Expert Opinions: Dr. Joseph M Curry MD

Professor, Vice Chair of Research,

 Department of Otolaryngology,

Sidney Kimmel Medical College, Thomas Jefferson University

Philadelphia, PA, USA

 

Dr. Curry is an Otolaryngology-Head and Neck Surgeon currently serving as Professor of Otolaryngology at Thomas Jefferson University. He earned is MD from Georgetown University and did his residency at Thomas Jefferson. He then pursued fellowship training at the University of Miami, where he subspecialized in Head and Neck Surgical Oncology. He has an extensive research background focusing on tumor microenvironment and its interactions with tumor cells. Further, he has published extensively on microvascular reconstruction. Dr Curry has more than 2.600 citations and an H-index=25

 

1.      Dr. Curry, why did you choose to specialize in Otolaryngology? What attracted you in the field then, and what attracts you now?

I think what attracted me the most when I first was considering what specialty to go into, was that I really liked the anatomy and the surgery of the head and neck. I think it was head and neck surgery that attracted me to the field. When I did the rotation as a medical student, I found it was the most interesting stuff I had ever seen, and the most exciting type of surgery that I’d seen so I was very interested in doing it.

When it comes to what kept me interested, during my training as a resident, I really enjoyed head and neck the most; the soft tissue surgery and the complexity of the procedures. I felt that was the most interesting and most challenging aspect of ENT for me. I really enjoyed both the cancer surgery and the reconstructive surgery, and getting to do that from a technical aspect. At the same time, taking care of patients in complex situations and helping them get through their cancer care is the most rewarding part of it! I think those are things that got me into it and kept me interested in it.

 

2.      Is there something that you don’t really like about the specialty or the subspecialty that you’re working on?

I think there are a lot of challenges to it. When it comes to cancer care, the only thing I don't like is when we don’t win, right? When you  deal with recurrences and that sort of thing, it can be really challenging for the patient. And you can feel that too since you’re very closely linked to the patients that you’re taking care of. It’s always tough. On the reconstructive side, most of the time things go very well but you can deal with complications there too and it can be challenging. So, you have to try and do the best you can with each of those. In the end I think there are way more benefits than downsides.

 

3.      How do you cope with the poor prognosis that some patients face as a result of their cancer? How challenging is this for you and how do you handle it?

You try to be frank and realistic about what a patient is dealing with. If you have a patient with a huge tumor or a lot of positive nodes or distant metastatic disease, you have to face those realities and just help them understand and cope. You take it one day at a time. You try to set realistic expectations for the therapy that is available but at the same time you try not to take away hope. You focus on preserving or optimizing time and function. And, the nice thing is that today is an exciting time with new therapeutic options and sometimes there are people who defy the rule! Sometimes patients get treated with immunotherapy and you have complete responses. This is the exception, so you can’t offer false hope. You need to give realistic expectations and take the wins where you can get them.

 

4.      There has been a recent discussion about TORS, given the results from ORATOR2 presented in this years ASTRO. While the study closed early due to high toxicity, many expressed concerns about the % of patients dying in the TORS arm (4% vs 0.2% in the ECOG trial). Do you have any thoughts about that & the role of TORS in oropharyngeal SCC in general, in the coming years?

On a broad scale we’ll move towards de-escalation of therapy in HPV+ disease, but we need evidence. There are a lot of ways to do that: de-escalating surgery, de-escalating radiotherapy, and de-escalating systemic treatment. We need to better understand who we can de-escalate and how.  Generally, the question is whether we could use a biomarker, tumor genetics, liquid biopsy, or radiomic approaches, to try to select the patients who are likely to do well. TORS has been effective at providing minimal access and decreased morbidity compared to prior surgical approaches and cohort studies suggesting better swallowing outcomes as well. The ORATOR trial brought the improved swallowing outcomes into question on direct comparison but the treatment of HPV+ disease will be evolving considerably as neoadjuvant systemic therapies and deescalated radiotherapy are explored. Orator2 showed good responses to de-escalated therapy but had 2 deaths in the surgical arm.  As TORS has evolved, the risk of death has decreased with strategic advances in management of the vessels.  There is risk associated with surgery but also significant advantages. I would argue that this is a moving target and likely to substantially decrease with evolving technique.  I think there always has to be a little of a push-back in terms of de-escalation, because right now with current management patients are generally doing very well, so we don’t want to put that at risk. So that needs to be done in a cautious and thoughtful way with well-designed clinical trials, so we don’t jeopardize the outcomes for the patients in terms of trying to push forward.

