Additional Info
- Audio Fileuab/ua196.mp3
- DoctorsJeyarajan, Harishanker;Carroll, William
- Featured SpeakerHarishanker Jeyarajan, MD | William Carroll, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4757
- Guest BioHarishanker Jeyarajan, MD Specialties include Head and Neck Surgery, Head and Neck Surgical Oncology, Microvascular Plastic Surgery, Otolaryngology and Surgical Oncology. Learn more about Harishanker Jeyarajan, MD
William R. Carroll, M.D., the George W. Barber Jr. Endowed Professor and widely-recognized leader in the field of head and neck oncology, has been named the chair of the Department of Otolaryngology in the UAB School of Medicine.
Learn more about William R. Carroll, MD
Release Date: March 31, 2021
Expiration Date: March 31, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
William R. Carroll, MD
Professor and John S. Odess Endowed Chair; Director, Head and Neck Oncology
Harishanker Jeyarajan, MD
Assistant Professor, Head and Neck Surgery
Drs. Carroll and Jeyarajan have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we give an update on the management of skin cancer of the head and neck. Joining me in this panel are Dr. William Carroll. He's the Department Chair of Otolaryngology at UAB Medicine and Dr. Hari Jeyarajan. He's an Assistant Professor and Head and Neck Surgeon in the Department of Otolaryngology at UAB Medicine. Gentlemen, I'm so glad to have you join us today. Dr. Carroll, I'd like to start with you. Tell us a little bit about what's happening with the demographics and rates of skin cancer. What have you been seeing in the trends?
William Carroll, MD (Guest): Well, thanks, Melanie. All of the types of skin cancer are increasing in frequency. There are increases in basal cell carcinomas, squamous cell carcinoma, melanoma and Merkel cell cancer. And by some evidence, they're up, almost double, over the last 20 years or so. Today we're going to be mainly talking about non-melanoma types of skin cancer and primarily squamous cell carcinoma. By some accounts, that one is actually gone up almost 200%, since the year 2000. So, it's really on the uprise and a big concern.
Host: Well, thank you for that. So, Dr. Jeyarajan, tell us the hallmarks of these types of skin cancers that we're discussing today and predictors of high risk lesions. So, while you're telling us the hallmarks and characteristics, speak a little bit about the risk factors.
Harishanker Jeyarajan, MD (Guest): Sure. Thanks, Melanie. So, squamous cell carcinoma is as Dr. Carroll said is the most common non-melanoma skin cancer there is, particularly in the head and neck region. So, generally we say that that 80 to 90% of cutaneous squamous cell carcinomas occur in head and neck. They can occur quite variably, but generally they'll present as a red or ulcerated indurated lesion, rising from the epidermal part of the skin, so the superficial part of the skin. Like classically in sun exposed areas, which is why the head and neck is one of the most prominent sites for them to arise in.
And they can grow at variable rates. They can grow quite fast. And we know that particularly in the head and neck, they do have also a proclivity to spread to the regional lymph nodes. Some of the more common areas that we see in the head and neck, we see them quite commonly around the ears and the back of the ears, the back of the neck. We quite commonly see them around the forehead, around the eyes, the bridge of the nose and the tip of the nose as well. Again, all areas that are prone to sun exposure. Exposure to sunlight is the most common cause of cutaneous SCCs, particular UVA and some UVB light as well. Around the world, I'm from Australia. Australia is quite notorious for having a high rate of skin cancers, but that is almost rivaled by the South of the US as well. We know that in general, the southern part of the US are five times more likely to get cutaneous SCCs in the head and neck than the Northern part. There are a number of risk factors. So, there are number of features that predict lesions posssessing what we call a higher risk feature. And these are the ones we particularly worry about in the head and neck cause a lot of cancers that arise in the head and neck do tend to portend to having high risk features, position, location of the cancer.
So, locations around the periauricular areas, so that's around the ear, around the eyelids and the bridge of the nose, all carry significantly higher risk of both local and regional recurrence. So, that's means that cancer coming back, but also carries a significant risk of metastasis to the lymph nodes.
Some other features that we find out on once we take the cancer out, the most worrying one is something called perineural invasion. With areas around the head and neck, particularly around the ears, the eyes and the bridge of the nose, the skin is relatively thin and the cancers often arise in very close proximity to big nerves.
And once they get to those nerves, they can travel pretty quickly along those nerves to deeper parts of the head and neck and even towards the brain. And so perineural invasion, which is a feature that we see when we examine the cancer under the microscope, is a significantly high risk feature.
Other significant risk features include size, particularly one's greater than two centimeters, invasion into the deep planes, into the subcutaneous fat, and any cancer in an immunocompromised individual or any cancer that has come back, carries a significantly higher risk of both coming back again but also of having metastatic spread to the lymph nodes. Dr. Carroll, would you agree with that?
Dr. Carroll: I do agree with that. And the factors that make squamous cell cancer of the skin high risk, you can kind of think of them in terms of patient factors. So, patients who are immunocompromised, patients who have recurrent lesions. Lesions that are large and in those locations that Dr. Jeyarajan mentioned, those are at higher risk. And then, there are tumor related factors or factors that are seen more on microscopic examination, such as poor differentiation or a deep invasion. In the current staging system, if tumors are greater than six millimeters in depth, they're thought to be, much higher risk.
So there are patient-related factors and then there's specific tumor related factors that make them, more at risk. Immunocompromised patients, probably a hundred times risk of developing a squamous cell carcinoma of the skin than a non immunocompromised patients. As, Dr. Jeyarajan mentioned, those that invade more deeply and invade nerves and all are particularly prone to recur and spread to lymph nodes.
Host: What a fascinating aspect of these types of cancers doctors. So, Dr. Carroll, as we're speaking about, and I've learned so much on these shows over the years about the really amazing advances in radiologic imaging that have augmented therapeutic capabilities and diagnostic capabilities. What imaging techniques are commonly used for this? Are there any that have changed the landscape for you?
Dr. Carroll: I would back up and say that, you know, most skin cancers that we deal with in the US are fortunately early stage. And they're taken care of lot of them in a dermatologist's office and they're very effectively managed. They don't tend to spread, that sort of thing. But the ones that are higher risk are the ones that we end up seeing at the university setting more commonly, and those are ones that we end up relying on the imaging for more commonly. And we go back to those lesions that are higher risk that we were talking about before. Those are the ones that we use the imaging modalities for most commonly. There's not a single modality that's kind of turned into the Holy Grail for imaging this type of skin cancer. But we make use of several different modalities sort of, depending on the situation that we're in. The most common imaging modality that we use is CT scans.
And we're looking at overall depth and extent of the lesion on those scans. We're looking at the lymph nodes in the area. And we're looking at things like bone invasion and things like that. So, that's probably the most common imaging agent we use. As Dr. Jeyarajan mentioned before with nerve involvement and things like that, we more commonly will use MRIs to see the cancer progressing along nerve pathways more effectively or invading centrally. There are lots of physicians that rely on ultrasound for looking particularly at nodal basins. It's a very effective, fairly inexpensive way of looking at lymph node disease. And in some people's minds, it's more effective at seeing the superficial lymph nodes and then advanced imaging, things like PET scans and things like that are usually done when we're quite concerned that there might be distant disease, less likely used simply to analyze the local and regional extended disease.
Host: Dr. Jeyarajan why is elective management of salivary glands important? And while you're talking about glands, speak about lymph nodes and how those are most effectively managed, if you would combine that for us.
Dr. Jeyarajan: Yeah, sure. No worries. So, when we talk about the head and neck salivary glands and its relationship to skin cancers, we're really talking about the parotid gland, which is one of the four major salivary glands that we have in the head and neck. The reason it's important is unlike the submandibular gland and the sublingual glands, the parotid gland actually develops and encapsulates after the development of the lymphatic structures in the head and neck do. And so it actually, the gland itself contains a number of draining lymph nodes and lymphatic channels within the substance and the capsule of the gland itself. And so it actually drains lymphatics from the rest of the head and neck before it reaches the lymph nodes in the neck. And I quote, prior Fellow of UAB and prominent Head and Neck Surgeon in Australia, Christa Bion used to talk about the parotid gland being what we call a metastatic basin for cutaneous head and neck cancer, in that is often the first area that cancer drains to before it moves onto the neck. And so that's the main reason to at least to be conscious of the parotid gland when you're managing a skin cancer, because if it's going to spread to the lymph nodes, the first area that will most likely spread to is the lymph nodes within the parotid gland.
We know that even in some of the larger series today, particularly in the South and in Australia, metastatic deposits from cutaneous squamous cell carcinomas make up around 30 to 40% of parotid cancers that we deal with. So, that really kind of blends into the next topic, which is how we manage the lymph nodes in head and neck skin cancers. And so in particularly in the head and neck where we know that cancers around the ear, the nose, and the eyes, have a higher risk for metastasizing relatively early to the lymph nodes, we will often clinically assess them, when we even dealing with a small tumor, so a tumor that's within two centimeters around the periauricular region, I'll often clinically examine both the parotid gland and the head and neck region for clinical evidence of nodal disease.
If we see nodal disease, within the parotid or within the neck, we know from a range of studies, both in cutaneous head and neck cancers but also in mucosal squamous cell carcinomas, that these are best managed in a multimodal fashion. What that means is they're best managed by surgical resection of the involved lymph nodes followed by adjuvant therapy. So, if we have clinical evidence that the cancer has spread to the lymph nodes, they're best managed with surgical resection, which would involve as superficial parotidectomy at least and resection of the upper lymph nodes in the neck. Dr. Carroll, would you like to talk about sentinel lymph node biopsies and elective management of the neck when you don't have obvious disease in the neck lymph nodes?
Dr. Carroll: So for, uncomplicated, non-melanoma skin cancers, we don't typically do elective node dissections. So, if there's no clinical or radiographic evidence of lymph node involvement, we don't typically do elective dissections. For the higher risk lesions, the question arises, should we be treating the lymph nodes in those draining basins that Dr. Jeyarajan mentioned? And one of the ways to determine if the cancer has metastasized to regional lymph nodes is using sentinel lymph node biopsies, and everyone's familiar with sentinel node biopsies for melanoma, and also for breast cancer and other things. It's used less commonly for cutaneous squamous cell carcinoma.
There've been a number of studies looking at the efficacy of sentinel lymph node biopsy, and I think the short answer is kind of the jury's out, whether that is something that should be routinely done. There's not clear evidence that it should routinely be recommended at this point, but a number of investigators have shown that it's feasible to do. And that usually you can identify the draining nodal basin when that's done and in the series that they've done that if they find that the sentinel nodes are negative, most of the time, the patient's neck remains negative. So, the negative predictive value of a negative sentinel node biopsy is quite high.
Host: Dr. Jeyarajan, tell us what is the role, if any of immunotherapy in skin cancer. What's exciting in the field right now?
Harishanker Jeyarajan, MD (Guest): So, with skin cancer, we know that the cancer itself due to the UV light induced carcinogenicity, the tumors themselves tend to have what we call it high tumor mutational burden, which is particularly unique to cutaneous SCCs, even when you compare them to other mucosal SCCs and to melanomas. And so that along with the fact that we see in people that have immune deficiencies or immunosuppression, these people tend to have a high rate of cutaneous SCCs. We know that cutaneous squamous cell carcinomas do tend to have an intimate relationship with the immune system.
We also know that, through numerous studies over the past decade or so that we don't have any great systemic options for management of cutaneous SCCs. We have surgery and radiation, but a number of retrospective studies looking at both platinum type chemotherapies and a phase three study from the trial group in Australia has shown that platinum type chemotherapy really makes no difference to overall survival in cutaneous SCC. And so the arenas can kind of ripe for some form of systemic treatment to treat distal disease, but also to try and improve overall survival on local regional control. And so knowing that cutaneous SCCs have a relationship to the immune system, people have started looking into the possibility or the applicability of immunomodulation, in the management of cutaneous SCCs. And recently there has been some really great work looking at a drug called cemiplimab. So, cemiplimab is an IGG 4 monoclonal antibody, that targets PD-1. So, PD-1 is a receptor on our T-cells that its signals program death in the cell cycle.
And by blocking the interaction of that receptor PD-1 with PD-L1 or PD-1 PD-L1, which is a program death cell leg on the tumor, it actually enhances the antitumor activity of your own immune system by directing T lymphocytes to kill the tumor cells itself. And so, the use of immune therapy has been relatively promising in other forms of skin cancer, but in cutaneous SCCs, it really shows a lot of promise and we know that in the past five to six years, there've been an international collaboration among multiple institutions around the world, Australia included and the US included, looking at the use of cemiplimab in the management of widely metastatic and surgically unresectable cutaneous SCCs and the results of both phase one and phase two studies have shown a significant tumor response in both of those categories.
So, tumors that have metastasized and tumors that are considered unresectable. So, that's really shown some promise. We know that the, the data hasn't shown that it's a, it's a magic pill. It certainly doesn't replace standard of care, which is surgery and adjuvant radiation. But we do know that there is incredible promise. Overall cells are responding to the immunotherapy, which has both been demonstrated under the microscope where you can see real changes in the tumor micro environment, but also clinically when you can actually see a response by reduction in the size of either the tumor metastases or the primary tumor itself. We still don't know exactly which cancers will respond best.
We do feel that it's probably going to be better in cancers that have a particular high tumor mutational burden. And it stands to reason that tumors that have a high expression of PD-L1 are going to be more likely to respond to this type of treatment, although it hasn't been exactly born out of the study so far, that's kind of what we're expecting to see.
I think in the future, one thing that this will promise is an extra arm of treatment or an additional arm of treatment to supplement or compliment primary surgery and radiation therapy. And that's something that Dr. Carroll and I have been looking into, is whether we can use cemiplimab in what we call a neoadjuvant setting. The current phase two studies have been used as an alternative in patients that have already had treatment or can't receive surgery. But one thing that will be interesting to see, is whether or not patients that present with local, regionally advanced disease or patients that have a bit particular higher risk of local recurrence, so people that have already had multiple recurrent cancers, whether we can give them cemiplimab in a neoadjuvant setting, so before we operate and allow the immune system to identify the cancer and start recognizing it as the enemy of the body and start attacking it before we even start surgery or radiation, and whether that will improve our long-term regional control and overall survival. So, I think that's kind of where the promise of immunotherapy lies with regards to cutaneous SCCs.
Dr. Carroll: I would agree with that. And, and we don't know yet how we're going to use immunotherapy in the future, all the way. But I think, it's clear that it's helpful in multiply recurrent or metastatic disease, that's otherwise untreatable, and these newer roles of using it in a neoadjuvant setting or using it as adjuvant therapy for high-risk lesions that have been removed along with radiation, for instance, those are where some of the clinical trials are really headed right now.
Host: Well, it's certainly a fascinating increase in your armamentarium of therapies for these patients. I'd love you each to have a final thought if you want to. So, Dr. Carroll, do you have any final thoughts you'd like to leave other providers with?
Dr. Carroll: You know, you think of skin cancer is just some small thing on the skin that is easily dealt with and most of the time that's correct. But in a high-risk situation or when the cancer has been neglected or has become quite large or in an immunocompromised patient, these cancers can be just as deadly as any other type of cancer. They need to be treated aggressively and often in a multi-modal fashion. And it's great to involve the entire team, the surgeons, the radiation oncologist, the medical oncologist, the pathologist, everyone, to provide the patient with the best chance of treatment.
Host: Dr. Jeyarajan, last word to you. What would you like other providers to know about skin cancers of the head and neck?
Dr. Jeyarajan: I would very much that to mirror Dr. Carroll's statement. These cutaneous SCCs, while 80 to 90% of them are very simply managed and in the head and neck region in particular, they can become quite deadly and often people that have a current squamous cell carcinomas, particularly in high-risk areas in immunosuppressed patients. The scary thing is they can spread without any obvious sign to the eyes. They can spread surreptitiously through tissue planes, into the parotid gland and into the lymph nodes. And from there very quickly migrate the skull base. These are best managed at a level where we have a multidisciplinary team that is really top-notch and has a lot of experience in managing these.
And this is a particular interest of mine and I very much appreciate seeing these kinds of cases and helping manage them because they can be quite difficult. But if managed appropriately, we can really make a significant difference and effect their overall survival.
Host: Thank you both so much. What a very informative episode this was. Thank you again. And a community physician can refer a patient to UAB Medicine by calling the MISTline at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, you can always visit our website at uabmedicine.org/physician. Please also remember to download, subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua195.mp3
- DoctorsGriffin, Bailey;Hodges, Alex
- Featured SpeakerBailey Griffin | Alex Hodges
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4665
- Guest BioBailey Griffin is an Occupational Therapist.
Alex Hodges is an Occupational Therapist.
