karl: Yeah yeah; it did occur to me that we should probably provide some context. So Compassion and the Art of Medicine, it's basically a really neat course they offer at Baylor where first year students come in, and there are second year students that also come in and they facilitate actually, but the first year students they come in and basically there will be different guest speakers talking on different topics. And they all kind of have to do with, I guess what you call like the “softer side” of medicine, right. Not so much about like facts and figures and scientific data on patient treatment, and more about how to treat a patient as a human being, how to treat each other as human beings, as physicians, as other health care providers, and how we can sort of keep in mind our interconnectedness and have a holistic approach to the way we conduct ourselves in a medical environment. So, for example, we had a speaker come in, a doctor who talked about his own experiences as a parent of a child with a certain, like I guess you call it like developmental and health issues. I think she was deaf-mute, was that the correct um expression? And just kind of getting insight into what that family's experience was like and what we can do as physicians to help people in that situation and provide the best care in that situation. And I'd say really more than anything it's about developing your empathy, right? Not just your clinical acumen, which we're learning in other areas. But here we're learning how to be an empathic doctor and a doctor that really knows how to reach people where they are and be with them in their struggles. 

Dr. Fields-Gilmore: So that's my view, and the one thing that I emphasize, because I don't know whether or not it was emphasized before I became the director, is because in medicine all of our brethren, we have been trained and we are often trained to ignore ourselves. And now that we're in this pandemic with covid-19 and you see all of our brethren who are passing away who are not getting their protective personal equipment and things of that nature, it's important, it is paramount, and Karl knows I say this, you have got to take care of yourself because if you don't give yourself compassion, you cannot give compassion to your patients. And so that's the thing that I bring to the table which I know for a fact has not been something that has been trained into physicians is, you know, don't be the martyr. Yeah, the reason why you can be a hero is because first you be a hero to yourself, take care of yourselves. If you, you know, go take a walk, I tell them go call the grandmom, if the grandma's still alive. Walk the dog. Those kinds of things. Do that self-care, because then you're able to be in the present and be in tune for the patients of what they need. So it's very important that we take care of ourselves.

Erik: Yeah that is, yeah. Do you have any, and you mentioned already how important it is, especially during this time, because, you know, of what's going on. Have you found it harder because of that, or do you like, maybe just because I'm sure many people are working longer hours now too?

Dr. Fields-Gilmore: I think that just like everything, everybody else and every other position, we're all on edge and so to be aware of that and to be aware of your own anxiety, to be aware of your own concerns, is really important for your health, for if you have family to take care of and then for you to be able to take care of the patient that you see. Also, to be a positive advocate so that you are protected to be able to do the job. Be smart about the job and be an advocate to be able to get the things that you need so you can do the job, so you can live to do the job. It's very important.

Erik: Okay, yeah. No I agree. So we kind of already covered this, but what would you kind of summarize is the kind of experience you want students to get out of the Compassion and the Art of Medicine course?

Dr. Fields-Gilmore: You know every year, I think it ends up being different because it takes, actually it takes a life of its own. As far as the theme, I start off with saying I think I want y'all to do to talk about each speaker, and then for some reason they all end up having a theme that goes together. And they don't talk to each other. I've said this before, I'm like, they don't talk to each other, they just ended up, that year ends up being about; this last year we ended up talking about homelessness a lot. So basically, for the course I talk to the speakers and I just, I go to them and I ask them to talk about different thinking for as far as what they, where they're coming from. So if it's a clinician, you know talk about these types of experiences. If it's, if it's, because sometimes we don't have just physicians, we have different types of people in the community coming in, and I ask them just kind of because you want people to talk about what they're good at. And that's how I approach the course each year, and it ends up being just really good. Because I don't, I try not to, I try not to control too much of what they're gonna say. I mean of course I say, you know you can't be saying a whole bunch of stuff that you're not supposed to say. You know, these are students! Don't be unprofessional, but, and because you know that’s what is so great: we all want to talk about compassion, we all want to talk about the stories, the antidote to stories that we have about our experiences with these, with our patients, and with the people that we interact with in the community. We all want to do that, and we don't really often have a chance to. And I'm not sure if a lot of people are able to talk about these things at home. You know, you gotta adhere to HIPAA, but you don't really have an opportunity to talk about that too much. You just keep doing the job, and so a lot of doctors and a lot of people in healthcare love talking about their experiences and imparting that wisdom. So I guess that's kind of a lesson in and of itself: the approach, instead of like having a set agenda, you kind of let the speakers to a certain extent help bring the agenda in the same way you should probably act with a patient. You don't just come in and say this is how this is going to be, you kind of see where they're at and let them help participate in the encounter. 

Erik: Okay, that’s very good. Well, to switch gears a little bit, to more generally talking about health care, we were curious if you have any thoughts on the contrast between private and public health care? Yeah, and just what your experiences have been in those spheres.

Dr. Fields-Gilmore: In private healthcare you have a lot more leeway than in public. Because you have some limited resources, you kind of have to make decisions and decisions are made for you about what can be done because of the limited resources of limited funding. Both if you're serving the underserved, you're serving the same population, okay same population the private sector. And like when I was working as a national health corps scholar and I was in the rural areas, they didn't have access to the gold card in Harris Health, right? They didn't have access to the Harris Health system because things like the Harris Health system exists in a lot of major cities. There's the, I think John Peter Smith or something like that in Dallas. So you've got that in a lot of major cities, right? Where the underserved can have access to care and they don't pay very much at all, but in the rural areas they're resilient. When I was in Laredo, when people needed procedures and things they would have bake sales.

Karl: That's great! I love that!

Dr. Fields-Gilmore: Yeah, they have bake sales to pay for that cholecystectomy or something like that, you know. And it's a different approach, the population, depending on how they get, how they have to go about getting what they need, you're gonna have a different type of mindset in your patient, right? And so you if you think about that, because if you have access to something, you're always able to get lab work and images and health care, and you don't really have to pay for it as opposed to, in order to get that lab work you have to find the money, you got to ask family members, you gotta have a bake sale, you gotta, you know, go to the church. So it's just, it was different experiences. Public health and public access to care and private, but both, I was serving both in both areas.

Karl: So would you say it's kind of like, for the underserved population specifically in kind of the public health system, you can not worry as much about the cost for basic kind of care things, but maybe you don't have as much freedom, whereas in the private the main concern is, “How are we going to pay for this?” but we can kind of do whatever I think is going to work best? Does that kind of make sense?

Dr. Fields-Gilmore: A little bit, but not, you know that might be five to ten percent. Because you're still worrying about money, okay. You, with the patients worry about the cost of things either way, okay. Because again, because in the public sector there's no, there's not a lot of funding. There's not a lot that they're going to get, right? This is what you get, and so then they end up having to figure out what are they going to, how can they get the money to get what they need. And then who do they access. Because they're so used to having this system where they have this access, this easy access to this; now they got to figure out, “Well who in the private sector can they contact?” Do they have a sliding scale? Are they going to work with them financially? And all of this other kind of stuff. So those are those challenges. And then they start thinking about, “Let me have a bake sale.” 

Erik: Are they the same? I mean, I guess this is probably going to depend on obviously each private and public hospital or clinic you're working at, but do you find a similar amount of like patient load in each one?

Dr. Fields-Gilmore: Yeah, you do. It's just a lot of people who need, a lot of people who are in need either way. 

Erik: Yeah okay.

Karl: I guess this is another thing we touched on a little bit, but just and kind of in general, how do you feel uniquely as a doctor we have power to impact the local community in a way that maybe somebody in any other position in the community doesn't?

Dr. Fields-Gilmore: I think that if you know and you learn and you're training how to make those connections, and you learn how to not just think about going to work. So that's why in the course, I try to have different types of people come and speak different perspectives. Because if you're not careful, you as a training physician will only think about, you'll have tunnel vision basically; like this is when you have a lot of different ways in which to get some things done. You can collaborate with a lot of different types of people and just have a lot of different connections and have a broader network. And so that's really important in order to get stuff done that you want to get done, that you need to get done, and then when things come about that you see need to be done in a community or with people and patients, then you have that network and connection and you can hopefully make it happen. I mean, and that's why I tell y'all in the class, sometimes it's not gonna work out right. Do not take that home and let that eat you up, because you know we're only human and you do the best that you can with what you have. But if you work really well at making connections with people, then you'll have more access as a physician and then hopefully you can get some things done when the time comes. 

Karl: And I guess that kind of ties back in with the concept of self-care…

Dr. Fields-Gilmore: Right!

Karl: And making sure you're taking care of yourself, because if you take care of yourself you're going to be more likely to love your job, enjoy your job, have the energy to make those connections, just do those initiatives to really push to get things done for your patients in the community. 

Dr. Fields-Gilmore: You're gonna care! 

Karl: Yeah exactly. Yeah little thing called burnout we're trying to avoid.

Dr. Fields-Gilmore: Exactly.

Karl: So I guess we're getting close to the end of the interview, doctor. We really do thank you for your time, but we do have one last kind of big, broad question for you which is: just how do you think we can most effectively demonstrate compassion  in our daily lives towards patients, towards the people we interact with in the medical field, and just in general? Like, what is compassion to you and how can we demonstrate that to others most effectively?

Dr. Fields-Gilmore: I think the most important thing to have to be able to demonstrate that compassion and to have it there at your fingertips is to always reflect that upon yourself, your family, your own experience. Think outside of yourself, think outside of your family, think outside of your own experience, and then say, “What if that were my mom, my son, my daughter, my, you know, what if that were me?” And then go from there, because you know, you, like I say in the class, you're gonna be tired, especially as a training resident. You're gonna be really tired and you're gonna have a lot to get done in a short amount of time and somebody's gonna be trying to give you their whole life story sometimes. And you're going to have to take the take a seat and take a moment, and you may not be able to sit there, listen to the whole story. But like they tell you when you're training, the history is the most important thing, right? You got to listen and even if you don't get the whole story right then and there, at some point you're going to have to listen. And sometimes you don't want to listen, because listening is the hardest thing to do. And then when you're really tired, you really don't want to listen you, just want to get it done. You just want to get the labs on, you want to get the images done, you want to figure it out, but sometimes you can't figure it out from the labs and images because you hadn't even sat down to talk to the patient. So just remembering that if it were you how would you want to feel, and I think it's also important the more experiences you have. I've been a patient, you've been a patient, you know, you were a kid, you were, you know, a pediatric patient, you'll be a patient as you grow older, and as you grow older you're going to have more experiences with the health care system because that's just the nature of growing older. And I think that's one of the reasons why a lot of your older doctors typically show more compassion, because they have more experience with the healthcare system as a patient. I think that's something that we all need to remember, and it's really hard if you don't have experience with healthcare as a patient. It's hard to understand when I'm talking to my students at residency, and there'll be something like, I had a preceptorship, I was precepting a resident and this patient's legs were like swollen and when your legs are swollen, yeah they hurt, I mean. And if you've never experienced that, you don't know that. So if, you know, my residents are like, “Oh we're just going to do this and just send them home,” and I'm like, “Have you ever had your leg swelling like that!? That is painful!” Like no, we're not just gonna do that. So that's important, to just think, “If I had this situation happening with me or if it was happening to my mom or my grandmother or my brother, you know, how would I, what else could I make you do?” You know, and one of the things is just asking more questions outside of just the health questions, you know, “How are you feeling?” That's “How are you feeling?” like “What's your pain level?” But “How are you feeling,” right? One of the things that I am learning consistently is with patients, it's not how you make them feel but how you make them feel. Yeah okay, so patients remember that they remember how you make them feel, because our goal is to get those numbers right. Our goal is to get those labs right. Our goal is to, you know, if you're a surgeon, you're going to fix it, but how do you make them feel? 

Karl: I mean I've already seen that a couple times in my very limited clinical experiences where sometimes it's like, doctor, in your example, “My legs hurt,” right? And yeah, they want you to stop their legs from hurting, but they also just want to feel like you actually care about them, you actually are empathizing or sympathizing. You're there with them in the struggle, and yeah. I get what you're saying when it's not about how they feel, it's about how they feel, you know.

Dr. Fields-Gilmore: Yeah. Exactly.

Erik: Well, I think that's really great advice for anybody, for everybody that's practicing medicine. I think we could all work on being a little bit more empathic. And so we really appreciate you taking the time to talk with us, because we know that you're busy right now. So yeah.

Karl: Please stay safe, you know. We appreciate what you’re doing.

Dr. Fields-Gilmore: Yeah yeah. Y'all stay safe. Y'all keep learning and listen, we're going to get through this Covid 19 pandemic. And we're going to have so much more information, it's kind of, I mean it sounds, it's kind of interesting to learn all this stuff, and we're learning things every single day. So that's what we kind of as scientists and physicians and, you know, and if we like that kind of stuff, but we don't like it the way it's happening, okay? We would rather not it be happening this way. So we're going to get through this. We are, so just stay safe, and you know, take care of yourself. Take a walk, do some exercise, drink plenty of water, and get some sleep.

Erik: Exactly. Well thank you.

Karl: Thank you very much. 

Dr. Fileds-Gilmore: Alright bye-bye.
[Music]

iTunes | Spotify | Google Play | Stitcher | Length: 38 minutes | Published: May 21, 2021

Dr. Anthony Maresso and Dr. Barbara Trautner will give their insight into the use of phages to combat the epidemic of antibiotic resistant bacterial infections today.

Transcript

[Intro melody into roundtable discussion.]

Juan Carlos: And here we are this is the Baylor College of Medicine resonance podcast. I am your host Juan Carlos Ramirez.

Sabrina Green: And I'm Sabrina Green.

Juan Carlos: And Sabrina is the head writer of this episode. And today we're going to be discussing phage therapy in the 21st century featuring Drs. Anthony Maresso and Barbara Trautner. But before we interview them we want to give you a little a little background. Sabrina would you mind kind of sharing what our phages anyway?

Sabrina Green: Sure! This is my favorite topic so phages or shortened for bacteriophages are viruses, but don't let that keep you from don't let that put a bad image in your mind because these viruses only infect bacteria. They don't infect human cells. And they're the most abundant biological entity on the planet and you'll hear in the interview a little bit more about phages. But right now just giving you a basic overview. There's estimated to be 10^31 phages on the planet. So this is more than anything, like if you combine bacteria human cells everything it's still not as much as there are phages on the planet.

Juan Carlos: And it's like what like Avogadro's number? When we think of viruses or bacteria phages and we always think like terrible things, especially right now, right? So this recording is taking place at the time of the coronavirus, right. So when we think of viruses we think of, you know, catastrophe and illness and but very rarely do we think about them being used as like treatments or in clinical setting.

Sabrina Green: Right and that’s why I think sometimes they can get a bad name. But these viruses have been studied since the 1900s and there have been no instances of phages ever infecting a human cell. So they're completely bacteria infecting viruses and they've actually when they were first discovered they were used for phage therapy. So phage therapy is
using these viruses to treat infections in humans or animals.And this actually predated antibiotic. So antibiotics the discovery of penicillin was in the 20s and so phages were actually being used in the US and in other countries before even antibiotics were discovered and continue to be used in the Republic of Georgia at the Eliava Institute. So here in the US they actually aren't they are not FDA approved for clinical use but they are used in agriculture and they're considered GRAS or generally regarded as safe. So very safe, but still we still need clinical trials in order to get them FDA approved for clinical use

Juan Carlos: I wonder what it takes to get them approved? I think its got to be like a lot of fear. and you know now I think we're just very scared of them.

Sabrina Green: If phage were just discovered today I think it would be a lot easier but because and it's funny though because we have so much research so much data out there about phages with the history of it still kind of makes it harder for it. I believe this is my opinion, for it to be approved for clinical use but like I said, if you were to discover it today, I feel like people would be just amazed and excited and we would start clinical trials right away.But in the U.S. It's still considered experimental. There are centers though that you can get phage therapy. Like if you have an antibiotic-resistant infection and you've taken antibiotics and there's really no drug that seems to be working you can get experimental approval for phage use and that is how these centers are actually getting patients to be treated with phage.

Juan Carlos: Cool. Well, I mean I'm pretty new to all use the use of bacteriophage in these clinical trials and to treat people with resistant bacteria. I'm hoping to really learn a lot more today through Drs. Maresso and Dr. Trautner!