 

5.      Aside from being a surgeon, you’re also a scientist- an HNSCC/Tumor microenvironment researcher with more than 1,600 citations. There is a discussion in the field about the importance of attracting/producing more surgeon-scientists. What do you think about that? How important is it in your opinion?

I think it's very important because you have the advantage of being a surgeon at the same time as being invested in the science and progressing the field.  As a surgeon, you have boots on the ground. You can see what happens to the patient as they go through therapy and interact with them and understand the cancer from a personal first-hand view. You understand it on the level that is a little bit deeper than someone who might be more removed, and I think there is value there. This provides valuable insights when it comes to the lab or research.

At the same time there is a limit to what you can be an expert in. You can only have so much expertise and knowledge. So, it really does depend on a team. You need to have people that are well integrated: scientists, clinicians, bioinformaticians and other disciplines. And it can be challenging. Sometimes it’s hard to even communicate with specialties that are working with the same disease (e.g. scientists, medical oncologists, surgical oncologists and radiation oncologists). So you need to have science communication skills, which is almost like speaking another language. So if you can understand a fair amount of the science, then you can work with people who have expertise in specific areas; allowing you to be able to bridge that gap.

There is a critical need for surgeon-scientists. Some other specialties or fields are further ahead.  For example, breast cancer or prostate cancer are more common so they can make more progress because there is  more funding going there.

And it’s not only a matter of prevalence, it's also a matter of location, which is particularly challenging and this is why I strongly agree with your point about multidisciplinary teams.

6.      So how do you balance clinical and research work? Do you split the working week? Do you have dedicated research time?

I do have some dedicated academic time, but in reality it becomes hard to split things cleanly in many cases because clinical demands don't always follow a specific schedule. I try to work in moderation and split the time so that there is a little bit of time each day to do some of the work that's needed in the lab, or on the research, or on the project associated with the non-clinical aspect of my practice. I have two days in the OR and two days in the clinic, so that's how I usually try to work things out. But it can be challenging to try and balance the two. That's one of the challenges of science; it's a huge commitment to dedicate yourself to research and compete for funding. There isn't a lot of funding, and you can spend a ton of time writing grants and they may not get funded because of competition. That's fair, but it can really be a challenge.

 

7.      I’d like to move on to residency now, if that’s okay with you. What in your opinion makes a competitive ENT applicant? What are you looking for?

I feel that the challenges of otolaryngology specifically derive from the fact that the pool of applicants is so great. Applicants need to meet the academic criteria and once they have that, what we’re really looking for are reliability and communication skills. We generally need to know that we can rely on the information that we are getting. When you're counting on someone to take care of your patients, you want to know that the information you get is accurate and if there’s something going on. You need to know that you will get that information. Communication is really important because you need to be able to know that you can talk to somebody and can rely on them to talk to you.  In a busy practice or in a busy residency program, being able to effectively communicate is extremely important, because it's going to prevent breakdown of the system and problems. So those two things are the most important things that we're looking for in general and a lot of the application process is about trying to figure out who has that.

The academics are important, just because of the competitive nature of the field. Also, we are obviously looking for some technical skill among surgeons, and the only insight interviewers have on that is the letter of recommendation and any information that comes from a student’s rotation.  You never know for sure based on the application, but fortunately it’s possible to build technical skills with training and practice if there is an issue. So, I would say that reliability and communication are probably the top two things.

8.      And how do you evaluate those? I mean obviously one thing is getting feedback from the program they're coming from, but other than that do you rely on the interviews or is there something else as well?

