Dr. Zara M. Patel, Department of Otolaryngology, Stanford University School of Medicine

 

Dr. Zara M. Patel, MD

Professor, Department of Otolaryngology and, by courtesy, Neurosurgery,

Director of Endoscopic Skull Base Surgery

Stanford University School of Medicine

Dr. Patel completed her residency at Mount Sinai, NY. She then pursued fellowship training in Rhinology and Endoscopic Skull Base Surgery at Stanford. She has served as Chair of the Education Committee and Member of the Board of Directors for the American Rhinologic Society. Dr Patel has published extensively in endoscopic sinus surgery, chronic rhinosinusitis  and olfactory dysfunction and her work has approximately 4,900 citations from other researchers.

 

 

My first question for you is why did you choose to specialize in Rhinology/ Skull base surgery? What was that attracted you in the field?

Well, when I first found out about ENT as a specialty, as a medical student, it was really by chance. I was doing an elective rotation my first or second year, I believe, and that was when I was in medical school at OHSU in Portland, Oregon. And I just happened to be put with Peter Hwang, who was a Rhinologist there at the time. So he was my first experience with ENT in general. And of course, as many people know, Peter is a wonderful person, became a wonderful mentor, really showed me all the exciting things about Rhinology and showed me that the people in Rhinology are my type of people, and that is what attracted me in the first place. And then, of course, as I went through residency, I really loved all the subspecialties of ENT. I think operating in all the different parts of the head and neck and the ear and the throat and the facial plastics, all of that is really fun and rewarding in different ways. But probably the thing that kind of sealed the deal was when I was in training, skull base surgery was still really in its infancy. You know, we were still just being able to expand the corridors away from the pituitary to the different parts of the skull base. And new techniques of reconstructing the skull base were being published all the time. And so it was a really exciting time in skull base surgery where you really felt like you were on the cutting edge when you were operating in that area. And that's probably what sealed it for me.

 

I see. I've had Dr. Carrau a few weeks ago, and he was telling me about this. It was really, really exciting to hear firsthand how his and other groups during that era, expanded from the pituitary to other areas and skull base. And of course, we had Dr. Hwang in Grand Rounds also a few weeks ago, and he gave a terrific lecture there. Is there something that you don't like about the field? I'm talking about the rhino skull base. I know it's a weird and probably a tough question or that you wish it was different, you know?

Yeah. I don't think that there's anything I don't like. You know, I think that there is still so much room for improvement in the type of research that we do in this field. And that might be one area that I would say we can work on. You know, in Rhinology, the level of research, especially on the basic science side, but even in our clinical research is not as high as in other areas of otolaryngology or medicine. It is it's still very rare to see randomized controlled trials published in Rhinology. I would say my randomized controlled trials are some of the few, and there are certainly others. But compared to head and neck surgery, compared to oncology, we're still behind as far as the overall level of research that we're doing in the field. And so, I think that that's an area that we can continually work to improve.

 

So, the level of evidence could get better. I understand what you're saying.

You have an extremely successful academic career, and I've noticed that you hold several leadership positions with Stanford, with ARS and with the Academy of Otolaryngology. I know that there are barriers that you may have faced as a woman in the field of medicine and surgery. How hard was it for you to get established and get the recognition you deserve in the academic surgery world ?

Well, I would say it's hard to step outside of your own reality and look at it from the outside. But I would say, you know, I've been lucky to have good mentorship and sponsorship throughout my career. And I do think that it's not always obvious to people what the barriers are that you're going through, because there are small but daily types of barriers that you're constantly encountering as a woman, especially in a surgical field. I would say the way in which you're expected to interact with your patients, the way in which you're expected to interact with other surgical staff in the operating room, the way you're expected to interact with your colleagues, both your peers, the colleagues above you, the colleagues below you that you're supposed to be teaching, like residents and students. There is an expectation. And of women in general. I would say in any profession, in any field, because of the broad cultural, societal expectations that we hold of women. And it's not just the expectations that men hold of women. Women hold it of other women as well. You cannot escape the way that you've been raised and the way that that has shaped your overall thought processes. You can work to break out of what you've been taught or what you've sort of accepted as a cultural norm. But it's pretty difficult to do that even when you're very aware of it, and most people are not really aware of it. And so I would say in that way I think not just myself and not just women in surgery, but women in general tend to have to prove themselves to be, you know, ten times better than the person next to them to be able to be accepted as an expert in whatever area it is.

 

And particularly this aspect that you're bringing up there, the fact that it's frequently internalized and it's not only imposed by others, is very important, I think. Did this experience change your perspective, how it affected the way you see things today, all these potential adversities that you have to overcome?