Release Date: March 25, 2021
Expiration Date: March 25, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Bailey Griffin, OTR/L
Occupational Therapist, Rehabilitation Services
Alexandra E. Hodges, OTR/L
Occupational Therapist, Rehabilitation Services
Bailey Griffin and Alexandra Hodges have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie: Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we examine occupational therapy's role in reaching independence. Joining me today is Bailey Griffin and Alex Hodges. They're both occupational therapists with UAB Medicine. Ladies, thank you so much for joining us today.
So Bailey, I'd like to start with you. Tell us about the field of occupational therapy. What's exciting in your field right now that other providers would want to hear about?
Bailey Griffin: So in occupational therapy, we focus on helping people across the lifespan to do the things that they do throughout their day. So we call those things occupations, which is why we get our name. We focus on adapting the environment and helping them gain the skills to do things like dressing, feeding themselves, getting in the shower, brushing their teeth, simple things like that, even up to helping them with higher-level skills like cooking, cleaning, doing laundry. So we look at the person as a whole and try to figure out what they need to work on in order to be able to do those things as independently as possible.
Melanie: And really, Bailey, your field has shifted a bit over the years. Can you tell me how you feel it has shifted? When you mentioned occupations, it's really not only that anymore, right? So it's kind of shifted and working hand in hand with physical therapists and all kinds of specialties. Correct?
Bailey Griffin: Yes. So when OT first became a thing, they worked a lot on knitting and crafts and that kind of stuff. And now, especially in the setting that Alex and I work on, we work very closely with physical therapy, with the physicians because we're in the inpatient rehab setting. So we really work more on the strengthening, their cognition, balance coordination, vision, all of the more medical side of things to allow them to do those things. Anything from, like I said before, dressing to cooking, to cleaning. So it really is a large span, which I think is one of the greatest things about occupational therapy as we hit on such a wide variety of skills.
Alex Hodges: I agree. And you know, we work with a lot of people. We really have physical therapy and OT teams, so we can talk every day and see what the patient really needs to work on. We collaborate with also like speech language pathologists, the physicians and nursing, the case management, neuro-psych. We look at all different areas of the patient to see what they kind of need the most from all of us.
Melanie: Well, that's certainly true. And it's an exciting time to be in your field. So, Alex, what does OT look like in the inpatient setting? You guys just touched on it briefly, but tell us a little bit about it. And what diagnosis do you work with at Spain Rehab? Tell us about your team and really what this looks like when you're working with inpatients.
Alex Hodges: So in inpatient rehab, each patient gets at least three hours of therapy a day. That's an hour and a half of occupational therapy and an hour and a half of physical therapy. And they may also get speech if they need it. We work on skills, like Bailey said physical and cognitive, dressing, toileting, bathing, showering, things that they might want to do at home. But we also work on, you know, strength, balance, cognition, neuromuscular reeducation, anything like that.
But the one great thing about working in inpatient rehab is that we can do things like cooking because we have a kitchen in our rehab gym, and we can also go on patient outings too, so they can kind of get out in the community and practice doing things outside of rehab.
Bailey Griffin: I'll elaborate on the types of patients that we work with. So at Spain Rehab, we have four medical teams. We have one doctor that specializes in traumatic brain injury, one that specializes in spinal cord injury, and one that specializes in stroke. We also have a fourth doctor that does all the general medical conditions, general debility, car accident patients.
And each therapist is tied to one of those teams. So I'm a primary therapist on the spinal cord injury team. So I primarily work with patients who have had spinal cord injury, working on adapting tasks and kind of meeting them where they're at to make them be able to be more independent with their daily activities. So we all kind of focus on our one diagnosis, that way we become more confident and specialize in working with that particular patient population.
Alex Hodges: Yes. And right now, I'm actually on the traumatic brain injury team. And depending on the severity of the brain injury, we might work on just simple things like alertness, attention, behavior, memory, motor function, or we could do higher level things like paying bills, medication management and cooking activities.
Melanie: How cool. And it really speaks to the innovation and the way you have had to be creative with your patients, right? So tell us a little bit first how COVID has affected what you do. And I'd like you to start, Alex, in just how has the pandemic kind of interrupted what you do. Have you been able to use telehealth with families? Have they not been able to be with you with the patient? Tell us how COVID has impacted occupational therapy at UAB Medicine.
Alex Hodges: Well, I think when COVID first started, we all had to do therapy in the patients' rooms. We couldn't use our gyms anymore. The patients were allowed one time caregiver with them, so that way, they could be hands-on to help the patient when they get home. But now, lately, we've been able to go back in our gyms and we just have to social distance. And I think they just passed that two caregivers are allowed to come and be with a patient at one time. So it's definitely been different and, you know, doing therapy in a small patient room has made us have to become more creative, but it's getting better.
Bailey Griffin: And we don't get any COVID-positive patients, but we've actually seen a lot of the after-effects of patients who have had COVID. So they come to us after they're finally medically stable and able to get physically stronger to go home. And it's really been eye-opening to see how COVID has affected people so bad.
You know, people are very weak. Many of our patients have been in the hospital for two, three, up to six months fighting COVID. And these patients are just so grateful to be alive. Their families are so grateful that they're alive. And it's been really cool to see how much progress they can make from where they started and eventually get to go home. It's been rewarding despite how horrible COVID has been.
Melanie: Well, I love that positive attitude. So tell us how you prepare patients' families and the patients themselves to be discharged home from inpatient. How do you work with the families so that they can be prepared to do what they need to do at home?
Bailey Griffin: So the end goal for all patients that come to inpatient rehab is to go home safely. One of the biggest things that we work on is training their family members to be able to help them and to feel comfortable and safe when they get home. So we do a ton of hands-on training, especially right before the patient discharges.
We have the family members help them with everything, help get them dressed, help them get out of bed, help with, you know, anything that they might have to do once they get home and make sure that they feel really comfortable with that. We also help with getting them the right equipment, shower equipment, dressing equipment. We work with PT to get them the correct wheelchairs, trying to address anything that they may need once they get home.
One of the big things that we love to do that Alex touched on earlier is take our patients on outings, which we haven't been able to do as much of since COVID, but it's really important to try to get the patients out into the community. Here at the hospital, they're kind of in a safe place. You know, everything's accessible, but going out into the community, to restaurants, the grocery store, to a movie theater or something like that will really allow us to help the patients in a more natural environment and figure out what they need and how they can still do the things that they enjoy doing.
Alex Hodges: Yes. And like Bailey said too, we can also prepare them by kind putting them in touch with other patients that are going through the same thing. So we've had a lot of patients that will call some peer mentors and talk to them and they just give them pointers about, you know, car transfers or the kind of car that they got or what kind of adaptive sports that they're involved in, just many different things, so they can feel comfortable talking to someone that's already gone through this.
Melanie: Bailey, what misconceptions do people often have about occupational therapy?
Bailey Griffin: Once I became an OT, I realized how many people do not know what occupational therapy is, even people in the medical profession. Somehow it's just kind of overlooked and blended in with a bunch of different things. So a lot of our patients will go in and they'll say, "Say, Oh, I already have a job. I don't need occupational therapy." And we're like, "Well, that's not exactly what we do, you know. The long goal would be for you to get back to work, but we're really here to help you do just your simple daily activities."
The other misconception is that OT only works on the upper body and PT works on the lower body, which it's a lot more to it than that. We're thought that we only work in the hospital setting or only work with arts and crafts. You know, there's a ton of different things that people think we do. So we spend a lot of our time educating patients and families and even other medical professions of why we do what we do and why our job is important and how we can help them get back to their full independence.
Melanie: It's definitely interesting. And I know as an exercise physiologist, people don't always understand the field anyway, and everybody knows what a physical therapist is, but not so much OT. And so thank you for that. I want you each to have a last chance for a final thought. So, Alex, why don't you start? Tell other providers referring physicians in the community and beyond what you would like them to know about occupational therapy's role in reaching independence for inpatient at UAB Medicine and why you feel they should refer.
Alex Hodges: Well, I think they should refer because it helps us really to be able to practice the day-to-day activities that they use in everyday life. So they're more comfortable before they're going home, their caregivers are more comfortable with helping them before they go home. And I just think, especially having three hours of day of therapy just gives them so much more than just going maybe straight home and then going to outpatient or home health. They just really get intensive therapy from us.
Melanie: And Bailey. Last word to you. What do you enjoy most about being an occupational therapist? And if you were speaking to medical students, specifically students, what would you like them to know about the rewards and the rewarding feeling that you get being an occupational therapist?
Bailey Griffin: So my favorite thing about being an occupational therapist, especially in inpatient rehab setting, is the relationships that we form with our patients. We see our patients for an hour and a half a day from anywhere for two weeks up to two months. So we see them through the hardest point in their life, all the way to where they're finally getting to go home and are becoming more independent. And the relationships that we form with our patients is really incredible. I mean, we just truly get to learn about these people and their families and get to know them. And it's so rewarding to see them make progress and to finally get to go home and have more confidence in themselves. So it's just very rewarding and we work with a lot of great people and a lot of great patients. So it's a great job.
Melanie: Thank you both so much for joining us today and telling us about occupational therapy, because as you said, not everybody knows what you do. So thank you again.
A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.
That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, you can always visit our website at UABMedicine.org/physician. Please remember to download, subscribe, rate, and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua187.mp3
- DoctorsVice, Jason;DeCarlo, Dawn;Locy, Marissa
- Featured SpeakerJason Vice, MS, OTR/L, SCLV | Dawn DeCarlo, OD | Marissa Locy, OD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4599
- Guest BioJason Vice is an Assistant Professor in the Department of Occupational Therapy, entry-level professional program. He is certified in gerontology education through the UAB Comprehensive Center for Healthy Aging and low vision through the UAB Low Vision Rehabilitation Graduate program.
Learn more about Jason Vice, MS
Dawn DeCarlo, OD is the Director, Center for Low Vision Rehabilitation.
Learn more about Dawn DeCarlo, OD
Marissa Locy, OD is an Optometrist.
Learn more about Marissa Locy, OD
Release Date: March 5, 2021
Expiration Date: March 5, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners no relevant financial relationships with ineligible companies to disclose.
Speakers:
Dawn K. DeCarlo, OD, PhD
Director, Center for Low Vision Rehabilitation
Marissa K. Locy, OD
Instructor in Ophthalmology
Jason E. Vice, OT
Assistant Professor in Occupational Therapy
Drs. DeCarlo, Locy, and Vice have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionUAB MedCast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please visit UABMedicine.org/medcast and complete the episode's post-test.
Welcome to UAB MedCast, a continuing education podcast for medical professionals, bringing knowledge to your world. Here's Melanie Cole.
Melanie: Welcome to UAB MedCast. I'm Melanie Cole and I invite you to listen as we discuss low vision awareness. Joining me in this panel discussion today is Dr. Dawn DeCarlo, she's the Director of the Center for Low Vision Rehabilitation at UAB Medicine; and Dr. Marissa Locy, she's an optometrist at UAB Medicine; and Jason Vice, he's a low vision occupational therapist with UAB Medicine.
Thank you all for joining us today. What a great topic. So Dr. DeCarlo, let's start with you. Tell us a little bit about the types of low vision that you deal with that come to the clinic. What qualifies as low vision?
Dr Dawn DeCarlo: So people have many different definitions for low vision. Some of which, you know, the World Health Organization tends to use less than 20/60. Some people use 2040. It's really not, to us, an acuity-based definition. Basically, somebody who's having difficulty with everyday activities because of decreased vision qualifies for low vision rehabilitation services.
Typically, we want all of our patients to already be having their eye health addressed, and those conditions treated as much as they're able to be. But some conditions like glaucoma and macular degeneration, diabetic retinopathy lead to permanently impaired vision that cannot be corrected medically or surgically. And that's where we come in to find ways to help people do the things they need and want to do.
Melanie: Dr. Locy, in relation to COVID-19, discuss how your patients have been relying on low vision aids, as many of them are older or have been isolating at home. How have delays to get patients in for treatment impacted their vision in a measurable way? What are some of the challenges you've run into with this pandemic?
Dr Marissa Locy: I think one of my patients said that actually the best. He was a return patient who came about a year later now, and his vision really hadn't changed, but he felt that he was more limited. Since he's not getting out and visiting with friends and family and doing activities outside of the house, he's trying to find more things that he can do at home, like reading and arts and crafts type things and all really fine-detailed vision. And he's kind of realized that his vision isn't what it used to be and it's more prominent now that he's at home trying to do those tasks. So he came back to me, now interested in looking at low vision devices and aids to help him with those daily activities at home to help keep him happy and doing hobbies that he enjoys.
Jason Vice: I just wanted to add that there is also a significant impact on the low vision population who are particularly already at risk for depression. So the impact on their mental health and dealing with low vision and the lack of participation in the activities they want to do has been pretty significant.
Melanie: Jason, I'd like you to expand on that because I was going to ask you that question anyway. So tell us a little bit about the emotional impact the pandemic has had on patients with vision issues. Really what have you been seeing and how have you been able to help them with these kinds of emotional, psychosocial, mental health issues?
Jason Vice: So the pandemic of course has been a challenge for everyone and particularly the low vision population as we've quarantined ourselves and isolated ourselves from one another for a good reason to practice good social distancing and hygiene. It's really been impactful for those individuals who already aren't able to participate in community mobility, their ability to get from one place to another is limited because they can't drive many times. So these are typically older individuals who maybe live alone. They can't get out into the community already, that they're limited because of their vision. And now, the ability of their family members to come visit them has also decreased.
There's also been a significant impact on their ability to participate in activities of daily living. So their ability to care for themselves, to do things like prepare a meal, or to manage their finances or even leisure activities like read a book, it's already significantly impacted. And so how they cope with the pandemic is different than how we may cope with the pandemic just that they can't do every day enjoyable tasks that we are able to do within our own homes. They have nothing to turn to because of their vision.
Melanie: It certainly has encouraged healthcare and really the healthcare community to be more innovative in delivering that kind of emotional support for patients during this. So, Dr. DeCarlo, why don't you give us an overview of the UAB Center for Low Vision Rehabilitation? How did it come about? Tell us about some of the services that you offer.
Dr Dawn DeCarlo: So the center itself was formed back in 2002 as a joint effort between the School of Optometry and the School of Medicine. It was created because the Eyesight Foundation of Alabama, which was at the time known as the Alabama Eyesight Foundation, conducted needs survey. And that needs survey show that the biggest unmet eyecare need in Alabama was for low vision rehabilitation services.
So they were invested in helping us getting going. And so the center has been in existence for 18 or so years. It's really important to us that we have a multidisciplinary approach to the care. So initially a patient is seen by an optometrist. We have had ophthalmologists that specialize in vision rehabilitation, but ophthalmologists are surgically trained and most of them do not want to do this non-surgical sub-specialty. So it's mostly optometrists that provide this care. So we have optometrists, we also have occupational therapists and we work with different state agencies and the state agencies that work with providing services to people who are blind or visually impaired vary pretty greatly throughout the country.
In our state, we work very closely with those providers who are located throughout our state. And we work with other resources like the National Library of Congress has free talking books that can be sent to patients, which think has been a godsend for some of our patients during the pandemic.
We also, in our department, have a group that works on looking at psychosocial aspects and they have a support group, which is going to start meeting virtually. I think they were hoping to get back to in person, but since we don't know when that's going to be now, they've started virtual meetings. So we work with them and we refer patients to their licensed clinical therapist.
So we have all three of those components and we do work with ages. The youngest I've seen is about a two-week old baby whose parents knew the child was visually impaired and they needed the assurance that that child was going to be okay. And I had 104-year-old patient earlier this month. So we really work with the gamut of age and we try to work within the constructs of the medical system to make sure that we're enhancing the quality of life of the patient, but also the safety of the patient. And I think occupational therapy is really key for that.
We have a lot of patients with diabetic retinopathy and the occupational therapist can help them, despite their vision loss, be able to measure their blood sugar, be able to be sure they're getting the right insulin dose, things like that. So it's not just about leisure activities. It's about things that are really essential to their health and wellbeing mentally and physically.
Melanie: Jason. I'd like to find out what the role of OT is as a part of this care team at the center and Dr. DeCarlo just mentioned the importance of this multidisciplinary approach. Tell us your role in this.
Jason Vice: Absolutely. I think a lot of the individuals who come into the low vision clinic have been told over the years how poor their vision is or how much vision they've lost. We really focus on teaching individuals to maximize their remaining vision, the use of the remaining vision. And if they're not able to do that, how to engage in activities using other means whether that's through assistive technology or adaptive equipment, whether it's learning to do a different task a different way.
From occupational therapy standpoint, we really address low vision from a functional perspective. We think about participation, what can we do to help this person safely engage in an occupation? Which that word, a lot of individuals is confusing because they think of their paid occupation or what they did for a living. But really what we mean is just everything that most of us want to or need to do everyday could be considered an occupation. So as Dr. DeCarlo mentioned medication management, all the way to meal preparation, being able to operate appliances in their home, financial management, reading, writing, all the way really up to driving a car.
