A few words about this Blog

     This Blog was created to integrate the information on different aspects of Head and Neck Diseases. Its target audience includes medical students, residents, Otolaryngologists/Head and Neck Surgeons, Medical and Radiation Oncologists, Pathologists, Cancer researchers and all other specialists interested in head and neck. 

Two men and the Ocean, Ralph Steiner (1921)

       Τhe main topics of interest are clinical and translational head and neck cancer research, and academic surgery. Through interviews with leaders in the Head and Neck field, the blog aspires to increase awareness among medical students and help as a platform to inform, educate and inspire. This effort wouldn't materialize without the generous contribution of all participating faculty, sharing their expertise and knowledge. 

       Please keep in mind that the purpose of this Blog is informative and the Blog does NOT intend to replace your doctor. You should ALWAYS comply with your doctors' advice.

PS: The Blog's conception was inspired by a discussion with the unique in so many ways KD.

      Please do not forget to cite the Blog when you reproduce the material published here.

Dr Michael Topf - Vanderbilt University

Michael Topf, MD

Assistant Professor of Otolaryngology-Head and Neck Surgery

Vanderbilt University Medical Center

 

Dr Topf earned his MD at the University of Rochester School of Medicine and Dentistry and completed a residency in Otolaryngology- Head and Neck Surgery at Thomas Jefferson University. He then trained in Head and Neck Oncologic Surgery at Stanford. Currently he is an Assistant Professor at the Department of Otolaryngology-Head and Neck Surgery at Vanderbilt University. Dr Topf is a pioneer in 3D surgical specimen mapping. He has over 60 published papers and more than 700 citations.

 

 

 

Why did you choose to subspecialize in head and neck cancer surgery after residency? What drew you to this field?

I have always been a bit of an oncology geek. I like clinical oncology, Kaplan-Meier curves and both non-surgical and surgical clinical trials. So, I think what, what drew me to head and surgical oncology fellowship was the care of cancer patients and the field of oncology as a whole.

 

Is there anything that you don't like about the subspecialty?

 I don't like that head and neck squamous cell carcinoma as a solid malignancy still has relatively poor outcomes, and that we have really not improved significantly in the last 2 to 3 decades. And with that comes patients that unfortunately don't do well from an oncologic standpoint. That's always challenging.

 

You're doing a lot of work with 3D specimen mapping. You've published a lot there. Honestly, I think it's quite amazing. I was hoping that you could share a few details about this, and also share how you see this technology involving evolving in the coming years.

Yeah, thanks for the question. It really started with a clinical unmet need. You know, as a fellow at Stanford, I saw difficulty in communication among members of the multidisciplinary cancer care team. This was seen in multiple phases of care. Intraoperatively, when we have anatomically complex resection specimens with multiple different types of tissue, that often require a face-to-face interaction between surgeon and pathologist. Particularly if the approach to margin analysis is a specimen driven approach. And this is time that the surgeon is not scrubbed in in the operating room advancing the case. So, I just wondered if we could do better with regards to intraoperative communication and delivery of frozen section results. If you think about it objectively, compared to other fields, why are we still delivering frozen section analysis results via telephone call without any visual aid in 2023?

You get a pathology report back a week or two after surgery for these complex cases, and inevitably there's some margin that may be close, hopefully not positive, but it happens- probably a fifth of the time for complex, locally advanced specimens. And we're again, left to written descriptions of the margin sectioning and the description of the specimen to try to reconcile those margins. The fact that there is a margin that is positive or close is concerning and potentially, an indication for adjuvant therapy. However, sometimes additional tissue has been resected that supersedes that area. And without a visual aid, those conversations between surgeon and pathologist are very challenging. These are also conversations that are had at multidisciplinary head and neck cancer tumor board, when we're dissecting through the pathology reports.

So, I thought there was a real clinical unmet need for creating 3D visual models of this specimen. I'd like to acknowledge a medical student who came to me with the background in 3D scanning: Kayvon Sharif, who really over a two-year period worked out a way to do this in real time with me and not interfere with normal surgical pathology workflow.

With regards to the second question, which is where I see it going, there are two barriers to widespread adoption. When I show people these scans and the protocol and the technology, I think everyone says “Wow, that's really cool. This is better”. But we still need to prove value, right? We need to prove the value of the technology because there are costs associated with it. So, we need to demonstrate value and that's going to be an academic and personal goal of mine over the next ten years. The other major hurdle is that the hardware and the software is not quite ready for the primetime yet. The vast majority of 3D scanners are not designed to 3D scan human tissue or resected specimens. And there are nuances that come with that. Similarly, the software that we use to annotate our 3D specimens to create these models and visual representations of the processed specimen is not designed for that use. So, we need to create software designed specifically to annotate virtual models of resected tissue. And when both the hardware software improves, I think that it's going to transform surgical oncology.

 

Having a background in Dentistry, when I hear you talking about this, there is one thing that comes to mind: dentists use these 3D scanners to do intraoral scans and they have multiple different software platforms for that. I wonder if you've had any experience with those or if there is any ideas from there that you could maybe apply to the 3D specimen mapping.

I think there's opportunity there. We have an active and ongoing study looking at an intraoral scanner that is used in the dental and oral surgery communities. The major issue is that the soft tissue resolution of a small handheld 3D scanner is not ready for intraoral 3D scanning. It’s really capable for scanning teeth, but when you start moving off of the teeth and start trying to scan the palate or the tongue, the resolution is poor. So in our hands the intraoral 3D scanners are not ready, but I'm sure that the hardware is going to improve in the next few years. In the future we could be using some sort of pencil 3D scanner in a patient's mouth to scan their tumor preoperatively!

 

Thank you. Now I want to transition to something different. Your department is consistently ranked as one of the top in the country. And my question for you is what did you and the rest of the team at Vanderbilt do to get there? And what do you do now to stay there? Because it's one thing to be ranked first, and it's another thing to consistently rank on top for so many years.

Yeah, I'd like to acknowledge that Vanderbilt's reputation and ranking is no thanks to me. I think you have to look at the people and individuals that built the Vanderbilt Department of Otolaryngology. It's a relatively young Department that started in the 1980s. But look at the previous Division Chiefs, Dr Ossoff, Dr Netterville, Dr Garrett, Dr Rees, Dr Haynes, and some of the early faculty members -some of them are still here- that built this Department and expanded it to what it is today. I think it starts with the Vanderbilt culture- we have a really good working environment. Everyone treats each other with respect. It sounds simple, but when you start with the working environment, you can create amazing things. I think that there's excellent support both for residents as well as fellows and faculty for research. There's a strong clinical research coordinator staff within the department that helps take clinician ideas and turn them into actual studies and produce meaningful prospective clinical trial results. Going back to our former chair Dr. Eavey, I think his vision for the Department and the residency training program, and his encouragement of faculty to pursue additional degrees, really had an impact in this place. I'm about to finish a masters of science in clinical investigation. When you look at the Department’s faculty, many of us have additional master's degrees. And I think that, that puts us outside our comfort zone and makes us better clinicians and academic researchers.

 

It is very, very interesting to hear about this approach. Now, I'll go to a different direction: is it talent or is it character that makes a good surgeon?

I would say it's both. But I would say character is probably more important than talent. Inevitably in surgery - particularly head and neck cancer surgery- you're going to have complications. How you handle those complications and the interactions with patients and their families is truly what makes you a good surgeon.

 

What, in your opinion, is a predictor of success during residency? What are you looking for in a resident?

Yeah, that's a good question. I don't know this literature as well as others, but there have been several studies that show that we can't necessarily predict who's going to be a good resident or a bad resident. And I think that the definitions of a good resident or a bad resident are something that is still a little unclear. But, you know, when I'm looking at residency applications, my favorite place to look at is the letters of recommendation. Perhaps I know the letter writer, but even if I don't, I think that you can learn a lot about an individual in a personalized letter of recommendation. And to me, that's where you get most excited to meet one of the applicants. I think the personal statement can also get me really excited to meet a prospective applicant!