 

I think it hasn't it hasn't really changed my perspective. I've certainly grown more tired of constantly having to deal with things like that. It doesn't really faze you when you're younger because you have more energy and you haven't already dealt with it for a decade. After dealing with for a decade or more, it certainly it wears on you after a while, which is why probably there's higher levels of burnout among women physicians and so on and so forth. But I do think also, you know, as you become more advanced in your career, especially in an academic setting, and you have women below you as medical students and residents, you feel more of a responsibility to speak about it, make other people aware of it. Ask for change in institutional settings, not for yourself, because I think it's much harder to ask for things, for yourself, for all of us. In medicine, we're used to just putting our head down and getting through and doing what we can with the situation at hand. But it is much easier to ask for things for your trainees because you realize you don't want them to have to go through what you went through.

 

Yes. And I think it's really admirable of you to say that- to fight for the next generation. Now, obviously, I have never faced the gender discrimination issue, but coming from an IMG background, I've had to overcome several barriers myself. So I think I can somewhat relate to the experience you are describing here. What does Stanford as an institution and as the Otolaryngology/Head and Neck department do to promote equity and diversity? Have there been any initiatives?

Yeah, certainly. I think Stanford overall as an institution is really good about keeping it at the forefront. And our department is in line with that institutional vision. Every department at this point at Stanford has a diversity equity inclusion representative and committee who are constantly trying to think of ways to address these barriers, not just gender, but also for underrepresented minorities in medicine, and really keep that at the forefront of our minds whenever we're doing anything else. So when we're interviewing for residency, when we're interviewing for a faculty position, when we're thinking about promotion or any of those things, it should be in mind. Now, of course, it's not to the exclusion of anyone else. You know, I unfortunately hear people as a response to initiatives like that say things like “well, it shouldn't matter. Any of those things shouldn't matter. It should just matter how excellent the candidate is”. Right. But that sort of takes away any awareness of the barriers that people face in order to prove their excellence and the opportunities that they may or may not have had to grow into excellence. And so I think that just having the awareness that those barriers and lack of opportunities have been there for some people versus other people is important. And Stanford's good about that.

 

When I hear people saying that we have to look only for excellence, and ignore everything else,  I think it's somewhat a covert way to say that “I want to keep doing what we've been doing for decades”. I'm inclined to believe that sometimes that's what's behind that. But it's really nice to hear you saying that you’re evaluating not only where someone is, but also where they began and the distance they they've traveled from there. Now, you brought up the residency and residency applications. And I'm curious to ask you if there are things that can actually make someone stand out in your eyes. And on the other hand, if there are red flags or things that drive you away when you read an application or when you interview an applicant.

Yeah. So I think things that stand out in applications are how personalized the application is to Stanford itself. I know it takes a lot of time to change things about an application because people are now applying to so many different residencies. But it does make a difference when someone can explain exactly what it is about Stanford that they feel they would really be able to take advantage of that. They've done research about what makes us special and unique and what they think that not only they would be able to take from that, but also what they would be able to bring to that type of environment or situation or program. So, I think those are things that make an application stand out. We are a very academically-minded program. I don't want people to think that it's the wrong choice to go into private practice after residency. But there are certain residencies that are really trying to train the next generation of academic leaders in our field. And that's what Stanford is like. And so, if someone wants to go on and become an academic leader, which is often a sub-specialized type of position, then Stanford is a really good place for them to come. We certainly have residents every single year that go into general or comprehensive private practice. So it's not like that doesn't happen. But to really take advantage of, and use Stanford as a springboard for the potential that it has the capability to allow you, future academic leaders in the field is really what we're excited about and what we're looking for. As far as red flags, I think that most people don't have red flags in their written application. It's much more when they when they're actually interviewing that you pick up on red flags. And, you know, I would say the main things are when you realize either through something they've said, or in the way that they're interacting with you or with other people, with other applicants or with other with the residents that are interviewing- any of those situations- that they are not a team player, that they don't know how to take personal responsibility, that they can't see examples of failure as opportunities for growth. Those are maybe red flags because, you know, it's a long, hard road. You've already been through so much training yourself and there's more training to go. And at a certain point, you need a high level of resilience to continue to go through that because times can get hard and things won't always seem fair and interactions with either patients or other colleagues, either within your own department or other departments, are not always exactly the way you want them to be. And to have the fortitude to deal with those situations gracefully, learn from your own mistakes, understand that you are capable of making mistakes, I think all of those are really important qualities to be able to get through that training process.

 

I understand. Obviously, Stanford is one of the of the academic leaders in the field, and it's very academically oriented. I'm curious to hear how important is research for residency applications? And as a second question, I know we always have this discussion about quality versus quantity in research. Now, I understand that it's really hard to evaluate that in 400 applications, but I'm curious if you have any thoughts on that as well, and if you valued more the one or the other, actually.

I think we always value quality. Now, of course, it's hard to evaluate that honestly on that many applications because there is not time to read every single paper of every single application. And so certainly things that stand out are being first author on publications, which represents the amount of time and effort that the applicant has actually put into that particular publication. That's much more important, If you have a few first author publications in high quality journals that will be looked at better than many, many middle author publications in low quality journals. So there are some obvious types of comparisons that you can do like that. But overall, it is a very difficult thing, I think. I think all of you guys are really, really good and people are doing more and more research. And earlier and earlier during training and trying to publish more and more. I think it is a difficult competition to be in. And I think that's why it's not the only thing that we look at. Certainly, it's important to us, but it's not the only thing. And, you know, there are certainly people that we've accepted that had lower numbers of publications than other applicants because we felt like they simply had a better feel for the program, better fit to our program. So there are many different factors that go into it. But it's true that certainly research is an important component of an application.