Sabrina Green: So that's the history. So what are we doing now with phage at Baylor College of Medicine? So we have TAILOR or tailored antimicrobials and innovated Laboratories for phage research. This is a service center at Baylor College of Medicine that's developing phages suitable for clinical use to help treat these vulnerable patients that get these antibiotic-resistant infections that nothing else can treat. They're also providing phage for other uses too in agriculture for instance. So joining us today will be Dr. Anthony Maresso. He is an associate professor at Baylor College of Medicine and he came from he got his PhD from the Medical College of Wisconsin, and then he got his postdoc at the University of Chicago in 2008 and shortly after he joined Baylor College of Medicine has been working in bacterial pathogenesis mostly but recently has been working with phage. So treatments for antibiotic-resistant infections using phage.

Juan Carlos: And we'll also be joined by Dr. Barbara Trautner who received her Bachelor of Arts from Princeton University her MD from the University of Virginia medical center, and she is currently a clinician at the VA Michael DeBakey Medical Center. She is a professor of Health Sciences services and research she is also a professor and director of the clinical and Health Services Research and she's board certified in Internal Medicine and comes very highly decorated with numerous awards and it's a pleasure to have them both here. So without further ado, let's get into the episode.

[Intro melody into episode.]

Juan Carlos: Welcome.

Anthony Maresso:  Thank you for having us.

Sabrina Green: Can you both tell us about yourselves and how you got interested in science medicine and research?

Maresso: Barbara you can go first.

Barbara Trautner: OK, I’m Barbara Trautner I’m an infectious diseases physician in the clinical practice at the Houston VA. I became really interested in research really late. Along the ways when I was an infection diseases fellow. And I was required to do a year of research. But I found the research was so directly relevant to improving my patients care. That really touched off a love of research that eventually inspired me to apply for career development award in the NIH followed by one from the VA and eventually completing a PhD in clinical investigation.

Anthony Maresso: My interest in science started when I was actually very, very young perhaps three or four years old. I recall being fascinated by the natural world in particular animals and reptiles and my father used to take me fishing my mother too at times and when I when I recall was maybe being four years old and catching a fish and just remarking at how slimy it was and wondering why it was that way. Why did it need to be slimy to be in water? And I don't think I've ever sort of wavered in my interests since then. I knew that I wanted to do something that would allow me to interrogate the natural world and so science was a way for me to do that. The interest in medicine. That is applying science to the benefit of alleviating disease in humanity occurred somewhat later. I wanted to be for the longest time a veterinarian, but then I worked in the veterinary clinic and I found that that was something that wouldn't allow me to dig deeper into real problems and then my mother got sick. She was diagnosed with lupus.

And when I recall from that was that she had really no ability to explain what was happening to her and neither did her treating physicians and that's when I sort of realized that I could use my interest in science to try to enhance levels of knowledge for things like this. Research is just a natural extension of that. So everything fell in line from that point forward.

Sabrina Green: Thank you very much for answering that how did you and I'll start with Anthony first get involved with phage research? And what do you find most interesting about phages or phage therapy?

Anthony Maresso: So to be to be honest, I've been I've been interested in phage ever since I was a postdoc at the University of Chicago, but sometimes when you get into research you are you have to sort of work on what the environment that you're in you have to kind of work within the confines of that environment. And so I've always had my eye on kind of the properties of phage because they're so such fascinating little, little creatures, but I had to be practical in being able to do the science in the particular lab I was in. So I've always had an interest in it from that point forward, but I came into it more concretely when my colleague here, Dr. Trautner and another colleague of ours a virologist Dr. Ramig sent to me a proposal that they wanted to submit to I believe it was the NIH and in that proposal they described how they were gearing up to use phage which are viruses that attack bacteria and they're very good at killing bacteria as a possible treatment for infections with a bacterium called Pseudomonas aeruginosa, which is particularly troubling for those that have Cystic Fibrosis and are badly burned. This organism can exist in those environments and infects those wounds. And I knew that at that point that this was the sort of an opportunity to finally get involved with my laboratory in this field of research because I had some extra seed money that the college had given me to do that.

And so it was just more or less an opportunity. An interest early on but not being able to take advantage of the opportunity until presented to me and Dr. Trautner and Ramig with an initial grant seeking my expertise really in bacteriology, which is my primary field of interest allowed me to then enter the field and it's been wonderful since then.

With respect to phage therapy goes back to the to what I started with when I talked about how I got interested in science, which is phages are are this, perhaps the world's greatest predator of bacteria. Antibiotics are often what people think of as killing bacteria, but phage have been co-evolving with bacteria and learning how to infect their cells for nearly two billion years. And so they've in essence perfected this process and so if one thinks sort of outside the box a little bit one realizes that phage can be potentially used is a way to control bacterial populations. And to clear bacterial infections even but the real the real benefit of phage unlike sort of chemical antibiotics, which do not have the ability to change in real-time. Their chemical structure is fixed in space and time. Phage are not bound by that limitation because the basis of their change is mutations in their nucleic acid, and they will acquire mutations with time just in their normal replicate of cycles and some of these mutations can be used to our advantage to improve the ability of a phage to target a particular bacterium and actually makes it make it more efficient at killing. And so the real difference here is that phage can be evolved in real time and adapted in real time to confront bacteria in real time. And it is this advantage that bacteria have used against us the fact that they adapt so quickly to our antibiotics become resistant to them and render them inefficient. But phage can be changed in about the same amount of time bacteria can and I think it's sort of incumbent upon us to explore the science of whether that can be used to develop antimicrobials to bacterial to treat bacterial infections in patients were antibiotics of sort of not been able to help them.

Sabrina: Dr. Trautner. Do you want me to repeat the question?

Barbara Trautner: Phage research has a little bit of a serendipity in it and maybe also a message to our students about how to prepare to go to scientific conferences because there's no science to preparing to go to a scientific conference so that get the most out of it. I was working with probiotics a benign E. coli as a way to ideally prevent urinary catheter colonization in persons with spinal cord injury and thus prevent symptomatic catheter-associated urinary tract infection. But I got really nervous what we're good probiotic because it was a weakened strain of E. coli, but I thought it could make people sick in the right setting. So then I said look at colicins which are antimicrobial product secreted by the E. coli that can kill other strains of E. coli because of the colicins are really just parts of phage that have entered into E. coli genome and that it makes these phage parts that kill other strains of E. coli.

Well, so it's pretty easy for me to get from there. Wouldn’t it be really cool to work with phage as a way to kill the resistant bacteria in people’s bladders that are causing UTI? And  then I looked up phage I didn't have a background in anything related to phage. I look them up on the web and I couldn't believe how cool they looked like they were the coolest looking little animals. And Anthony said he wanted to start out as being a veterinarian. Actually I did too until I realized animals couldn't talk to me and then I switched my sights to being a doctor.

Phage are the most amazing cool animals and kind of like the bacteria. I feel like they could all be my pets just like all the bacteria that I worked with. So the way I really got in the phage research though is why you have to prepare for scientific meeting. So I was going to a meeting on device-related infections and I think I had some little piece to present but I was clearly the junior person among the presenters. So I looked up every other presenter and their last two papers and one of the people so I could have conversations with them about their work. It was a small conference room about 25 speakers. So one of the people I looked up have been doing studies with trying to prevent urinary catheter colonization by the pseudomonas just like I was studying that he was using bacteriophage for it. And so we struck up a conversation. He worked at the CDC eventually I sent my research the technician from my lab to his lab learn how to work with phage and it was all because I had read his papers before I went to the conference and heard him speak.

Sabrina Green: Cool. I didn't know that story. Thank you!

Barbara Trautner: Yeah, I can shoot original papers by Rodney Donlan. He's at the CDC and the first author is Fu and it was a bacteriophage cocktail to deal with pseudomonas colonization of urinary catheters. I just couldn't believe how relevant it was to my own work. They were working with the same silicone type catheters. They were using real urine. They had encountered a lot of the problems I had encountered and so we really had a great conversation that took off from there.

Sabrina Green: So actually phage therapy has been used before and it's still used in other countries. Why do you think it is not in use in the US but still widely used in Eastern Europe and are there actual roadblocks to getting phages approved for use in the US and what do you think these roadblocks are? I'll start with you, Dr. Trautner.

Barbara Trautner: Yeah, people don't trust it. And I think it's because not only did it come from Eastern Europe, but until very recently they were not good clinical trials and there were a lot of people a lot of the phage studies are a little bit like some of those overly zealous case series you see of weird things like vitamins or something. That just doesn't end up working. To be specific, I got a email from someone wants help with their mother who's got a just organism in a wound and they're looking for help with treatment and I said we would be glad to help but I really need to talk to your treating physician first her treating physician first so I can look at the situation see is that, you know amenable to phage work. I gave my cell phone number and asked the doctor to give me a call. I haven't heard a thing. I mean, they're just suspicious of phage. They won't give me a call. I try to reach out to them. I think cause they're alive. I think people don't know what it is. And there's a lot of quackery out there that gets mislabeled as appropriate medical care and I think phage are getting lumped in that group, unfortunately.

Sabrina Green: So you think a lot of doctors feel that way or just the general public?

Barbara Trautner: Oh, no, I think it's doctors. I don't think the problem is with the general public. I mean, you know you have those are the radio and they managed to convince the general public that all sorts of things are good for your health. I think its doctors and the suspicion of a living organism. I think people hear experimental and they think I don’t have time to mess with that. I don’t want to do that. And I get that. I mean I'm a practicing clinician. It's so hard to find time in your day to do anything even slightly different because you're very overwhelmed with what it is. You got to get done that day. So we need to make it really easy for practicing clinicians to access phage therapy that is experimental with us doing the work for them.

Sabrina Green: Okay. Anthony.

Anthony Maresso: Yeah, I would agree with Barbara and what she said, but I would also add that. I think there are two other major driving factors that have sort of suppressed phage science and phage therapy and in America. Not directly suppress. This is just a sort of an indirect product of just what happened. The first is history. So phages  were discovered in the late about 1917, 1919 by two scientists and they described this unique activity where they could see a clearing of bacteria on a plate with some bacterial extracts and drop of water and they wondered there is something in this that's killing these bacteria and so it wasn't really realized till much later about 20 years later these actually viruses that do this, but we now know that they were they were in fact discovering and finding phage and so it became this because bacteria were killing people on at a regular rate. I mean normal healthy people would die from bacterial infections and scourged children, for example, all over the world. There was great hope that this thing that was discovered was somehow going to prevent people from dying from bacterial infections. And there's even a book Lewis Sinclair. It's called Arrowsmith. They describe this process where this guy discovers basically what it amounts as phage. He's going to use it to save the world from a plague-like bacterium. And then what happened was people jumped into it really quickly industry sort of jumped into it. They didn't really know what they were working with. This was before the time of like very controlled trials. Very controlled science very wild west type of ways of doing scientific and it many of the early investigations of the use of phage didn't work. And so the American Medical Association essentially wrote it off as being too inconsistent, but the reason it didn't work is because of the nature of what it actually is. It's a complex organism that goes through a life cycle of infecting bacterium. And you have to understand that life cycle to help make it work. Now let's flip to antibiotics. Penicillin the activity of that drug was discovered in the late 1920s. That story is well known about the growing of the mold on the plate in a clearing bacteria. So what happened was there was an excitement around that. But it took 20 years almost 20 years actually about 15 and World War II soldiers were getting infections on their wounds with bacteria for a company to actually figure out how to synthesize penicillin chemically in the lab. Once that happened that changed the course of modern medicine because it became evident that you could very quickly make chemicals that killed bacteria, and it could be standardized and then that could be scaled up and you can treat millions of people by doing that.

And so everybody that was sort of a pharmaceutical company at that time jumped into this exact process. Find chemicals that destroy antibiotics synthesize them and standardize it and then scale it up. And that's the Golden Era of antibiotic discovery and making what we call the classic years of antibiotic discovery. But no one really realized that one day that bacteria would become they would change and throw that entire industry on its head. But society got ingrained in that process in that mentality that you had to make a medicine. It had to be a chemical structure. It had to be standardized and it had to be scalable and that's the only way you would make new medicines, right. So a lot of it really is history. This is what society sort of accepted whole generations believe that this was the way to do it and when you grow up thinking that that's the way you do it and something else is offered as an alternative. It's hard to change. In fact, you have to have a generational change in thinking for the sort of that to become the realization and a new way of doing things. But I think the other reason which is a lot less sort of lengthy of an answer is phage every phage in and of itself is a different biological entity and you cannot apply a universal process to all phage. And when we in fact try to do that, it fails we have to understand the properties of individual phages and tailor them to specific infections and to specific diseases. And that is where we will find the consistency. We need to sort of get excited about this as a treatment.When the old model is applied to phage like antibiotics, it doesn't work. So in order for phage to sort of become accepted we have to sort of reinvent a new model to evaluate them from and so it's really a two-part answer.

 Sabrina Green: So what do you perceive to be the future of phages and they're used to treat infections in humans or animals? And can you talk a little bit about TAILOR which is a project that maybe Anthony can talk a little bit more about. So, Dr. Trautner.

Barbara Trautner: The future of phage. It’s uncertain. It’s truly uncertain. I spent a lot of time thinking about it. Sometimes I jot down notes in the car. How would I have applied phage in this clinical situation. I’m on the medicine team right now at the VA. And I think about where would phage have helped us and where would they have not helped us? They have such a narrow therapeutic window. And the bacteria and phage tend to co-exist. So any particular bacterial strain is going to become resistant to the phage its exposed to fairly fast. So I feel there's going to be certain clinical scenarios where they're very helpful. In a few doses maybe for stabilization, but maybe not so much for most of the longer-term treatments and then there are other settings where someone suffering from an intractable infection is gone on for a long time and we may be able to tailor phage that help us and that's just help us gain ascendancy with the person's immune system working together along with antibiotics.

I don't think they going to have, they are not going to be a replacement for antibiotics. They don't work the same way as antibiotics and we're going to have to have very good clinical trials that are rigorous that test phage in these very various scenarios before we see them come into practice. That’s why I thought about the future.

Anthony Maresso: Yeah, and I'll bet that I agree and I would add two additional parts, which is I think there's a scientific part and then there is a medical part. I think the scientific future of phage that is the sort of study of phage is going to be rather robust. It's estimated that there are 10^31 total phage on planet Earth. Which is more than the noble amount of stars in the observed universe. Each of those phages estimated they have 70% of its genome uncharacterized. And in fact those genes have no annotation or known resemblance to anything that are in the databases. So one really interesting scientific part of phage research is we can use phage as the largest repository of unique biology on planet Earth. The genes that they encode are likely completely unique because of what they have to do to prioritize their life cycle dominant over the bacterial one.

And I think that will be a rich source of scientific investigation in the future. The medical one is going to be I think bore out by the science as Barbara mentioned clinical trials, but also the basic science needed to investigate how phage work whether they synergize with the antibiotics what elements of phage will be more effective and what context can we apply the phage to. I think when the research is performed and we have more answers along that line will have more clear answers as to what the future of sort of phage therapy will be.

Would you like me to comment on TAILOR?

Sabrina Green: Yes.

Anthony Maresso: Okay. So it's I'm glad that I have the opportunity to talk about something that we've done in the laboratory, which is this TAILOR initiative which stands for tailored antimicrobials and Innovative laboratories for phage research. So what Baylor College of Medicine is done is they've sort of taken some of our work and decided that they would invest in it. And so we were able to create this initiative whereby if anyone has any particular bacterial problem, and it doesn't necessarily have to be an infection of a patient an agricultural problem where bacteria are a nuisance. It could be an environmental problem contamination or just interest in phage biology in general, but certainly as it also applies to clinical medicine. What we're able to do is use basic science techniques to sort of enhanced properties of phage. Use directed evolution to make phage more specific to a specific bacterial problem and then learn about how we can adapt that to solve problems that bacteria cause in the real world and it's a great team of young scientists in my laboratory. Sabrina is a part of that. Dr. Trautner is a part of that. Dr. Ramig a virologist colleague is a part of that and Dr. Terwilliger who is the project manager and what we hope is that people will come to us with bacterial problems.

And sort of work with us to find ways in which we can apply phage to solve those problems. Maybe we'll get lucky and we will solve some of them problems. But what I think will come out of it is a lot of basic science that will help us learn about how we can tailor phage to be better at solving some of these bigger problems. And then also learning just about the natural history of phages. They co-evolved with bacteria, which is a fascinating topic.