 

What qualities are you looking for in a resident? What is important to you? I understand that the letters, based on what you said, are very important to distinguish and realize who's who. But what, what kind of qualities are you looking for in someone?

It might sound simple, but my answer is reliability and trustworthiness. I think you have to start there. My subspecialty is doing large cancer operations and reconstructions on patients. The perioperative care of those patients requires trust. Faculty aren't able to be in the hospital 24/7 but there is a resident in the hospital at all times. You need to trust that individual. So, for me, trustworthiness and reliability are the two most important qualities that a resident should have.

 

How important is research for you when you're evaluating someone. Does it play a role at all?

Yeah, it plays a role. For us at Vanderbilt, as a larger academic department of otolaryngology, it's great to see students that have participated in research. We now have a research track position, under the leadership of Justin Turner, one of our rhinologists. And that particular resident spot is really meant to train clinically and also academically a future surgeon-scientist that's going to have a career of discovery. And that could be in any aspect of research: clinical, translational or basic science. We just had our first match last year and look forward to future matches.

 

Are there any red flags for you in an application or during the interview? Things that are an immediate dealbreaker for you?

I don't know if there are any things that are a complete deal breaker for me on an application or an interview. Our approach to interviews and applications at Vanderbilt is very much a democratic process. We have several faculty reviewing applications, an entire committee, and the majority of the Department interviews candidates. So, I think it's more of a team approach. I trust my partners, and my residents who are also participating in this process. Certainly, if someone said something that I didn't like, that may be reflected in my perception of an applicant. But it's the whole body of the Department's review that I think is most important. Everyone's vote counts and is equal.

 

What are your goals for the next decade as an academic surgeon?

Clinically, I'm in my fourth year of practice now. I look back at how much I've grown as a surgeon, as an oncologist, and I look forward to future growth. Academically, I have aspirations to transform the way we approach surgical oncology, even beyond head and neck cancer. We're now using our protocol in breast oncology and musculoskeletal and bone and soft tissue sarcomas. I look forward to future collaborations in these areas. And personally, my daughter Madelyn just turned one this past week. So, I think further development of me as a father will be important over the next decade. That's what I'm most excited about in the next ten years. And I think I'm at a perfect place to do all three because I have wonderful senior partners: Eben Rosenthal, Sarah Rohde, Kyle Mannion, Robert Sinard, Alex Langerman, Jim Netterville, to develop me as a surgeon, as a clinician, as an oncologist, as a father and as a researcher. So, I'm, I'm very fortunate.

 

I know you have a strong presence on Twitter.  I'm just wondering how important having a presence there is and how influential it can be, in your opinion. I can tell you that from the perspective of a junior trainee it has been very helpful. But I just wanted to hear what you think about that.

Social media is very important for me. I look at social media as a way to learn. Gone are the days of receiving a in print journal as a way to stay up on the literature. I stay up on the literature by going to meetings, but also by social media. I follow JAMA Oncology, Lancet Oncology, Head and Neck, Laryngoscope, JAMA Otolaryngology etc. and that's how I learn my literature. I look at what they've recently published, I click, and I then I read the article. I am often told by or asked by trainees and colleagues, how do you stay up on the literature? And I say Twitter. It’s a powerful tool to learn. I also like to use it to disseminate our team's research. There is data to suggest that researchers that are more active on social media are going to have more reads of their paper. We do research to help our patients and also for people to learn about our research. So, if there's something that is going to apply to a broader audience, then I'm going to do it- particularly if it's if it doesn't take much time, which I don't think social media does. So, that's my approach to it. Also, you can learn from other people posting their experiences or their reviews of papers and trials. It's an awesome way to stay up to date.

 

Thank you so much Dr Topf!

Thank you. 

Dr Mark Edward P. Prince - University of Michigan

 

Mark Edward P. Prince, MD, FRCS(C), FACS

Charles J. Krause MD Collegiate Professor of Otolaryngology & Chair, Department of Otolaryngology-Head and Neck Surgery

University of Michigan

 

Dr Mark Prince earned his MD at Dalhousie University in Halifax and completed a residency in Otolaryngology-Head and Neck Surgery at the same Institution. He then trained in advanced head and neck oncology and microvascular reconstructive surgery at the University of Michigan. Currently he is the Chair of the Department of Otolaryngology-Head and Neck Surgery at the University of Michigan, and previously served as the Program Director at the same Department. Dr Prince has >200 published papers. He also co-leads a collaborative education initiative at Komfo Anokye Teaching Hospital in Kumasi, Ghana.

 

 

Dr Prince, you have a very unique career pathway with a background in the armed forces and also in engineering. So, my question for you is why did you end up choosing medicine and otolaryngology in particular?

On a superficial level, it's probably an easy question to answer but in reality, it's much more difficult! I think that both of those experiences, engineering and the Navy, taught me something pertinent to medicine. Engineering taught me a lot about how to think and gave me some ideas about how to approach solving a problem. That was an important set of skills I acquired and led me to a realization, that there was a lot that an individual could contribute through an intentional problem-solving approach. The armed forces experience came from a desire to serve my country, but also to make a difference in the world. The combination of my education as an engineer and my training in the navy gave me a great foundation to build on.

So how does that lead to medicine? Well, I don't think it naturally leads to medicine necessarily. It could lead almost anywhere. My story about how I got to medicine is not so unique. One factor was my older brother who entered into the field of medicine. I think hearing from him stories about what he was learning in medical school, combined with some of the stories my mother told me - she was a nurse at one point in her life - made me more interested in the human condition. Staying in Halifax in Medical School also kept me close to my girlfriend (now wife) and medicine seemed like a great place to make a difference and maybe to apply some of the skills that I was collecting along the way through these other things that I'd been doing. At this point in my life, it's really hard to know exactly what I was thinking back then. Sometimes I wonder if it just seemed like a pretty cool thing to be doing, medicine, with a lot of opportunity, and maybe that's not a bad reason to choose to get into something.

 

I see. That's a that's a really unique way to think about it, I think. Now, I wonder, is there something that you do not like about the specialty or the particular field of head and neck?

I didn't really answer the second part of your first question. I'm thinking now, why did I end up in otolaryngology? So, I'll just reflect on that a little bit because it's perhaps pertinent to the second question about what I don't like in otolaryngology. I was trained as a naval officer and as an engineer. Then I went to medical school, and I switched my career path in the Navy to a Medical Officer. I was what they call a General Duty Medical Officer, which is essentially a primary care physician. I also was lucky to be able to specialize in hyperbaric and diving medicine. When my time in the Navy started to come to an end, I was looking for other opportunities. Otolaryngology, which is something I had some exposure to in medical school, seemed like an interesting combination of clinical work, procedural work, and had the continuity of care, which was something I really loved about primary care.

 I think that's what drew me to Otolaryngology - It is a very unique combination medicine and surgery with continuity of care. There are others that are similar, but none that has the same degree of flexibility. You can be very clinical, you can be very procedural, you can be somewhere in between. You can look after people for years and years or you can see them for a short period of time. Otolaryngology has an amazing ability for you to design the practice that you want.

To answer your next question, whether there is anything that I would change. The obvious answer is that it'd be great if the world didn't need people like me, right? I mean, wouldn't it be wonderful if I could expend my energy, enthusiasm and my training doing something else? Not that I don't enjoy what I'm doing now. I love it because I do think I help people, but it would be an amazing world where nobody suffered from head and neck cancer.

It seems like a fanciful or superficial answer, but it's a truthful answer. If I were to give you something that's a little more immediate to my daily life and that of my patients, it would be to shorten our operating room turnover time.

 

Yeah, absolutely. And you said that it might sound superficial, but I have to tell you, it doesn't sound superficial at all to me. From an epidemiology or preventive medicine perspective, it's very deep, right? Someone getting in the OR to receive a procedure like that is a systemic failure on so many levels, prevention-wise. So, it's really deep.