You have the process: the application, the personal statement, and their letters. After that, you have the interview. You take the information that you have in the 15 or 30 minutes of that interview. There is a benefit of having done it for a long time; many of our interviewing faculty interviewed many, many applicants over several years. That experience helps a lot in general too. However, I would say that many of the people that apply are excellent candidates, and so there is a high probability of winning.

 

9.      What's the role of research in the selection process? Do you expect it, do you request it?

It certainly has become an additional standard that research is going to be in the application. The question is really in what and how much. I think that we generally like to see that they have a few publications. That's going to obviously make you stand out, because if you think about it, you don’t really know the quality of a project that has never been presented or published. You don't know how to assess that. But if we have something that has been presented at a good meeting or has been published, then we know that at least somebody has reviewed it. When its peer reviewed, that gives you an idea of the quality and level of effort indicated by the authorship position of the applicant. It tells you that that person has gone through that process and experience, and they’ll bring that skill to their residency.

So, what we're looking for in addition to a good application is a skill set. If an applicant brings a skill to a program, they're going to add that in and that's going to help that program grow which is valuable! We really value those kinds of things.

Now a lot of students worry about having publications in another specialty. That doesn't even matter because evidently they've chosen to go through ENT. So what if they changed their mind as a second year? I don't think you have to have your whole life figured out! What matters is that when the time came to apply, you chose Otolaryngology. So to me, a student that has two or three publications in some other field is better than somebody who has no publications but did research in Otolaryngology. There is just more value there! None of those things are deal-breakers, but I always advise the students to not worry if their research is not in Otolaryngology.

 

 

10.   Isn’t it better though if it is in Otolaryngology? You know, in terms of proving your commitment and dedication?

Yes, but at the same time most of our students are young. They’ve only had two and a half years since graduating college to really get it all figured out. I'll tell you that when I started medical school, I didn't know there was a separate field called Otolaryngology; I had no idea! I figured that out as I went through the process. So yes, I think it is better if it is in the field. That would be great. But also, to me the most important thing is that they show that they have the skills to accomplish something like that.

It's like using being an Eagle Scout as a good predictor of success in life, right? I think showing that you have that skill or ability is more important than what field or specifically it was in. Obviously, it's not the same for everybody. Demonstrating that you have a long-term interest and expertise (i.e., having a PhD with a background in Otolaryngology) is going to bring you to a whole new level in terms of skillset. But the main thing is being able to publish.

 

11.   Do you consider IMGs in your program? What does it take to consider one?

I don't think it's necessarily a deal-breaker. We have had some international research fellows apply. When I was a fellow at the University of Miami, they had taken international graduates as well. So, I think that’s not necessarily a deal-breaker. It's a challenge mainly because you're competing with the big pool of American graduates, but it's not impossible. It generally takes time though. The rate, if you look statistically, is going to be lower because it's a small field. But again it's not impossible! It just takes the right person, the right skillset, the right background and it has to present as an opportunity to a good program. We have interviewed international graduates but again, those were handpicked people.

 

12.   You mentioned deal-breakers so I want to go on the other end of this spectrum and ask you what would make someone stand out. Is there something that you saw at some point and impressed you about an applicant?

I mean the standouts mostly come from the clinical experience we have with people. There are many standouts when it comes to the application, right? Some people have amazing scores or sometimes people have an impressive list of publications or some other very unique experience. I always tell people to try not to stand out with their personal statement. You want to have a very clean personal statement, because it can be a real pitfall.

But sometimes there is something in there that catches your eye such as a unique experience. But I think the way that people stand out on the applications is with the number of publications, their background, or if they have an extensive experience in otolaryngology research or some other area. Sometimes the interests and hobbies can stand out but I would say that on most occasions, it's with research.

The board scores vary greatly but the most obvious way for people to stand out is when they spend time with us. When they do a rotation with us, that is where we get to know their commitment, interest, and expertise because you can interact with them in real time. Sometimes people will take on a project with you, do research with you, and they will just really wow you! They will write something or come up with something on their own that’s very high level, so there are different ways that people impress us or stand out, but those are the main things I think that we think of.