So physicians that are out there that are listening to this. If you have a challenging clinical case where antibiotics are not going to work or they've been tried and there's really no other hope the FDA does allow in some cases the compassionate use of experimental therapeutics to try to save the life of patients. And in this case, we could adapt our phage to the specific bacterium that your patient has make sure it's safe and clean and doesn't have any undesirable properties and is efficient at killing at the bacterium and we can ask the FDA for permission to be able to use this as an experimental therapeutic for your clinical case. And that's one of the components that TAILOR is trying to bring so if you're interested in those possibilities, you can contact myself or email the TAILOR Group, which I think there might be links and stuff embedded in this podcast or you can contact Dr. Trautner as well. We'd be happy to try to talk about how we can help.

Sabrina Green: Okay, the last question since this podcast really goes out to students who are probably looking for labs to rotate in. Can you talk a little bit about the way that you approach mentoring you both have won awards or gained recognition for being really great mentors as well as researchers. So, Dr. Trautner, can you talk a little bit about your mentoring approach?

Barbara Trautner: I'd be glad to. Mentoring is my passion. I have several passions, but that's certainly one of them is one of the best things about being an academician is the opportunity to mentor why it means so much to me is because I was so lost as a fellow as an infectious diseases fellow. I felt that I just didn't know where I wanted to go next with my career. I had a young child. I had no sense of why I was bothering to complete the fellowship because I didn't know my career goal. I didn't really have a sense of what academic medicine would mean and I was saved from that morass by a really good mentor who was our ID section chief new at the time and met with me and basically sat me down and said to me Barbara you're destined to be in academics. This is what you're going to do and it was so helpful to me. I stayed in the fellowship. I did an extra year to learn how to do research. I applied for the career development award, ended up in the Ph.D program all because of that one good Mentor followed by subsequent really good mentoring team. So I want to deliver that to other people. I don't want them to feel lost like I was so I like to work a lot with people at the postdoctoral level, which is the clinical fellows because they still can take so many different career directions and they can use so much guidance in that but I have mentees from all levels including some in high school.

Anthony Maresso: It's very difficult question to answer but I think what I would say was there's just no greater honor than being able to being able to train the next generation of scientists. These individuals are going to be the future leaders of our country. And they will be the future leaders of our planet and we have some really big problems to solve not just in medicine but in population explosion, in averting wars, sustainable agriculture and probably at some point in the future interstellar travel. And all of that is going to require capable scientists and I view my role as just sort of passing the torch on.

If I had to give advice about an approach to take and I'm not so sure that this is the best approach but it is what has worked for me. It is that I think you have to have an absolute belief in the people that you are working with you have to believe in their skills and their talents and in their determination and that they are going to try to find ways in which they can better improve the state of all humanity.

That's going to be different for each individual person and you have to have a personality that is able to resonate with each of their individual personalities and never ever give up on them. That's a rule that I steadfastly go by is that you have to try to find what they're really good at enhance that and subtly try to improve upon their limitations and it is different for every person. It's an individual challenge of itself and I have to say that it is much more challenging than the science itself, but it is the most rewarding part by far.

Sabrina Green: Thank you, both for talking. But thank you. Dr. Anthony Maresso,  Dr. Barbara Trautner. I'll talk to y'all later.

Barbara Trautner: Well, thank you for including us for organizing this thank you Juan Carlos for working with us.

Juan Carlos: It's been a great pleasure having you both. It was a pretty awesome. I always learn something new and I'm just kind of pretty fortunate to be part of this effort. Thank you so much.

Maresso: Thank you.

Trautner: Okay, thanks. Appreciate it.

iTunes | Spotify | Google Play | Stitcher | Length: 50 minutes | Published: April 9, 2021

Dr. Andreas Tolias discusses his journey into artificial intelligence research and how he and his lab are developing cutting-edge algorithms from discoveries in neuroscience to better understand the brain’s perceptual inference and decision making, along with the many challenges. Dr. Tolias and his lab have one goal: to harness the algorithmic power of the visual system to generate the most cutting-edge algorithms to better analyze data and gain deeper insights into the mysterious and mathematical complexities of the most evolutionarily advanced sensory organ.

Transcript

[Intro melody into roundtable discussion.]

Erik: And we’re here. 

Juan Carlos: Here we are again. 

Erik: Yes. So, uh, this is the Baylor College of Medicine Resonance podcast. I am one of your hosts Erik Anderson.

Juan Carlos: I am another host and the lead writer for this episode, Juan Carlos Ramirez.

Kiara: And I am another host, Kiara Vega.

Juan Carlos:  Along for the ride. (All laugh). 

Kiara: Along for the ride, yes. 

Erik Anderson: Kiara is going to educate us about any Neuroscience that we get wrong in this.

Juan Carlos:  Fill in the gaps for today.

Kiara: I hope my PI is listening – (laughs) – so he can be proud. 

Juan Carlos: Yeah, ‘cause today we'll be talking about the advent of using methods in artificial intelligence to understand the brain and Dr. Tolias will discuss his journey into artificial intelligence research and how he and his lab work developing cutting-edge algorithms from Neuroscience work to better understand the brains perceptual inference and decision-making.

Erik: Man…yeah…

Juan Carlos: Ooo!

Kiara: Yeah, that’s a lot.

Juan Carlos: Yeah, so I guess it would make better sense to start off by defining artificial intelligence and when it began. It’s, it's like a buzzword in everything nowadays. The theory and development of computer systems able to perform tasks that normally require human intelligence, such as visual perception, speech recognition, decision-making, and translation between languages – sort of, the Inception of artificial intelligence was created to tackle these problems and the first development of the electronic computer was in 1941, which was followed by the first stored computer program in 1949. A man by the name of Norbert Wiener was the first to theorize that all intelligent behavior arose from feedback mechanisms. And they, after that the Logic Theorist designed by Newell and Simon in 1955 was considered the first AI program to ever be created and subsequently, Dr. John McCarthy, which is well known in the computer science and machine learning environment, is an American Computer scientist who coined the term ‘artificial intelligence’ and held its first conference in 1956. So, we're going to way back in time. 

Kiara: Yeah.

Juan Carlos: So, it's nothing new, really. It's just now we're figuring out ways to use artificial intelligence, especially in the biomedical space. Yes, that shows a lot of cool promising techniques. So, how has artificial intelligence changed the way we approach biomedical research and life in general? Well, hopefully, Dr. Tolias can answer a lot of these and in the cutting-edge world, but in general, the use of machine and computer vision, speech recognition, language translation, monitoring tools and robotics, and healthcare, financial investing. It's, I mean, it's everywhere.

Kiara: Everywhere.

Juan Carlos: But recently, we’ve made lots of strides in the biomedical space.

Kiara: and another development that I know that AI is being groomed for is Diagnostics, like, to play a very big part. 

Juan Carlos: Yeah, especially when we have, nowadays we have so much data, you know, so much data. We don't know what to do. We have to parse through all this data and it could take lifetimes for a one sole human being to accomplish in one PhD but the data analysis in biomedical research has really accelerated the pace at which we analyze data, and it really has fostered discoveries unattainable by previous methods. Dr. Tobias’ lab utilizes a subset of artificial intelligence called machine learning to decipher the network-level principles of intelligence. He is part of this collaboration of neuroscientists, physicists, mathematicians, and computer scientists focused on brain research for a machine intelligence to engineer a less artificial intelligence. This group is called the Neuroscience Inspired Networks for Artificial Intelligence (NINAI) or NINAI, right? 

Erik: So, it sounds like artificial intelligence you’re just saying, that you know, is a computer. Like a logic machine that is artificial. 

Juan Carlos: Yeah, artificial intelligence is kind of an umbrella term for using machines, right? Computers, right? To perform tasks that otherwise humans would normally do, right, but to a much better degree.

Erik: Yeah, because I mean that was in here when you were talking, because you were talking about Turing. I imagine were talking about one of the first computers, because yeah, I think I always just had an amorphous idea of “Oh, yeah. I know artificial intelligence. I've seen Steven Spielberg AI films.” (Laughs)

Kiara: The robots!

Erik: Yeah, robots! Exactly. That's what I think. 

Kiara: That’s what I thought.

Erik: Yeah, totally but – 

Juan Carlos:  Sky Net!

Erik: But It really is just any computer, it sounds like, and then the Deep learning, is just, yeah, I guess, feedback mechanism that you can just feed. 

Kiara: You said that they use machine learning? Yeah, to reverse-engineer. Right? 

Juan Carlos: Right, right. So, to create algorithms that are going to – 

Kiara: - kind of put to extract the principles from the biology and try to – 

Juan Carlos: - understand how the brain just makes everyday decisions important decisions – 

Erik: - with the idea being, I mean, this is obvious, but anybody… I guess I'm not trying to come at anybody that hasn't made this connection, but the idea being that – (laughs) I guess I am – that the brain is a giant computer. (laughs) So, you can study it likewise. 

Juan Carlos: Yeah, and so he'll tell us a lot about his background, what brought him here, but I will have to preface the interview with: there's a lot of deeper learning – no pun intended – that one would have to, sort of, read up on to fully understand what he's trying to convey and it's an action-packed episode for sure. Just have to keep you on the edge of your seat. And then it's also very positive, right, for the future. So, there are a lot of good takeaways.

Kiara: It’s amazing, I mean, it's been called a ‘moonshot’ what they're trying to do in his lab. 

Juan Carlos: Really?

Kiara: Yeah, because, well besides the projects where they’re trying to reverse-engineer principles, biological principles, and then instruct machine learning algorithms. They're also trying to image the biggest volume of the visual cortex in mice that has ever been. But yeah, they, that's why okay, what they're doing is so amazing and it's so ambiguous that they have, they have the competency, the materials, and the people to just kind of make it work or that's the that's the goal. Right? It's very, very hard to do trying to do. 

Erik: Yeah, there is an MD/Ph.D in the lab, that I think just recently left but presented his data at my seminar and they call it like the ‘million-dollar Mouse’ because – 

Kiara: Platinum mouse. 

Erik: Yeah, the Platinum Mouse, is that it? 

Kiara: Yeah, that's it. 

Erik: (laughs) Okay. I'm thinking of the million-dollar man! 

(All laugh)

Kiara: Close enough!

Erik: I need to check my references 

Juan Carlos: in the future though. 

Erik: Yeah, in the future. 

Kiara: Yeah, Platinum mouse. Yeah, that's one of the mouse that they used to image the cortex. And they're actually like, reconstructing it. They have these collaborations with Princeton and other labs where they’re trying to reconstruct a 3D model with using electron microscopy. And then also 3D modeling these areas of the cortex.

Juan Carlos: Makes me want to join us live now.

(All laugh)

Kiara: Yeah, his lab is amazing.

Juan Carlos: Well, without further Ado. Let's prepare to get our minds blown by some very fascinating work in Neuroscience. Let's go to the episode. All right.

[Interlude melody]

Juan Carlos: Welcome everyone. My name is Juan Carlos Ramirez. I'm your host of the Baylor College of Medicine residents podcast. I am here today with Dr. Andreas Tolias. Welcome, Dr. Tolias. 

Dr. Tolias: Nice to be here.

Juan Carlos: I have to be honest. I've been, I've been kind of looking for this moment for a long time and I've been telling people “we're going to have Dr. Tolias come on the show for the second season” and when they ask me about you, you've done like so many things in such a short amount of time. It's kind of difficult for me to tell people exactly in a few sentences who you are. So, if you wouldn't mind could you explain a little bit about your background or yeah, where you went to school. 

Dr. Tolias: Yes, right. So, I did my undergraduate degree at Cambridge University in Natural Sciences and then my Ph.D at MIT in Systems and Computational Neuroscience and then some post-doctoral training in Germany at the Max-Planck Institute in Tübingen also in Systems and Computational Neuroscience. And I study how the brain works, how the brain computes information, and how it gives rise to intelligent behavior. Particularly, I study visual perception or visual inference, how is it that the brain is capable of doing all the wonderful things that enable us to see the world. Although this sounds like a very simple problem to us, it’s the exact opposite. It's actually a very complex computational problem. It involves large chunks of our neocortex – in some primates up to 50 or 60% of the neocortex is dedicated to processing visual information system. So, it’s mathematically very complex what it is trying to do. In my lab with my collaborators were trying to understand how these, what are the algorithms of the brain and how it implements them to give rise to intelligence. We think that these, if you want algorithms that learn, are going to be generic. There will be similarities with maybe some differences but similarities with other things that we do in cognition, decision-making, and other sensory perceptions. In parallel, we're trying to build models of the brain. These are sort of machine learning models or AI models that to try and mimic the brain’s capabilities. For example, we're trying to build a model that's capable of doing visual recognition of objects in par with what the human is capable of doing. So that's sort of our, if you want, the aim is to understand it at the systems level and computational level, but then test this understanding by building models that are then dealing with the real-world complexity in trying to solve, you know, these interesting problems.

Juan Carlos: Okay.

Dr. Tolias: So, that sort of, I think, describes…so of course you know I work at different levels of the systems. We go all the way from individual cell types: What is the function? How they’re arranged? How many cell types there are in the brain? You know, the molecular level: try and identify transcriptomally how they are, how they're assembled in circuits and how these circuits function, you know, when animals either see visual images or make perceptual decisions on those images or movies.

Juan Carlos: Wow. So, I'm more familiar with the wet lab side of research and you know most of the time when people go into the lab, they have their experiment, and they have certain readout that they're looking for. So, like, short-term and long-term goals. What does that look like in a day in life for you in your lab? 

Dr. Tolias: Yeah, so in my lab there is a wide range of expertise and it's a very collaborative lab.  There are people who have expertise in a molecular level, other people the cellular and systems level, circuits level, you know, doing uh, very complex in-vivo recording experiments where we can record on the order of 10,000 neurons simultaneously from an awake, behaving animal, using neuron imaging methods. And also, people with very strong machine learning and computational skills to help build models to help analyze this data. So, it's a very collaborative lab and each project, usually, you know, every person in the lab, whether a student or post-doc or senior researcher has their own particular project they’re working on but they collaborate with other people to get this kind of bigger pipeline in place so we can really finish a particular question or address it to a certain extent. So, it's not, you know, people work individually on their own project and some people are more on the experimental side, others are more on the computational side or machine learning side or AI side, if you want, but really most of these projects involve a lot of collaboration back and forth, people sort of help each other.

Juan Carlos: So, it sounds like you have almost every capability.

Dr. Tolias: Well, not all, but we also have an extensive network of collaborators here in Baylor, but also in Europe and in Canada and other places here in the United States. We work together because we do not have all the expertise locally. So, that works very well. Some people have more expertise in machine learning and deep learning or AI or people in microscopy and stuff like that.

Juan Carlos: So that's in your lab, but outside of your lab you work with physicists, mathematicians, computer scientists.

Dr. Tolias: Yeah, a lot computer scientists and physicists as you said. We have a very strong collaboration in Tübingen in Germany and another one in New York and Columbia University, Toronto University, and Cornell where there are some physicists there either working with the technical side of things or the imaging side or more on the computer side or deep learning side. 

Juan Carlos: So, you have all these people coming together to focus on Cutting Edge brain research projects. And is this, I think I’ve looked it up, it’s called NINAI?

Dr. Tolias: Yeah, so we have an organization that we formed a few years ago is called NINAI which is basically the umbrella organization that enables all our team that is very extensive. It involves people from the Allen Institute in Seattle, Princeton, Cornell, here in Houston Baylor, you know, Rice University Tübingen, Columbia University, New York, and Toronto the Vector Institute, and we kind of collaboratively work together in understanding how the visual cortex gives rise to inference. By inference I mean, like how it enables the brain to effortlessly recognize things like objects or compute the depth of objects that basically allows you to see the world. 

Juan Carlos: So, basically, it’s making these innate decisions that we kind of do very effortlessly.

Dr. Tolias: Unconsciously! That’s right! Experts call this unconscious inference. There something called the Moravec’s Paradox, which is: things that are very difficult for us like memorizing things or let's see playing chess or solving math equations to some extent.

Juan Carlos: Playing Go.

Dr. Tolias: Playing Go, you know, when they go on computers now in AI systems are much, much better than any human and they can learn very fast. There is for example, you can take a computer, even let’s say the size of your laptop program it using deep learning to solve how to play chess and beating the world champion in a few hours, which is quite impressive. 

Juan Carlos: Garry Kasparov was the first victim. 