There is a really neat book called “Upstream: The Quest to Solve Problems Before They Happen”, by Dan Heath. The book really reminds us about how we should be thinking about solving problems. In the United States, Canada and many other places in the world, we are very good at spending a huge amount of effort and energy to solve a problem when it becomes visible. Which is fabulous in one sense; if we spent the same amount of energy effort upstream from where the problem occurred, we might create even more remarkable results though.

I'll give you a non-head neck cancer example: type 2 diabetes. We're inventing wonderful drugs, which help people with their type 2 diabetes. I think that's incredibly valuable- it’s really amazing that we have developed these remarkable new treatments and we should keep doing that. At the same time, we should also think about providing better nutrition, opportunities for people to get exercise, education and eradicating inequities regarding nutrition and access to health care for less privileged groups. That approach would also have an incredible impact on type 2 diabetes. But it's a very different way of solving the problem than our typical approach. It’s an approach to preventing the problem from occurring. Much harder to do, I think, because sometimes the interventions required to solve the problem upstream seem abstract ideas whereas once you see Type 2 diabetes develop it is a concrete problem. How are you going to get fresh fruit and vegetables into an inner city? I mean, that seems a lot more difficult than treating somebody with type 2 diabetes with a new drug.

 

And it can probably have a greater impact, like you said, than fixing the problem at the point that it becomes really obvious. Now, I had the question actually here about how your previous experiences and background affected your career and your leadership style, but I think you have told me a lot about that already.

Let me tell you one more thing. I think a lot of people have misconceptions about how the armed forces and leadership work. I suspect that many people think that you get a rank and then you can just tell people what to do, and they run off and do it. That's really not how it works, though! I think the armed forces give really great leadership training. The training focuses on educating you about how to effectively work with teams, and how to give responsibility and authority at the right level so that people are ready and able to make decisions. In the Armed Forces, and in medicine, we need to train people to do their job at the highest level possible and then give them the authority and the responsibility to make decisions.

A leader in the Armed forces must be a great manager of people. They have to be able to identify strengths and weaknesses and work on those with the individuals they lead. In a very real way, the goal is to develop each individuals’ skills to the highest level possible. That's not hierarchical, that's no just telling somebody to do something. The team must trust and respect each other enough to do whatever they're asked to do. That trust is not easy to develop, right? That's not just wearing a rank on your shoulder that does that. To be a good leader you have constantly work to achieve the best for every member of your team.  I am not saying you have to join the armed forces to learn how to be a good leader. But people often ask me “How did being in the Navy made you a good leader? You just wear a rank, and you tell people what to do”. The answer is the Armed Forces has a focus on individual growth and teamwork that works very well in most circumstances. Importantly they do not think that excellent leadership skills come with a rank and the invest in developing those skills.

 

In my mind, at least, what you're describing is a very progressive leadership style. And it's really important that you explained how the Navy background led to that. I can definitely see that now. And it's good that we are having this in medicine as well today, at least in some places! Now, moving back to the Department, it is consistently ranked among the top in the country every year, maybe for decades. What did you do, personally and as a team in general, to first achieve, and then retain this distinction?

Well, the two questions are very much linked, because the first thing that comes to mind is the culture that is present, not just in my department, but at the University of Michigan, in general. That culture is a culture of great generosity and collaboration. I think that people here really are interested in success as it relates to the team and the members of the team, not solely individual success. The generosity piece refers to the fact that I've seen people here sharing all kinds of information, knowledge, new techniques, and even new thoughts that they have, about how to solve current problems or future problems. People here are willing to do that, because they recruit a lot of really good people, decent people who want to do the best, but also because the success of the team is seen as at least equal, if not more important than the success of any one individual.

I think our department reflects that culture, perhaps at a level that's even a little bit higher than the general level at Michigan. We don't measure value just on the amount of money somebody makes in their clinic or the number of R01s that somebody has in their lab, or the number of papers written. We believe that our people all bring value in many different ways to the department, and we believe that everybody comes here, with the intention of trying to do their best and to make things work.

Culture is really something that makes Michigan unique. I have benefited from that culture! If you look at my CV and the things that I've done, I've been fortunate to be in a place that's been so supportive and with people who've really helped me achieve the things that I have done with the members of my team.

Now as far as what have I done to retain this distinction for our department- what I have done really is what prior Chairs have done: tried to sustain and grow the best culture. We focus a lot on our culture here. We have a 360-degree evaluation around the values that our department has: civility, inclusion, engagement, accountability. We're asking people to evaluate each other and to judge their performance simply based on how they adhere to those values and demonstrate those values. It's part of our effort to have not only the most inclusive environment possible, but also one that's very supportive and behaves in the right way in every situation.

 

Thank you! My next question is somewhat related to this one. And it is about what makes a good surgeon. What makes a good surgeon? Is it talent or is it character that's most important in your opinion?

A lot of times students will ask me “what are you looking for in a in a resident” or, faculty members might ask me “what are you looking for in a faculty member?”. My answer is that what makes a good surgeon is the same things that make a good person. What makes a good surgeon is the same thing that makes a decent person, somebody that is always going to try to do their best and do the best for the people around them, whether that's for patients or other members of their team or whomever.

My dad used to like to use the word decent. I think what he meant by that, was just to treat people the very best way you can. One of the really important factors to being a decent person is not being afraid to say, “I don't know” or “somebody else does it better than me” or “I need help”. I believe that to be a really good surgeon, you need to have the humility to say those things. They're often true and if you can't ask for help or you can't send a patient to somebody else that, does it better than you or is more experienced, then you're probably not going to be the very best surgeon you can be.

Is it character or talent? I think, having trained a lot of residents and worked with a lot of medical students, most people can be trained to be technically good surgeons. It's a technical skill! There are some people that may have issues that make it difficult for them to acquire those skills, but even those individuals in the right environment can acquire them. So, to me, the technical aspects of being a surgeon, which is where talent can often make surgery look easier are not as important as the character. I really do think having the right approach to patient care and working with others is the really critical piece to being a great surgeon.

 

I see. Now, you obviously you have trained a lot of residents, and you said that you get asked a lot what are you looking for in a resident? My question will be slightly different. What is the difference between a good and a great resident?

I think, Jason, a lot of what makes a good resident is what I just reflected on. That, the resident who is really committed to always doing the right thing in every aspect of their training is going to be a great resident and doctor. When I say doing the right thing, I mean, for example that if you don't know something, you won’t be afraid to say so and you'll go and learn it. I believe that the drive to always do the very best, and do the right thing, that leads to a lot of wonderful things. Because you'll never take on something you shouldn't. You're never going to not keep up with your continuing education. You're never going to treat people poorly. We all make mistakes, and we do things that we regret, but if ultimately, your goal is to really try to do the right thing, you'll fix those things as well. And you will apologize and do whatever else needs to be done to fix things. We spend a lot of time trying to identify the students that have this quality in them.

 

Thank you! Now, I can't avoid asking you about research- you're doing cancer stem cell research, which is honestly amazing, and you have produced an incredible amount of work in this field. How and when did research become a part of your career? We talked about engineering, and we talked about your career in the Army before. But when did you start becoming interested in research as well?

Not until quite late, I’d say. In medical school we were asked to do some projects and not necessarily publish. I can't say that I was particularly interested in doing something very novel or very innovative and committing a lot of time to that. I was mostly focused on learning how to be a good doctor.

Interestingly, a couple of things happened once I started working as a General Duty Medical Officer and in hyperbaric medicine. I became aware that there was a lot of opportunity in diving medicine for advancement and new learning, and that got me interested in reading a little bit more of the literature and really trying to understand some of the science behind hyperbaric medicine.