So our goal is to focus on what the patient is really most interested in and what they want to get back to doing and developing a patient-centered plan of care to help them get back to those activities.
Dr Dawn DeCarlo: The other thing I want to add is that because low vision rehabilitation really is rehabilitation, we do spend more time with our patients than your typical doctor. And if you have vision loss, it can be very intimidating and daunting. And so you're in your retina surgeon's office, and he's saying, "I'm going to give you intravitreal injection of Avastin" and all of a sudden you're here and "I'm getting a needle in my eye." That can be frightening. And you may not be thinking about the questions you want to ask about the diagnosis and the prognosis and things like that. And then that retina surgeon has to see a lot more patients a day than somebody who specializes in rehabilitation does.
So by sending patients to rehabilitation specialists, the doctors providing the treatment of the underlying disease are really getting an extra bang for their buck in terms of what they're doing for their patients. That takes them less time, lets them be more efficient in their delivery of care that's so needed and lets us spend the time explaining to them and that helps patients accept their vision loss when we are able to explain those things to them and moving through those stages of acceptance to vision loss is really important in being able to do the things that are important to those patients.
Melanie: What a great point. And Dr. Locy, what's exciting in the field right now? Tell us about some of the latest technology for visual aids and low vision.
Dr Marissa Locy: So a lot of new technologies, as far as wearable low vision aids. A lot of it in the past has been more desktop or portable devices. These are things that you wear like glasses. They can change the contrast. They can change the size. They have a lot of cool inputs where you can connect with things, so you can even watch your Netflix right there on your low vision aid. So especially for those who are really tech savvy, there are a lot of cool new wearable devices.
There are a lot of devices that are also looking at optical character recognition and they will have cameras attached there that can read print and it's for patients who have very little vision remaining, they can read their mail again. They can read their newspaper. They can read their prescription labels.
For those with smartphones, there are a lot of new apps on the smartphones also. Some that do some of those same things with OCR, optical character recognition. There are other things where you can connect with a volunteer via your smartphone, and that volunteer might be, you know, miles away, but they can help you read the label on your food package, how long do you have to put it in the microwave, things like that. So we have a lot of really cool technology that we can work with patients one-on-one. A lot of it is just tailoring it to what their needs are and what their goals are.
Jason Vice: So that's the great thing about having this clinic located here in a major urban setting. These individuals see that these products exist sometime on television or through media ads. You know, we have a lot of those devices here on site and our low vision eye doctors can evaluate them, see if these devices are appropriate for them. And if they are, then we can provide additional training for them on how to use the device and how to use it for everyday activities before they invest in some pretty expensive equipment that may or may not work for them.
Melanie: I'd like to give you each a chance for final thoughts. So Jason, I'd like to start with you as this pandemic has affected so much of the country and the challenges we've discussed a little bit, how have you been utilizing telemedicine? Have you been utilizing it? And how are your patients liking it from rural areas, being able to maybe, you know, have an appointment with you? Tell us how you're utilizing it and what you see happening in the future. Do you think that you will still utilize this technology after the pandemic has cleared?
Jason Vice: That's a great question. And I think that this has been sort of a game changer in terms of telemedicine and telehealth. I believe that after the pandemic, it's going to be really no looking back in terms of virtual visits. Again, you know, we're from Alabama, it is a relatively rural state. So it's difficult for individuals from the corners of our state to make it centrally to Birmingham where we're located and particularly true in the pandemic with some of our patients have been a little more uneasy about getting out into the community.
The way I've adapted is for those individuals who maybe aren't as comfortable coming as frequently to therapy, I've been able to do e-visits with those individuals, whether it's by phone or a virtual platform to check in with them between our sessions, I've been able to do initial evaluations and treatments via telehealth. UAB has a portal that we utilize. So for those individuals who aren't able to come in directly, we're able to work with them from their homes.
And so I think that the insurance agencies are going to see the value in this and that we're able to get care out to more people who wouldn't be able to make it in otherwise. And I think you'll see much more utilization of tele and e-visits in the future.
Melanie: Dr. Locy, next to you, what would you like to tell other providers about the clinic? What's unique, what you do to go above and beyond, and the importance of this multidisciplinary approach that you have at the UAB Center for Low Vision Rehabilitation?
Dr Marissa Locy: I think it's important for providers just to understand that if they have patients who are not where their goals are, as far as vision, if they're struggling to do any kind of daily activity because of their vision, that they should refer to a Low Vision Rehabilitation Center. We often spend, as Dr. DeCarlo alluded to, an hour or so with a patient. So we take a lot of time with each patient to really make sure that they're able to do the things that they need to do and they're safe and it's a lot of hands-on time with these patients.
Melanie: Dr. DeCarlo, last word to you. Expand a little on referral criteria for the Center for Low Vision Rehabilitation at UAB Medicine, what you'd like other providers to know about your team and the exciting work that you're doing there.
Dr Dawn DeCarlo: So our referral requirements are very, very loose. We don't restrict. Basically, if the patient feels that their vision is not adequate, we are happy to see them. That does mean that occasionally we see people who would have been just as well served going and getting glasses somewhere else, but those are pretty few and far between. But what we tell the providers that refer patients to us is that if your patient's not able to do the things they need or want to do, go ahead and refer them.
Sometimes patients, especially patients receiving the anti-VEGF medications for wet macular degeneration will have good acuity on an eye chart and you look and you go, "Well, you know, they're reading really well on that eye chart, but they're complaining." People with macular degeneration can have scotomas in their central vision that interfere with their function, despite good performance on a high contrast acuity card. They can also have impaired contrast sensitivity, which severely impacts their ability to read. And we have time to delve into how central scotomas are impacting things, how contrast sensitivity is impacting things. And we know the recommendations to make, to help people get by, and not just get by, but excel at what they want to do.
And when we need to, we get them into occupational therapy. So it really should be guided by what the doctor is hearing from their patient. We also accept self-referrals because sometimes patients will end up talking to each other and say, "Well, have you gone to the Low Vision Center yet?" "No, I haven't heard of that." And I think that because low vision services are not as widely available as everybody would like them to be, not every physician is trained that this is an option. But if you think about what happens after somebody has a stroke, do they get rehabilitation? If they have any functional deficits, the answer should be a hundred percent and that's fairly true, I believe.
In vision rehabilitation, people can have a lot of vision loss and yet somehow people will say, "Well, I'm sorry. There's nothing more I can do," and that's just not an acceptable answer anymore. And we have contacts all over the country. We are all very active on the national level and even the international level. So if a physician reached out to us and they were from another state, we would be happy to try to contact them with a reputable low vision provider in their area.
Melanie: That's great information. Thank you all for joining us today and telling us about the UAB Center for Low Vision Rehabilitation. It's really, really an important center. And thank you for all the great work that you're doing.
A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.
That concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua193.mp3
- DoctorsWindham, Sam III
- Featured SpeakerSam Windham, III MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4649
- Guest BioSamuel T. Windham, III, M.D., joined the faculty of the UAB Department of Surgery's Division of Acute Care Surgery in 2001. He currently serves as the Medical Director for the Surgical Intensive Care Unit.
Learn more about Samuel T. Windham, III, M.D
Release Date: March 18, 2021
Expiration Date: March 18, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Samuel T. Windham, III, MD
Director of Surgical Critical Care; Medical Director Legacy of Hope
Dr. Windham has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole Host): Welcome to UAB Med Cast. I'm Melanie Cole and I invite you to listen as we discuss Catastrophic Brain Injury Guidelines and Organ Donor Management. Joining me, is Dr. Sam Windham. He's the Director of Surgical Critical Care and the Medical Director of Legacy of Hope at UAB Medicine. Dr. Windham, thank you so much. What an interesting topic that we've got here today. Thank you for joining us. Why don't you start for other providers, a little bit about catastrophic brain injury and the most common occurrence.
Sam Windham, III, MD (Guest): Well, thank you for having me today, Melanie. Catastrophic Brain Injury Guidelines, so they're really a simple set of parameters provided to healthcare providers to aid with the management of those patients who have sustained a very severe and sometimes, unfortunately quite often, a non survivable brain injury. Let me kind of back up a little bit to the need of why these guidelines were developed, because that does put an important framework of why we have them in place.
We know that organ transplantation has become a lifesaving procedure for many patients in organ failure. In fact, there's 120,000 people in the United States on the waiting list for a life saving organ. Unfortunately, many of those patients will die from their organ failure, never having received a transplant. And this is simply due to the fact that demand exceeds the supply. There are many people in the fields of organ donation as well as transplantation that are working on all aspects to try to help this problem with the waiting list. One particular interest of mine and that we're focused on, is that of preserving the chance for organ donation following brain death declaration.
In the United States, approximately 2.2 million people die every year, but less than 1% of those deaths occur in a manner to allow for organ donation following brain death. So, there's some key aspects that are important to allow for organ donation. Number one, is to capture the referral of every patient that might have the chance for donation. Number two, would be preserving the chance for donation once that patient is progressing towards brain death and after brain death, and then finally and an area of interest of mine is that management of the organ donor, after they have been declared to try to reverse all the negative effects that have happened to the body with the brain death process.
And so Catastrophic Brain Injury Guidelines, they were designed to really help with that second point that I just mentioned, and that is to preserve the chance for organ donation. Many healthcare providers take care of those patients that have catastrophic brain injuries and know just how unstable those patients get. And so, these guidelines help with the management and dealing with that instability.
Host: So then Doctor, what are the current guidelines for organ donor potential for these patients?
Dr. Windham: These guidelines were made to help support any kind of catastrophic brain injury. Some of these, the patients have trauma such as gunshot wounds to the head or car accidents, strokes, intracranial bleeds, a cardiac arrest. Overdose is becoming a lot more frequent here in the last few years. So, regardless what kind of injury has been sustained by the patients, these guidelines are made and developed to help support those patients. I guess, key to understanding the guidelines is to understand why the patients become unstable following the catastrophic brain injury. That gets to kind of the physiology of that catastrophic brain injury.
The first reason for the instability, is that often as patients progress with their catastrophic brain injury, their response is much like the septic patient in the intensive care unit. They have the same cytokines and inflammatory mediators that are released and then thus behave just like a septic patient. And this was described by Schwartz in the Journal of Cell Transplantation in 2018. So, just as the septic patient needs a volume resuscitation and hemodynamic support; so does that patient with a catastrophic brain injury. A second reason for the instability is that with the increased intracranial pressure from the catastrophic brain injury, ultimately the blood flow to the brain stops, which is the point of brain death. When that happens, all the central nervous system hormones are stopped being produced and that leads to instability from diabetes insipidus, as these patients will have large volume urine output and become hypovolemic really quickly, as well as they have adrenal insufficiency because the central nervous system no longer produces ACTH.
The third reason that the patients become unstable is that with the progression to brain death, the heart becomes stunned in up to 30 to 50% of the patients progressing to organ donation. And that just has to do with the physiology of that brain death process and the stunning of the heart. So, the guidelines were made to develop and overcome each of these three entities to help stabilize the patient. There are many iterations of the Catastrophic Brain Injury Guidelines, and I don't know that any one is better than another. And so we have typically adopted a very simple group of Catastrophic Brain Injury Guidelines at Legacy of Hope.
Number one, is to maintain the systolic blood pressure greater than 90. If you're having trouble doing this, administer fluids, if they are behind. Add vasopressor support if needed to help achieve this goal. And that can come in any form, whatever the physician feels appropriate. Most commonly those are levophed or vasopressin or Neo-Synephrine.
And then third, if they're having trouble maintaining the blood pressure, is consider invasive monitoring and access to help achieve this goal. The second component of the Catastrophic Brain Injury Guidelines we have is to maintain the urine output between the range of half a cc to one cc per kilo, per hour and less than 300 ccs per hour. To help achieve these goals, first can administer fluid if they are behind and the urine output is low. And second, if the urine output is very high to start the vasopressin as this will help take care of the diabetes insipidus, which is likely to be present.
Third component of the CBIGs would be maintain a PAO2 greater than a hundred and fourth component is to maintain a normal pH between 7.35 and 7.45. So, these are the four guidelines that we encourage to be followed. They seem awfully simple, but believe it or not, just by performing these, the donation potential can be preserved in a tremendous way.
Host: Dr Windham, is there a point that the healthcare teams and sometimes families realize that the injury is not survivable and if the healthcare teams sense that, might they often direct less care, less resources to these patients? As you're giving us these guidelines, can you tell us steps in the process that will hopefully mitigate that?
Dr. Windham: First and foremost, these guidelines were really what would you do in order to get a patient better? In the case, that this is a survivable, so each one of these is good care. And in that case, that the patient can survive this, it gives them the best chance to survive. We do see very often, the care being decreased, we do know that it's non survivable and I don't think that's out of negligence or mal-intent but simply sometimes out of compassion for the patient to avoid unnecessary interventions if they're not going to be of any benefit and sometimes even in this last year, when we saw limited supplies, that played a role in I think limiting of resources of that, the limitations that COVID had to some of our very stretched medical staff and resources. But in general, if we can really aim to provide these simple interventions it really will afford better care for the patient all in all.
Host: Well, then tell us how you've been instrumental in increasing organ recovery rates at Legacy of Hope, directly impacting the number of transplants you've been able to do. Tell us about your role there, Doctor.
Dr. Windham: Well, I started in 2015, I joined the staff and then have since become Medical Director there. And actually, let me start by saying that it's really been a team effort. And I give credit to the team, all the way from our leadership that has really been living out our mission and providing the needs for our teams to do the work that we do. Our family support is also another group that's part of that team that they do such a tremendous and wonderful job working with the families to not only enhance the donor potential, but enhance the grieving process for the family as much as is possible. Our transplant coordinators is another member of that team. They work very long and hard shifts with all aspects of the donor management. And there's so many people behind the scenes on our team, such as our Perfusion Techs, quality department and others that work for this mission. So, the successes that have happened in the last few years are certainly not just what I've done, but my role in the part of this larger mission. I've tried to speak around the state to different groups and encouraging this management of the catastrophic brain injury in order to observe the potential, because I do you know that little steps done by anyone around the state can sure help our donor potential. And then we've also been able to implement several protocols to reverse the damage that is experienced with the brain death process and have been successful in those. In the first year, we were able to more than double the number of lungs able to be offered for transplant.
And then in the second year, as we rolled out new cardiac protocol that no one else in the country has been doing, we were able to have more than 150% increase in the hearts able to be transplanted. So, it's really been a wonderful opportunity to work with Legacy of Hope in developing these protocols.
Host: And what great work you're doing too, Doctor. So, tell us a little bit about how hospitals that have larger donor abilities and a great deal of experience in donor management before the development of these guidelines, are they the ones guiding and helping to expand the use of these CBIGs in the guidelines? Tell us a little bit, if you see this being used on a broader multicenter level where you might expect increases in successful attainment of donor management goals, that may be more pronounced.
Dr. Windham: Yes, we do have certain hospitals in our coverage area that do have a higher amount of organ donors that are referred to us. And that's mainly due to the volume of patients that they take care of and the type of patients that they see. Certainly, the patients from stroke centers and trauma centers do have a higher donation potential. And so the hospitals do play a role with respect to the size and the volume that they refer to us. I would say probably more importantly is the individual healthcare worker. And that is, there are certain doctors, nurses, respiratory therapists, chaplains, all people involved in the care of patients with critical brain injuries that are donor champions. You know, they seem to be the ones to capture the potential that the patient has. They really offer good care and for the patient and then support for the family as that patient is progressing through a non survivable injury. And so, I've found it's probably less so the hospital, as opposed to those people that are our donor champions. And we're really trying to cultivate that relationship with individuals from each hospital so that we can really optimize the referral from every hospital.
Host: Doctor, we just to have a few more questions. And can you tell us some of the goals you're achieving and even some of the goals that were met less often in the post CBIGs and what you would like to see happening in the future?
Dr. Windham: I think importantly in the next few years, the government's going to be holding us to certain statistics about our donation rate and our transplantation rate. And so we have been meeting weekly with our leadership team to help prepare ourselves to really function at the highest level. One of those components will be to roll out and really have the buy-in or the implementation of CBIGs throughout our hospitals. I've been, like I mentioned, I've been trying to go around the state to emphasize the CBIGs and other elements of donor management to these hospitals. And at each place, I really try to stress, how much a difference it can make.
There are two articles in the literature illustrating that. In Critical Care Medicine in 2012, there they took 360 donors and they managed them with a certain group of guidelines or goals, just like I mentioned. And they found that if they could meet those goals in the management, they increased the number of organs per donor from 3.6 organs per donor, to greater than four organs per donor. This was then repeated in JAMA Surgery in 2014, in which they took 671 donors who had even greater degree of sicknesses and co-morbidities and found that meeting the early guidelines and goals, they could increase the donor potential from 2.1 to three organs per donor.