Dr. Tolias: But now with deep learning its more impressive, but even more interesting if you create an image for, let’s say banana, you know, versus an apple you can effortlessly say ‘this is a banana’ or ‘this is an apple,’ but modern AI system, they're very easy to fool in ways that for you, it would be like a joke, you will never be fooled. This is called the Moravec’s Paradox. It seems that stuff that are innately easy for us or children, you know, how to walk, how to hold this bottle and drink from it, you know, without putting too much pressure, too little pressure and having it fall. These are very easy for us but they're very difficult for robots or AI systems but things that are more difficult for us, like playing Go, they’re very easy. This is a paradox and why it's like that and some of it is really what you were saying earlier. We think that in the course of evolution, let's say we had millions of years to evolve very good neocortex that does very advanced vision to survive because you’re in the jungle and you mistake a tiger for food or something you'll get eaten out. So, you won't survive. You don't have time to think about it, it happens very fast. So, we evolved to be visual geniuses, if you want, and we can effortlessly do it and we're studying very complex mathematical problems very easily but things that are like more modern like 3,000 years ago came up with Go in China and try to figure out how to play, they’re not intuitively obvious to us, so we need to think about it probably using parts of our brain that are more recently evolved like the frontal lobe. So, in some ways, we’ve perfected some aspects of our intelligence, this innate intelligence, and you have even some animals when they're born, they can immediately do some of these tasks. So, I think that is one hypothesis why there is this difference.

Juan Carlos: Often times, we take for granted how difficult these tasks are for a computer to do because we’ve been doing them effortlessly for so long and sometimes, we don’t understand how difficult or what an accomplishment it is for something like AlphaGo, or the stuff that’s going on in DeepMind or even a Canadian group that publishes that they have created an algorithm that can detect cats out of YouTube videos, you know for us that's very easy.

Dr. Tolias: Exactly. You know, it seems like in the last few years, especially since 2012, there has been like a renaissance of artificial neural networks or deep learning that is, in a very crude level, trying to approximate how the brain solves these problems, you know, so it’s built by artificial neurons, connective synapses, these synapses undergo plastic changes due to some objective function, maybe as exactly the way the brain works but in some ways its similar, and then they enable engineers and computer scientists to build these remarkable algorithms that are already influencing our everyday lives when we go do a Google search or we talk to Siri or we talk to Alexa, it’s kind of background , there is some sort of artificial intelligence network around it.

Juan Carlos: Yes, algorithms are everywhere! They run our lives.

Dr. Tolias: Exactly.

Juan Carlos: We can’t really survive without them nowadays it is but I think it's more interesting to understand the power of algorithms and AI and machine learning in biomedical research. So, such as AI in Neuroscience and how they’re kind of driving each other: we understand the brain, which helps us build better algorithms to better understand the brain

Dr. Tolias: Yes. Exactly. It’s kind of a circle. Our lab, and our collaborators work at the interactions between Neuroscience and AI. So, on the one hand we're using deep learning which is, let’s say, the most successful form of AI right now and may probably change, to model the brain and get insights. We use the same tools that people, let’s say to program a computer to play Go, we use it to model the brain, and build predictive models of how the brain works and then try to understand how the brain works by using these tools because don't forget that, you know, with modern Neuroscience we’re capable of collecting very large data sets. In deep learning, it’s really, sort of, if you want success is the ability to analyze and make inferences when you have large data sets, especially with a lot of labels. So, for example, we could experiment where we show a lot of stimulation to an animal, record their activity through the model of transfer function. Now then we use this method to model the brain and gain some insight and the hope is then by understanding something about the computation of the brain that we can build smarter AI algorithms that then can maybe not just analyze our data better but also can be used, for example, to recognize faces or do voice recognition or to do more robust analysis of all other sorts of kind of data. So that's kind of the goal here, is to go into this. But at the very basic scientific level, you know, we’re not ourselves, you know we’re not trying to, we're trying to like, learn the basic principles, if you want, and then reverse engineer the brain out of the principles, and putting these principles into some demonstration that, you know, this information that we learn from the brain can be used in successfully advancing machine learning. 

Juan Carlos: So, aside from studying and enhancing studies in the brain and learning how the brain works better. Do you suspect that we can use these algorithms to, uh, to further enhance or at least accelerate some research in other domains like cancer? 

Dr. Tolias: Yeah! Yeah, for example, you know, I think that's the goal, right? Umm, okay. There are two things I want so say there: One is that modern, let’s say you look at cancer research. You know we have a lot of technologies now to collect a lot of data including, let's say single cell sequencing or large studies where, you know, we do DNA sequencing in humans, and we look at their different types of phenotypes. So, you know, basically this is my personal view, you know, biomedical research is very successful in developing technologies that are relatively cheap to collect a lot of data, but we do not know how to analyze it and we don't know how to understand this data. The whole field of, let’s say genetics and molecular biology is based on this idea of you know, we, we think very serial, you know, causal manipulations are done one gene at a time. We don't even know how to think of this High dimensional gene or protein interactions that happen and most of the diseases are very multifactorial based on many genes, in combination of genes and environment in ways that we don't even have the right, you know our brains did not develop how to analyze this is and maybe we don’t have the right mathematical tools but what we have is the capability to collect a large amount of data. So, now with deep learning, if we have a lot of labels in these data. For example, let's say we sequence all everybody and we record their phenotypes, and we know in 10 years who’s going to get cancer or not.  So, we do this chronically. It's possible to build a model for now that's going to predict who's going to get what you want some sort of Black Box model that, you know. But the problem is that old-age Alzheimer’s is a good example, right?  Like, if we could follow, we could, let’s say record everything that someone eats now, how much they exercise, what is their DNA or their relatives, who they talk to – we monitor them 24/7 and we collect all this data for 20 years, 30 years, and we say ‘okay, who is going to deteriorate at what rate?’ Maybe we can build a predictive model from now that’s going to predict: ‘this is gonna happen to you, this is gonna happen to you, this is gonna happen to you’ but the problem is that it's a very complex data and we don't have the time or you know, we can collect large data but to do this very chronic data collection, we haven't built a society to do. Now there are countries like China, is trying to do stuff like that because there is a very top-down system. So, it is easy for, you know, someone to give an order and everything is done systematically. 

Dr. Tolias: Now, the brain though, in vision, we did not evolve to look at DNA, you know, sequencing letters and understand what the relationship between that and Alzheimer’s or cancer but we’re very good recognizing images. So, if we understand, but we don't need a lot of labeled data – we do a lot of unsupervised learning and we do inferences by understanding something deeper about the data that is not just this brute force with simple input/output labels. Let’s say, a child can learn the concept of an apple from a few examples whereas a machine with a modern deep learning algorithm needs thousands of these examples to really become good at it. At least that’s sort of, those are some recent developments. They are generally speaking, this is, you know, they’re not very robust. Should we understand how the brain learns from a few examples of vision, then maybe we could come up with ways that instead of the input being images is DNA sequences, but based on the same principles of learning, you know, of drawing inferences in a more causal, you know, maybe even suggesting experiment like a child may learn the concept of an apple because it knows something about curvature because he has to touch that apple. So, that’s more causal manipulation. The brain is wired to from a few examples an learn robustly, and maybe we can translate those algorithms to other domains where instead of being images in a robot touching things is if you want an AI scientist that looks at this data, let’s say, an algorithm, but instead of having original to look at images it reads sequences of DNA and looks of behavior in some other space, you know, phenotype, or how much people eat lead or what is their habits. Then maybe even do some perturbations where, you know, the way the child touches the apple, we may make suggestions or change your life, you know, it sort of tries to learn from a population level then builds an understanding of what causes cancer, let’s say, that the human it would be impossible for you to do because, it's just because we did not evolve to process that kind of information. Then once we have these models, these predictive models that train on few examples for you know, then maybe we can analyze these models and then we can gain an insight to have what’s called externability/interoperability from the models. So, that's kind of a very long-term vision that may take decades to achieve but I think that sort of, we may see that happening within our lifetime. You know, there are doctors and scientists that are machines, basically, that are much more capable of interpreting what learning about this data and gain some insights and then they tell us.

Juan Carlos: That’s something that I’ve, kind of uh, I mean, aside from kind of blowing my mind a bit, I’ve been reading this book called Deep Medicine by Eric Topol and it kind of touches on some of those ideas – that we just don't have the brain power and the speed but we can design models that do this for us. And then from there we can create these predictive models, as you were saying, but it does, it also talks a lot about the challenges but in your opinion, what are what do you, what do you feel is like the greatest challenge?

Dr. Tolias:  I think one immediate challenge is organization and accessibility to the data. You know, for example if you go into a hospital or even a big research organization or even a big biotech company or a firm, I’m not sure they have the data organized in ways that are easily accessible to computer scientists to be able to build these models and the problem right now is, this is a particular problem because these algorithms – not the ones that I’ve been talking about before which is a more vision for the future – but current algorithms work very well with your very large data sets and unless you have this very large data, so, let's say you want to build a system that predicts, maybe better than any radiologist who’s going to get cancer or not from a mammogram and is much more accurate, right? So, it has a much lower false-positive rate and false-negative rates. Now, that algorithm is trained on maybe 10 million data points. It may, like, reach that performance but let’s say it trained on a million, it may not. And then what is the quality of this data? Because it’s going to have to be annotated. For example, we have to have chronic data where we say, you know, this person did this test at this point in time, the doctor decided it was negative. Next year, they came back in and the doctor wasn’t sure and the doctor did a biopsy and it was still negative but this other patient was positive. So, you need these chronic data, so you need a very well-organized system of the data well-annotated by humans, right now and then well-organized in a way that you know, and we're not talking about data sets that are very large necessarily, although they are very large but not very large by computer science standards. Even from my lab, we have much larger data sets that we collect in an experimental lab, but I think they're just not, you know, the way hospitals have been built and the way their software works and the way that data science works, they were not built for this type of deep learning, if you want, or modern AI analysis. They were built for doctors or individual scientists or statisticians to download some of these data for you as a doctor to find this patient, his history, you know, and it was like what a human-based interaction, you know, it wasn’t for large-scale science, and I'm not sure what’s going to solve this problem, you know, I don't think, I think that's a challenge and all that. That's a challenge that everybody, including here at Baylor, is worried about and thinking about and as I said, you know, it would be interesting to see which country or which organization, and it may have to happen at a very large scale at the federal level where someone, you know, gives incentives or motivation for very large-scale project like that. The NIH has projects like that, you know. The other thing is that people understand the importance of these, so there's a lot of open accessibility to the data. For example, I forget, but some hospitals now, as long as the data is deidentified based on regulations that you have to abide by, they want to make them available to the world because, you know, this could save lives, you know. So, many people are very protective of this, and protectionism too, can be bad. People are very protective of their data and other people are not and they work together they’re going to win right? So, it will be interesting to see how these things evolve and also maybe if you want to have impact, especially in a country like the United States that is very multicultural, you have to be careful that this is also, you know, there's no biases built into the model because of different genetic backgrounds or different nutrition in different people. So, it needs to be done in a very sort of organized way, I believe, but in a large scale, and I think that right now is not, uh, it's a challenge as far as I can see. Now, I think there is an improvement in the last few years, like, I think a group from NYU did something with mammograms that had many thousands of images and Google, I think had something like that, recently collaborating with I don’t know how many hospitals. You know, DeepMind is working on that with NIHS.

Juan Carlos: I think this, kind of, has spawned an area of what is called ‘medical intelligence.’ And so, it's the gathering of as many data regarding the health of people in the now, like fitness trackers, you know. For me, I'm obsessed with a fitness tracker to my heart rate, how much I sleep, when I'm stressed, all these things, but I look at it and you know all I can really draw from it is “Well, I didn't get enough sleep on that day and maybe that's why I was tired. I was cranky”, all the stuff, and in the long term it may usually lead to stress or whatever but an algorithm gathering all this data and analyzing it can tell me “Oh, you’re at an increased risk for diabetes” or something. So, I think that's an underlying spawn of a new enterprising, if you will. But as you mentioned earlier, there is some friction or you, you mentioned that there are algorithms that could be really good at detecting radiological graphs of patients that can tell them much better than a human that you have a certain diagnosis. So, this kind of instills fear in some people, you know. I’m surrounded by medical students here at the Baylor. They even have electives that focus on how to adapt to the uses of technology in the clinical setting. So, how would you, how would you respond, or can you comment on people having this fear?

Dr. Tolias: I think it’s just, It's actually not just for the medical students. I think there's a fundamental problem with the educational system not just in the United States but around the world. For example, if you study biological sciences and medicine, you do not get trained as the, let’s say, mathematical or computer science or physical sciences. You know, you don’t learn programming, you don’t learn – and I’m not saying that every doctor should be like, able to program these things – but you need to be educated enough to understand the limitations and the expectations because these things are not, I mean, if they were perfect, you just press a button and it would be game over, nobody would go to medical school to just cover up with being everything integrated but not right now. Maybe that's what it will be sometime from now but it’s not going to happen, right. So, I think right now is a more scary situation because people need to be educated, and starting from undergraduate to medical school, as you said, there is the lack of the programs to educate people, do you know what I mean? And, it is an issue, I’m not going to say it’s not because eventually, let’s say you are a doctor and someone like you that is interested in this thing, reads, is educated, and understands it, then you’re going to do this as your Ph.D., and then say, you become a radiologist – now you'll be able to adapt to these things, understand them better versus one that is used to, like the old-fashioned way of doing things, right. So, these would be assistive technologies in the beginning. Like, you know like assistive driving, like Tesla or something like that, but I think it's very important for the doctors to have an understanding on how these things work so then they can also know how to trust us, but even more important, it can actually contribute more effectively to the researcher that’s being done. For example, what it would take to – and not just doctors but like, administrators and the problems are similar, administrator in the hospital, I’m not sure they’re trained like that, so they don't really understand or even systems administrators like data scientists in hospitals, right. What does it take to organize your data? What should I do as a CEO of a hospital? So, then it gives me a competitive advantage to my patients to bringing AI technologies, so it’s not so much of a fear of, you know, “oh, people are going to lose their job”. I don’t think that’s the problem right now. The problem right now is that some people may not be getting trained in the right way to be able to fully function in this great new world. 

Dr. Tolias: Laughs out loud. Do you know what I mean? I don't know what Baylor is doing particularly but there is worry in many places, you know, you need for example, maybe you should have courses in deep learning. You should have people, you know, like how people take statistics, which is kind of more traditional statistics and learn about Analysis Of Variants or epidemiology, you know. This is a different form of statistics. I think you need to get trained in this stuff. So, you have some understanding of what these technologies can and cannot do, but also it enables especially people who are interested in research to contribute to this because it’s not like the doctor who doesn’t know will be able to do this kind of research, that’s impossible. You know, people that are experts in deep learning or computer science are the ones doing it. But you need this synergy between varying fields.

Juan Carlos: Yeah, ‘cause I always used to have, I kind of shared the same fear before, you know, I started reading more but I guess I'm a little different. I helped I wanted to be a software engineer when I was a kid and all that went away and life happened, and now I'm kind of back in a position where I realized that it's becoming more important. 

Dr. Tolias: Oh, yeah. You have an advantage now. You know, even if you want to a doctor, your software engineering background now, it's going to give you an advantage over, you know, other people because you are the one that is going to be capable of being more in driving seat to make these decisions “What should be useful? What should be used?” which can contribute to research because, you know, we’re entering a new era. I feel the educational system, even if you go to like, even engineering schools and you take biology courses, I’m not sure in the curriculum how much computer science they do or if they even have to know how to program. You know, even if they understand, you know, the fundamental things about, you know, data science. So, these are important, right.

Juan Carlos: I think when it, kind of, uh, cemented in my mind that I was going to pursue even on a personal side, just kind of, learn on my own since I was a student. I was doing some graduate coursework at Hopkins. And then I was also in a lab that breast cancer research that collaborated with a bioinformatics lab, and we had lab meetings once every two weeks or so, sometimes informally and I think half of the time we spent trying to understand each other from the wet side – the biological side – through “how do we use these algorithms to better understand this RNAseq data?” so from then on, I noticed like, I realized I have to learn! I have to yeah, not just because I want to be an M.D/Ph.D. but just as a researcher, I want to be able to have that capability to do at least some part, some of that analysis in-house.