I was fortunate I had a chance to go to the Defense and Civil Institute of Environmental Medicine, in Toronto where some really cool stuff is being done in aerospace and diving medicine. I didn't actually start doing anything then, but when I joined my Otolaryngology training program in Halifax, at Dalhousie University I was interested in trying to do learn something about research and doing something unique. I was very fortunate to run into one of my very first research mentors, Joseph Nasser. Dr Nasser, was interested in craniofacial growth and development. I won't go into the details of the project, but I spent a significant part of my time as a resident -all fitted in around clinical work because we didn't have a research block- doing some basic research.

When I finished my residency, I came to Michigan for my fellowship. And I was very lucky there to bump into Dr Tom Carey, who's quite well known in the field of head neck cancer. He had some really interesting perspectives on biology and how it might affect response to cancer treatment. So, I ended up dabbling in his lab. He was very generous, and I learned about basic science research from him. That experience in Michigan really made me very excited about biology, cancer, and basic science research. In retrospect it wasn't so purposeful- it was just an opportunity that came up that I took advantage of. Then there was some intentionality on my part about learning more about it and getting engaged. That led to an interest in cancer research. That's how it started: with me as a resident with a mentor who was very excited about science and then a fellowship, that gave me some opportunity to learn a lot more.

 

I know you have at least some ongoing research projects, if I'm not mistaken. How are you able to balance your clinical and admin duties today, along with your research projects?

Well, first of all, I don't balance them in the sense that they're not equal! The amount of effort that I have put into different things throughout my whole career has varied depending upon the needs of whatever was going on, the amount of time I had, and what was happening in my personal life. So, I manage them by working hard, and by being intentional about understanding how much effort I can apply to various things. Then the part that's great fun and makes it all possible is engaging with great colleagues, collaborators and teammates so you don't have to do it all yourself! I think that anybody that feels that they do it all themselves is probably misguided. For me, I've been very intentional through my life, to make sure that I that I'm a great team member and work hard as part of a team.

There are times when the rest of the team is focusing a lot more on the lab. Right now, a couple of my partners do all of that, while I'm spending a lot of time running the Department and trying to continue my clinical practice. It's really the team that will allow you to do a tremendous amount, much more than you could ever do on your own. Developing meaningful relationships, where you share the triumphs and sometimes the failures is what leads to success!

 

My final question is a more personal one. How would you -as an academic surgeon- would like to be remembered? What would you like to be remembered for?

For me, it's a very simple question to answer. If a few people thought that Mark Prince did his best to help others, and it made a difference to them then I would be very happy with that. If more than a few were able to say that, I'd be ecstatic!

 

Thank you for sharing these, Dr Prince!

Dr. David Cognetti, MD - Thomas Jefferson University

 

Dr. David Cognetti, MD

Professor & Chair, Department of Otolaryngology - Head and Neck Surgery,

Sidney Kimmel Medical College,

Thomas Jefferson University

Dr. Cognetti is an internationally recognized leader in head and neck cancer. He received  his medical degree from the University of Pittsburgh. He trained in Otolaryngology-Head and Neck Surgery at Thomas Jefferson University and did his fellowship in Advanced Head and Neck Oncologic Surgery  at the University of Pittsburgh Medical Center. Dr. Cognetti has numerous contributions in head and neck squamous cell carcinoma and salivary gland pathology. He has authored >120 publications and approximately 2,500 citations. He has served in multiple leadership positions within the American Head and Neck Society, and the American Academy of Otolaryngology-Head & Neck Surgery, among others.

 

Why did you choose to subspecialize in head and neck surgical oncology?

That's a great question. I just did a Head and Neck Cancer Awareness Week webinar yesterday with some patients with head and neck cancer. One of the questions that the moderator asked us - we had our multidisciplinary team present- was this exact question. So, it made me reflect on this. When I went into medical school, I didn't really know what I wanted to do, in terms of specialty. I was relatively naive. When I went through third year, I found myself liking much of everything. I liked variety, I liked new things, technology, etc. And I remember late in that year is when I was exposed to ENT/ Otolaryngology, and I thought it just had everything: exposure to young and old, men and women. But really what was great about it was the collaborative nature in addition to the innovation and everything that went into it. So that drew me to the field. But what really drew me to head neck oncologic surgery, if I had to be really honest, was watching Dr. Eugene Myers as a medical student, being exposed to him, doing clinic with him, and seeing his relationships with his patients. In the end, it was the head and neck cancer patients. Yes, of course, the surgery is fun, and the anatomy is amazing. We all know that. But at the end of the day, the enriching part of it is the relationships that we build with our patients, and the impact that we have on them, and quite frankly, the impact that they have on us.

 

That's a really, really interesting way to see it. Thank you for that. And is there anything that you don't like about the specialty in general or the sub-specialty?

Honestly, no, I don't have anything. Sure, it's difficult at times, both emotionally and physically. We see people through very difficult things. The complications can be hard on us, as surgeons and caregivers. But I wouldn't say there's anything I dislike. It's an incredibly rewarding field.

 

I'm glad to hear that. Now we want to move to some more clinical questions. Over the past 10-20 years. We've seen the studies on laryngeal preservation, the efficacy of chemo-radiation in HPV+ HNSCC and the more recent breakthroughs with targeted therapies, immune checkpoint inhibition etc. Where do you think this is going? Where do you see surgery in the in the future of cancer care? Will surgery retain its position, or are we transitioning to more debulking approaches followed by targeted therapies and systemic treatments? What is your take on that?

Oh, great question! And you're right. It's fun to look back at our history and see how much has changed in a short time. I consider myself a pretty young guy, but even in my relatively short career, there have been lots of new things introduced, like robotic surgery, immunotherapy, etc. All came after my training. There are now new things coming out yearly that are impacting how we approach things. And I think the speed at which the care of head and neck cancer evolves is only going to quicken. So that's exciting. That should excite people going into the field. Just before I joined the field, there was a lull in people going into head and neck surgery in part because of the VA trial that you referenced. Everybody was worried that surgery was going away. So why would you go into head neck surgery? And then there was a big rebound around my time and thereafter.

I would say I don't see surgery going away in my career, in your career, or in the career of current medical students. There will, however, be an evolution in the role of surgery, almost guaranteed! You could take the word surgery out and replace it with anything else radiation, chemotherapy, immunotherapy and whatever the next thing is. There will be an evolution in the role. I don't like the term “will surgery hold its position?”. I think we as a field, across disciplines, work together well and recognize that we all want the best outcome for the patient, both oncologically and functionally. If that's our goal and new advances mean we're doing less surgery, no problem! There will always be something for us to do.

 

I'll have to admit, it was a quite provocative question. I mentioned on purpose the first chemoradiotherapy studies in laryngeal cancer, because like you said, initially there was this enthusiasm about chemo-radiotherapy, and then the paradigm kind of changed again. The next question will also be somewhat provocative: You mentioned robotic surgery. And we saw the ORATOR-2 trial last year reporting surprisingly and probably unexpectedly more deaths than what we saw before in ECOG. What is your take there? What is the future of TORS?

In the ORATOR studies, I applaud the achievement of randomized data. Surgical RCTs are very difficult to do. I am grateful for the investigators, and grateful for the patients quite frankly. A challenge is it's a very small sample size, in terms of surgeon experience, adoption curve and other things that could impact outcomes. As a result, 1 or 2 deaths make a big difference there. The mortality data doesn't necessarily translate to the national and international experience. So, I don't think ORATOR-2 is going to end TORS. It hasn't. I do think there remains a role. In fact, as we look at some of the new treatments, TORS could play a role with neoadjuvant approaches where surgery is confirming pathologic responses that allow us to deescalate the adjuvant care or eliminate radiation therapy, which contributes most to long term toxicities. There is a balance here. There are currently patients who are getting surgery for oropharyngeal cancer that aren't benefiting. But I think, in general, TORS will still play a role for the foreseeable future.