Now neither one of those seems like a lot, but just to give a framework, what that would mean for our organ procurement organization, is that with the number of referrals and donors that we managed last year, that would mean 220 to 260 more organs for donation in last year alone. And that's incredible to think about how much more that would be available for those people that are on the waiting list in lifesaving gifts. Really, we're trying to stress that importance to the hospitals. And that's one of our major focuses around the state, currently.
Host: That's an incredible focus. Dr. Windham, as we wrap up, what would you like other providers to know about how the use of Catastrophic Brain Injury Guidelines before brain death has led to more stable donors, maximizing transplantable organs, your Legacy of Hope and what you're doing there at UAB Medicine.
Dr. Windham: Yes, the first off, these guidelines are really simple and they can make a tremendous difference. Number one, that if the patient has a chance of survival, it gives him the best chance of survival. But when that chance disappears and they are not going to survive, then it gives the best chance to preserve the gift of donation.
And then second is that each individual can make a difference. You know, so often in medicine we get part of bigger schemes and sometimes don't necessarily feel we can make a difference. But each individual can make a wonderful difference just by implementation of these. When you implement them, each physician and caregiver is giving the best care they can to the patient.
Also implementing them, they give the best chance for the recipients on that waiting list to receive the gift of life. And then lastly, implementation of them really helps the families. You know, if the patients get better, then wonderful, those patient's families are eternally grateful for those healthcare providers for what they've done for their loved one. But if that's not possible, then it gives the best opportunity possible for our family support and resources that we have to work with the families in their grieving process. I just can't imagine what those families are going through. And they're really remarkable families that can take their worst moment in time and think of other people.
And having that opportunity to work with our family support gives them help and aid in going through that grief process. We do have a yearly picnic when we're not under COVID isolation and where the donor families can get to meet the recipients and it is truly an amazing event to see the opportunities for healing and compassion that happens. So, the implementation of the CBIGs by anyone out there certainly helps in all aspects of the donor, the recipient, as well as the family and gives us a chance to help turn around those organs for organ donation.
Host: Wow. I got chills, Dr. Windham. What a remarkable program that you are running there at UAB Medicine. It's just, that's just amazing what you're doing there. So, thank you so much for joining us today. And a community physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician. Please also remember, as always to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua191.mp3
- DoctorsCannon, Robert
- Featured SpeakerRobert Cannon, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4594
- Guest BioRobert M. Cannon, M.D., is an assistant professor in the Division of Transplantation, specializing in liver transplantation and hepatobiliary surgery.
Learn more about Robert Cannon, MD
Release Date: March 2, 2021
Expiration Date: March 2, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Robert Cannon, MD
Surgical Director, Liver Transplant Program
Dr. Cannon has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen, as we discuss the protocol for liver transplant for patients with Hilar Cholangiocarcinoma. Joining me is Dr. Robert Cannon. He's an Assistant Professor and Surgical Director of the Liver Transplant Program at UAB Medicine. Dr. Cannon, it's always a pleasure to have you join us today. Tell us a little bit about Hilar Cholangiocarcinoma or CCA. What is it and how prevalent is it?
Robert Cannon, MD (Guest): Yeah. Well, thank you for having me. I'm always happy to be back. So Hilar CCA is a very rare tumor actually. It's only diagnosed in about little over one patient for every a hundred thousand people yearly. So it's something we only see sort of a few times a year. But, we would obviously see more in concentrated referral centers. And what it is, it's a cancer of the bile ducts. So your liver, one of the many functions it does is it's constantly making a substance called bile that helps us digest fat and the bile exits your liver and travels to your intestine through a tube called the bile duct. It's essentially a part of the plumbing of the liver. So cholangiocarcinoma is a cancer of those bile ducts.
And in particular, a Hilar Cholangiocarcinoma and that's based off the location and what's known as in the liver hilum. So it's right where the ducts exit the liver and that's in a very difficult location to treat. Typically, it's fairly advanced by the time it's diagnosed because patients are often asymptomatic early on and then surgical resection by the time most people are diagnosed is no longer an option. And unfortunately we really don't have very good chemotherapy for these patients. So, typically it's carried a very poor prognosis because patients are typically advanced by the time they present.
Host: So what's that been the standard of care when you do come across this situation? Tell us a little bit about the history of liver transplantation, liver transplantation alone, and with adjuvant therapies.
Dr. Cannon: Yeah, so essentially most patients, the standard of care has always been surgical resection, complete removal of the tumor, which often requires a major liver resection as well. Oftentimes we have to remove two thirds or more of the liver along with the bile duct in order to completely remove these cancers surgically.
Unfortunately, the vast majority of patients are already unresectable, due to a more extensive tumor, that can't be surgically removed at the time of diagnosis. So typically, chemotherapy has really been the only option for these patients, but the chemotherapy available has really not been very active against this cancer. So, survival has been very poor in patients who can't be resected, Even in patients who've undergone surgical resection, actually survival is not nearly as good as we see with other cancers that we can remove, such as colon cancer or even metastatic colon cancer. But seeing that, how much resection improved the outcomes, the group in University of Nebraska, early on first started a protocol where they would start very intensive neoadjuvant chemotherapy and radiation prior to transplantation. And they found early survival benefit there. So, then really the researchers at Mayo Clinic, really pioneered this and sort of developed the protocol variation of which is used by most transplant centers around the country who were doing this.
And this involves, again, a very prolonged course of chemotherapy and radiation upfront, followed by staging to make sure that there's no disease that spread to the nodes and for the patients who make it through this protocol, they can then undergo liver transplantation. So, these were patients who were previously thought to be unresectable, which is essentially a death sentence.
But now that patients are able to get through the protocol and can be transplanted, can really enjoy very good survival it's equivalent to, or sometimes even better than those who are able to undergo resection.
Host: Well, you just touched on this briefly, as far as patient selection. So, what do they have to have completed before this would be an option? What's the criteria for entry into a transplant protocol, that's not amenable to resection? Tell us a little bit about who's considered unresectable or who fits the criteria into this protocol program.
Dr. Cannon: Certainly. So criteria for resectability essentially, we have to think that we'll be able to remove all of the tumor completely, cause otherwise if you're leaving tumor behind, you haven't really helped the patient. So what makes the tumor unresectable is if it's either invading the main portal vein or hepatic artery, or if it's growing bilaterally into both sides of the liver, into the bile ducts, because we can't remove the whole liver and survive.
So that's typically what makes people, patients unresectable. Another thought is, and that's in sort of cholangiocarcinoma that just arises out of the blue, which is the vast majority of them, in the United States. Now in the setting of primary sclerosing cholangitis, actually, some would consider all of those patients unresectable based on the fact that all of their bile ducts are abnormal and they have a much higher lifetime risk of cholangiocarcinomacarcinoma. So, patients with PSC in general, are just considered unresectable, by many programs and that'll allow entry into neoadjuvant and transplant protocol. In terms of specific selection for who's eligible, so after making the diagnosis, one of the biggest things is there clearly has to be no metastatic disease outside the liver.
And there has to be no nodal metastasis as well. So, cancer that spread to the nodes, is a very poor prognostic indicator and those patients who have been found not to do well after transplant. So, metastatic disease or nodal metastases are one contraindication and the other is the tumor size.
So, if they have a mass, that mass has to be less than three centimeters in order to qualify for the protocol. Finally, and perhaps most importantly is they can't have had a transperitoneal biopsy of the tumor itself. So, either a percutaneous biopsy of the tumor or more commonly an endoscopic fine needle aspiration of the primary tumor itself will rule patients out for potential transplant. Cause there can be peritoneal seeding that results in metastasis later. So, those are our sort of inclusion criteria for patients who we will considered for the protocol.
But in general, you know, we really don't want the burden of deciding who's transplant eligible and who's not, necessarily to have to be on doctors in the community taking care of cholangiocarcinoma patients. We'd be happy to evaluate all patients with CCA and then we'll be happy to try and find the most appropriate therapy for them. It may be resection. It may be transplantation, or there may indeed be patients who unfortunately aren't candidates for either, but you know, we'd be happy to, sort of take on the care for all those patients.
Host: Well you certainly are a preeminent expert in this field, Dr. Cannon. So for this to be successful, what neoadjuvant therapy is recommended and does liver transplantation following this type of therapy have efficacy in the treatment of CCA?
Dr. Cannon: Certainly. So, yeah, it's a very well prescribed treatment regimen. And we have to get our regimens approved by the United Network for Organ Sharing in order to get transplant priority for these patients. So at UAB, our regimen is going to include induction with three to four cycles of the combination of gemcitabine and cisplatin, which is a very standard chemo regimen for this type of cancer. This will be followed by external beam radiation over a course of three weeks, during which time they're also getting five FU as a radio sensitizer. Finally they'll undergo catheter-based brachy therapy to the tumor and to get an extra radiation boost to the region. After they've completed their chemo, radiation, they'll then stay on maintenance oral chemotherapy until the time of transplant.
Now, typically once they've completed the upfront chemo, radiation, once they have gotten their meld exception point, which is what will give them priority for transplant, they'll then have to undergo a staging laparotomy. During that, what we will do is dissect out all the portal lymph nodes and send those to pathology.
Cause again, I think as we discussed earlier, they have to not have nodal metastases in order to get the benefit of transplant. So, this is where many patients who do drop out of the protocol and don't make it on a transplant; this is a common point of failure. And some of the data from the Mayo Clinic will suggest that up to 20% of patients will have positive nodes found at this staging operation. But if the nodes are not involved, then they can go on to transplant and the survival is really been excellent. So, one of the big determinants of survival and one of the important ones is whether this arises in the setting of primary sclerosing cholangitis, or sporadically. So, results are really excellent for patients with PSC. Five-year post-transplant survival for transplanted patients at Mayo Clinic, with PSC is 77%. So, that's as good as any other disease we do transplants for. Survival is not as good for patients with de-movo cholangiocarcinoma. Their five-year post transplant survival is only 56%, still much better than they would have had without surgical resection. And just with chemotherapy. Well, they wouldn't, they're not candidates for surgical resection, but I mean, with chemotherapy alone, so there's certainly a survival benefit for transplant for these patients.
Host: So would transplantation with neoadjuvant therapies be better treatment than resection for patients with potentially resectable disease?
Dr. Cannon: So that's a very interesting question and one, that's the subject of active debate. There is an ongoing clinical trial being run in France right now known as the transfil study. That should complete enrollment this year. And that may hope to give us an answer to that question, but that's certainly with the results we've seen with transplantation, that's certainly a question many in the field are asking. Now from a practical standpoint, in order to get transplanted with a deceased donor, at least, it's a requirement, that the patients be considered unresectable. However, with the living donor transplant, it could be potentially considered for resectable patients. Particularly if some of the data that we expect to come out over the next few years does prove that transplant would be superior even to resection.
Host: Well you just, so my next question, which was appropriate prioritization for the deceased donor liver for CCA patients awaiting that. But so moving on from that, and before we wrap up, as the curative treatments remain challenging, what are some advances in hepatobiliary techniques that have improved the results and the outcomes of these tumors?
Dr. Cannon: So really in hepatobiliary surgery, I think the surgery itself has not changed a lot, probably over the last 10 years, probably better adiuvant therapy I think it was one of the bigger things that's going to improve the survival. So a while back there was a trial known as the billcap study, which really, compared capecitabine orally in an adjuvant setting.
Now it didn't include just Hilar Cholangiocarcinoma. It included other biliary cancers as well, but there was a significant survival benefit with oral capecitabine following complete resection of cholangiocarcinomas. And I think that's been probably the first improvement we've seen in awhile in survival and hopefully there will be some trials with some of the newer immunotherapies and checkpoint inhibitors. We don't know if there's any role for those in biliary tract cancers as yet, but I'd be interested to see what comes along.
Host: And do you have any final thoughts for other providers? You mentioned briefly before that for community physicians and when you feel it's important, they refer, will you please reiterate that Dr. Cannon for us?
Dr. Cannon: Certainly, I think if you have a patient with Hilar Cholangiocarcinoma, certainly send them over. We're happy to see them and evaluate them to see whether they'd be a resection or transplant candidate. And we love working with our partners in the community.
Host: Thank you so much, Dr. Cannon, what a great guest as always you are. And a community physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABmedicine.org/physician.
Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. Until next time, I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua194.mp3
- DoctorsPeyton, Chas
- Featured SpeakerChas Peyton, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4654
- Guest BioSpecialties include Urologic Oncology and Urology.
Learn more about Chas Peyton, MD
Release Date: March 23, 2021
Expiration Date: March 23, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Charles C. Peyton, MDAssistant Professor, Urologic Oncology & Urology
Dr. Peyton has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA Category 1 credit. To collect credit, please visit UAB medicine.org/medcast and complete the episode’s post-test.
Welcome to UAB Med Cast, a continuing education podcast for medical professionals. Bringing knowledge to your world. Here's Melanie Cole.
Melanie: Welcome to UAB Med Cast. I'm Melanie Cole. And today, we're discussing testicular cancer. Joining me is Dr. Chas Peyton. He's a urologic oncologist and Assistant Professor at UAB Medicine. Dr. Peyton, it's a pleasure to have you join us today. So tell us a little bit about the incidence and demographics of testicular cancer and what have you been seeing in the trends.
Dr Chas Peyton: Well, thanks so much for the invitation to discuss this today. Testicular cancer fits into a broader category of what we call germ cell tumors of which 90% of germ cell tumors arise from the testicle. The remaining 10% arise from the mediastinum or the retroperitonium. And most testicular tumors are derived from what we call intratubular germ cell neoplasia of fetal gonocytes that don't undergo normal differentiation.
Testicular cancers are sporadic and relatively rare. And they account for about less than 1% of all tumors in men. However, it's definitely the most common solid tumor diagnosis in men ages 20 to 34. Thus, it's a critical tumor to kind of know about in men this age who usually don't have other ailments.
In 2020, it was estimated about 9,600 cases of testicular cancer of which 440 men died from their disease. The overall survival of testicular cancer ranges from about 95 to 97%. So it's a very curable disease, which is why it's important for men to know about it. However, this is remarkably improved from the 1970s where five-year overall survival was approximately 80% to 83%. A lot of this improvement has to do with the development and use of cisplatin-based chemotherapy.
Melanie: So interesting, really, the advances that we've noticed in the last, as you say, 20 years. Tell us about risk factors since this is relatively uncommon. Tell us a little bit about who might be at risk and then also what are the presenting symptoms. What would a man notice? And would he be the first one to notice something going on or might it be a provider or how does this work?
Dr Chas Peyton: So there are a few things that put men at risk for testicular cancer. One is an undescended testicle or what's known as cryptorchidism. That has four-fold increase in the relative risk of developing testicular cancer over a lifetime. Additionally, men that have a delayed orchidopexy or when the testes is brought back down into the scrotum, that's also a risk factor.
There's also epidemiologic associations between low birth weight, gestational age and twinning. They actually are also risk factors, but not nearly significant as undescended testicle. But one of the most important risk factors you have to know is that a man who has a prior germ cell tumor in one testicle or elsewhere in their body is at risk of having another germ cell tumor much more than standard population with no history of testicular or a germ cell tumor.
In terms of family history, risk between brothers that have had testicular cancer is about eight to ten times higher than the general population. And the risk between a father to son is about four to six-fold increase compared to the general population.
In terms of symptoms, the classic symptom is a painless testicular mass. Occasionally, we'll see a reactive hydrocele as part of this, but painful masses are more likely to be infection or trauma. So, painless, palpable testicular mass is always a testicular cancer until you prove it's not.
With advanced disease and metastatic disease, you can see signs of increased abdominal girth, belly or back pain, early satiation, obstructive uropathy, weight loss, anorexia, fatigue, palpable abdominal masses, supraclavicular lymphadenopathy, shortness of breath. And in rare cases, you can have hemoptysis with multiple lung metastases and then neurologic symptoms in patients with brain metastases.
Melanie: So interesting. So then doctor, tell us a little bit, if this mass is found on an exam, what's the next step? What are the recommended imaging modalities and some valuable prognostic tools that can aid you in your diagnosis?
Dr Chas Peyton: Sure. The minute someone notices a painless particular mass, or in general testicular mass at all, a scrotal ultrasound is the starting point. A scrotal ultrasound is 92% to 98% sensitive and about 95% specific. If you confirm a solid mass in the testicle, immediate referral to a urologist is what you need to do. Never order a biopsy of the testicle. We don't biopsy the testicle through the scrotum ever.
The additional workup that's needed when a testicular mass is found is serum tumor markers. And the blood serum tumor markers you obtain is beta hCG, an alpha-fetoprotein level and a lactase dehydrogenase level. You order these before you perform the orchiectomy.
Additionally, it's often recommended to go ahead and stage the patient with a CT with contrast of the abdomen and pelvis prior to the orchiectomy and a chest x-ray. However, if certain tumor markers are elevated, I'd recommend getting a CT scan of the chest.
Melanie: Well, then doctor explain testicular cancer staging after orchiectomy. What are the components and why is this so important?