Dr. Tolias: Exactly. You as a biologist or let’s say, scientists that are biologists, you have the intuition to setup the right problem. But in computer science, because of their background, does not or intuition can take many years to develop, longer in some cases than learning technical skills like how to write software, right? So, if you and that engineer don’t talk the same language, you have a problem because it’s not like you give someone data to analyze and something is going to come out. How you set the problem and then knowing what the limitations or what kind of problems from the technical side are, can be solved. So, you need both you and the engineer have to sort of come together and you need to understand a bit of the tools that they use are capable of or not capable of, and what are the limitations, and they need to understand what biological data is, what the format is, and I think that is lacking because, as you said, you know, maybe when you were at Hopkins you guys would meet with Engineers, every week or every few days and kind of discuss and you would read each other's papers or other papers in the future. So, you need that kind of synergy can get things happening, otherwise, it will be very hard, and not only hard, it can also lead to errors where people like, you give someone the data and they don’t know the limitations, they discover stuff that is just artifacts, you know, and then you're not, you don’t understand the result and you don’t understand the limitation or the technical stuff that gave rise to it. You know, why it could have been over-fitting the data or, you know. 

Juan Carlos: Right.

Dr. Tolias: You know, it’s dangerous too. So, the lack of people that can understand both fields and talk to each other. It's not just slowing down progress, but it can also be dangerous. You can read papers that are like, wrong because of this problem.

Juan Carlos: Wow. I think I certainly see some medical schools, at Baylor here, we have a strong kind of focus into making that change, more of like a technological push. But, when I was doing my interviews, I interviewed at Sinai in New York and it was explained to me that part of the curriculum there for every medical student is to learn how to code a little and I was like “Wow,” I was pretty impressed.

Dr. Tolias: Yeah, some people are more pushing in that direction, I guess. I don’t know the details but yeah, that’s impressive.

Juan Carlos: Well, for me it was like it's something that was a, I saw it as a pro. Yeah something positive, but not all medical students would have shared that. But I think now, because AI has either been glamorized or it's been used as a scare tactic. I'm not sure I did think maybe to leave me to listen to this podcast specifically this episode over and over to sort of, learn that yeah.

Dr. Tolias: Yeah, and I think people like you should be given the opportunity to sort of, follow it, especially if you’re very interested in the research.

Juan Carlos: I'm excited to see what, what happens in the future because it's, in essence, all of this is all to improve the quality of human life, and the use of AI and machine learning in medicine is to improve the quality of human life for patients and for ourselves too. Uh, so the idea of just having, having that fear and rejecting it and creating friction for it to be incorporated into our medical system, it seems counterproductive, but I think for everyone for our listeners that kind of had a fear or maybe a further interest in enhancing your computational skills and how that could possibly improve even the way you look at problem solving, I think it’s a lot different. I think somewhere just looking into what the positive impact of AI are is a good start heading that, you know, it's all that we can share about that today. 

Dr. Tolias: Yeah, it’s great to be here. 

Juan Carlos: So, there you have it. This has been a revelation in AI with Dr. Tolias. You've heard it from the expert’s mouth what is going on and what the limitations are in the field and highly encourage everyone to pick up the book Deep Medicine. It breaks it down very simply and helps you understand a little bit more about the use in health care or in research. And so it's all we’ve got for today. But uh, it'll take some time for my brain to unpack all of this information. But I really, I really appreciate you attending. 

Dr. Tolias: Thanks a lot. It was my pleasure.

[Outro melody.]

iTunes | Spotify | Google Play | Stitcher | Length: 59 minutes | Published: March 22, 2021

Dr. Michael Kauth talks about his research in LGBT Veteran health, involvement in LGBTQ advocacy, educational career, and trajectory. We asked him about his involvement with the Montrose Center on the Board of Directors and current efforts to support the LGBTQ community. We also discussed issues that members of the LGBTQ community have accessing proper healthcare and the role of stigma in quality of care.

Transcript

[Intro melody into roundtable discussion.]

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

Snigda: And I'm your other host, Snigda Srivastava.

Juan Carlos: and today we'll be talking with Dr. Kauth, and we will be learning about his research and LGBT veteran Health, his involvement in LGBTQ Advocacy, educational career and trajectory, we’ll ask him about his involvement with the Montrose Center on the board of directors and current efforts to support the LGBTQ community here. We will also discuss issues that members of the LGBTQ community have while accessing proper health care and the role of and stigma and quality of care. So, welcome!

Juan Carlos: So, Snigda, why Dr. Kauth?

Snidga: So, as a student, a second-year medical student at Baylor, I took an elective course in the LGBT Health Care literacy, and that's how I met Dr. Kauth. He was the course director for, for that elective and through that course, I was exposed to a lot of really interesting topics regarding LGBTQ health and advocacy, including lectures on topics about Healthcare considerations for men who-have-sex-with-men, women-who-have-sex-with-women, LGBTQ youth health, and a lot of other various topics. Through this course, we also had an incredible panel with LGBTQ patients at the Montrose Center that he organized, and he's actually been a member of the board of the directors for Montrose Center for over eight years now. So, having someone who's so involved in the community and advocacy was really inspiring. We also had a panel with Baylor physicians in the LGBT community, which is awesome to see as an aspiring physician in the LGBT community and so I really loved that course, and I thought that dr. Kyle could be an excellent person to interview for this podcast.

Juan Carlos: Yeah, and he seems to be very active, you know, in many different areas and really kind of spearheading the LGBTQ here at Baylor and you know is really speaks to our like diversity and inclusion here at Baylor. It's, we all feel very loved and this is just very interesting and very necessary stuff that has to be done. But you mentioned a little bit, he does some research in LGBTQ Veteran Health. 

Snigda: Yeah, so he is also part of the VA as well. So, he's a psychiatrist there and he's also done a lot of research and has published, like publications and edited a book recently in 2018 on transgender health for mental health professionals, which was really cool. He's also an author! 

Juan Carlos: That's right! His latest book is called The Evolution of Human Pair-Bonding, Friendship, and Sexual Attraction, and this book really presents us an opportunity to see an evolutionary history of romantic love, male-female pair bonding, same-sex friendship, and sexual attraction drawing on sexuality research, gay and lesbian studies, history literature, anthropology, and evolutionary science.

Juan Carlos: Dr. Kauth’s book also talks about employing evolutionary theory as a framework, close same-sex friendship as examined as an adaptive trait that has harnessed love, affection, and sexual pleasure to navigate same-sex environments for both men and women, ultimately benefiting their reproductive success and promoting the inheritance of traits for friendship. There are certain chapters that consider the desire to form close same-sex friendships and ask if this is embedded in our biology concluding that most humans have the capacity to form loving, meaningful, and sexual relationships with men and women. Furthermore, this book takes on a unique interdisciplinary approach and is essentially, is essential for reading for those studying and working in sexuality research in anthropology and sociology, evolutionary psychology, and gay and lesbian studies. It will also, will also be an interest to marriage and family therapist as well as sex therapists. So, it's kind of an all-encompassing book. Sounds very exciting and it's only 224 pages of exciting – exciting cutting-edge research. Snigda, any thoughts?

Snigda: I think it sounds very exciting I'm really looking forward to hearing what the audience thinks.

Juan Carlos: It sounds very exciting, I mean, his book just came out in November and we're all excited to see sort of the what the community thinks about it, but it would come as no surprise that the book will be very exciting to read. Dr. Michael Kauth is, like we’ve mentioned, the director of the LGBT Health here at the department of the VA and a professor of Psychiatry and he has authored several things, and this would be also another one of those that would be nothing short of exciting. So, without further Ado, let's talk about LGBT health and Veteran health care and LGBTQ disparities with Dr. Kauth. Let's go to episode.

[Interlude melody]

Snigda: So, welcome Dr. Kauth. 

Dr. Kauth: My pleasure to be with you. 

Snigda: So, how are you? How are you doing? First of all, this is during the time of covid-19 and the whole quarantine coronavirus thing. How are you doing?

Dr. Kauth: I – I'm I'm okay. It's certainly strange times right now and I miss interacting with people face to face. That's probably the hardest part. I can, I can do my work from home, that is not nearly as satisfying as being able to interact with real people. There's just an energy around people that you don't get by talking online and seeing them on video.

Juan Carlos: Very strange times. 

Snigda: Yeah, super strange. How has that affected your work like day-to-day?

Dr. Kauth: A lot of my lot of my work at least at the VA is virtual because I work at a national level and I talk with people all over the system, and so that really hasn't changed much. That work continues. My work at Baylor though is a little different, that tends to be more face-to-face and teaching classes and interacting with students. And right now, that, that doesn't happen in that way. We don't have face-to-face meetings and lecturing and teaching is done through Zoom, which works but, it's a little weird not being in the same room with people and sometimes having a delay in the communication. It's an adjustment to be able to make that work but people I think are generally patient and willing to work it out because frankly that's the way things have to be right now.

Snigda: So, can you tell us a little about yourself and how you became involved with research and advocacy and LGBT health?

Dr. Kauth: Yeah, certainly. I'm a clinical psychologist by training. I'm a professor in the department of Psychiatry at Baylor and do teach at Baylor. Most of my work, though, has been at the VA and I've got two major roles there. I'm director of the LGBT Health Program for all of the VA and we oversee to Health Care policies and some clinical support programs and generally work to try to get clinicians to follow best practices and policy. The other major role at the VA is I'm co-director of a research and education center called the South-Central Mental Illness Research, Education, and Clinical Center or MIRECC – that's a mouthful – and our Focus there is on finding innovative ways of delivering best mental health practices in the U.S. I was, I was raised in a very small town in Kansas, a town of 4,000, and went to school as an undergraduate at Wichita State University. And that was a great experience and in kind of towards the end of my undergraduate career or maybe the beginning of my master's program in psychology, I came out as a gay man, and that was in the early mid 80s and HIV/AIDS was really hitting the east and west coast about that time. It was just beginning to reach the Midwest, in fact, it was actually already there, and people didn't know it, but it was already there, and it was really frightening people, but that HIV/AIDS certainly was affecting me and my community people, that I knew, and I began passing out condoms on campus and volunteering for organizations to increase awareness and knowledge.

Dr. Kauth: When I was in my master's program as a graduate student and doing a practicum at Community Mental Health Center, I started seeing HIV patients in part because I really wanted to, I wanted to help and in part because regular staff members were afraid of seeing those people, they were afraid of getting the virus through this having them in the office. Which was sad, but I started seeing mostly men with HIV and started to realize quickly that there wasn't a lot I could do as a therapist with meeting them weekly. What they really needed was greater social support. They needed to be connected with other people. It helps them. They were very isolated. They were afraid to tell other people that they had HIV. They were afraid of being discriminated against – all understandable. And so, what I did was I organized a support group. I was the very first support group for HIV people in Wichita, Kansas and that support group became quite popular and morphed into two other support groups of different variations. We were meeting in the basement of a Unitarian Church and that, that carry on for a little more than a year, I think, and about that time, I was ending my time in Wichita. But I was connected with other people in the community who were delivering other services to HIV people like dental services or physicians who were willing to see HIV people or funerary services. There was a guy in the Social Security Administration office who was really good at helping people with their disability claims, and we pooled our work and founded a nonprofit organization to be an umbrella for all of these services called and we called it AIDS Support Services not – not a cool name, but that's what it was and that was really rewarding and gratifying and soon after we formed the nonprofit and I left to go to school at the University of Mississippi to finish work done on my degree. While I was there, I really got my first taste of research and I spent a couple of summers working with an HIV researcher at the University of Mississippi School of Medicine in Jackson, Mississippi. And Dr. Jeff Kelly, who is a psychologist, and he was working on an idea to change social norms within large groups of people, mainly gay men who went to bars and changing social norms around using condoms using the Diffusion of Innovation model to do that. It was a great experience. Probably the most fun job I ever had because I had got to go to bars and talk to people about sex and grab free drinks from the bartender. Didn't get paid a lot. But that experience also taught me how research works. How a big research organization functions and it was very welcoming there. I realized it's not something that I wanted to lead myself but I really like to be part of research. I enjoy working with really bright people and analyzing data and writing papers and that gave me, kind of, my first taste in publishing so, that kind of got me started both in advocacy and research in this area and it told me also that you know, I can make a difference. 

Snigda: That's a really powerful story! It's awesome that you're able to, like, make such a big difference. Even as you're saying like even as someone who doesn't have like an amount of power that you would necessarily need for like policy change, but you can make like real change in the community. That's super inspiring to me also, and I guess Juan too because we're both very interested in research as well.

Juan Carlos: Anything research we’re always like ‘tell me more.’

(All laugh)

Dr. Kauth: It's a fascinating way of life. It really has the brightest people involved and that's stimulating. It's super stimulating the be part of that world. Also, a hard part and money kind of, didn't like, was that, that constant cycle of anticipating the end of your funding and preparing working on getting new funding, that part wasn't so fun. I really enjoyed working with people who are doing research and being part of the research. So, now I kind of have the best of both of those worlds. I get a hard-money paycheck from the VA and I get to work with researchers on their projects as an operational partner and helping them craft their work in a way that can help with policy and help with best practices in healthcare.

Snigda: Do you have any stories from your early advocacy work of people that you interacted with that like, really left a mark? 

Juan Carlos: Like a role model figure?

Snigda: Yeah! 

Dr. Kauth: Yeah! Several. The faculty member who was leading this HIV work at the University of Mississippi, Dr. Kelly – amazing individual and the clarity of his writing really helped me a lot and learning how to write and how to very concisely and be persuasive and communicating your ideas. He's also a very passionate person and wanted to make a difference and I really enjoyed seeing that passion. I guess also the passion of the whole team because like I said in research you have to worry about where the funding is coming from often people in research aren't getting rich. They're not making a lot of money and they're doing it because they really want to because they want to learn. They want to learn new things. They want to communicate those ideas and they want to make a difference in the system. So, and being part of and riding along with that passion was just super stimulating and super helpful. That's something I wanted to do. 

Snigda: Yeah, that's amazing. That's such a cool story. Juan, did you want to take the next question? 

Juan Carlos: So, I guess the reason she asked me is that, as a as a veteran myself, I’m kind of always interested to see what people are doing for the veteran community and it and this question is kind of based off of one of your last or recent publications in the American Journal of Public Health. I guess I’m just kind of wondering what your most fascinating ideas or questions that you have in regard to researching and LGBT and veterans in their access to health care, in your experience. 

Dr. Kauth: Yeah. What is really interesting to me is trying to figure out how stigma and discrimination, especially within the military, contributes to health disparities among LGBT veterans. There's been some great work done recently by Ilan Meyers to conceptualize a model of how the this occurs and he calls it the Minority Distress Theory and the idea behind this I think is very helpful because it helps us kind of think through these steps and how health disparities that occur but it also provides us some possible pathways of interventions and the idea is that larger kind of distal stressors like stigma within society as well as individual more proximal kinds of stressors, our personal experience with stigma and discrimination, the internalization of those experiences, both of those things individually and together contribute to maladaptive ways of coping like drinking too much, eating too much, not exercising, doing drugs to manage anxiety, and poor health seeking behaviors. It also contributes at a larger level to barriers to accessing healthcare because it’s not thought of as something that's terribly important. All of those things collectively together lead to differences in health outcomes with stigmatized populations like LGB people and T people as well. And I make that distinction because there's another group of folks who kind of expanded on that model and conceptualized the Gender Minority Stress framework that looks very similar to the Minority Stress framework that also conceptualizes how transgender individuals can end up with greater health disparities, poor mental and physical health outcomes compared to non-transgender or cisgender people. How do we intervene? How do we build up people's resilience to moderate those poor health outcomes to minimize the internalizations of these negative experiences? It's very hard at a to kind of reduce those larger societal messages of stigma and discrimination but we can, at a personal level, help people cope better and to engage in more healthy behaviors and healthier ways of coping with those stressors, even if we can't reduce the stressors themselves. 

Juan Carlos: It's wonderful. It's especially given that, you know, it's not, it's no secret right? That the military isn't that touchy-feely environment that really allows anyone who wants to seek help right? To seek it before they separate from the military and then once you separate those, those opportunities to get help are you even lessened or more lessened or more scarce, I guess you would say, and so I mean, I personally know a lot of people who revert to unfavorable coping mechanisms, and you know, it's just kind of a slippery slope from there. 

Dr. Kauth: Yeah, and this is not just an issue for the VA. A lot of people have them stick and belief that the VA sees all veterans. We do see all veterans who come to our doors, but the majority of veterans get their health care from private practitioners who, unfortunately, don't always ask about military service and they aren't aware of how military service may put people at increased risks of certain health conditions and they need to ask those questions and they need to follow up and find out that information. I think that's true for sexuality and gender identity as well. If Healthcare Providers don't ask those questions, then they don't know that somebody may be at risk of particular health conditions. They can't follow up. They can’t address those issues. You know, kind of the intersection of those identities are also important and can put people at even greater risk. So, LGBT veterans may be at even greater risk of some mental and physical health conditions compared to non-LGBT Veterans because they got that double or triple dose of stigma to deal with. 