 

It’s really great to hear this from you! Obviously, Jefferson is one of the few places with such a big volume of cases- it sounds like the department has a lot of experience with it. And in the past few years, or past few decades, Jefferson has trained some of the new generation leaders. So, I wanted to ask you about about that. What in your opinion makes Jefferson Oto unique? What are the main strengths today? And also, are there any areas that you feel that you can improve?

I appreciate your recognition/acknowledgement of the Department, and what we've done in the past decade to two. It's been tremendous for me to be here and participate in helping to drive that advancement. It's been with fantastic partners. So, I will just emphasize that you can name many people, but if you're looking Divisionally Joseph Curry -who I know you’ve previously interviewed -, Adam Luginbuhl and many others have been just outstanding partners for many years now! In terms of what are our strengths, I think there's a passion here amongst us, that's shared. We have a very strong collaborative spirit, in terms of pushing the field forward and offering the best care of our patients. We're committed to education. Starting our fellowship helped drive us forward because, as you said, working with the next generation of leaders and helping train them, helps us get better.

And finally, we have a passion for innovation. We're really excited about new things. When immunotherapy came on the scene, we started doing window of opportunity trials, and neoadjuvant trials because we want to learn. We want to help drive the evolution of the care that we talked about earlier. Maybe that's a point we can tag back to that previous question when you asked whether surgery will have a role in the future. It is better to ask whether surgeons will have a role in the future. I think surgeons will always have a role if we are participating in defining the future of the field, obviously with the patient's best interests in mind. That's what we try to do here.

 

I didn't mention that before, but it really made an impression on me that you noticed the wording, when I asked about surgery retaining its position, and you corrected me there. You were absolutely right. Surgery is one thing and surgeons are another. The fact that you actually rephrased that, I think it reflects on the collaborative spirit that you just described. Are there any areas that you feel that you're actively working on improving or that you envisioning improving in the next decade or so?

That's a broad question, I have to think about that. I mean, we're doing a lot of work here. As I mentioned, some of the clinical trials we've been working on are looking at the neoadjuvant setting. The other thing that we've been fortunate to participate heavily in is photo-immunotherapy, which I don't know if you're familiar with.  You are probably familiar with traditional photodynamic therapy. In that you infuse the patient with a light sensitizer. Then you target the tumor with light, and it's a nonspecific tumor kill. In photo-immunotherapy, the difference is that the light sensitizer is conjugated to a monoclonal antibody. It allows the light sensitizer to therefore attach directly to and concentrate at the tumor cells. This theoretically increases tumor kill and theoretically decreases systemic effects like light sensitivity, etc. We are really excited with what we've seen in some of these early clinical trials.

My point is that there are things coming down the pike that we haven't even thought of yet that potentially will be in the hands of surgeons, even if it's not traditional surgery. And going back to some of my message before that, we as surgeons and surgeon-scientists should be the ones to drive it.

 

I have to admit that I haven't even heard about photo-immunotherapy. It really sounds exciting and obviously very novel. And if you have a few more minutes, I wanted to ask you a couple of questions about residency as well. If you don't have the time, it's absolutely fine.

I have the time. This is this is some of the most important stuff we do. People did this for me, Jason, and I am happy to pay it forward to the next generation of applicants.

 

I really, really appreciate that. So what in your opinion, makes a competitive residency applicant? What are you looking for personally and what would make someone stand out in your eyes?

I might rephrase your question because as an applicant it's hard. We have a brief window with each applicant and it's a competitive specialty. So you do need good board scores and good grades. Strong letters of recommendation are very important. You want to show interest and engagement in the field. That's really where the research comes in: to show your interest, show your dedication to completing projects, etc. In terms of does that translate into a good resident or how do we pick them, that's a little bit more challenging. But I will tell you what I often say to the people who are interviewing with me who ask me what we are looking for in an applicant. I tell them we don't have a specific model that we're looking for. It's not a cookie cutter. We don't want them all to be the same. There is great benefit to having diversity of residents, and just diversity in general: different skills, different learning styles, different everything, that's good.  That strengthens our residency. The two things that I say are important for people to succeed in residency, and quite frankly, succeed in their careers and even succeed in life, are that you need to care and you need to be honest. You need to care about a job well done. You need to care about the patient. You need to care about your colleagues and partners. Support goes back to collaboration that we talked about before. And you need to be honest. And what I mean by that, especially as a resident, but even as far as you go in your career, you need to be able to admit when you don't know something, you need to be able to ask for help. You need to be able to admit when you're wrong. In your training it is important to build trust, but even in your careers, you need to build trust with your patients as well. So maybe humility is a better word.

 

I was about to ask if there are any red flags, but based on your response, I think one can infer the red flags from there. Probably dishonesty would be one of those I presume.

A huge red flag, yeah! You could be the most talented resident in the world, but if you're not trustworthy..

 

Absolutely. And I understand that you've had IMG colleagues before, but did you have any experience in the past with IMGs in residency? Would you consider one in your program?

We have had an IMG fellow. I don't think we've had an IMG resident in our program in the past. But I certainly would consider one, yes.

 

You have answered all my questions with some very, very interesting and inspirational answers. Thank you so much!

Thank you!

Dr. Eleni M. Rettig, MD Brigham and Women’s Hospital, Harvard Medical School, Harvard University

 

Dr. Eleni M. Rettig, MD

Assistant Professor, Department of Otolaryngology - Head and Neck Surgery,

Brigham and Women’s Hospital, Harvard Medical School,

Harvard University

Dr. Rettig is leading figure in head and neck cancer. She received  her medical degree from Baylor College of Medicine. She trained in Otolaryngology-Head and Neck Surgery at the Johns Hopkins University and did her fellowship in Head and Neck Surgical Oncology  at the Mayo Clinic. Dr Rettig has numerous contributions in head and neck squamous cell carcinoma and adenoid cystic carcinoma. She has authored >50 publications and approximately 2,600 citations.

 

 

 

The first question for you is, why did you choose to specialize in head and neck surgery? What attracted you in the field back then and what attracts you right now?

In head and neck cancer surgery specifically, I really enjoy the surgeries and I really enjoy the patients. And I think it's important when you think about your future as a physician or as a surgeon, to think about not only the surgeries that you do -because I enjoyed a lot of different types of surgery within ENT-  but also think about the time you're going to spend in clinic with these patients, and the time you're going to spend rounding on the floor, or your research interests, and think about how all those align. I really enjoy spending time with my head and neck cancer patients and meeting their families and talking to them through their diagnoses as well as the surgeries. Also, the research is just fascinating to me! There's so much that we're learning about these types of cancers. How we manage them changes year to year based on what we're learning on the research side of things. The surgeries are long and can be difficult, but I always found that time flies when I'm in the OR doing these types of surgeries. I think that says a lot about how you want to spend your time during the day. You know, when you look up and are surprised that six hours have passed, when you are in the OR.

 

I see. And is there anything that you don't like about the specialty? I'm talking about the sub-specialty: head and neck surgery.

It can be challenging and it's definitely not for everyone. The hours can be long, and you have to have the support from your family to facilitate that career. It can also be emotionally exhausting, I think. To take care of sick patients and talk about death and dying on a daily basis can be difficult. So you really have to take care of yourself, too, in order to make it a sustainable job.

 

 

Yes. And is there something in particular that you do in this regard? Like what helps you cope with it on a day-to-day basis?

I think I have very strong family support. I have two children, and my husband takes care of them during the day. That allows me the flexibility to stay later if I really need to. But also, he's just very supportive about my career and how I can help people with my training. I also think having some sort of activity that refreshes you mentally and physically is very important. For me, spending time with my family and exercising are very important.

 

 

I see- it’s refreshing! You have been a successful professional athlete in the past, and I'm wondering how that helped you in your professional career, if you feel that it did, and how it affected your career trajectory.

Yeah, it has absolutely helped me. Much of surgery and much of taking care of patients, especially being part of a multidisciplinary team in the care of cancer patients, involves being on a team with many different parts. There's no way you can do it all by yourself. Having played on a team before and understanding the way that teams succeed has been very helpful for me, I think. People ask why I like to do surgery, and part of it is just that you're working with a team, and everybody has to be on their game. But it's also social, and you're creating something and you're helping someone.