Dr Chas Peyton: Right. So the critical in testis cancer is staging. And the primary way you stage them is removal of the testicle. So anyone with a solid testicular mass, you have to remove it. Urologist does it through an inguinal incision, and then you can completely stage the patient once you have the testicle in your hand. And we can look at it under the microscope and we can get the imaging that I just mentioned.
Of note, in terms of diagnosis and workup, often in the community people order PET scans, which are really not indicated. CT PET scans are only useful in very specific situations that we could talk about some other time. But to stage somebody accurately, you perform the radical orchiectomy through an inguinal incision, not through a scrotal incision. You don't biopsy the scrotum and you don't perform an orchiectomy through the scrotum, because it can disrupt lymphatic channels and spread the tumor potentially to other places where it usually doesn't go.
In terms of staging, we have clinical staging, according to the AJCC TNM staging system that's done after orchiectomy. The T is the primary tumor, which goes from 1 to 4 and 4 invades the scrotal skin. The N is the nodal stage and that's based on the retroperitoneal nodes, that is considered the regional lymph nodes for the testicle and that's based on size and number. And then the M status is based on distant metastases, either pulmonary and non-regional versus non-pulmonary and non-regional.
Lastly, in testis cancer, unlike other cancers, we have an S stage. And the S stage is a serum tumor marker level. After you remove the testicle, you wait a certain amount of time and you repeat the tumor markers and then you have an overall clinical stage picture once the tumor markers have come down. They usually have a half-life of about five to seven days, depending on which one.
There's one additional staging component that begins right before initiation in chemotherapy if this is advanced disease. And then we qualify patients into good, intermediate and poor risk for more advanced disease. If surgery is indicated, meaning removing the lymph nodes in the abdomen or removing other sites of disease, you have a final pathologic staging, which can provide the most information after you remove the testicle, they've gotten chemotherapy or not gotten chemotherapy in some situations. And then you perform what's called a primary or post-chemotherapy retroperitoneal lymph node dissection. That's when we'll have the most information as far as survival probabilities and predictive outcomes and whatnot once they're pathologically stage and surgically complete. But not all patients make it to that stage for various reasons, either they get cured or other things.
Melanie: Well, then speak a little bit to other providers about the emotional aspect of this type of cancer and how it affects men emotionally and what kind of help there is for that.
Dr Chas Peyton: Well, April is Testicular Cancer Awareness month. So you'll see lots of things on the internet. I think we have an excellent support system at UAB and there's great websites out there. The most notable one for testicular cancer support is testicularcancersociety.org.
In terms of men, these are young men that are getting a bad diagnosis and it's very tough. The other thing that's critical to understand, and I haven't mentioned much about, is that fertility's a huge deal for men in this age group that have testicular cancer. You can remove a man's testicle and they don't lose any fertility if they had normal fertility beforehand. But once you start giving chemotherapy for more advanced disease and doing these big operations, like retroperitoneal lymph nodes dissection, there's severe implications or really important implications of fertility. So that's a big stressor for men. I've had multiple patients that are completely infertile now after the testicular cancer. So that's a big deal.
The other thing to know is that men in this age group, if they get this diagnosis, in certain social situations, they're notorious for not following up appropriately. They're busy. They feel healthy otherwise. They keep on moving along in their life and that's when they get in trouble. They don't follow up and don't adhere to the cookbook recipe for testicular cancer, because like I told you, this disease is almost 95, 96, 97% curable, but you got to stick to the cookbooks. So that's really important. And what I mean by cookbooks is like the designated guidelines that are important to stick by when you're managing this disease. You won't achieve that cure rate if you don't do what the guidelines say, basically.
So it's really important to provide some emotional support and family support and really characterize the patient in terms of how they're going to respond to the treatment you're telling them. And sometimes that actually influences us in what we're going to do. But if I don't think a patient's going to show back up ever again after I see them, I may treat them a little differently to give them a slight advantage in their followup versus someone I know is reliable. So there's a lot of nuance medicine and social support that's involved with these men because they're so young when they get this diagnosis usually.
Melanie: There certainly is. And what great points that you've made for other providers. As we wrap up, Dr. Peyton, tell us any new exciting game-changers in the detection or treatment of testicular cancer. Looking forward to the next 10 years, what do you see or hope is going to happen in your field?
Dr Chas Peyton: Right. Well, the most exciting thing in testicular cancer right now is a new serum tumor marker called microRNA, and there's a bunch of trials going on right now. And this is going to be a way more sensitive and specific serum tumor marker to tell us and guide us how to move through the treatment patterns.
For example, in a lot of situations, once men have gotten chemotherapy for big masses in their abdomen from testicular cancer, we will remove those masses, but up to 40% of the time we remove those masses, but there's fibrosis, there's no tumor left. So we will have done an operation, it's a big operation and not really taken out any residual tumor because the chemotherapy basically cured it. But we don't know that right now. MicroRNA may be able to give us a glimmer of hope in delineating in that situation, which patients need surgery and which ones don't. So that's very exciting.
The other thing is, as we've advanced surgically over the years, there is way more effort now to offer occasionally what's called a primary retroperitoneal lymph node dissection to patients to avoid chemotherapy. I've gotten into it, but chemotherapy has a lot of side effects as does surgery, but the side effects for chemotherapy in somebody who's 20 is long-term and they accumulate later in life.
So being able to offer upfront surgery as an option to avoid chemotherapy is becoming more and more of an option for patients. But nonetheless, chemotherapy is an absolute here to stay forever for testis cancer, because it's one of the only few solid malignancies where cisplatin-based chemotherapy can actually cure men.
And lastly, just a quick mention of robotics on the side of surgery, there's debate in the literature, but now we're minimizing surgery as much as we can. Retroperitoneal lymph node dissection, people are very weary of doing it because it's a complex operation. It will always be complex that requires a big incision and a long hospital stay.
But now with the advent of robotics, we're really getting some great ways to do this robotically through small incisions and send men home quickly and provide them that surgery option, without maybe as many issues or prolonged hospital stay as they had in the past with a big, big incision that's required for a retroperitoneal lymph node dissection.
So those are three of the things I think that are up and coming and definitely the most exciting will be this microRNA thing that pans out over the next five to 10 years.
Melanie: What an exciting and interesting time to be in your field, Dr. Peyton. Thank you so much for joining us today. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.
That concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, you can always visit our website at UABmedicine.org/physician. Also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua189.mp3
- DoctorsThomas, Carisssa
- Featured SpeakerCarisssa Thomas, MD, PhD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4570
- Guest BioI am a board-certified otolaryngologist and fellowship trained in head and neck surgical oncology and microvascular reconstruction. My clinical practice focuses on reconstruction after surgery for head and neck cancer, including skin cancers and Mohs defects. I perform the entire range of reconstructive options from local flaps to pedicle/regional flaps to free tissue transfer.
Learn more about Carisssa Thomas, MD, PhD
Release Date: February 23, 2021
Expiration Date: February 23, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Carissa M. Thomas, MD, PhD
Assistant Professor, Head and Neck Surgical Oncology
Dr. Thomas has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie: Welcome to UAB MedCast. I'm Melanie Cole. And today. I invite you to listen as we discuss oral cancer. Joining me is Dr. Carissa Thomas. She's a board-certified otolaryngologist and fellowship trained in head and neck surgical oncology and microvascular reconstruction and she's an assistant professor at UAB Medicine.
Dr. Thomas, it's a pleasure to have you join us today. So let's start with a little background on incidence and demographics of oral cancer, the most common pathology. Tell us what you're seeing in the trends.
Dr Carissa Thomas: That's a great place to start. So each year, about 3% of all new cancer cases that are diagnosed are oral cavity cancer. So this would equate to approximately about 53,000 cases per year. Men are disproportionately affected compared to women, but we see it in all races. So roughly about 10,700 patients each year will die of oral cancer.
You know, the five-year overall survival rate is of course dependent on the stage of the cancer at the time of the diagnosis. But if you look at all stages of oral cancer, the overall rate of survival is about 60 to 65%, which we think is quite low. And despite advances in surgical techniques over the years, as well as in radiation delivery, we've had new chemotherapeutics and immunotherapy now, the survival rate really hasn't changed significantly in decades. And so, even more unfortunate is it seems that black patients have a worse survival, and that's likely because of a variety of factors.
Median age at diagnosis is usually the early 60s. But in the last many years, we've been seeing an increasing number of young patients without the typical risk factors that are being diagnosed with oral cancer, especially tongue cancer. And anecdotally, these patients seem to do worse overall. And then finally, the most common pathology that we see in oral cancer is squamous cell carcinoma, which is arising from the mucosal lining of the oral cavity.
Melanie: So then let's talk about risk factors for a minute, because you know, you just briefly touched on it, but what are the risk factors and some signs and symptoms to watch out for?
Dr Carissa Thomas: So the most common risk factor that we've known about for the longest time is tobacco and alcohol use. And the two together have a synergistic effect. Additional risk factors include poor oral hygiene and then also something called betel nut or quid, which is most commonly used in kind of like the Southeast Asia area. But like I mentioned earlier, we are seeing oral cancer in patients who have none of these risk factors. And we really don't know why they're developing oral cancer. And so this really just tells us that we still have a lot to learn about this disease process.
And I also want to always put in a plug that you can reduce a person's risk fairly significantly if you quit smoking. And the studies have shown that if someone quits, they get reduced risk of developing oral cancer as early as one to four years after quitting. And if someone has quit for more than 20 years, then the risk is back down to being equal to that of a non-smoker.
And then, as you mentioned, what are some of the signs and symptoms that we look for? The most common signs and symptoms are usually a non-healing lesion or ulcer in the mouth. Patients can get unilateral otalgia and they can have oral bleeding, obviously pain, sometimes a neck mass, dysphagia, odynophagia and an unintentional weight loss. And we usually say, if any of these signs or symptoms are present for three weeks or more, then an evaluation by an otolaryngologist or a head and neck surgeon is definitely warranted.
Melanie: Well, thank you for that. So tell us a little bit about diagnosis itself, who most often diagnoses this? You said if people have this, they can go see an otolaryngologist. Are dentists involved in this diagnosis? Are they checking for oral cancer these days? And are you working with them? Do they recommend? Give us a little bit of a background on how it's diagnosed.
Dr Carissa Thomas: So I think dentists are getting more and more aware of oral cancer. For us, it always seems very common because we see it so often. But in a general dentistry practice, the chances of them actually seeing an oral cavity cancer just based on statistics is quite low. But I think through a lot of the educational efforts that have been ongoing, and I know, you know, here at UAB, our colleagues in oral surgery are very active in educating their dental colleagues. I think we're improving the ability of dentists to recognize this disease. And I think some people have noticed when they go in for their normal dental cleaning, that a lot of dentists are now incorporating a neck exam where they're palpating for lymph nodes and they're doing a more thorough oral cavity exam to look for these lesions.
Unfortunately though, we still do see a lot of patients where we get this very classic story where they've had this painful lesion and everyone thinks it's related to a tooth issue and they've had the tooth extracted and they've had these different procedures done. And only after extended period of time do they finally decide that they need to do a biopsy and diagnose the oral cancer. And so we still have some room to work on our education and just getting this in the forefront of people's minds.
You know, once they come to see us in clinic, our workup is your standard workup that anyone does, a very thorough history and physical exam. One thing we always include is something called a flexible fiberoptic laryngoscopy exam in the office, and that's to assess the entire upper airway including the nasopharynx, the pharynx and the larynx, just because there is the possibility of having a secondary cancer at the same time in a smoker and you want to know that upfront.
And then if a biopsy has not already been done, then we would do the biopsy for the definitive diagnosis and that usually can be done in clinic, but sometimes we do have to go to the operating room and do what we call a direct laryngoscopy to get the tissue that we need.
And then imaging wise, we like to have a CT neck with contrast, to look for extent of the local disease. We also look for regional metastasis too lymph nodes in the neck. And usually, we do some sort of CT chest or PET scan to look for distant metastases within the most common locations being lungs, bone, and liver is what we're looking for.
And then finally, occasionally an MRI is also done and it's helpful to assess the amount of tongue involvement as well as for perineural invasion.
Melanie: Dr. Thomas, we've talked about risk factors, a little bit, signs and symptoms, but what about HPV? And what role does that play in developing oral cancer?
Dr Carissa Thomas: Yeah, that's another really good question because I think people are hearing a lot more about HPV these days, especially as some more famous people have had cancer caused by HPV. So HPV or the human papilloma virus is extremely common viral infection that most people have been exposed to. And the vast majority of people will clear it, but for reasons that we still don't fully understand, there is a small percentage of people who will have a persistent infection and a portion of those people, for again, reasons we don't know, will actually then develop into cancer.
But in the head and neck, the most common site for HPV-mediated disease is actually the oropharynx, so that would be your tonsil and tongue base squamous cell carcinoma cancers, and we don't see it very much in the oral cavity. And for that reason, since HPV-driven cancer in the oral cavity is so rare, we don't even routinely test for it here at UAB. You know, typically when we have a biopsy sample and we're worried about HPV, we send either for HPV testing or its surrogate marker, which is p16. But oftentimes for oral cavity lesions, we don't even look for it because we know that the chances of it being HPV-driven are so low.
Melanie: So interesting and what an exciting time to be in your field. So Dr. Thomas, tell us about standard of care. And if you catch it early or even in the middle, does immunotherapy, you mentioned that a little bit earlier, play a role? Tell us what's new and exciting in treatment options for oral cancer.
Dr Carissa Thomas: So we actually utilize kind of the whole spectrum of treatment for oral cancer. And that spectrum is surgery, radiation, and chemotherapy. Our goal is to try to do a unimodality treatment, especially for those early stage lesions, but sometimes a bi or trimodality therapy is indicated based on the stage or if there are unfavorable pathologic features that are found.
So for oral cancer, surgical excision is the first-line treatment. So that would be tumor extirpation and then a local, regional or microvascular free tissue transfer reconstruction, depending on the size of the lesion. If there are regional metastases and lymph nodes, then that also necessitates a neck dissection at the same time. But we know that even in early stage disease, if the depth of invasion of the tumor is three to four millimeters or greater, that patients, if they have an elective neck dissection upfront, have a better survival compared to observing them and then doing the neck dissection if they develop disease.
So most of these patients end up getting lymph nodes removed from their neck, even without an obvious lymph node that's involved with cancer. And then if you have a tumor kind of at the midline or crossing over the midline, then we take out lymph nodes on both sides of the neck or do a bilateral neck dissection.
And then after surgery, post-operative radiation treatment is usually indicated if they have a large tumor, if they have bone invasion, a lymphovascular invasion, perineural invasion, multiple positive lymph nodes or extranodal extension or a closer positive margin on the resection specimen. And then we add chemotherapy to that radiation if there is extranodal extension in the lymph nodes or those closer positive margins.
Immunotherapy is kind of our newest and most exciting treatment modality that's come into head and neck cancer in the last probably I would say decade now. At the moment, it's only officially approved for recurrent or unresectable disease and we've seen that these immune checkpoint inhibitors can prolong survival with pretty tolerable side effects.
But unfortunately, only approximately 15% of head and neck cancer patients will actually respond to immunotherapy. And we're still trying to find a robust marker to predict responders. So we definitely have some work yet to do in this area kind of understanding how immunotherapy fits in, if it could be a primary treatment modality and figuring out which patients are actually going to be good responders, or if we can change their biology somehow to make them a good responder.
Melanie: Dr. Thomas, one overlooked, slightly overlooked, aspect of this type of cancer are the devastating effects of appearance and function on a patient and are among some of the most disabling and socially isolating defects of cancer. When you are talking to other providers, what would you like them to know about the goals that you've been speaking about for treatment and protecting those vital structures, function and form, and the sensitivity of this type of cancer for the patient?
Dr Carissa Thomas: Yeah. I mean, I think you hit it right on the head, like the side effects of our treatment are very devastating to patients because it impacts their speech, it impacts their swallow, and it can impact their appearance as well. I think obviously catching the cancers early means less treatment, which means better outcomes for speech and swallow. And so that sort of having an awareness of this possibility and recognizing some of these signs and symptoms early and getting them in to see an otolaryngologist early would be great so we could limit the amount of treatment we have to give.
And then I think the secondary part of it is just realizing that a lot of these patients need lifelong therapy to help with these side effects. And a lot of the therapy is speech therapy. We also do a lot of lymphedema treatment, which is a lot of massage to the neck and the face to both help with appearance and swallowing. But you can't really ever say like these patients don't need any more therapies. This is kind of lifelong. We need to keep them plugged in to the medical system and we need to keep making sure that they're getting the therapy they need and the exercises they need to get the best outcome possible.
Melanie: And as we wrap up, is there anything exciting you'd like to share with other providers as far as research developments that are ongoing at UAB and what you would like them to know about referral?