Juan Carlos: Oh, yeah. Yeah. It's a lot to deal with mentally.

Dr. Kauth: One of the things that I've learned about advocacy is that you can't be a one-person show. You're not effective if it's only you. You are most effective if you expand your capacity, if you inspire other people to be advocates themselves and pull them and broaden the scope of your work and let them do their thing too. So, one of the one of the exciting parts of advocacy for me, at least within the VA is helping to change the culture within VA. A lot of Veterans, as you probably know, think that the military and the VA are kind of one in the same. They’re just two ends of the spectrum and they're very different and have different policies in place and slightly different cultures. But there's some of that military culture that is brought to the VA and some larger societal culture that's part of the VA and I am working to try to change that and to create a more welcoming friendly environments for people who feel stigmatized by providers to have conversations about sexuality and gender identity. So, patient know that this something that they can, and they should be talking to their Healthcare Providers about because it has health consequences and that they're getting their needs met.

Juan Carlos: Yeah. So, I think for like a veteran having someone who is openly receptive or just simply asking, you know, it's like “Yeah, great! Let's talk about it. I've been dying to talk about this” and it’s just laying it all out there. Just that act alone. I think it's therapeutic. But you're right, you know, like more physicians need to know to ask the right questions when it comes to this patient population. Yeah, and then in your advocacy, this is sort of, are their organizations or are there certain things that you've done that are now sort of in place in practice? What is or could have been the most rewarding and highlight of your advocacy?

Dr. Kauth: Uh. I'll share a couple of things. One of them met at the VA, one of them at Baylor. You know, in my work in the VA and trying to change culture, one of the things that I'm most proud of and I think we'll probably be most effective is we managed to get identified with every facility and LGBT veteran care coordinator. Some facilities have more than one and it is their job to assess the needs of LGBT veterans at that facility and work to provide all of the services that we need to be providing for those veterans at that place to connect with community organizations to educate staff and to, more generally, create a welcoming friendly environment for LGBT veterans. It's those people on the front line that will make the most difference in the system. Doing policy, issuing a policy, asking people to read it, is not going to do a lot. It's the implementation of that policy that makes the difference and it's those people at the front lines who do it. So, I'm very, very proud of that work. And what is rewarding is to get messages from those people in the field of various facilities who send us photographs of like Pride events at the VA, which they've never held before. 

Snigda: That's awesome!

Dr. Kauth: And to see it happening is really, really cool. Yeah. 

Snigda: Wow, that must have been really hard to like, get that approved.

Dr. Kauth: It is it is difficult to get changes made but it is possible. Yeah, the VA can be a really neat and flexible system sometimes, but it has a surprising amount of flexibility. There are a lot of good people in the VA who want to do the right thing. And it's not always easy to know what the right thing is. But one of the things that I've learned in my career at the VA is persistence counts and if you're persistent you will win, and you just have to keep hammering with the right message to the right people enough time and you can get your message through and you can make things change. And it is possible. 

Juan Carlos: One thing there is a military, which is kind of fitting, right? Is that saying, ‘the squeaky wheel gets the grease.’ So – 

Dr. Kauth: That’s right! (chuckles)

Juan Carlos: If you just continue and you stay persistent and you're adamant about change and it'll happen.

Dr. Kauth: Keep hammering home! This is what we need to do. This is the right thing to do for our veterans and people listen to that message. 

Juan Carlos: That's awesome.

Dr. Kauth: Yeah. Let me, let me share an advocacy story about Baylor. I mean, I came to Baylor in 2007 after Hurricane Katrina. I've been living in New Orleans prior to that and yeah, things were bad, and my husband and I decided that we couldn't stay there. We needed to move for a variety of reasons and through my job at the VA I was able to transfer my position over to Houston, which was a wonderful transition for me in a lot of ways and immediately got involved with Baylor, who seemed very eager to partner with me. I started lecturing in classes and a couple of years later, I took over the Human Sexuality class from Dr. Basinger. We've been running the course for several years because they were really interested in the topic and they felt like that this was material that wasn't being covered in some of the other courses and I agreed with them and I thought it was a cool idea and was really excited by their eagerness to do something and so, together, we wrote the course. We developed the proposal and sent to the Curriculum Committee and they approved it, which was great, and I've been offering the LGBT Health course since 2014. That's been really great, and it's been due to student excitement about the topic and wanting to learn more. I really enjoyed that, and the visibility of the course has made me a magnet in some ways that lots of students even faculty member with faculty members will come to me and ask advice or want to share ideas about expanding LGBT Health interests or activities at Baylor which has been pretty cool. It's thrilling to see like the BCM Pride Group engaged in activities or the graduate student group engaged in activities and more visibility of LGBT health issues and in other courses or other activities that are going on on campus. It's been huge explosion of activity since 2014. I don't know if that was me. I don't want to take all the credit for it. But I think the existence of visibility of that course helped make it possible – gave some room on campus for other people to decide, you know, maybe I could do this too and they did.

Juan Carlos: Well, we appreciate your modesty in the impact and implementing such big change. 

Snigda: Yeah! 

Juan Carlos: I know that, at least in our class which is about 200 students, they're very interested in how to manage LGBTQ patient encounters. And so, when you were mentioning about faculty and students’ sort of seeking out information from you, I'm sure there would be a large majority of our students now who would be interested in: 1) Is there a course? And they would probably really, really interested in doing an elective on that and then 2) following your work and advocacy, and then 3) getting involved, so – 

Snigda: Yeah, as a student that took your course, yeah you were being modest for sure, that course was actually, it taught me a lot. I was already interested in the topic and I guess maybe the people that take the course or a little self-selecting in that way, but I learned a ton from that course and it also made me a lot more optimistic about like how much we can actually impact LGBT Health as like, hopefully future Physicians, and yeah, I just honestly, I want to echo what those students said like about how you're like you are the perfect person to be teaching this course, you know? Given how much experience and knowledge you have in the field. So yeah, I love the course.

Dr. Kauth: Thank you! That's good to hear. I'm very glad to hear it. Thanks for sharing that. You know, you don't always know what impact you have on other people. Mostly, you don't know. You hope for the best, but I do see effects like you, in particular, inviting me to be part of this podcast, which is a really cool thing. And I appreciate that, and it probably wouldn't have happened if you hadn't been in my course and I've seen other people do things too that leads me to suggest that they were inspired and that's, that's really gratifying to see.

Snigda: So, when we, when we were like taking your class, we talked a lot about how you kind of mentioned this already, but stigma and a lack of proper knowledge on LGBT Health can affect the quality and access to healthcare for LGBT patients. Is there any advice that you would give students or physicians in the healthcare field to reduce those disparities?

Dr. Kauth: Providers and students are in a perfect position to be strong advocates for people who have little voice in the community. People who get into Healthcare want to help. They want to make a difference. They want to make people better. And so, they're already advocates in a way. It's just because since you're just directing this in a different way and how they can get involved is to get informed, learn more about the topic, and be knowledgeable. A very important way that they can be advocates is among their colleagues and when they hear anti-LGBT statements, even jokes, say, “You know, that's not okay. I don't believe that. I don't want to hear it. I think that's wrong. That's not the way I practice or live my life” or whatever to feel, whatever it is that you say that kind of put a stop to those statements. As a colleague, that has a very powerful message amongst your colleagues. So, I encourage people to do that behind-the-scenes. Other things that Healthcare Providers can do and stuents can do is get involved in LGBT issues and they can do that in a number of ways: participating in events like Pride events, volunteering your time in LGBT organizations, giving lectures, volunteering in other ways. Giving money is helpful, and in your practices, being sure to include resources and information that's important to the LGBT community. I like to tell the story in the class because it's sad but it's true. I’ve been in Houston since 2007 and seen a number of healthcare providers myself for different reasons and out of those probably 10 or 11 different Primary Care Providers, only one of them ever had LGBT patients and some of those providers had advertised themselves as friendly to the LGBT community. So, I found that really surprising and odd. If there isn't material or information in the environment that recognizes LGBT people, they're not going to feel that they are respected there. And so, all of those things together can help make a difference and are, you know, relatively easy things to do. If you do just one of those things you can, you can make a difference. 

Snigda: Yeah. I'm always amazed at like, how much of a difference even a small thing like a pamphlet can make or a poster just to make people feel like comfortable sharing what they're going, with like going through. 

Dr. Kauth: Yeah, absolutely. And that reminds me of a story about the VA but one of the things that we have done was try to increase the presence of LGBT in the Healthcare environment. And there was one primary care provider who told me, this was a couple of years ago, he had one of our posters as a screensaver on his monitor. They don't allow this anymore, but they did at the time and the message on that that poster that was on his monitor was “We serve all who serve.” And it had a rainbow dog tag as part of the poster and you know, a patient that he had been seeing for a long time in his office and saw that screensaver and said, “You know, I have to tell you I'm a lesbian” and he was a little taken aback because he first he hadn't asked about her sexuality before and so he felt bad that he hadn't done that. And he was a little taken aback because it was the screensaver that made her feel comfortable that this was a space where she could talk about her sexuality and she hadn't been able to do that before. 

Snigda: That's incredible. 

Dr. Kauth: So, it can be a very small thing like that, that communicates to people that this is a safe space. This is something that is okay. I can talk about these issues.

Snigda: That's yes, that's amazing. Uh, I did some work as an RA in undergrad with advocacy and I also kind of noticed that like, just like, passive things like that, like a poster on the wall could make such a big difference like someone might not even realize that they're going through something and they'll see a poster and they’ll be like “hey, wait a minute, that’s like me” and that can really get things going. It's pretty amazing.

Dr. Kauth: Yeah. Absolutely. 

Juan Carlos: Posters and pamphlets, I mean, they do an awesome job. They sound great. I'm more interested in the active stuff and you mentioned that there's a lot of active advocacy just so that we can try to prepare for future events and maybe have the podcast cover the events, what are the biggest events that we do here at Baylor?

Dr. Kauth: Yeah. There are Pride events that occur in June. This season probably won't be face-to-face activities on campus, and I don't know yet how those are going to be morphed into something that's online and virtual that can still involve people. It's unclear. But I've noticed that around the city, around the country, face-to-face events are being canceled. And that's, that's a little sad. Yeah, but those kinds of annual events are places where people can get more involved and visible. I'll tell you one of the most powerful things, I think, that has been happening for students is in new student orientation for first-year students who are coming in. There are a series of group discussions organized around different topics that have included wide range of topics and especially LGBT health and they offer these at different times so they can involve different groups. You all may have participated in some of those. I don't know. I've been involved for the last couple of years in leading some of those small groups, but it's not just me. There are other faculty members who have come in and led those groups too and I think it's a great way of introducing to students the connection between sexual orientation and gender identity and health issues and why those are important health issues and how to think about health in those ways and how to create a more affirming kind of clinical practice. So, very early on, kind of, lays the groundwork for students thinking about LGBT health issues in a very affirming kind of way. Hopefully they get more content information later on in their training. I don't know but it's a great foundation to begin with and so I encourage other faculty members and all of the incoming students to take part in those kinds of activities.

Juan Carlos: Well, yes. Yes. I guess I meant when this COVID, you know, lockdown gets sorted.

Snigda: Yeah, so BCM Pride has a few events that they do every so often like every two or three months. They recently had like a like a Valentine's party where they had a lot of like baked goods and there was like a tea party. It was, it was great. That was super fun. But yeah, they if you, I think if you join the BCM Pride Facebook page, they do a lot of advertising on there. So, if anyone's interested who's listening, that would be somewhere to check out. Yeah. Dr. Kauth, I think you wanted to say something. 

Dr. Kauth: Well, I would just add to that, that of course, you don't have to be an LGBT person to participate in LGBT activities or in BCM Pride. You can be an ally and allies are incredibly important. So, there are far more allies than there are LGBT people. 

Snigda: Right! So, I think we've covered a lot of really interesting themes about LGBT health and advocacy. Dr. Kauth, is there anything else that you would like to share with our audience?

Dr. Kauth: Uh, let’s see… I did want to, I did want to share this, that while back here, you had asked about mentor role models who really helped put me on an academic path. And this was a Social Psychologist at the University of Mississippi, Dr. Dan Landis, who taught the human sexuality course for undergraduate and graduate students, and I hadn't thought of myself as an academic up to that point, but he was very much an academic and focused on human sexuality. I enjoyed taking the class as a graduate student. I actually was a teaching assistant for a year after that and we, Dr. Landis and I became close and one of those years he decided that he wanted to put together a proposal for protecting human sexuality and invited me to help draft it, and the textbook never got published. The publisher didn't pick it up, but the experience taught me that I could write and I had something to say and it was a lot of fun, especially writing about human sexuality kinds of issues and so, I really valued that experience. It taught me that it was important to make connections with faculty members who are working in areas of your interest. They're real people and they have lots of, lots of information and experiences to share and can provide you opportunities that you hadn't ever thought about and those opportunities will open up new doors for you that you hadn't considered and so writing those, writing those chapters convinced me that I could write other chapters, I could publish, I could write a book, and eventually, I did. I published my first book in 2000 on Theory of Sexual Attraction and I am now working on my fourth book that will come out later this year. It is going to be called The Evolution of Human Pair-Bonding, Friendship, and Sexual Attraction that will be published by Rutledge and it is such a rewarding experience to do something like that. But I credit Dr. Landis for putting me on that pathway with showing me that this was something that that I could do. 

Snigda: That's so inspiring to hear and yeah, it's really optimistic for some students just starting out to see someone who's been able to like really make such a big difference and has still like maintained so much like modesty in spite of all the success. But yeah, this is this is really inspiring for me. 

Dr. Kauth: Well, and I have to say, if you want to make a difference, you can't do it for yourself. If it's only about yourself and getting that positive feedback, you will not end up helping people, you'll just be looking for that kind of positive feedback, the positive interaction. Like I said earlier, you can't know what effect that you have on people. You have to hope for the best and let them do their own thing. What you can do though is, you can plant seeds with other people. You can, you can give them information that can Inspire them that can help them see things in a different way and that's the best you can do and then look to see what effect that has and that's its own reward and looking back and seeing how you have affected other people at a distance. They've gone off and done their own thing and they made a difference themselves, but it's a very delayed kind of gratification and you have to be willing to accept that in order to I think to be an effective change leader. 

Juan Carlos: So, I have a kind of question, just out of curiosity. Currently at the moment, we're kind of going through learning disabilities and autism spectrum disorders, and I have been chatting with a colleague of mine Priscilla Bigner who does work in mental health counseling and aspiring clinical psychologist, and so, we know that kind of autism spectrum disorder are more likely to, sort of, be transgender and identify as non-conforming, but would you be able to comment on what research has been done into dealing with sort of autism spectrum disorder and transgender?

Dr. Kauth: Uh, certainly. Research has shown that people who often identify as transgender or gender-diverse have a higher prevalence of learning disorders and tend to be more on the autism spectrum. Why that is, is not clear. The connection between the two is not clear. It could be a process that is parallel to gender identity issues and just happens to co-occur. I don't know that there's any kind of causal connection and similar to research and things like attraction among people. There are a lot of things that are associated with a prevalence of same-sex attraction that, how are those things causal and how they're connected isn't always clear and I'm not sure that we can make a lot of that information just yet. I think it’s; I think that the process of how people think about their gender identity, their internal sense of self is, probably both a biologic process and a social process and there are things that happen within our bodies allow us or kind of shift our thinking into “this is part of me, or this is not part of me.” And this is consistent with how I think about myself or not consistent with how I think about myself and then in society we get messages about how we should interpret those basic and biologic senses of this is consistent with who I am, this is not consistent with who I am, and in terms of how we think about our gender. But we don't really know what the causal connection is to why some people have a gender identity that's congruent with their sex assigned at birth and why some people have a gender identity that's not congruent with their sex assigned at birth. It’s probably a very complex process where we're only able to find like associations at this point or things that kind of occur together with people who have a transgender identity. I know that doesn't really answer your question that that's really the best that we know at this time. These are things that tend to go together and that's all we know. 