 

So, it sounds like you feel that there are lots of similarities between the two.

There are. And I think that's why you see a lot of athletes going into surgery because we enjoy being, you know, part of a team.

 

 

Yeah, absolutely. I'm a former water polo athlete myself, so I can totally relate to the team feeling. Now, in your first response, you talked about how treatment options, treatment patterns in head and neck change on a yearly basis almost at this point. Honestly, there has been a lot of innovation in the field in the past decades. Where do you see the field going in the next decade?

That's a huge question! I think I'll focus on the biomarker aspect of our fields because that's what I'm interested in and working on right now. I think that a lot of what we do will be impacted by what we're learning about biomarkers, in particular, liquid biopsy for HPV-positive disease, which is what I'm working on. But also, I think we're going to start to use it more and more for HPV-negative disease, too. We're just starting to look into that. But for HPV-positive disease, what we're seeing is very exciting. There are different uses for liquid biopsy, potentially in screening, although there's a lot of work to be done there, diagnosis, monitoring response to treatment, potentially risk stratifying, for treatment intensification or de-intensification, and then surveillance. There are just so many different facets of this disease where I think we're going to see biomarkers having a role. That said, I think we need to be very careful in how we approach it because it's definitely not a one-size-fits-all solution to all of our problems. We need to learn a lot about who it may work for and how to use it.

In addition, immunotherapy is completely changing the face of our field in head and neck cancer, in particular right now in cutaneous squamous cell carcinoma. We're seeing a lot of changes day-to-day in how we practice based on the use of cemiplimab.

 

 

Now you mentioned de-escalation, and I was wondering if you can share a few thoughts about that and meaning that we've seen that HPV-positive patients do significantly better than HPV-negative ones. And there has been a significant number of negative trials in the escalation. I don't know if you have any thoughts about that and what do you think is a good way or a good approach to stratify those patients and identify the ones that can go with de-escalation?

 

Yeah, that's the million-dollar question, right? How do we stratify and select the patients? Because, frankly, most patients do well, but the ones who don't do poorly. HPV-positive disease can be devastating for a small percentage of these patients. I really applaud a lot of the work that's going on right now to figure this out. The initial excitement about de-escalation is definitely tempered by several big trials that essentially show that de-escalation is not for everyone. In addition to clinical factors, for example, the Mayo trials found that extra-nodal extension is incredibly important; those patients should not be deescalated. I think there will also be some molecular factors that we look at, and I don't think we know yet which ones those are going to be, but there's a lot of exciting work going on in that area. For the time being, it probably makes sense to continue overtreating some patients just to prevent some of the failures that we do see in HPV-positive disease. I think that a lot of that will change in the next ten years.

 

I understand. Now, you have obviously published extensively in HPV+ head and neck squamous cell carcinoma and adenoid cystic carcinoma, and it sounds like your research is an important component of your career. So, I was wondering how have you been able to balance it with your clinical practice, your administrative duties, and everything? How does research factor in there, and how do you manage it all?

It's a great question. It's challenging, right? It's very challenging. I decided very early on that because I wanted to do microvascular reconstruction and ablation, I would not pursue the NIH-funding track because, for me personally, I don't think I could do both of those things well, like having my own lab, spending a lot of time writing grants, being a reconstructive surgeon, and also having a home life where I'm present with and supportive of my family.

So the research that I do is mostly born out of my clinical practice and out of questions that come from seeing patients. The clinical trials that I have are mostly just based on the patients I see and the questions that I think would be helpful to answer for them. They naturally go together. Also, it's been very helpful for me to work with colleagues; most of my research is very collaborative, and I have wonderful colleagues here at Dana-Farber that I can work with. There's also a research infrastructure here. Without those things, supportive colleagues that are brilliant, interested, and good to work with, and the research infrastructure of a place like Dana-Farber, I'm not sure I'd be able to do it. So it's very much a team sport for me, and that's the only reason that I can make it work.

 

 

You've worked with and mentored a lot med students and residents. What, in your opinion, makes a successful resident and a future successful academic surgeon? Do you have any advice for more junior colleagues.

The medical students and the residents that I've worked with are all brilliant and all work very hard, and I rarely have to tell anyone to work harder. I would say the advice that I would give is to work smart. Identify projects and mentors that will help you to focus your interests. I think early on, it's good to talk to a lot of different people and see what the different opportunities might be. But at some point, you do want to narrow your focus, and that will allow you to be more efficient. You don't want to have your hands in a million different projects; you want to have a clear path forward, setting limits on what you're doing. The same goes for your career in general. Setting limits on the time you spend at work is incredibly important because it's not sustainable to just keep working. You have to have something outside of work that reinvigorates you, that energizes you, and allows you to be your best self and do your best work while you are at work.

The best advice I ever got was as an early attending. I heard this talk- it was about looking at your work as a garden with a fence. You have your space and your amount of time, and whatever is inside those limits, do a really good job on your garden. But there's also a fence and a boundary, and you need to decide what's in your garden and what's outside your garden. Work hard on the things that are within your boundaries. That was really helpful for me because just because you can do something doesn't necessarily mean you should. To make this career sustainable, you need to set limits on what you're doing. So that's been really helpful for me.

The other piece of advice is if you have a research interest, it's helpful if it aligns with your clinical interests and with who you're working with. See what your resources are and try not to force it. If you are interested in research, a lot of times, it will organically happen. But if you try to force it, it may not work out as well.

 

 

Thank you so much, Dr Rettig!

 

Dr. Carol R. Bradford, MD, MS, FACS Dean, College of Medicine, The Ohio State University

 

Dr. Carol R. Bradford, MD, MS, FACS

Dean, College of Medicine

Vice President for Health Sciences, Wexner Medical Center

Leslie H. and Abigail S. Wexner Dean’s Chair in Medicine

Professor, Department of Otolaryngology-Head and Neck Surgery,

The Ohio State University

 

Dr. Bradford is an internationally recognized head and neck surgeon-scientist, currently serving as the 15^th Dean of The Ohio State University College of Medicine.  Dr. Bradford received her master’s degree in microbiology/ immunology and her medical degree from the University of Michigan. She completed a residency in otolaryngology – head and neck surgery at the University of Michigan. Dr. Bradford specializes in head and neck cancer surgery, focusing her research on identifying and evaluating biomarkers that can predict outcomes. She has published >370 peer-reviewed articles and contributed to more than 20 book chapters (>34.000 citations; h-index=90). Dr. Bradford was elected as the first woman president of the American Head and Neck Society in 2012, and was also inducted into the National Academy of Medicine in 2014. She was the president of the Society of University Otolaryngologists in 2017 and also served as president of the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) in 2020 .

 

My first question for you is why did you choose ENT? What attracted you to the field?

 

Great question! I usually call it Otolaryngology - Head and Neck Surgery, and I chose that field early in medical school. As a medical student at the University of Michigan, I was a class advocate and a student council member. I met great people who were pursuing Otolaryngology, including one of the senior class advocates. She and I talked about it, and I was immediately interested. And as I learned more about the field, I found the anatomy really fascinating. I like to say for otolaryngology: it's who we are as people. It's how we interact with the world around us. It's all ages, in both general otolaryngology and in the diverse subspecialties. I just think the specialty has a lot to do with who we are as human beings.

 

As a head and neck cancer clinician, I really wanted to meet patients when they are at what I consider to be a crossroads in their lives. All those things — and having the ability as a clinician to impact what really is the essence of how we interact with the world — were incredibly important to me. The field is filled with  amazing human beings. It just is!

 

Is there something you don't like about either the specialty or the sub-specialty that you're into?