Dr Carissa Thomas: Yeah, I think there are a lot of exciting and active areas of research going on right now at UAB related to oral cancer and kind of covering the whole spectrum of the disease process. And so going back to immunotherapy, we are actively participating in a lot of the trials that are examining using immunotherapy as a first-line treatment for oral cancer.
We also are active looking at different imaging modalities that might help us in the operating room and actually achieve clear margins at the time of tumor resection. And that would limit the need potentially for chemotherapy afterwards and some of the side effects from that.
We have other people looking at treatment of these long-term side effects of radiation, such as lymphedema. And we have a trial starting soon where they're going to look at like an at-home massage system to help with lymphedema treatment. And we have different trials looking at osteoradionecrosis.
And then finally, myself personally, I'm really excited because my interest lies in the role of the oral cavity microbiome and oral cavity cancer. And seeing how that community of bacteria in your mouth changes when you have cancer and how it might impact cancer progression, prognosis, and also the response to immunotherapy.
And the other area that we're looking at actively is how the oral cavity microbiome as well as the gut microbiome might contribute to the pain that these cancer patients experience and to see if there's anything that can be modified to potentially reduce the need for narcotics or opioids.
Melanie: It's so interesting. What an informative episode, Dr. Thomas. Thank you so much for joining us today.
A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua168.mp3
- DoctorsMullins, Haddon;Willig, James;Zinski, Anne;Harada, Caroline
- Featured SpeakerHaddon Mullins, MD | James Willig, MD, MSPH | Anne Zinski, PhD | Caroline Harada, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4365
- Guest BioHaddon Mullins, MD is a General Surgery Resident.
James H. Willig, MD, MSPH, is the Associate Dean of Clinical Education in the School of Medicine. He attended Medical School at the Instituto Tecnologico de Santo Domingo (INTEC) and completed his residency at the University of Virginia Roanoke-Salem. At UAB, Willig has earned an M.S. in Public Health and completed an Infectious Diseases Fellowship.Learn more about James Willig, MD, MSPH
After completing her doctorate, Dr. Zinski spent six years in the UAB Division of Infectious Diseases investigating the impact of behavioral interventions on patient self-care behaviors, including screening and retention in care.
Learn more about Anne Zinski, PhD
Caroline Harada joined the School of Medicine faculty in 2008. She completed her undergraduate work in biology at Brown University in 1996, and, after a year of living in Bolivia teaching an after-school program in an orphanage, began her medical education at the Yale School of Medicine, graduating in 2001.
Learn more about Caroline Harada, MD
Release Date: November 9, 2020
Expiration Date: November 9, 2023
Disclosure Information:
Planners:
James Willig, MD, MSPH
Professor, Infectious Diseases
C. Haddon Mullins, IV, BS, BA
UAB Medicine
Jill Deaver, MA, MLIS
UAB Medicine
Adam Roderick, M.ED.
UAB Medicine
Anne Zinski, PhD
UAB Medicine
Caroline Harada, MD
Associate Professor, Geriatric Medicine
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Presenter:
James Willig, MD, MSPH
Professor, Infectious Diseases
Dr. Willig have no financial relationships related to the content of this activity to disclose.
There is no commercial support for this activity. - TranscriptionUAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
Melanie Cole (Host): Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re talking about feedback in medical education. In this panel, are Dr. James Willig. He’s the Assistant Dean of Clinical Education at UAB Medicine. Dr. Haddon Mullins, he’s a General Surgery Resident at UAB Medicine. Dr. Anne Zinski, she’s an Assistant Professor in the Department of Medical Education at UAB Medicine. And Dr. Caroline Harada, she’s the Assistant Dean for Community Engaged Scholarship at UAB Medicine.
Dr. James Willig, MD, MSPH (Guest): Welcome to the forth chapter of bedside teaching for the medical educator podcast series. Today, we will focus on the provision of feedback. The ins and outs of how to do this difficult task effectively. We have some special guests with us today. Our first guest is –
Anne Zinski, PhD (Guest): Anne Zinski from the Department of Medical Education.
Caroline Harada, MD (Guest): I’m Caroline Harada. I’m Assistant Dean for Community Engaged Scholarship and a Geriatrician.
Dr. Willig: I’m James Willig. I’m on Infectious Disease or pus control as some call it. And we are here with our host –
Haddon Mullins, MD (Guest): I’m Haddon Mullins, third year medical student here the University of Alabama School of Medicine.
Dr. Willig: Take us away Haddon.
Dr. Mullins: So, the first question is going to deal with how and why do you give feedback. So, is your feedback theory-based, is it practical-based? Do you have a set of tools or an overall structure that you think about when you are giving feedback and how does that inform the feedback that you are giving?
Dr. Harada: So, for me, I don’t think there can be learning without feedback. And that’s pretty well grounded in adult learning theory that you can’t learn unless there’s information being fed back into the system to correct and improve a process. And so, when I teach on the wards or in my clinic, I try to set expectations really early about that. That feedback is going to be a part of every day and everything we do when I have an interaction with my learners. So that the learners know that it’s coming, and I find that the more often we have feedback, the more often I give feedback, the less scary and intimidating it becomes for the learners as well as for me. Because sometimes giving feedback is kind of scary and intimidating for me frankly. And so, if everybody knows it’s coming, and knows it’s coming frequently, then I think it tends to take away some of the negative feelings that often accompany feedback.
Dr. Willig: For me, I like to sort of make it very clear from the very beginning that my job is to help you get better. And really say that from the get go and say that that’s going to include – we’re going to talk about every encounter as it happens. I really move to where I used to really focus on doing a thorough mid-month evaluation and an end of rotation evaluation. I’ve moved forward to doing more feedback right after each clinical encounter throughout the day. And that really, I think sets the expectations and follow through with I’m invested in you, I’m going to try to make you better every day and here’s something that I think you can get better on today. That creates a good culture to really expect that conversation.
And then when I do a mid-month, I use a structure that I learned from a gentleman called Donald Steinweg where he would sort of sit the learner down and really say heh, everyone of us is a combination of skills, knowledge and attitude. He would then use the RIME model, the reporter, interpreter, manager and educator model and sort of map out where I as a learner was supposed to be on that model and then he would say okay so, you’re an intern so I expect your reporting to pristine. I expect your interpretation to be improving and your management is sort of your aspirational goal where you are focusing on. So, the skills that I expect from you, are – and then he would sort of talk about the skills that are expected with where I was on the RIME as the background.
Then he’d talk about the knowledge that he had seen me sort of express and where he thought the gaps were and what I needed to improve. And then he talked about attitude and sort of really talked about how empathy and how I related to families and patients and the greater healthcare team and really give me very direct feedback that was really based on observations that he had seen throughout the process. He really used to jot everything down as we were on rounds and it would be very much like last Tuesday, you did this when this other event happened. And it was incredibly helpful to get sort of that detailed feedback. But that’s how the mid-month would be and how the end of month would be.
The thing that I’ve added is that throughout the course, I don’t get to mid-month and give you feedback, we get feedback throughout the whole way.
Dr. Harada: Yeah and I think that’s so important. It’s almost like more of a coaching model that we take in medical education where we say today, just like a sports coach would say, hold your bat a little bit to the right when you go for that swing. I say to my student, when you are checking proprioception, next time I saw where you put your fingers on the toe, that wasn’t exactly right. Next time I want you to do it this way. And just those little teeny pieces of information that you are feeding back into their system, that’s feedback and that’s super low stress and can be done like 12 times a day if you are working with a student in your clinic.
Dr. Willig: Dr. Zinski, you have a lot of insight into pedagogy and I wonder how you approach this question.
Dr. Zinski: Sure so, as a [00:05:41] in education, I’m always going to start with theory Haddon. So, I’m thinking about how the theory of experiential learning and so I’m thinking about very basic structure for something like feedback and so I’m thinking about having an experience, doing and then being able to reflect on it, reviewing and those are always the doing and reviewing are going to be the very first part of it as a learner. I’m going to do it and I’m going to review it. And I’m going to review it hopefully with someone who can help me make conclusions about what’s going on, so with a teacher. So, I’m doing and reviewing, I’m making conclusions with someone who can help me that’s my preceptor and then I plan ahead if I’m thinking in a cycle for what I’m going to do and review next. And so, that had a lot to do with Caroline’s adult learning theory but specifically, it’s Kolb’s experiential learning theory and it has a lot to do with the way you think about learning and giving feedback for learning.
Dr. Willig: So, just applying that to like the rounds, so it would be the student did a presentation. They have a chance to as a team, we review that presentation and then we reach some conclusions in terms of heh, this was really good, this was really bad, that we might give that feedback after that presentation. And then the charge to the learner is to start thinking about tomorrow’s presentation and sort of start planning on how tomorrow’s will be different.
Dr. Zinski: Absolutely. Or how it would be the same because you reinforce things that were done well during the review. So, components to keep, usually that starts with something like I noticed and you talk about a way that they met a goal or the way that they achieved something that was successful and then the next statement traditionally is I noticed something else that the student did that might not relate to the goal in the way that you had intended and you have another learning moment where you can say the way that it’s intended as a reminder is goal x, y, z and then you review together until you get understanding and plan for the next day.
Dr. Mullins: So, do you see the – it seemed like the way you approach it, it seems to be very learner-focused, would you that’s correct, and that the teacher is more of a facilitator to promoting self-reflection and providing self-feedback?
Dr. Zinski: So, I think it is – I believe in therapeutic alliance and so if you read about feedback in medical education there’s also a theory about therapeutic alliance and agreeing to what’s going to happen next. I also believe that there is someone who is – has more training than you in the room and so, that authority provides them an opportunity not so much to give advice but to be able to facilitate learning for a learner. And so, it’s learner-focused but I do understand that there’s an expert in the room.
Dr. Mullins: That’s a lot of what I read too. I think a big part kind of like Dr. Willig was saying is as an experienced clinician, you know what standard is and that standard should be communicated but then as the expert, you are able to observe where the student has gaps and the structure of feedback should be focused on closing those gaps. As experienced or practicing clinicians, how often do you see students engage in self-feedback or do you all try and promote that or is it more of a coaching model that’s more practical to use just on the wards in general.
Dr. Harada: I’d say that it varies widely. Some students are very insightful or very interested in self-assessment and they tend to learn much faster. Because they are constantly asking did I do that right when I presented the medication list? Is that the way I should do it or not? Those students, they get their feedback because they are asking for it. Other students are probably more like I was when I was a medical student, they are more shy, they don’t want to trouble the Attending by bothering them by asking and they feel like it’s selfish or self-centered of them to do that and so they might not ask. Or maybe they just don’t care, and they feel like they are doing it right and so they don’t even question it. so, I guess I would say the answer to your question is the level of self-reflectiveness varies widely among medical students but sort of as the educator, I fell like it’s my role to encourage everybody to be self-reflective and to ask them those questions even if they don’t bring them up themselves.
Dr. Willig: I’d like to pull in two threads of some of the things that you mentioned. The first is Dr. Zinski, when you mentioned that you should give also, highlight the practices that were done particularly well so that they can be sort of encouraged to come up again on subsequent days. I probably am guilty of not doing that enough but when I see something done well, I don’t necessarily mention it. I kind of think oh they got this. But I should probably – that’s an opportunity for feedback right there that I’m leaving on the table. That I can definitely see, you know, you did an amazing job when you did this particular thing in this presentation. And make sure that the student knows that that’s underscored to carry forward.
The other thing, one of the things that Dr. Harada here mentioned, the learners that have different personalities and how they will interact with the Attendings, that’s very interesting to me because you see – I see that all the time. I see some learners that are very quiet, and the problem is that sometimes I might interpret that student that’s being quiet and respectful from their perspective, I might interpret that as being uninterested or not engaged. And by kind of setting the expectation of we’re all going to give each other feedback here, I want to hear – I’m okay with hearing feedback from you, that’s great. I need to get better too. And I’m going to give you feedback every encounter that even if it’s just pointing out something that was positive, I think that creates a climate where the learner’s personality won’t really hurt the learner there.
One thing I will say about your question on self-reflection Haddon, is that very specifically at the mid-point, I think I would ask or and at the endpoint, what are your thoughts on how you have performed. And then sort of get the self-reflection of the student so you understand where they are and sometimes the students are really insightful and they really point out the things that they can get better and sometimes the students are way off base which let’s me know that that feedback conversation is probably going to be more extensive than I had initially thought depending on where the learner is. But I would hesitate to use that every day after every patient encounter is kind of thing so tell me how you think you did. It’s kind of the wards. It’s fast moving. Maybe it’s no tell me how you think you did; it’s let’s get this done.
Dr. Mullins: What about some more specific components of feedback and not being from what I’ve read, and you can agree or disagree that most importantly based on direct observation, accurate and timely, specific, and actionable. And [00:12:39] even goes as specific as saying, formative feedback should include more nouns than verbs as opposed to like a summative evaluation that’s adjective and adverb based. Do you need a specific code as that or does it need to be more natural or is there some kind of code or specific checklist that you hit when you want to give feedback?
Dr. Zinski: So, for me, I structure all of the feedback messages that I give on what I call 4G model and so I think about the goals of what we are doing, or an objective and so that’s the first G is my goals. And then I give an observation that relates specifically to that goal. So, not I noticed that something happened that has nothing to do with my goals. I noticed that something happened and then a description of how that relates to my goals. So, I’m giving an observation that’s based on behavior and a goal. And then I tell them where they glow, that’s one G. And then I tell them room to grow, that’s the other G and it all ties back to whatever that observation, however the observation related to the goal. And so, by the time I’m done, I’ve reminded them of where we’re trying to get to. I’ve talked to them specifically about the I noticed performance. So, I can never be wrong which is kind of nice. And then I talked about a way to get better and a way that they are doing something that I’d like them to maintain moving forward.
And remembering that in a coaching model, there’s a lot of very specific but also advising type feedback happening. In an apprentice model, which I believe is more appropriate for something like a clinical setting. They’re going to be doing a lot of watching and then you have a high stakes situations where there is going to be a lot of learning going on. And so, they are going to be doing a lot of reading and a lot of teaching all at once. And so thinking about the four G’s is an easy way so that you don’t have to think about learning and think about teaching and think about patient care and keep changing your hats. Just have that framework for everything.
Dr. Harada: Anne, you’re really good when you talk about the I noticed that statement. And I think that’s something that really is key to giving feedback. Can you talk more about how you do that?
Dr. Zinski: So, it starts with being a great observer which might be a whole different podcast one day. But being able to observe someone’s behavior which tells them two things. The first thing is, you’re watching them. Which is beautiful the same way that my GPS is watching me. They are not always telling me a whole lot, but I know they are monitoring me because they show me my tiny little icon on my map and so they’re watching what I’m doing and then they make sure that they notice when I’m making correct and incorrect turns and they let me know. And they speak up when I’m on the right track or not.
And so the same way my GPS might say I noticed, without me I noticed that you made a wrong turn and here’s what we’re going to talk about next. I like to look at a student or as much as I can, or as long as I can and notice what their behavior is. And it establishes trust is number one. And it gives you something to talk about is number two and that you are watching things that they actually did, again, you’re never wrong because you’re not trying to guess their intention and you’re not judging why they did it. you’re telling them what they did which gives them a beautiful learning moment.
Dr. Willig: I think that part is as important. You’re being very intentional about how you phrase this. I noticed that you did this. There’s no judgement. There’s no interpretation. There’s just fact. You did this.
Dr. Zinski: Absolutely.
Dr. Willig: And then, that’s the first G, so that’s –
Dr. Zinski: So, that’s going to be my given observation.
Dr. Willig: Given observation. Okay. So I give an observation. And then the next step would be –
Dr. Zinski: Tie it to an objective. And so, when I start, yeah, go ahead –
Dr. Willig: So, here, like heh I noticed let’s say give an example of when you did your abdominal exam, you forgot to do – you didn’t palpate the liver. Or you didn’t palpate the liver appropriately. So, just kind of carry me through that.
Dr. Zinski: So, I noticed when you gave your abdominal exam just now, you didn’t palpate the liver. You give them a minute, not a whole minute, like count to five to think about what you just said. And then from there –
Dr. Willig: One of our objectives is to know an abdominal exam.
Dr. Zinski: Or a complete abdominal exam includes. And review with them so that they have a sense of what the goal was what it is.
Dr. Willig: Okay so first you give an observation, and then goal tied to a goal or whether the objectives of the rotation, the next things are glow, what were they, glowed and then –
Dr. Zinski: Room to grow.
Dr. Willig: And room to grow. Glow and grow. So, the – where would you integrate the glow there in that abdominal exam example?
Dr. Zinski: So, sometimes the glow is there if I said, I noticed that you included all components of the abdominal exam and review what they are. So, that’s important because a complete exam will allow you to – and so you told them that they did well without having to high five or even add a judgement at that point. And if you were going to change it into a grow, you might say, I noticed that you didn’t palpate the liver when you gave your abdominal exam. Remember, that the abdominal exam includes these components and so next time we’re going to make sure that those four are in that.