Juan Carlos: But yeah, you know, it's just, these are things that we kind of think about as we're learning, and we learn about gender identity and that development and then disorders and cognitive development. So, if one isn't aware that they're developing this way, you know, there's, you're kind of prone to not being able to identify in a certain gender. And then that will likely predispose you to some increase risk of – 

Dr. Kauth: Sure! Sure. You know, I would add to that, we really don't know a lot about causes of sexual attraction. Why are some people gay, some people bisexual? Why are people heterosexual? We don't really know. The current research tells us that there are some things that tend to be associated with same-sex attraction, but they're probably not causal factors; that they're just correlative factors. However, there's been like zero research on causes of heterosexual attraction because that's the normative attraction and in society, we don't feel like it's important to investigate things that are normal or typical. They need no explanation because they just are, and that's really the wrong way to think about it and it's an empirical question. How did we get this? What causes this? To understand how we are who we are. 

Snigda: Yeah. I think that really gets to the whole idea of like baselines, I guess and how we decide what a baseline is. And yeah, it just makes me think a lot but that's, that's super interesting and I'm definitely gonna look out for your book what it does come out. It sounds really fascinating.

Juan Carlos: Well, you seem to have a way with words and shifting paradigms at an Institutional level. So, hopefully we will see kind of a wave of change going into in favor of the contents of your book.

Snigda: Alright! Well, any last thoughts?

Dr. Kauth: No, it's been a pleasure talking with both of you. I've really enjoyed it. And this has been a wonderful experience and I'm excited to have the opportunity to share my work with other people and glad that you're interested. Thank you. 

Snigda: Thanks so much! 

Juan Carlos: It has been a pleasure having you on the podcast show, Dr. Kauth. Hopefully, we'll have you on again and discuss your books and future endeavors and successes and thank you so much!

Dr. Kauth: Thank you.

[Outro melody.]

iTunes | Spotify | Google Play | Stitcher | Length: 56 minutes | Published: March 4, 2021

Dr. Sandra Haudek discusses her journey from a career in research to clinical education at Baylor College of Medicine. We will learn about the Foundations Basic to the Science of Medicine course and a little more of the personal history of the woman behind it. We will also discuss wellness, her dancing hobby and her past experiences with stem cell research. 

Transcript

ERIK: And we're here. This is the Baylor College of Medicine Resonance podcast. I'm one of your hosts, Erik Anderson.

JUAN: I'm another host, Juan Carlos Ramirez.

KARL: And my name is Karl Lundin. I was the writer for this episode.

ERIK: Yeah, Karl, you might have actually been the writer for the most episodes right now. You're number one.

KARL: I want the award at the end of this year, I always knew I was the greatest. This is good confirmation.

ERIK: Yeah. We're very modest here.

KARL: Oh I know I am. 

ERIK: Uh, so yeah and actually though, speaking of modesty, the person that we were just saying how just nice of a person the instructor that we interviewed on this episode is . . . 

KARL: Yes, today we're going to be talking with Dr. Sandra Haudek. And yes, she is one of the nicest people in the world, very kind, very modest person, also happens to be the director of the Foundations of Basic Science and Medicine program at Baylor. So basically that's kind of like the first year courses, lectures, you'll take in sort of the Basic Sciences things like, you know, biochemistry and that sort of stuff they give you . . . 

JUAN: All of the things we love.

KARL: Yes, who doesn't love some good biochemistry. Um, no, but that Anatomy, you know kind of the foundational content you need to know before you can go into the clinics as a medical student so that a lot of the stuff that's like tested for on the MCAT, things like that. Yeah, really great person, really great to get a chance to talk to her. In addition to being academic director, she also has a pretty interesting life though, we got into. She of course has a pretty extensive research background. She's not Ph – er, she's not an MD, she's a PhD, so she comes to Medicine kind of by way of basic science research. We’ll talk a little bit about, that get into some interesting topics there. She did some research on cardiac inflammation and fibrosis, some interesting research involving TNF as a mediator for some of these phenomena and then probably at least, for my year of med school – me and Erik's year of med school – the most popular lecture she taught was on the topic of stem cells, which she also has a little bit of research experience and it is also a very interesting topic we get into and she has some really cool insights and ideas about that.

ERIK: Yeah. I remember she was really excited when she taught us – did we – just had like, I think just one lecture on stem cells, but I remember she taught it and you could tell how enthusiastic she was about – I mean, they're very cool, I mean, don't get me wrong, so it's easy to be enthusiastic about it.

KARL: We had a lot of passion, and also passion, like, kind of a rat surrounding some of the interesting not just scientific issues. But also there's, like, stem cell research is a great place to explore a kind of the intersection between, you know, scientific philosophical and sort of ethical issues as they interact when we apply scientific principles and scientific discoveries to healthcare, right? To medical treatments, which is a very important, but often maybe not as much emphasized part of our education.

ERIK: No. Yeah, I think you're right. 

JUAN: And she's kind of like the epitome of, she's not a busybody but she does so much, right? We really have no excuse, like “I don't have time for this”, “I don't have time for that”, she actually balances life quite well and kind of pushes it in all directions. Yeah, cuz she also organized or organizes the Scholastic – yeah. I'm gonna edit this out. Actually, but what I'm trying to say, but I don't remember it is the Scholastic Research Symposium. She organizes that.

KARL: I do vaguely remember talking or hearing about that. Although once again, I'm not the big research guy. Sitting in the room with the M.D./Ph.D.s, you know, I'll cede that to you for –

ERIK: We should know it all.

KARL: But yeah, Dr. Haudek, very interesting person. Very wonderful human being too, I think we’ve all had some real positive experiences. She just always is a very kind friendly person, always willing to help you out. I remember one time – she would just do these nice things for our class. One time she brought in a big old platter of cookies and there's all these different cookies and treats and sweets from, Dr Haudek. Like where were these cookies where are these sweets coming from she like, “oh, you know, I had a little get-together this weekend” and we kept trying to talking with her about it and we kind of got hers like, “oh, well, it was my birthday this weekend”. “Well, Dr. Haudek, you didn’t tell us it was your birthday!”. And so of course, later in the day we surprised her during histology. We all sang Happy Birthday to her and it was just a very sweet moment and well deserved for a very wonderful human being. Also, an amazing ballroom dancer. Apparently. Yeah, that's another thing she'll mention briefly in her last lectures, but interesting thing we’ll get into in the interview today. She also, her and her husband are involved in the world of – I guess you call it competitive dancing, although apparently they haven’t competed as much in the last few years, but it's another interesting little thing we get into; and also talking about kind of how you can have an intense hobby like that and have that be an important part of work-life balance in some of these kind of, I guess high-intensity fields like, you know, the professions in science and medicine; or it's easy to get absorbed in your work, but it's important to always have other things in life, too and we get into that a little bit as well.

ERIK: Sounds like a good talk.

JUAN: Let's get over to the episode.

ERIK: Yep. All right.

JUAN: Here we are. Juan Carlos Ramirez, one of the hosts for the Resonance podcast, the Baylor College of Medicine.

KARL: This is Karl, I was the writer for this episode and thank you for joining us Dr. Haudek.

DR. HAUDEK: My pleasure to be here, I really like talking to you.

KARL: Yes, we're very happy to be talking to you. Dr. Haudek, for those who don't know, she is the course director for Foundations of Basic Science and Medicine which is kind of the first set of courses that students start on here at the medical school; and also a very wonderful and kind human being, and we thought it'd be lovely to have a chance to talk to her today for this podcast episode. So Dr. Haudek we thought we'd just start out by asking if you could tell us a little bit about your background.

DR. HAUDEK: First of all, I maybe thank you for having me here. I really enjoy telling you and your colleagues more about me, my personal life, my professional lives, my interests, and so on. 
I am originally from Austria. I was born and raised in a town called Innsbruck in the Alps. So I was told I could ski before I could walk with, like, Innsbruck was a town where the Olympics were twice. But I was 10, my family moved to Vienna, the capital of Austria. No mountains, no skiing. And so I had to start dancing.

After high school, I went to the University of Technology in Vienna and I started genetic engineering with an emphasis on biochemistry, of which I graduated with a Master's degree. We do not have Bachelor’s degrees, at least at that time. You just go to the Master's degree right away. And after the Master's degree, only if you have a Master's degree, you are eligible to enroll in a Ph.D program, which I did I enrolled in Vienna in my Ph.D program and that was biochemistry. And I started this program and I had the opportunity to go and explore a different country. I always wanted to be in an English-speaking country. I always wanted to be somewhere else. I traveled a lot my whole life. I was very interested in learning about other cultures and other people, so I really really like this opportunity to go for one year to Dallas, Texas and work at UT Southwestern.

That one year turned into six years. I did finish my PhD, yes, and then after I finished it – actually, I had to go back to Austria to finish it and defend it, but then I was offered the postdoc position. My mentor was Dr. Brett [Giroir]. He was, you can see nowadays, in the White House talking about the COVID 19 testing kit incidences. Yeah, it was interesting for me to see him now on TV. 

KARL: That's very interesting.

DR. HAUDEK: It is. After six years in Dallas, I was ready to move on. I knew I wanted to stay in the US. Also, because I met my nowadays husband in Dallas and we both decided to stay in the US. And we applied all over the US for jobs, and it was Houston where we both had an offer, and be both very good offers. And that's how I came to Baylor.

KARL: So was biology, biochemistry – was that a passion that you always had, even as a child?

DR. HAUDEK: Actually, it was chemistry. My high school, I had a teacher who really really influenced me greatly. I just loved the way she talked. I loved her lessons, was very easy for me to learn it. And I actually wanted to study pharmacy, it was my real passion – organic chemistry, pharmacy, yet in Austria at that time, pharmacy – I didn't know much about industry at that time. But working in a drugstore was not my future and vision and so I decided not to study pharmacy, but keep it a little bit more open. So I started chemical engineering.

I think that the drug before I started chemical engineering. Yes. And then in the last years of my study I had my first course in biochemistry and I learned about DNA and proteins and I thought “oh, this is really cool because I love that thing”. And so I took an elective in genetic engineering and I took electives in biochemistry. And also I graduated in chemical engineering and knew at that time that my PhD should be in Biochemistry.

KARL: Interesting. So it's kind of a process of experiences one leading to the other.

DR. HAUDEK: Exactly.

JUAN: And you get to use those skills to this day.

DR. HAUDEK: Well, I forgot a lot of it. I remember a few years ago. I went back to Austria and I had to go through all my books and course notes and everything, and I had notes in my hand and I don’t remember ever writing them.

JUAN: I think some of us feel that way about six months ago in med school, perhaps they can – when did I write this?

KARL: So did you want to ask a little bit about her research experiences, Juan?

Dr. HAUDEK: Okay, so my research experience. When I accepted my PhD advisor position in Vienna, I knew that I wanted to study a topic in Biochemistry, and I knew that I would like to go to an English-speaking country. And so when I first met him, Dr. Hans Weiler – I am still very close with him today – he told me that he has this project which involves investigation of the transcriptional aspects in the promoter region of the Tumor Necrosis Factor Alpha gene with special emphasis on Nuclear Factor Kappa B and AP1 transcription factor protein-coding regions in the baboon compared to the human. And I remember sitting down looking at him and the only thing that I really understood was it somehow involves a monkey?

Well, everything else sounded great. And so I decided I'll go for it and I'll do it. And this is how my most intimate relationship with TNF-α or TNF started, because TNF has been my protein of Interest throughout my whole research career. I started with the role of TNF in sepsis, and it’s purely genetic engineering – sequencing and identifying promoter of the transcriptional regions in the promoter region in sepsis. And then, after a few years from sepsis, I was interested in TNF in the heart, during heart failure specifically – not just to sepsis – and that is actually what brought me to Baylor. Dr. Douglas Mann, he used to be Chief of Cardiology at Baylor. So he was interested in TNF in heart failure. And that was also the reason why I came to Baylor, to work with him and his group.

And from there on, after my postdoc was finished, I stayed at Baylor and I moved into the Michael E. DeBakey Heart Research Center, which was located or still is located in a Methodist Hospital in the Fondren building. So my lab and my office for more than 15 years was on the sixth floor in the Fondren building in Methodist, and I was interested in chronic heart failure. And during that time TNF was a little bit pushed into the background because I was more looking into general cytokines and growth factors that influence the differentiation of precursor cells or stem cells into fibroblasts or other cells in the heart, not specifically cardiomyocytes, but other cells. And so that's how my journey into stem cell research started.

After a few years after identifying factors and identifying a stem cell source in the bone marrow and in the blood, I circled back to TNF, and in my last research here – so I investigated specifically the TNF signaling cascade in those precursor cells. What makes them differentiate into a cardiac fibroblast or what makes them differentiate into a monocyte or macrophage. So here TNF again.

KARL: Interesting. So I – and forgive me, I don't have a super large amount of, fund of knowledge in this area, but is the main interest in fibroblasts because they'd be involved in scarification of the heart tissue?

DR. HAUDEK: Yes. Fibroblasts were always underestimated because the focus was always on the cardiomyocyte, and only in the in the late 2000s the role of the fibroblast was acknowledged. It was not just the structural cell, but it actually has some function, some very important functions. And yes, it is most important also in acute myocardial infarction where some of the heart tissue dies off and the scar tissue forms. And yes, it's the fibroblasts who mediate the scar tissue. And yes, I work peripherally on this, but my main interest was fibroblasts during chronic heart failure such as on the hypertension.

So I worked with mouse models that received angiotensin infusions or surgical mouse models in which their aorta was constricted or mouse models with mini infarctions. And then observe over time how fibrosis develops and what the process is for scar formation in acute heart failure. How detrimental it is in long-term chronic disease development because the more fibrosis you have the more elasticity is lost, and the heart needs to overcome the resistance and pump harder. And so long-term, you do want to inhibit fibrosis in a chronic condition.

KARL: That makes sense. And it probably could also derange some of the contractile activity if it's interfering with the constriction of the myocytes and the organization of the myocytes. So that actually sounds really interesting. So, basically you were exploring the role that these fibroblast have in chronic heart failure patients and – just real quick. How does TNF circle back?

DR. HAUDEK: So TNF signals through two different receptors, receptor 1 and receptor 2. Receptor 1 is highly investigated and it's also the receptor sought to be signaling apoptosis in cells. Whereas TNF receptor 2 is thought to signal positive effects of TNF in cells in general, but the role of TNF receptor 2 is less much, is much less known that of TNF receptor one. And so my goal really was to sort out the differences between those two receptors, which was kind of difficult because you really had to work with knockout models because they were – most antibodies available for inhibit, or most Inhibitors of TNF that are available target both receptors and don't discriminate between the two.

KARL: So by knockout models, basically, you would find a mouse lineage that had one receptor functional but the other receptor not functional and sequence it. 

DR. HAUDEK: Exactly.

KARL: Interesting. And did you find anything you think is particularly noteworthy you'd like to share with us?

DR. HAUDEK: Well the way in our studies, it was the TNF 1 receptor that was detrimental. I confirmed but there was, but again it was one specific myocyte process that has the option of either differentiating into a monocytes or into fibroblasts and there are those M1 and M2 macrophages in the middle – I don't want to go into detail – and the TNF really made a significant difference in which of the two outcomes it can steer the differentiation.

KARL: Okay. And the monocyte would be the more beneficial outcome, whereas the fibroblasts would lead to the more chronic heart failure type outcome?

DR. HAUDEK: It depends on the situation. Sometimes you want one, sometimes you want the other. So in an acute model for instance, you first want to have the monocytes that clear the wound, and clear off debris, and want – you need inflammation to start the baseline for good scar formation. It’s a timely asset, the inflammatory cells in the heart, and then after they have done their job the scar formation process starts. Now, that’s in acute infarct. Now in chronic infarct, in chronic heart failure, you do not have cardiomyocyte self-death so you don't lose cells, so there is no need for scar formation. So fibroblasts that would develop in long-term heart failure would deposit collagen in between cells, and does make it sticky in between cells and influence the mechanical aspects and electrochemical aspects between cells and that contributes. So in long-term heart failure, you want to inhibit fibrosis actually and also only have a minimum amount of new cells as well.

JUAN: What if something like this discovery in acute versus the chronic, what does that sort of mean for in the clinical setting? Is that change therapy or – ?

DR. HAUDEK: And again, it's been a few years, so everything I say is the status of a few years ago. So I have that disclaimer. Myocardial infarct, in the beginning, was the first target of most clinical trials and also stem cell therapies. However, nowadays even so myocardial infarct is very prevalent. If a patient receives adequate care within a certain amount of time, which is pretty standard today, the survival chances are very very high. In other words, today, if a patient seeks help adequately and timely, the patient will survive the infarct. However surviving infarct is the first step – then afterwards comes the long remodeling phase, the adjusting to it, the regeneration of the tissue. So a lot of problems – long-term chronic problems – happen three to five years after the infarct. So now that most patients survive we have increased problems of remodeling and long-term impact. So just go back in time when people died of a heart attack, then there was less prevalence of remodeling and long-term failure.