 

Curiously, no! There are a lot of decisions I've wavered on in life, but my choice to pursue otolaryngology is one decision that I have never questioned — not for one moment or one day. I absolutely love the discipline, the field, the care and the complexity of the care. It is an amazing field and it is getting to be less of a best-kept secret. It has medicine and surgery — almost a bit of everything in it.

 

Yeah, it's definitely a very, very broad spectrum there. And so many, so many different options.

 

Yes, and I always like to say that most fields of medicine have a medical discipline and a surgical discipline — such as neurology-neurosurgery, nephrology-urology — but otolaryngology does not. There is not a medical discipline of otolaryngology. It is an anatomic region, not an organ system. You cross over a lot of different organ systems, like skin aerodigestive and respiratory special senses. For me, it is an absolutely fascinating field!

 

Yes, absolutely. And everybody's going to want to go into it!

 

There is also a lot of innovation in the field, like cochlear implantation and free-flap reconstruction. I have had the privilege of working with some of the first head and neck free flap reconstruction practitioners. 3D printing is really fascinating, and I was at the ground level with some of those discoveries with my colleagues. The innovation piece is really interesting.

 

Yes, and of course, the recent advances in robotic surgery or endoscopic surgery and I know Ohio State is really big on both of those.

 

Yes, robotic, endoscopic, laser, the list just keeps going! There is a lot of technology and innovation in the field.

 

You've had an amazing, extremely successful career so far. Growing up, I never had to face some of the gender-related barriers that I presume a female leader in academic medicine has to face. But obviously coming from an international background, I had to face some obstacles myself. So, I think I can remotely relate to what you might have faced there, but I really wanted to hear how hard it was to get established and recognized in the academic surgery world as a female person.

 

Great question! I'll share a short story that happened while I was in medical school at Michigan. I was fortunate and very blessed to be selected to join the residency training program at Michigan. They normally accepted four residents per year, but that year they only took two residents because they were launching a new T32-funded research training program.  So, that year it was even more challenging to match into Otolaryngology at Michigan. And at that time, essentially all the faculty and nearly all the residents ahead of me had been men. There was one female faculty member, Dr. Amelia Drake; she joined the faculty for a few months before pursuing a pediatric otolaryngology fellowship elsewhere. She was one of the only female faculty members ahead of me in otolaryngology at Michigan and that was for just six months. I was the only female resident. Then, when I joined the faculty, I was the only female faculty. But aside from that, there were many moments where I was sort of the only woman in the room, and in fact in the program. But it started to change. The chair at the time was Dr. Chuck Krause, and before anyone was focused on diversity, equity and inclusion, he had established a Diversity Committee in the department in the late 1980s. He was well ahead of his time and deeply committed to diversity. And I can honestly say, aside from being the only woman in the room — and I do think that that does come with different lived experiences — I actually did have a lot of support, both as a resident and as a faculty member. But I do think that becoming a resident and then a faculty member allowed me to also have those conversations that sort of changed the paradigm of how we can become more diverse and how can we be more inclusive in our selection processes.

 

One of the things that was a time-related issue for me was whether it was acceptable to have children during residency. I was married prior to starting medical school, and I think at that time it really was not acceptable to have children during residency. I was asked about it and it was pretty clear that it would not be accepted. That doesn't happen now, thankfully, but I complied because that was sort of the expectation and waited to have children. I am a proud parent of two wonderful children, and my daughter is actually a fourth-year medical student at the University of Michigan. I had my children early on as a faculty member. And again, even in those moments, I really was lucky to have incredible mentorship, sponsorship and support for my career. That was an important part of my career trajectory: having those key mentors and sponsors who supported me. There was one oculoplastic surgeon at Michigan who to this day is a dear friend, and she was also having her kids at about the same time I was, so I had some peer mentorship. But I think you almost have to become part of a system to change a system.

 

That brings me to my next question. It sounds like you played a major role at that, but obviously, this paradigm has now changed. So system-wise, that's different now. But how did this these experiences affected you as a person? How did they shape you as a as a person?

 

My experiences have made me very aware of the need to be inclusive, to give everybody a sense of belonging and to pay real attention to strategies that can mitigate and overcome both implicit and explicit bias. I am also very interested in developing programs  that help give everybody a chance to thrive and be successful. And again, I am grateful to have had many opportunities to develop those programs as chair, as executive vice dean and now as Dean. I am also blessed to work with some great collaborators to write about those topics and publish in those areas, and also to speak at our national meetings.

 

Many years ago, I did a national presentation on implicit bias, and back then it was probably a little early to be talking about it. There were two PhDs on the panel who clearly stated the science behind implicit bias, and it's pretty hard to think that people don't have implicit bias once you actually learn the science behind it. We all do. But how do we help people understand their implicit biases and overcome them? It's interesting. I asked, “Do you think you have implicit bias?” trying to assess the audience's understanding of the subject. As I recall, about 20% of the people said no. The point is having these conversations and understanding that our lived experiences do impact how we think about the world around us and how we approach conversations, and all of us have different lived experiences. You have to recognize that one person's journey is not the same as what somebody else has experienced in their life. And I think it is critical to be really sensitive and seek to understand how those different lived experiences impact how people approach the world.

 

Technically, the IMG background does not fall within the spectrum of what we call diversity. But I was wondering besides the technical definition of it, do you think that IMGs – faculty, residents or fellows- contribute to the diversity of a program?

 

Absolutely! I think all forms of diversity are valued. International medical graduates absolutely do contribute to the diversity of our training programs, and our training programs define the diversity of the future physician workforce, which is also really important and there is robust data to support that. Our goal to achieve equitable and top-tier health care outcomes is related to diversity of thought, perspectives, backgrounds and approaches. Clearly there is scientific data that connects the diversity of the health care workforce to achieving health equity goals and outcomes. So absolutely, yes! And I will say, in that same context, we all know that residency training programs are getting more and more competitive. Part of the reason for that in the United States right now is that the number of medical student slots at medical schools keeps growing, but there has not been a compensatory increase in graduate medical education spots. And so again, IMGs and U.S. medical grads are the pool applying for all these positions. The system does not line up all the applicants to each and every training program perfectly — not everyone gets a match — but I do think the training programs are becoming more competitive. And then the question is, how are IMGs evaluated along with U.S. medical graduates? Of course, every department and program does that a little bit differently. At my former institution, we had somebody who had gone to medical school somewhere else and then had become very involved in research programs and projects at Michigan, and he and others did match into our training program. I follow these amazing people's careers to this day and they are all incredibly successful! Here at Ohio State, we have some specifically designed positions to help with this. For example, in internal medicine we have an IMG program that international medical graduates can specifically apply to, and there’s plenty of room for innovation in this space as well.

 

I’m wondering what your experience has been with them. You said that you still in touch with some of them.

 

Yes, I do! Everybody is unique and different. One person actually repeated residency and continues to be on the faculty. The challenge is the competition for those spots. IMG candidates should be evaluated for their qualifications, just like every other candidate.

 

Understood. And now obviously in all your previous roles and your current role, I presume you have reviewed hundreds, if not thousands of applications for every level: resident fellow and faculty positions.

 

Yes. I have had the privilege of interviewing many, many candidates for positions.

 

So as a person with so much experience in that, I'm curious to hear if there are things that you can tell me that stand out in your eyes. I presume everybody applying for a position at Ohio State, or Michigan before that, is an exemplary candidate on paper. But I'm curious to see what things stand out for you, either on the resume or during the interview.

 

Under my leadership at both the Ohio State College of Medicine and the University of Michigan Medical School, we implemented best practices for faculty searches that are applicable to residents, faculty and staff. We aim to deploy inclusive hiring and selection processes, and part of that is implicit bias training. Every search — whether it be for a resident or faculty applicant, a dean or another leader — should be governed by a search process with a search committee that has been educated in best practices for searches on implicit bias. There should always be a diversity representative, there should be diversity of membership on the search committee, and all voices need to be heard. And then, you need to evaluate which characteristics and qualities you are seeking.