Dr. Willig: I see. I see. So, you end in either the glow or the grow. But it dichotomizes the end. So, that’s great. So, I can give good feedback like this was great and this is why, or this is what I observed, that’s important because one of our objectives in this course is to find this and this is what was great about it, please keep doing it. Or gosh, I noticed you did not do this thing, that’s an issue because it’s an important part of what we learned in this course is to do these things and here’s how you can get better. So it kind of goes – even though it’s four G’s I use three at a time.
Dr. Zinski: That’s right, yes. That works and I think especially too, you can use it if you notice something that the student didn’t notice and so, I can also use the words I noticed that there was a little mark on your patient’s face. Once you’ve observed that they didn’t see the mark on the patient’s face. So, you can also notice when they didn’t see something. Or when – so if something’s missing, or if they did something extra. I noticed you went ahead and did a neurologic exam on someone with knee pain. And then you’d start that whole conversation. So, you can notice a lot of different things and you can notice when something is missing. You can notice when something is extraneous. But you are noticing facts and that gives you a lot more credibility.
Dr. Harada: Because, and that’s really important I think because I’ve had that situation where I give feedback to a student and they argue with me about it. They disagree with me. And that’s my fault because I haven’t been as objective and behaviorally based as I should have been. So, that’s something that I’ve really learned more recently is like nobody can argue with me if I say this is what I saw in the room. So, I think that’s a really useful important trick.
Dr. Mullins: So, let’s talk about that too a little bit more and from what I’ve read, is that a lot of the problems with giving feedback or when you run into students that really need it are defensive about feedback or reject feedback. A lot of times, that comes from a lack of feedback in the past. And that if you don’t deliver feedback on the frontend, what happens is students will start to create their own paradigms of giving themselves feedback and they start to either self-validate or self-criticize in ways that in the future make them less responsive to beneficial feedback. How would you all respond to a student to whom that has already occurred to where they haven’t received beneficial feedback in the past and now, they are with you. You are trying to give them constructive feedback. They are resistant to it.
Dr. Harada: I’ve had that happen so many times where students would say, but for the last three years, I’ve always done the abdominal exam that way and nobody has ever told me it was wrong before. How can I be wrong after all of this time? And that’s really tough and it speaks to the fact that we’re not doing as good a job as we could as an institution of medical educators. And so, what I usually say in that situation is I’m really sorry that nobody has told you this before, but this is – let’s tie it, as Anne says, tie it back to the learning objectives. We want you to be able to do an excellent abdominal exam by the end of this rotation and part of that is these are the five steps, and these are the three steps that you didn’t do or that you did incorrectly. As long as I keep it really behaviorally based, based on what I observed and tied to those objectives for the rotation, I think it’s easier for students to accept that maybe they have been just doing something wrong because it’s so easy to adopt that no news is good news philosophy where if nobody told me I was wrong, then I must be right. And that’s not actually true.
Dr. Zinski: I also think there’s a focus on grading and summative assessments and less of a focus in some educational settings on the observation part. So, there’s a lot of really well intended people who give advice about what they would do all the time, but they forget to give an observation, or they forget to do the observation of student skills or a certain kind of behavior. And so, once that’s lost, you lose your message. Because your message is about what the student did for a learning moment. And so, they may not have had that student who didn’t get great feedback before, might not have had someone who was a great observer watching their behavior. They may have been looking for a grade that says you’re fine or you passed versus looking for observations all the time.
Dr. Willig: Let me try to conceptualize that a little bit. Say that I have this great story about this mistake that I made in the abdominal exam and something that I learned when I was in training. If I walk out of the room and I tell you this story, you are suggesting that the impact of that story would be much greater if I could sort of say heh, when I saw you do your abdominal exam, I noticed that you did this. It’s important that we do this abdominal exam because it’s one of the things – goals for this course. Here's how you can do better. And then the reason I know that is because and then I tell my anecdote. That would be the correct way to frame that learning anecdote within this context.
Dr. Zinski: Sure, so there’s always room depending on your relationship with your learner, to add a personal anecdote, to add a piece of advice, to add an experience that you may have had in the past. But giving them the pieces of their learning moment are going to be important because they’re novices. Don’t forget that they are novices. And so sometimes we have to be incredibly literal and intentional about the messages that you’re giving and noticing their behavior and then relating it to the objectives because they might not have done a lot of reflection and they might not know the objectives by heart like you do. And so, putting that together for them is incredibly important in early stages of experiential learning.
Dr. Willig: and I think frankly I’m sharing the anecdote because I think it’s important that I took something away from it and if you’re telling me that if you put it in this framework, it’s going to be even more impactful, that’s a positive.
Dr. Mullins: And so what about the evaluation because I feel like I’ve seen from personal experience, students especially in the first two years, there really aren’t a lot of opportunities for feedback. It’s not like on the rounds or on the wards and so what happens is students fall back and they place maybe too much importance on things like standardized testing exams and quizzes and tests and evaluations. So, the evaluation becomes feedback. So, does the potential for evaluation affect learners’ perceptions of the feedback they are receiving?
Dr. Zinski: So, I’ll start my answer by saying – by making the distinction that feedback at least when we’re talking about in a clinical setting or experiential type learning is going to be a different kind of feedback because it’s skill-based, experience-based versus when the assessment is going to be something that is knowledge-based or recall-based. And so, I’m going to look for that in maybe a written exam and look for a score on an exam if I’m testing recall. Whereas once I’m in a experiential learning environment, I will likely be testing skill and knowledge again and those will be together and most of the learning is done in that experiential place. And so, that’s a big area of distinction in medical education because you get a lot of classroom and small group learning and then you get this hard does of experiential learning and so the formats are [00:26:06] I’m being specific today to clinical setting.
Dr. Mullins: Would you all say that learners understand the difference between assessment of recall and assessment of skill based learning and how that feedback is or should be given?
Dr. Zinski: I don’t know if learners or faculty always understand the distinction, but I do believe that faculty know what they are trying to help students achieve. And so, I think a good faculty member knows the goals and objectives of their program or their rotation by heart and is trying to find the best ways to gauge those things with assessment.
Dr. Harada: Well what I was going to say is to your earlier point, I do think that students are so scared that when I give them feedback, it’s a sign that I’m going to give them a bad evaluation but sometimes, it makes it hard for them to learn from the feedback because they are – the other part of their brain is going oh my gosh, this means I’m getting a terrible evaluation. And so, what I try to explain early on, is actually this is a way I’m going to get you a good evaluation by the end of the rotation because if I can give you these small corrective pieces of feedback, as we go along, as well as, encourage and reinforce the good things you’re doing; that’s going to end you up at the end of the rotation getting a great evaluation if you can actually do the things I’m trying to teach you, you’ll be better. And so, I try to present that up front and early to try to allay student’s fears that any corrective feedback I give them is a sign that they’re going to get a bad evaluation. Because it’s not the case.
Dr. Willig: And I think one of the questions on our evaluations is was this learner responsive to feedback. And it’s interesting as I hear you speak, to sort of ponder how we are maybe making that issue worse by sort of building it up to oh it’s just going to be a test and it’s an evaluation. But I think to your point, I think a lot of learners don’t understand the difference between this is skill-based and we’re going to - repetition and iteration is how we’re going to get better. I’m going to give you feedback every day to get you to a point where you’re an expert as opposed to there is one final assessment at the end and it’s high stakes and that’s all there is. I think that type of anxiety and sort of I got to get this right, because it’s all my eggs are in this one basket. I think some of that translates over into the clinical setting and I think our learners need to hear us say, heh, over here, it’s iteration, it’s repetition, and we’re going to get better every day. It’s a different environment. It’s a different type of learning.
Dr. Zinski: And it’s formative. Remember that your tests and your exams and your summative score is meant to be summative, it’s meant to be a summary or a grade or a score or judgment about how someone did that’s the sum of a lot of our formative stuff is to shape our learners into something else.
Dr. Mullins: So, maybe make it clear that to a student, that might be so heavily evaluation based and it’s just been engrained in them for so long, make it clear that this formative instruction or formative feedback, the goal is to help you receive a better summative evaluation or assessment at the end.
Dr. Zinski: I’m going to say the goal is to help you learn.
Dr. Harada: To help you be a great doctor.
Dr. Mullins: Yeah, that’s –
Dr. Willig: Yeah, if you say – I always tell the students that if you set your bar at getting 100s in this rotation, that is probably slightly above the lowest bar which is passing the rotation. Your bar is I want to be a great clinician and I want to be a patient advocate like those are the stratospheric goals that you set for yourself. This evaluation, this is sort of – you have to pass to keep moving along in medical school but if this is the ceiling, of what you’re reaching for; you are way underselling your potential.
Dr. Mullins: So are there any specific or particular situations in which giving feedback is harder than it necessarily should be?
Dr. Harada: So the situations that I find the most difficult to give feedback in are the ones in which a student truly hasn’t been given any feedback for a long time and they are doing something like egregiously incorrectly. And often, it’s something about, something that involves sort of their personality or their just sort of intrinsic approach to their work. That’s the kind of thing that’s a lot more difficult to give feedback on compared to how you did the abdominal exam. And so, those are the situations that I struggle with and that I know a lot of my colleagues struggle with when you are giving feedback about you didn’t show up on time or you appear uninterested in your patient when you were interviewing them.
Dr. Willig: Or you judged your patient a certain way.
Dr. Harada: Right or you came out of the room and said something completely judgmental about your patient’s request for morphine.
Dr. Zinski: And so because it’s hard to describe that behavior?
Dr. Harada: Because it feels personal. Even though I’m describing it, it’s so obviously wrong in my eyes, that it feels like I’m saying that they are a terrible person and I’m worried that they will interpret that I am saying that they are a terrible person. And sometimes they do. And so it feels very – much more sensitive and much more personal when you start talking about a behavior like that.
Dr. Zinski: So, I would argue that telling someone that they were judgmental or dismissive or aloof is not an observation it’s a [00:31:41]. And so, it’s noticing a behavior that did that that’s very, very tricky and so you can get a gut feeling or I’ve had a gut feeling that a student was doing something that maybe didn’t have great intentions or even worse, annoyed me. But the thing that I have to do for them is watch them and be able to tell them what they did. Because if I start with a judgment, it is dismissed. Because I judged. And really, that’s not true. If I give a judgement if it’s negative, people don’t like that. If I give a judgment like great job, they will eat that up for dinner and lunch and so, the idea that I can not say you are aloof, but say I noticed that you looked at the screen and only made eye contact with the patient one time during the entire encounter. And be able to give them a learning moment and they might refute it and say no, I looked at them twice. And you’d say, so you only looked at the patient twice during the encounter. And so then you can have a conversation about the truth that just happened without saying aloof and it take five extra seconds and some great observation skills which again, is probably another podcast. But it’s the best part, it’s the truth part.
Dr. Willig: Tell us more about just regular skills-based feedback that where the student is not performing at a satisfactory level in terms of skills and we now have to provide feedback about that.
Dr. Zinski: So, a lot of the things that we’re talking about today, as far as giving observations all the time and doing something that’s timely and when I say timely, I mean within 24 hours because we tend to forget. And so, if I’m thinking about getting with a student or talking about a learners performance every 24 hours, I’m doing something much more preventive so that I have far fewer tough situations with learners.
Dr. Mullins: And you mentioned the therapeutic alliance earlier and I had read about modelling that on the educational alliance. And how important is the perception, the students’ perception of the feedback they are receiving?
Dr. Zinski: The feedback that is going to reach a learner in a way that makes sense for learning is going to be observation-based feedback. And so, a student isn’t always ready to hear that they didn’t do well the same way any adult learner is not ready to hear that they didn’t do well, but you can’t reflect on your performance all the time. We do it, all day long. And so, hearing that, with within a teaching moment, and then relating it back to the goals that I’m supposed to achieve as a learner; reminds that learner here’s truth about my performance and here’s what we’re all trying to get to. And so, that is rejected far less than something that was delivered with advice or judgment that is much more easily and personal and in learning situations, much more easily rejected.
Dr. Mullins: So, good feedback can in turn frame the perception of the student inherently.
Dr. Zinski: Absolutely. Good feedback when presented well, is something that helps the student learn. It reminds the student that you are helping them to get somewhere.
Dr. Willig: I always reflect that some of the things that Dr. Zinski has taught me is sort of the four – I would say the cardinal signs of good feedback and it’s got to be timely. The closer to the moment that the observation happened, the better. The more it’s impact on sort of helping that student learn and correct that behavior, the more you let things fester; it’s almost like an infection, you let it fester, it’s going to grow. It’s going to be a bigger problem. So, address it, acutely. So, timeliness.
The second thing is it’s got to be tied to an objective. So, again, I know where I’m going, my job it to make you better – a better physical exam, a better history taker. You need to know better know these concepts for this illness, so I have be objective and the feedback then is tied to that objective.
The third thing is it’s got to be specific. And I think we’ve heard about how important it is to really say I saw you do this, or I observed – this is my observation. It’s very much what exactly was seen by the teacher and we can go from there. And ultimately, it’s got to be actionable. My opinion about what you did, my judgment is not necessarily going to help you get better. What’s going to help you get better is you are here, specifically, and to get to the next rung up the ladder of skill, these are the things that you need to build on. So, those four things have helped me very much, really shaped my feedback messages and as I hear you speak today, I really appreciate the concept of timeliness in terms of how close to that – as immediately adjacent to the observation, the more the power of the feedback that you deliver.
Dr. Zinski: Absolutely. And I like to use the example, remember the dinner that cooked me three night ago? It wasn’t salty enough. And they say what, I don’t ahh. But if I said, oh I just tasted the meal that you’re cooking, do you think we could get some salt in there and so I would ask them if that was something they would do or I’d say I just tasted the meal that you cooked, I noticed that there’s no salt and then I have a moment that someone can make a decision about what they want to do next and how they might cook next without forgetting or judging that they’re a bad cook.
Dr. Willig: And frankly, if it’s timely, you have a chance to correct it and we see the tragedy of a student getting to the end of a rotation and hearing feedback that they could have corrected easily earlier on and now they are getting a summative evaluation of a certain kind because all the formative opportunities were left at the wayside and frankly had the student heard those things, they would have corrected them, they would have had time to correct them and they had the will and the interest and the desire to correct them, they just never had the chance to. That sad situation is one that we encounter still.
Dr. Zinski: Sure, this reminds me of the GPS example and the reason that GPS works for a few moments is because there is a GPS monitoring me via satellite watching what I’m doing. And so if I set a destination, together with the lady who helps me in my phone; to get to wherever I’m going, I set that destination and I know that – I trust that she’s monitoring me and I can see it because I can see my icon making turns and not making turns and she doesn’t wait until I’ve made five wrong turns to say you’re lost. And that sucks. You did a terrible job driving today. She tells me every time I need to make an adjustment. I’m watching you make a left turn when we are supposed to be continuing this way to get to wherever it is that we set together. And so that GPS is something that we’re used to, that’s a model that we’re used to. And when I make a wrong turn, she doesn’t call me a jerk, when I make a wrong turn, she lets me know – reminds me of the goal. And so that’s something easy to remember for GPS and teaching.
Dr. Willig: Well let me tell you a very difficult one that hearing you is making me very uncomfortable remembering a situation where I mean both the student and I – or in this case it was a resident, we judged this patient and we judged them in very different ways. And the issue on hand was one of us wanted to send the patient home and one of us felt that the patient was not ready to go home because it was going to – the temperature was going to drop and there was actually going to be an ice storm that day. And this was a homeless person. And we fell on very different sides of the spectrum on that issue. And the resident was visibly angry at my decision to keep the patient in-house and had some very strong thoughts on healthcare utilization, a lot of important like it’s great that you know about those things, but at the same time, what I felt like I had was a de4cade of experience at that point so, I think the best thing here, is to just wait until tomorrow.
So, again, I could say that. I could – you know the student was visibly angry, he was aloof, he was all of those things but boy this became something where I really stumbled to give feedback and the only thing I could – I looked at the student and I said, they were literally trembling, clenching their fists when we walked out of the room. And I said, you seem really angry right now. Can you help me understand what’s going on? And it didn’t go well from that point. But let me – I mean that would be a situation where I want to give feedback and my feedback could be something if I passed my judgment like boy, you’re being a little heartless guy. But that would be the most terrible thing to do. And he sort of told me well you’re being completely foolish and disrespectful of healthcare utilization and all these things. It was a very fraught issue, but I think neither one of us was – an communicated effectively there. I wonder what you would do with that?
Dr. Zinski: So the difference of opinion is always going to come up because you will be a different levels of training and most of us just had graduated learners who got out of two years of book smarts, book studies and so, they might have a different kind of perspective that someone who has just had five or ten or twelve years of experience in the healthcare system. And so this is when it comes back to the really great truths of having goals and objectives that you care about and that you have memorized and then really being able to observe somebody’s behavior that relates to those goals. And so if you don’t have and I anticipate that you do have a goal about healthcare systems; you have a beautiful teaching moment about interacting with patients and learning about the healthcare system.