 

Can you mention other things that you feel are very important? You previously mentioned some of the things that might be red flags. So, inferring from that I can understand things that are important for the program. But is there anything else that you can think of that is very important or factors in during the process, besides research?

Yeah, I would say a lot of applicants have sort of varied educational background, so it's always interesting to see when people have a background in something other than a traditional biology or chemistry type of background. It's also interesting to see what they've been able to do with whatever it is, whether it's biology or chemistry or engineering or computer science type of background. If they've been able to utilize that skillset once they've entered into the medical world to create sort of innovative lines of research or taken advantage of programs that allow them to develop that background into a way in which they could utilize that in medicine in their careers. That's always interesting to see.

And then, I would just say the earnestness of an applicant. It's very easy, especially when people are so accomplished, to come off as arrogant, or like they know they're the best candidate and that can be slightly off putting, and it can downgrade how excellent their candidacy appears. Being earnest and being humble about your qualifications and your experience sort of allows other people to applaud them more. So, all of those things, I would say are important.

 

I wonder, did you have any experience in the program with IMGs? I wonder if Stanford ENT had one in the past or if you would consider one.

Yeah, we have had them in the past and we do consider them strongly. You know, we really try to understand all the hoops that you have to jump through to just get to the same level as someone that's trained here in the US. Outside of that, we really just compare the applicants equally. If an IMG has just as great of an application as a US candidate, then they would be considered just as highly. We've certainly had IMGs come through before. I would say that often the ones that have been successful in matching have had some time at Stanford. So the one that jumps to mind is Do-Yeon Cho, because he just came and gave us a Grand Rounds this last week. But, you know, he had completed an entire ENT residency in South Korea. He came in, was a visiting scholar with Peter Hwang for at least a couple of years, was probably one of the most prolific publishers of all the visiting scholars that we've had, did a ton of research and published a ton during those two years. And so really proved himself, you know, not just to Peter, but everyone that was interacting with him, the residents that were going through the rotation that he was doing research with and interacting with his personality and his teamwork and his dedication to sort of proving himself. All of those things came together to allow him to match into our residency that next year. So, I think that that definitely does help. But there are other IMGs that we have matched, that did not come through Stanford. So yes, there's definitely been IMGs that we have matched before.

 

Now moving on from residency applications, I wanted to ask you, going back to research and clinical practice: Where do you see the field going on over the next years? You mentioned better and more clinical trials, so I'm curious to see if there are other things that you have in mind in clinical practice and research, that you want to see happening in the field.

Well, I think, one thing that a lot of people will say is that it's so difficult to run a clinical trial involving surgery because, if you are not offering surgery to a subgroup of patients, they'll go somewhere else. They don't want to be “excluded”. There's a lot of different reasons why it's hard to run randomized controlled trials in a surgical practice. It doesn't necessarily mean it's impossible though. And as we can see from many other fields, patients are willing to enroll in trials. And so I just hope that that becomes more of a standard of how we evaluate interventions versus how we currently do, which is much more commonly sort of either retrospective studies or prospective cohort type studies, which are good also, but just not at the same level of evidence. There is definitely a place for research like that, and I also continue to do research like that, but they're susceptible to certain biases that we all know and are aware of. And so I hope that the level of evidence continues to improve.

I also think that there's so much room for more basic science and and translational type research in Rhinology. And as we graduate more and more fellows with basic science and translational backgrounds, I think that that is going to become part and parcel of our field. Certainly, we have fellows that we've graduated that now have their own labs and are able to move the field forward in that way. And I'm really happy to see that.

As you may know, I've been doing research in smell disorders for over the last decade. However, until the pandemic, not so many other people really cared about that. I think that one thing I expect now, is a lot more people understand how important smell is. And I expect that we're going to see a lot more people doing research in it. Now, there is a downside of that, something I am actually seeing now is that a lot of people are doing research without having read the literature very thoroughly. So, they're just repeating studies that we did ten years ago and actually not doing them as well, because they don't understand the factors that you have to control for, which are specific to smell disorders versus chronic sinusitis, for example. So, it's great to see a lot of new interest and energy in that field. But it's a little frustrating to see people not actually go to the literature and see what's already been done and established and instead just kind of putting a lot of time and effort into studies that are not well controlled. And unfortunately, we cannot actually make good conclusions from those types of studies, which therefore will not move the field forward. So, hopefully that will continue to evolve and change, and people will understand how to do better research in that area as well as we move forward.

 

I agree, it's very important to build on what's already been out there or at least be aware of it. Thank you so much for this wonderful opportunity to interview you and get to know more about your career!