 

Regarding resident applications, we ask ourselves these questions: What does the application say about the background and the experiences of the individual? How did the applicant do in medical school? Michigan and Ohio State are educating leaders, so they put strong emphasis on not only clinical training, but also on identifying future leaders in the field. There is a strong emphasis on education, scholarship and potentially discovery. Those are all the objective. But once people get an interview, it is almost like starting over again. I look for what matters to be a physician and a resident, such as work ethic. Also, I love to think about the whole person, so sometimes we would ask, “What book would you recommend we read?” It's a fun question because we should all be expanding our minds, and it's always fun to see what books people have recently read. I also think being able to function effectively on a team is a great thing.

 

There is also a difference between having a reference who says a candidate will be a great resident and having a reference who says a candidate has done extraordinary things and will be a leader or the next Nobel laureate. Different lived experiences are important, too: Were you a college athlete? Have you overcome adversity? Do you have empathy and compassion? How well do you communicate? These aren't just random qualities. These are the qualities that are important to be a great physician who cares for patients, families and communities. The evaluations must be inclusive and holistic in all aspects because we all have different lived experiences. Even if two people are in the same room conducting an interview, hearing exactly the same thing, they will each filter it through a different lens. Valuing the perspectives of all members of a search committee is really important. It is a fascinating process!

 

I wonder, are there red flags? You know, things that you might pick up that would be a deal breaker for you.

 

Honesty and integrity are non-negotiable. They are not easy to pick up on in an interview, but honesty and integrity are the core values. There are a lot of careers that are easier than a career in medicine. Medicine takes a lot of humility. Graceful self-promotion is great, but humility is a strong quality, because every day there is something we don't know yet, we haven't discovered yet or we just don't know. To be a fabulous doctor, you must have an enormous amount of humility.

 

And it sounds like it's a very fine balance there, or at least that's the way I see it. I think part of the solution there is to be mindful of how damaging arrogance can be for relationships.

 

I am a big fan of behavioral-based interviewing techniques, which means you ask people to talk about their experiences. An example would be if two people were trying to accomplish something together and one of them had to negatively impact a colleague in order to advance. That would not be a good thing and this person would probably not work well in a residency program. And I don't even know if that has ever happened.

 

I see. Thank you for that! It seems like the the academic world is changing. We are transitioning -or at least that's that's the way I see it- from individuals and individual “stars” to teams. And I see that most of the surgeon-scientists today are working within larger groups. So it's not a one person show anymore, I think. I was wondering what do you think about that, and what in your opinion would make someone successful in academic otolaryngology.

 

In an academic world and a promotion pathway, you can be an individual scientist or a team-based scientist, and those are different parallel career tracks. Specifically in otolaryngology and with clinician-scientists, there is a lot to be gained from team-based work. It's that diversity of thought that makes a difference. Also, the reality is that as a head and neck surgeon, you are going to have to spend some days seeing patients in the clinic and then doing surgical procedures. Other disciplines can be sort of 80% research, but I think it is really hard in otolaryngology, especially early in one's career, to be so heavily weighted in the laboratory. It is hard to stay up with your patients and with modern-day surgery and to stay competent. There is a movement for teams to work together to accomplish goals. In translational research there can be teams working on clinical trials, biospecimens or cell lines. There is a lot of team science that happens and it's a good thing.

 

How did you maintain a balance between the two or three different things? I mean the clinic, your research and your leadership positions. You've been the Department Chair before, you're the Dean now. How do you balance all those things?

 

Great question! It’s one of the questions I have asked applicants: “If you had a five-day week, how would you divvy it up?” And it's funny because some people say a lot of surgery, but then when are you going to see the patients? Because you really need to meet them beforehand. Over the course of my 30-plus-year career, the time I have spent doing different things has varied widely. Currently I am most heavily focused on administration due to being the dean of the College of Medicine here at Ohio State. It is always hard to balance everything. You also must have some work-life balance or integration as well.

 

There were seasons of my career that I was very clinically active. I began my clinical career at the VA hospital. That is also where my lab was at the time, and I had taken a Fellow from the World Health Organization to help work in the lab. He was an otolaryngologist from a different country who was looking to come to the United States and ultimately did so! He worked in my lab for a long time. So out of the gate, I was both in the lab and in the clinic, and I was a section chief at the VA.

 

There were moments we had lots of funding and then moments of less funding. I still maintain a clinic schedule and an OR schedule. When I moved into the chair role, that was when I really had to begin to meaningfully cut back on my clinical practice while continuing the research. And then the next big change was when I began serving as executive vice dean. It was an enormous job that took boatloads of time. And then you just start to realize that it gets harder and harder. I served as the co-leader of a major project on our specialized program of research excellence (SPORE) for 12 years. And as that was ending, I was becoming more of a co-investigator rather than a PI on some very large grants and contributing in that way. I was still clinically active, but less so because of the commitments.

 

Then fast forward to coming to Ohio State to serve as the dean. A few things automatically happened: one was that I didn't have my clinical practice that I'd built over 30 years with a lot of follow up of cancer patients, so that changed. All my research was based upon HIPAA-protected clinical trials, and that research was difficult to transfer to a new institution. So I still do publish that work and other work, but currently, I do not have grant funding and I am heavily focused on my administration efforts.

 

Your career and your efforts will evolve. When you get a big grant, you have to make some adjustments in the other things. And when you have a big administrative role, you have to continue making adjustments in what you are doing with the rest of your time. The fun part is these careers offer so much diversity, and the types of roles you can have and play, which is part of why academic medicine is fascinating. There is so much to it!

 

Do you you still have a clinical component in your work to this day?

Yes, but my practice is quite limited. I have clinic on Monday afternoons in The James Cancer Hospital.  I see patients with cutaneous malignancies and parotid/thyroid conditions.

 

 

It always seems so exciting to me how one can transition from one to the other and have different percentages, like you said, of research or clinical work or admin work and go back and forth. It's really fascinating for me. I think it's so much more interesting than having a set schedule for say, 30 years or so. So going back to research, I wanted to ask you how important you feel that research is for residency applications. And my follow up question on that would be about quality versus quantity in research, for this level in particular. So no, not faculty level, but residency level.

 

Yes, and the programs differ in their emphasis. There is a diversity of otolaryngology programs in our country. Because it has become more and more competitive, we look at research, scores, the letters of recommendation, etc.

 

I am going to sound like an academician, and maybe that’s because I am, but research is how you advance a field. In any realm, it is how you advance diversity, equity and inclusion. It is how you advance well-being. Anything that you write about or present at a national meeting is, in theory, about changing the world, hopefully for the positive. Scholarship, broadly defined, is important. For some, that could be bench or translational research or health services research, for some it could be quality and safety, or something else entirely. The point is that work that demonstrates that you're working creatively to either inform or advance a field, I think, is an important characteristic and quality.

 

It is sort of the lifelong learning. How are we making the world a better place? Because in patient care, it is one patient at a time. You are not going to change the discipline by providing care one patient at a time, but it could be biotech innovation, like 3D printing, which is not necessarily a research grant project. All those things count. Quality is always more important than quantity. You also have to look at what opportunities you have. A high-impact paper has much more impact than a case report. A case series is better than a case report. All are important, but the more impactful the work, the more significant the science. The impact of the work makes a difference.

 

It's really interesting that you bring up the parameter of evaluating where someone begins from, which is very important. Because it's not always the same, right? Not everyone has the same opportunities or the same experiences.

Yes, and I think the other point is broadly defined: impact and scholarship. I have worked on promotion decisions in partnership with provosts now at two different places for many years. The hardest thing to measure is the impact — there is no objective way. There's grant funding and publications, but what we are really trying to discern is impact. There are lots of ways to impact a field. You can have a great idea and develop something novel. You can write and talk about best practices for search processes. There are a lot of interesting ways to define scholarship. But I think everybody is looking for sort of the sparkle, the unique thing that somebody is going to bring to the training program.

 

Thank you so much Dean Bradford!