And so, if you have an objective that’s based on learning the nuances of the healthcare system, I can say, I noticed that you advised the patient – I noticed that you advised the team et cetera, et cetera or I noticed that you made a recommendation about x, y, z. In this particular situation, when we’re thinking about healthcare systems and then go back to whatever your objective is. The nuance stuff is the stuff that gets us in trouble if we can’t get it back to a learning objective. It’s a difference of opinion then you can look at somebody and say I noticed that this happened. In my opinion, I would do something else and you let them know that you’re having a difference of opinion and this might not be a learning moment, this might be a moment where you are having a difference of opinion and you’re having a professional conversation that isn’t a feedback moment about someone’s skills and how they can get better.
Dr. Willig: So, that’s interesting. So, in that scenario, it wouldn’t go into – it wouldn’t be heh, here’s my thought on what we should do, my opinion versus your opinion; it would rather be – because I think there’s two principles that are sort of – relationships with patients is one of our objectives. To have good and empathy and those things. Another one of our objectives is to have good healthcare utilization. And I would argue that the student had a fantastic healthcare utilization case and I think I had a fantastic patient interaction or treatment of people case. But that wasn’t going to be resolved simply by the objectives. Because I think both of us were standing firmly on an objective so perhaps the path through would have been to say listen, we are having a difference of opinion. From my experience, and what I’ve seen, doing this job for this amount of time; this is what happens here. So, from what you’re saying and all that, I’m not arguing with you that that isn’t valid. I’m saying that that’s a different perspective. Ultimately, I have to make the decision here as kind of the senior person on the team and this time I’m going to decide this. When you are the senior person on the team, you may very well choose this side differently and that’s okay. We are having a difference of opinion here. Is that how you would frame it?
Dr. Zinski: I would maximize the learning moments that that person could have so, if there’s something to tie back into a learning moment for this person, then I would give that to them because that’s our job. And then I would make sure that yes, it’s very distinctively different to have an open conversation coming out of the teaching alliance and maybe more into a negotiation, a professional negotiation about the way that you would manage care.
Dr. Mullins: So, would say that like subjective opinion and formative feedback are not compatible?
Dr. Zinski: So, subjective opinion as far as sharing that with a student, sharing judgment is not something that you want to do as part of objective feedback ever. And we accept it because we accept nice job, and we accept atta girl and atta boy and nice work back there kind of things and we’ll take the subjective as long as they agree with something that I think is positive and the negative that was no good, that didn’t work or that was a mess is something that we reject because it’s judgment and we recognize the judgment when it’s negative. And so, good feedback is based on - good skill feedback is based on the doing and reviewing and the doing and reviewing and you have to be able to say, this is what you did, this is how we’re going to reflect about it, don’t forget, this is how it relates to your goals. That’s the learning way, if you care about learning outcomes, that’s [00:45:52].
Dr. Willig: Thank you. That was an uncomfortable situation I think to go through and even just re-discussing it, I think me feel just a little uncomfortable still. But I appreciate the addition to the tool set of just kind of taking that offline and sort of saying heh, we’re having a difference of opinion here. And that’s okay and taking it out of the feedback context because when I tried to give feedback about that, it really was my judgment kind of leaking through the feedback that I want to be was heh, you ought to be a little bit more like me pal and that’s completely wrong. That person is their person, they have their experiences and they are equally as valid as mine. So, it’s important not to insert that into the conversation, our personal judgments but rather keep it at the level of professional, objective feedback to make sure that learner is getting better and if we disagree with them, it’s okay. But this is not the forum to discuss that.
Dr. Zinski: Sure.
Dr. Willig: Thank you. That’s a great way to end that. Haddon, any closing words?
Dr. Mullins: I think that was the most informative session yet. So, thank you Dr. Zinski, Dr. Harada and I hope you all enjoy. Thank you.
Dr. Zinski: Goodbye everybody, thank you.
Dr. Harada: Thank you.
Dr. Willig: Thanks.
Host: And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patients or more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua190.mp3
- DoctorsDure, Leon
- Featured SpeakerLeon Dure, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4559
- Guest BioLeon Dure, MD is the Director of Child Neurology.
Learn more about Leon Dure, MD
Release Date: February 22, 2021
Expiration Date: February 22, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Leon Dure, MD
Director of Child Neurology
Dr. Dure has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole: Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen as we provide an overview of Tourette syndrome and its management. Joining me is Dr. Leon Dure. He's the director of Child Neurology at UAB Medicine.
Dr. Dure, it's such a pleasure to have you join us today. So let's set the stage for other providers. What is Tourette syndrome? How prevalent is it? Tell us a little bit about it.
Dr. Leon Dure: All right. Tourette syndrome is a condition that's defined as individuals who express a combination of both motor and vocal tics. There are chronic tic disorders that either only have motor tics or only have vocal tics, but I tend to think of them all as pretty much under the same umbrella. The duration of these tics has to be for a year in order to qualify for this diagnosis.
Now, in terms of prevalence, it's actually fairly common. Although once considered to be a very rare and exotic disorder, it's estimated that anywhere in the low single percentages of the general population have features that would be diagnosable as Tourette syndrome.
Melanie Cole: Well, then let's talk about that. Who's most commonly effected? Give us a little bit about average age, demographic breakdown. What do we know?
Dr. Leon Dure: It's definitely present in all ethnic groups. And everywhere around the world, people have Tourette syndrome. It does tend to impact boys more than girls. And the usual age of onset is somewhere within about six to eight years of age. It's been estimated that in terms of tic frequency, how frequent their takes are occurring, that may peak at a later age of about 10-1/2 to 11 years of age, although there are adults and certainly teenagers who continue to manifest tics as they get older.
Melanie Cole: Speak about the tics a little bit. Are they cookie cutter? Are they different for every patient? What are some of the characteristics of these symptoms and what is the wide range of them?
Dr. Leon Dure: That's a really good point. The tics are in themselves normal movements. What makes them abnormal is the frequency and context. So anything can be a tic, meaning that simple blinking or mouth opening, et cetera, can be a tic, but it's defined more by that frequency and context of activity that makes it a tic disorder as opposed to just a normal movement. So tics tend to be most prevalent in the head and neck, although they can involve any body part.
I guess one other feature of tics is the fact that they can also be very simple, just single movements or complex. And this tends to be individuals with a longer history of Tourette syndrome who may have tics that have strung together into a much more complex activity or complicated movement. Vocalizations can also be similar. They can be very simple in terms of just an exhalation or a sniff or cough to actual words and phrases.
Melanie Cole: So let's talk a little bit about comorbid conditions. Have you seen that children with Tourette's often have these comorbid conditions such as OCD or attention deficit disorder? What other disorders are associated with Tourette syndrome?
Dr. Leon Dure: I think that is something that I focus on quite a bit in my clinical practice, because I believe that the morbidity from Tourette syndrome is really dictated more by these other comorbid conditions. And it's true that obsessive compulsive behavior or obsessive compulsive disorder and anxiety are quite frequently seen in these patients as well as an attention deficit disorder.
I think that other comorbidities have been reported that include things like depression, cognitive dysfunction, et cetera. But these are much less common than just more of a garden variety attention deficit disorder or obsessive and compulsive behavior.
What is very interesting to me is how little that is appreciated prior to the visit with me. I may see the patient because they're referred for tics, but the frequency with which you find these anxiety-related features is striking.
Melanie Cole: what an interesting field that you're in, doctor. So speak a little bit about treatment. When is treatment provided and why is it so hard to treat? Is this a very complex disorder? Tell us a little bit about what you do, what role medication plays, give us an overview of how you treat these children.
Dr. Leon Dure: So for your listeners, I have to fully disclose that I have a very unique situation here. And so my treatment strategy may differ from what is encountered in other parts of the country. And to amplify on that, I am a pediatric neurologist with movement disorder training and I've been here for over 20 years. And so I basically serve the entire state and I see all these patients and I see them at a fairly young age.
My belief is that the first step is education. I think that most younger children are in themselves not impaired or distressed by their tics. This is typically something that families worry about more. That's also a feature of the condition that this association with obsessive and compulsive behavior that tends to be a familial tendency. And so you can often identify the parent who may have some anxious tendencies because they are bothered much more by the tics than the child is. So I don't typically recommend any medical therapy or other type of therapy at an initial visit. Now, an older child who may be distressed due to behaviors that they can't control at school or that impair social function, these are things that do warrant an intervention.
Now, traditionally people have talked about using medications, and there are a variety of medications that have been used. But the treatment effect is not exactly robust, if one thinks about how clinical trials have been carried out. And so earlier in my career, I became less enamored of a medical approach and began to adopt the cognitive behavior strategies for the management of tIcs, and this is a validated therapy that is quite helpful. And in our institution, this is done with a trained occupational therapist. And so this treatment works very well. And it's so effective that I seldom, if ever, have to use medication for management of tics.
And I have to qualify this a little bit because I've only been speaking about treatment with regard to tics, but that tends to be the issue that people tend to focus on. I do believe that there is a significant role for pharmacologic management of obsessive and compulsive behavior as well as anxiety, again, if there is an associated distress or impairment.
And then finally, it's very clear that the morbidity of kids with Tourette syndrome is so tightly related to their function, that attention deficit disorder has to be adequately managed, and that could be managed with again more standard techniques such as stimulants and other agents for management of that problem.
Melanie Cole: Dr. Dure, what an interesting and comprehensive perspective that you have for this syndrome. Since the potential for stigmatization can be very high, as you mentioned a little bit briefly before about socialization, tell us about this development for a positive and supportive perspective on the part of the patients' families and even the school and the community, because as you said this can create quite high anxiety for the children that suffer from some of these symptoms.
Dr. Leon Dure: Well, I think that I am benefited by the fact that I tend to see children at a fairly early age and I'm the first neurologist or any specialist to see most of these children. And part of my educational talk that I give to families is to indicate to them that at least at an early age, the tics are not a source of distress or impairment.
And even though friends of children may be aware of these tics and they may ask questions about them, they really care more about how the child does otherwise. Are they a nice kid? Can they play sports? Are they good students? That type of thing. And I think the currency in childhood is not so much these issues relating to differences that they might be teased by, but rather the positive currencies that kids can exhibit.
And what I've found is that children tolerate a lot of tics, believe it or not, both the individual as well as their peer groups. And I've had teenagers tell me that they did not feel the need for any type of therapy, because they themselves were involved in supportive social group, a supportive family, et cetera. So what I try to do is to get the family to reorient themselves away from tic expression and more towards, again, manage anxiety, manage school performance, and provide a positive environment for the child moving forward.
Melanie Cole: So, as we wrap up, doctor, from the viewpoint of a pediatric neurologist who has served as the primary consultant for statewide population, how has this experience informed a more holistic approach and led to novel management strategies? What would you like to tell other providers when they have patients come to them with Tourette syndrome, with tics, with any of these comorbid conditions and why you feel it's so important that they look to the type of treatments you've been discussing today?
Dr. Leon Dure: I think there's really just two main points I'd like to make. And one is that it is unfortunate that the degree of anxiety and obsessive compulsive behavior is fairly easy to miss if you don't ask the questions. And it's true that most primary care providers are not necessarily well trained in this and it's not their fault, but it is something that could probably be remedied. I think the familial aspects of this in terms of a tendency towards anxiety in other family members is something that also needs to be considered.
I guess the last point I'd like to make is that even though I practice in a rural state in the south and this strategy that we've employed for the past 15 years or so is somewhat novel, it's been validated because the most recent practice parameter for the treatment and management of individuals with Tourette syndrome recommends a cognitive behavioral approach for management of tics as well as good deal of psychosocial education. So I feel like we've been on the right track and that this is something that people need to be aware of as a treatment modality.
Melanie Cole: Great points. Thank you so much, doctor, for joining us today. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. And that concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua186.mp3
- DoctorsAbed, Sumayah
- Featured SpeakerSumayah Abed, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=4524
- Guest BioSumayah Abed, MD is an Assistant Professor whose Specialties include Family Medicine.
Learn more about Sumayah Abed, MD
Release Date: February 2, 2021
Expiration Date: February 2, 2024
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speakers:
Sumayah Abed, MD
Assistant Professor, Family Medicine
Dr. Abed has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie: Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we discuss women's health services within family medicine clinics. Joining me is Dr. Sumayah Abed. She's an assistant professor and family medicine physician at UAB Medicine. Dr. Abed, it's a pleasure to have you join us today. So why is women's health an important part of the overall family medicine practice?
Dr Sumayah Abed: The number of visits Americans pay to the family physicians are the highest among all other specialties, which is 192 million visits annually or 48% more than the most visited medical specialty. Therefore, family physicians need to make the best out of those visits to offer the needed counseling, screening and other preventative measures.
According to the Centers of Disease Control and Prevention, CDC, women outnumber men in primary care physician visits by more than 30%. This puts us as family physicians and our colleagues in OB-GYN under a lot of challenges to improve the screening of common and important gynecological conditions.
For example, 7% of women between 21 and 65 years, which account for 8 million American women never had cervical cancer screening with Pap smear and more than 11% of women have irregular screening. More than 12,000 American women are diagnosed with cervical cancer each year and more than 4,000 die of it annually.
Our goal as family physicians is to reduce the deaths from cervical cancer to or close to zero with universal screening that allows early diagnosis and, hence, early treatment and cure. There had been nationwide decline in the family physicians practices offering women health, which may have contributed to reduced screening.
We at UAB Family and Community Medicine are offering women's health services to our patients to improve the early detection of serious women health condition to improve our patient's wellbeing.
Melanie: What good points you made, Dr. Abed. So how did your background overseas affect your choice to lead the Women's Health Program and Family Medicine at UAB?
Dr Sumayah Abed: I finished my OB-GYN residency in Qatar, and then I did family medicine residency here in Alabama. And during my residency training in both specialties, I enjoyed practicing preventative women's health, such as screening cervical cancer with Pap smear and breast cancer screening, counseling about contraceptive methods and performing long acting-reversible contraceptive procedures such as Depo injection, intrauterine device insertion and removal and contraceptive implant insertion and removal. This background enables me to focus on women's health in my family practice.
Melanie: Well, I imagine that it would. And what an interesting topic we're discussing today. So then tell us what other health services does the family medicine clinic offer? And how do you tie this in with women that maybe see their gynecologists, as you mentioned your statistics about how many women are seeing primary care providers? Tell us how this all ties together. How do you start offering women's services in a family medicine clinic?
Dr Sumayah Abed: So besides screening and contraception, family physicians manage many other woman's health related illnesses, such as polycystic ovary syndrome, infertility, vaginitis, sexually transmitted infections, pelvic inflammatory disease, unusual and abnormal bleeding disorders, postmenopausal symptoms, preconception health, management of a chronic medical disease during the pregnancy and screening for domestic violence.
Melanie: Well, then tell us about the best time for doing women's health screening and counseling?
Dr Sumayah Abed: Any visit for a woman is a good time for screening. Pap smear can be performed during any checkup visits, and sometimes even during sick visits after discussing with the patient, especially during the pandemic, to spare the patient another visit to the clinic. I prefer to do this very important screening as soon as possible. We follow the guidelines of American Academy of Family Physicians, United States Preventive Services Task Force, and American College of Obstetricians and Gynecologists. For example, cervical cancer screening for average risk woman starts at the age of 21 and continues until 65 years. For high risk groups, it can start earlier and continuous for longer time.
Melanie: Have you run into any challenges, doctor, in organizing women's health services within a family medicine clinic? Are there any challenges you'd like to let other providers know that are considering incorporating this into their practice?
Dr Sumayah Abed: So during COVID pandemic and for the safety of our patients and the health workers, a lot of elective procedures were put on hold together. After starting to reopen, many health care facilities, including family medicine clinics resumed their elective procedures such as screening for cervical cancer and breast cancer, intrauterine device placement and subdermal contraceptive implants insertion and removal. Also during COVID 19, the CDC recommended screening patients for COVID-like symptoms before the clinic visit to ensure the safety of the healthcare workers and other patients. Those measures are taken to reduce the distraction of woman health screening and preventive interventions.
Melanie: Well, then how do UAB family physicians address these issues for their female patients? And what do you want to change? As we wrap up, tell us what you would like to change for better improvement in women's health. Where do you think the most important needs that need to be met are located?
Dr Sumayah Abed: I'm glad that you asked this question. I wish to see more women's health education during family medicine rotation of medical school students. I am looking forward to starting a women's health program for hands-on training of medical students about the conditions I mentioned earlier. I would also like to see family medicine residents spending more time in women's health training.
Melanie: Thank you so much, Dr. Abed, for joining us today. What an important topic to incorporate women's health services within the family medicine clinic. Thank you again. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.
That concludes this episode of UAB MedCast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
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