KARL: Yeah, your heart was just gone.

DR. HAUDEK: The second thing is – obesity, diabetes, one of those really classical clinical scenarios that are very prevalent nowadays. They all impact heart function in a chronic way. Hypertension for instance. A lot of people have hypertension and this, in addition to treating their hypertension diseases and symptoms, their heart is the one suffering also because the pressure is higher on the heart and the heart has to work a lot harder against that long-term hypertension. So eventually, yes, there will be mechanisms that will lead to heart failure.

JUAN: With people that have the, sort of, these predisposing factors like obesity and hypertension, the set, sort of does that change the timeline of when they need to seek help or or when these remodeling issues occur after the myocardial infarction?

DR. HAUDEK: That is a very good comment. I have to say I have not been working on this in the last five years, so I'm not really up to date. But yes, I do know that current research is really geared towards how to influence that remodeling phase. And also how can you reverse adverse remodeling back to normal? There is a lot of research going on in that direction.

KARL: So I think you touched on stem cell therapies in this discussion. I’m wondering if you could kind of discuss how that kind of circles back in here. And some of the issues surrounding that you may encounter.

DR. HAUDEK: I love the whole stem cell topic. Also, I never – I do not consider myself as a typical stem cell investigator. I am always peripherally working with them. I think the closest I ever worked with stem cell was in the late 90s in Dallas, but I worked with mouse embryonic stem cells and I tried to differentiate them into cardiac myocytes; and it was a side project, Dr. Shuar and I we worked on this together. And for a whole year, I tried everything, every protocol, everything and I think I only saw like three beating cells in this whole year. So that experiment was a failure.

KARL: So three that contracted like muscles, that actually had a contractile to them? Okay.

DR. HAUDEK: These typical signs for cardiomyocytes, you can see it easily in the in the dish if cells are contracting then they are most probably cardiomyocytes. And so that was my first long-term experiment with embryonic stem cells and even though it was a failure and we did not continue that project and I never picked up on it, but it really set the stage for me to really think about what are those cells? Why do we work with them? And what did I actually try to do? Now again, this was in the late 90s, meanwhile, there are protocols out there how to differentiate pluripotent stem cells into cardiomyocytes. Plenty of them. So today probably would be an easy, easy process. However, it really intrigued me, and at that time, while I was doing it, I did not think about it that much but afterwards – maybe in the early 2000s – I revisited this project. I don't know that it's just me that if something doesn't work, I'm very persistent and I always go back and think about what went on and so my interest sparked in embryonic stem cell research.

And also I never did it again in the lab myself. I read up on the literature. I got involved in discussions. I researched on my own and then also expanded into adult stem cells and fetal stem cells. And I started talking, first to family members and then to friends, and then to others about what do they think about it? And I realized that many people either did not think about it at all or had a very non-scientific view, and that intrigued me even more. And so I started in the Houston community going around to schools, retirement communities, other communities, and talked to people about stem cells and I realized there was a huge need because in the 2000s, early 2000s was really the hype of stem cell therapies and stem cell supply and I think during the elections for president, I think it was President Obama, it came out that in his election communications, he had to make a statement about stem cells and that intrigued me a lot. It's like, why would that matter for a president? Actually, it was under President Bush that the big stem cell debates started. But why would that matter? Why would that be a stake in the election? Why not talk about cancer or obesity or something – why stem cells? And so that that made me look into this and also other people around me are interested. So to come to a point, it was my goal to educate the public, and private, and students about what stem cells really are, what you can do with them, what is their promise, why is there such a hype about it? And what do we do now?

JUAN: Yeah, I think one of the most memorable things that you've said to us as a medical students while you're teaching these stem cell lectures is to – you really challenged us to think about, you know, stem cells and know more about it obviously for medical school, but to sort of dive into the ethical hurdles that have been brought up in the past and then the present and what we think will happen in the future. To think about these things as physicians. How do you think that's kind of changed in the past and now, and sort of going forward?

DR. HAUDEK: First of all, I don't think it has changed. I think it's the same hurdles, the same ethical decisions, the same problems. I do have to say that I only have this one hour with medical students and there is a lot of scientific knowledge I probably should emphasize more on while teaching the first class. And so I – every year before, up to the minute before I enter MacMillian, I'm thinking “am I going to talk about this today or not?” Because, so far I’ve always decided for yes, I'm going to do this, because in the end there are always a few students who are impacted by what I say. There are also students who are totally not impacted and they receive email saying, like, why you do this, it was absolutely not relevant, and I should just quit doing this. So I get both messages. But I do think that this is my one and only opportunity to bring it up. And so I think I will keep doing this.

My goal here is not just to challenge students about thinking about stem cells, but also in general challenge students to not take everything at face value. I think it is really important, the critical thinking and having an opinion about anything, and I use stem cells. But anything that they have to make their own decisions in life, what do they believe in and whatnot. And that goes through their medical training, through their basic science training, through whatever other training everyone has. And so I'm very passionate about this, yes. I wish I would have more hours.

KARL: Well, I think it's valuable. Often throughout science and including the medical field we can get tempted to think of just the very cold, factual, logical scientific side of things, but we really especially in medicine kind of exist in an interface with very high ethical implications, and a lot of the decisions and things we have to think through and make decisions about are going to involve taking scientific information and an ethical framework and sort of trying to interface between those two to do, you know, what we think is right for the patients and for society. So I think it is a valuable exercise to consider the ethical implications of what you're doing as a scientist.

DR. HAUDEK: Thank you. Yes, I would like to continue also with the induced pluripotent stem cell technology that is now readily available. The discussion has mellowed down a little bit because more and more people really take advantage of IPS cells and kind of step away from the embryonic stem cell. It has its own set of problems, granted, but it does not have the problem of the destruction of an embryo. That is a huge, huge, huge advantage over all the other ones. Now with the adult stem cells there has never been that problem to begin with –there are other ethical problems, standardization problems and things, but with the IPS technology I think that will go forward and that will be the future of stem cell therapies. In combination, and I want to really emphasize, that in combination with tissue engineering. Stem cells alone, by itself, will have a big impact but the greater impact will be the combination of stem cells with scaffolds, with material, with equipment, with devices, together.

KARL: You’re talking about, like, so this is a gross simplification. We don't just have the cell that's maybe been induced to differentiate around a certain pathway, but we might have some sort of mesh framework that the cells are provided to grow around to help shape the structure that they're trying to make – is that what you're saying?

DR. HAUDEK: Exactly. So it is absolutely necessary to collaboration between scientists and clinicians, but to involve engineers, to involve engineers knowledgeable about different materials. Physicist who can calculate a nanotechnology to make very, very thin fibers for instance. 3D printing, 3D printing opens the door to having these 3D scaffolds where cells can be seeded on and then as a whole can be used in an application. So I think in the future this is really where, in my personal opinion, will be the greatest impact.

KARL: And also just a real quick point of clarification. You mentioned induced pluripotent stem cells. So I’m wondering if you can just explain really quickly to the audience that may not know what that is and how that differentiates from the traditional embryonic or other types of stem cell.

DR. HAUDEK: Okay, so that embryonic stem cells stem from zygotes. Actually the zygote divides into a morula and a blastocyst, and then you destroy the blastocyst and take the cells and culture them in a tissue culture plate. And those are your embryonic stem cells. Embryonic stem cells and IPS stem cells are both very highly potent, very high – so that's why they're called pluripotent. That means it has the capacity to regenerate every single cell type, every single of those 220 cell types that are found in the human being. That's why they are super potent. Now, the more often a cell divides and the more often it differentiates, it loses that potency. That's why in an adult organism the stems cells that we isolate are only multipotent. Because they have lost already the capacity of making many cell types. So they usually, they stay within their germ layer lineage. They cannot go to others. Once they move further, eventually, the endpoint is the fully specialized cell.

Now, IPS technology is a method in which you take a fairly differentiated cell, like fibroblasts for instance, and you genetically manipulate that cell to go backwards, which is against every nature mechanism. You use a viral vector to induce the expression of certain transcription factors, specifically, four transcription factors and those four transcription factors are named after the person who invented it and that was Shinya Yamanaka. So those transcription factors are called Yamanaka factors. And so the expressing genes, those Yamanaka factors, are induced into an adult cell and their expression is forced; and by doing so the cell is forced to differentiate backwards into an original pluripotent cell. That's why they are called induced pluripotent cells. So it's going backwards against nature to the same point where embryonic stem cells are, or supposedly are. Now once you have this dish – so you started with fibroblasts, and you have a dish of pluripotent cells, and then the pluripotent cells you can make all the 200 different cell types that you want. And so you only have to have the recipes to do so.

KARL: So the basic advantage is going to be instead of having the ethical implications of potentially having to destroy an embryo, you can take some cells from an adult. And before those stem cells weren't going to be as useful because they only had a limited range of things that can differentiate into, whereas if we can use IPS you can go back and use those cells from an adult theoretically in the same way that we could use in embryonic stem cells. Is that the basic advantage?

DR. HAUDEK: Yes. Thank you.

JUAN: I think it would be nice to sort of switch gears. You also have this side of you that many people don't see – that work-life balance that that is kind of, you set up as a kind of as a role model for us to sort of work on both our professional and then pursue the things that make us happy outside of our scientific pursuits. But in your case, I think it's still somewhat professional. Would you care to elaborate?

DR. HAUDEK: Well, thank you very much for calling me your role model. That that really makes my day because that's really what I want to be.

JUAN: No, absolutely.

DR. HAUDEK: Thank you. Throughout my life, I was always very curious and very open to exploring different aspects. The switch from research into education was a gradual switch. It was not one day to the next, and I did it because – not by default, it was an active decision. I did have opportunities to continue in research, but I actively decided against it. I like – I enjoy working with individuals of any age and any level from students to faculty. I enjoy the one-on-one meetings, enjoy the social aspects, I enjoy the communication. And this is really what's driving me – what has driven me into education and what is still driving me today. So my first advice for life-work balance is really enjoy what you're doing professionally and in your life and in your private life. Yes, we all work hard. But if you really like what you do, it's not really work. If that makes sense.

JUAN: Agreed.

KARL: Definitely.

DR. HAUDEK: I really enjoy going to work. I really enjoy the things that I do and so that is already part of my balance. Now I am also open, I talk about what I think and feel, hopefully in a respectful way. And I always assume the best in the other person in front of me.

KARL: I think that's a good principle.

DR. HAUDEK: Yeah, we are all equals kind of, I feel we are equal so I often ask students for advice. My biggest interaction is with the MS1 students during the course, but I really like that some of the students during in their fall-up years. They still come to my office every once in a while and tell me hey, you know, I'm doing this and that or just ask me how you are and then  I ask them for advice and say hey, I just did this in the course and I got terrible feedback. What am I doing wrong? So I appreciate that.

As for life-work balance in its essence. Yes, at home, I think it's important to have a supportive partner with whom you have general interests in common, but also who complement each other. There are things I hate to do, like cooking. That’s my husband, and I do the laundry for him because he doesn't like to do that one, so we complement each other. But we do have a common hobby and that is dancing in our case and it is very important to keep our hobbies alive and not move it away because work takes over. So for instance we have a rule we have training every Friday evening for years. There is absolutely nothing that can make me stay on a Friday and work longer than six o'clock. Usually I stay until seven or eight some days but not on Fridays. I just have, even if the deadline is not reached, I have to go home because Friday evening is dedicated dancing evening.

KARL: And you say hobby, but this dancing gets pretty intense. You guys go to competitions and stuff like that. Right? Could you tell us a little more about that?

DR. HAUDEK: It used to be very intense. Unfortunately after hobby, it stops being intense. I started that as a teenager, you know, Vienna is a city to dance, the Viennese Waltz comes from the city. We have, during Carnival – we have more than 300 public dance events in Vienna. Every weekend, you have a choice of 10 different ones, and so it is pretty standard in Vienna to go and learn how to dance. But here in Houston, you learn to play soccer or football. In Vienna, you learn to dance period. I continued dancing after that initial learning. When I came to the United States in my mid-20s, I thought I would start horseback riding or something. So in my mindset I thought okay, this is not old, and then I was in Dallas and I couldn’t resist checking out that one single dance school that exists, but actually they were two dance schools in Dallas. And so I thought, okay, you know just at least go there once and check it out. And coincidentally on that one day, there was this person from Holland who danced there as well, and we immediately clicked and we started to dance. 

Well, make this very short that person is now my husband. Dancing went into dating, then went to marriage. So for many years, we stayed social dancing. It's a hobby. It's great exercise, great cardiovascular exercise. It is very social, you meet people. Importantly, it's a hobby that you and your partner together. And I think that also contributes to the work-life balance; you do something with your partner together. And now around 2008, I think we started to become interested in joining competitions. And this is when the really intense time started. And if intense, I mean five evenings per week training. Lessons with trainers, going through the country to different competitions, get your points, get into the system.

And once you are in this, it's just – your mind is set in this, and your ear towards, and it's not just dancing. It's then you have to have to dress up, and you have to have the makeup, then you have to have the connections and the trainings and I think be moved up the chain. And actually I admit I am quite proud of it. We made it into the final six, so our best placement was this international amateur competition for our age group and our type of dance, and that was really a major, major achievement. And our goal was to become among the top three. I think we had good chances. We were on the right roll and Harvey hit. Our house got flooded two feet underwater. And with that, everything changed – you don't have time to do anything other than working, then most necessary things, and taking care of your house, and taking care of your family. And even though everything is great again, we have not found back into the momentum of competitive dancing. 

JUAN: But you still do it?

DR. HAUDEK: We still social dance, at least twice a week.

JUAN: Well, I guess now because of the COVID social distancing dance . . .

KARL: Are there talks for virtual dance competitions, virtual dancing, right? 

DR. HAUDEK: It's not competitions. They have been canceled, unfortunately. Our dance school has virtual training sessions online and I have a group class where you're just do what the instructor’s doing. Or you can have a personal one-on-one question where you literally put up a video and you dance and the instructor gives you feedback on how you dance.

KARL: Wow. That's great. People still finding ways to stay active even in self-isolation.

JUAN: It really highlights, right, what's important . . . 

DR. HAUDEK: Social socializing is important, but I also believe exercise is really important – at least it's important for me. And so since we don't dance that often anymore, I started little bit running. Yeah. I'm not sure if I could call it “running” running. I mean those two months that I run every other day.

KARL: So Dr. Haudek, just changing gears a little bit, talking more about some of your educational work at the school and kind of some of the new roles you’ve taken on in the past few years with the undergraduate medical education office and all that I was wondering if you'd be willing to explain some of that to us give us some inside information, you know.

DR. HAUDEK: So while I did my basic science research, I was always interested in education and I always reached out teaching graduate students mostly in the lab, and in the classroom and then one day in 2010 I met Dr. Goodman. He took me into his wings, or under his wings, and he made it possible for me to start lecturing in the Foundations course. And every year, I had one more or two more lectures. So I went from one lecture at the very beginning to my maximum, I think, of 30 lectures a year ago. But that really changed my life and that really influenced me of making the active decision, devoting my time hundred percent to education. So in 2017 was when I made that final step and I started in the foundations course. It took me two years and meet everyone to get used to things. So in 2018, 19, two years ago, so I course director and it is really an all year-round job. So if you ask me what my typical day looks like I really have to divide it into the first six months, January to June, and into the second six months, July to December.

Let's start with July to December. This may be the most applicable to you. I sit in class every day. I meet with students every day. I write exams every day. I talk to faculty every day. I make schedules. I put out fires. I communicate with everyone. I make sure everyone is where the person is supposed to be. And it's a 12-hour day during that time, it is a really long time. And most of my other projects I work on are kind of reduced during those six months because my primary goal is really that course. So I still do admissions interviewing every Friday. I still participate in curriculum development every Monday. But many of my other things are kind of on the back burner.

Now in the other six months when I do not have to sit in the lectures, I have so many different things to do. And that is also part of what I like. First of all, I do need to write up all the documentation for the Foundations course, but I'm also involved in the faculty development. I am the director of the peer coaching for educators program, which means we support faculty in their teaching skills. We teach them how to be a good teacher. I'm also involved in other faculty development like faculty awards, guidance, I advise people on promotion or I give a lot of workshops for faculty. I'm also on the faculty Senate and I organized three conference. As you know, I organized