Podcasts about clinical practice committee

Advanced practice providers (APPs) are a key component to effective team-based care, but what is it that our APP team-members can do in an oncology practice? Join the Co-hosts of the APP podcast series, Todd Pickard (MD Anderson Cancer Center) and Stephanie Williams (Northwestern University Feinberg School of Medicine), along with guests Wendy Vogel (BroadcastMed/APSHO)) and Tammy Triglianos (University of North Carolina Basnight Cancer Hospital), as they highlight the services and examples of what APPs in oncology can do, their role as an APP in team-based care, if and how they bill for their services, and how they are reimbursed.  Speaker Disclosures: Stephanie Williams: Consultant or Advisory Role – CVS Caremark Tammy Triglianos: Consulting or Advisory Role – Pfizer Todd Pickard: No relationships to disclose Wendy Vogel: No relationships to disclose  Resources: Podcast: Advanced Practice Providers - APPs 101: What and Who Are Advanced Practice Providers (APPs)? Podcast: Advanced Practice Providers – An APP's Scope of Practice Advanced Practice Providers - APPs 101: Physicians Assistants (PAs) and Advanced Practice Registered Nurses (APRNS) in Oncology If you liked this episode, please follow the show. To explore other educational content, including courses, visit education.asco.org. Contact us at education@asco.org. TRANSCRIPT The disclosures for guests on this podcast can be found in the show notes. Dr. Stephanie Williams: Hello, everyone, and welcome back to the ASCO Education podcast, and our fourth episode of the Advanced Practice Providers series. I'm Dr. Stephanie Williams, a medical oncologist, and your co-host for the series, along with physician assistant Todd Pickard. We'd also like to introduce you to our guest panelists today. Returning guest, Wendy Vogel, along with Tammy Triglianos. We'll take a moment to let them introduce themselves, starting with Wendy. Wendy Vogel: Hi. Thanks so much for having me today. I'm Wendy Vogel. I'm an oncology nurse practitioner by trade, and I am the Executive Director of APSHO, the Advanced Practitioner Society for Hematology and Oncology. And thanks for having me here today. I'm really excited to be here.  Dr. Stephanie Williams: Tammy.  Tammy Triglianos: Hi, everyone. Thank you for having me. And I'm excited to join this group for our conversation today. I'm Tammy Triglianos. I am a certified oncology nurse practitioner practicing in North Carolina. My career has been dedicated to caring for oncology patients, even starting out as a nursing assistant and then as a registered nurse practicing in a variety of settings. I've been a nurse practitioner for almost 20 years now, with the past 15 specializing in GI medical oncology.  Dr. Stephanie Williams: Thank you.  Todd Pickard: Thanks, everybody, for being here today.  Dr. Stephanie Williams: In today's episode, we will be highlighting the services and examples of what advanced practice providers in oncology can do and describing if and how they bill for their services and how they are reimbursed.  So let's get started. Wendy and Tammy, I'm starting in my clinic, 8:30 in the morning. We have a full panel of patients, patients who just need reassessment, chemotherapy prescribed, reevaluation, bone marrow biopsies, test results. How do we work together to see, as a team, these particular patients, or in other words, what can you do to help me through my days as an oncology practitioner?  Wendy Vogel: Wow, that's a great question to just jump right in and start with. I'm excited to talk about that. Well, I think that, you know, as we always are talking about our team approach, we would look at that schedule. And hopefully, the AP and you have their own schedule so that we're able to divide and conquer and be able to accomplish that schedule, see all the patients in the most efficient manner possible. Hopefully, I've looked at all my patients beforehand and see if there's anything that I need to collaborate with you on. Looking at our labs, you know, maybe scans, talking about any changes in plans that we might anticipate together, and so on.   Tammy, would you do the same?  Tammy Triglianos: Yeah, I'd like to echo your point, Wendy. Having independent schedules, I think, makes for a more efficient workflow in the clinic. And in my practice we have a team meeting with our clinical pharmacist, physician, myself, and our nurse navigator, and review last week's and even prep for the upcoming week, trying to anticipate and make sure people are set up and orders are in, and we're prepared for the week to come. Day of, as you know, can get pretty hectic. But since we've done a lot of that prep work, I think it makes for the unknowns that pop up in clinic easier to connect with each other, with my physician and other team members.  Todd Pickard: I agree. I think the great thing about how physicians and APPs work in teams is that the team can decide what's best. I have done everything from having my own independent template so that I have patients that I'm responsible for to a general template where the physician and I just divide and conquer at the beginning of clinic, and we say, “Okay, you see these patients, I'll see these patients, and we'll back each other up if we need to.” All the way to seeing every single patient along with the physician when we are seeing a lot of news and consults, very complex, very acutely ill patients. And we basically just work as a team the entire day on everything.  So it's really interesting about the conversation that I think we'll end up doing today is the “what” versus “how.” What APPs do is– really, honestly, APPs can do anything and everything unless a state scope of practice or an institution's policy specifically says they can't. That's the good news is that we pretty much can do everything but the “how,” that's a really interesting question because a lot of different things come into play. Position preferences, which could be influenced by their own personal experience or their own personal preferences of style versus, you know, having a misunderstanding of what APPs can and can't do. Then there's the institutional policies and the state scope of practices that come into play. So I think this where we'll end up spending some time today.  And, you know, Stephanie, maybe we could start the conversation with you a little bit around physician preferences and what your experience has been, and some of the things that you've noted around the physicians as part of this team.  Dr. Stephanie Williams: I've worked with APPs, both inpatient and outpatient, and I think it is very important to have that team-based approach. Patients really appreciate that, knowing that there is always a provider, someone there that they can turn to. And I think that's one of the great things about APPs is they always seem to be there for patients to turn to and for our nurses to turn to, to get help too. Both our clinic nurses, our infusion nurses, and our inpatient nurses really appreciate having that extra clinical provider available to them. I think as a physician, during my day, what I would like to see is us getting through our panels of patients, whether we're together, which is not as efficient as if we're independently seeing patients, but also help with things like procedures that need to be done on patients, phone calls at the end of the day, peer-to-peer reviews in order to get either medications or tests done for our particular patients. Filling out forms, no one likes doing that. No one likes filling out disability forms or other insurance forms, but those are all things that we all need help with in terms of doing. Ordering consults, seeing new patients together. I work in the transplant field, so they're complicated patients, so it actually is very helpful to have, to see a patient with your advanced practice provider so that you can come up with a treatment plan together that you know you can then follow throughout the course of hopefully that patient's treatment and recovery. Chemotherapy orders is another place that we need, that can be very valuable, whether it's the initial chemotherapy order, which were usually the physician or pharmacist initiated, but those follow-up chemotherapy appointments or problems in the infusion clinic are also helpful areas.  There are some physicians, though, who want to have an APP simply as their scribe, to follow them around in clinic and to then begin whatever orders they feel is appropriate for that particular patient. That is not the most efficient way to see patients, particularly when you have a large panel of patients that you have to see.  Wendy Vogel: Exactly. It really isn't. I will just tag off something you said about the AP being the scribe. That's probably one of the most expensive scribes that a physician could employ, and what a better use of our time is to not be a scribe. You know, there are other people who could really efficiently be a scribe better than the AP, and the AP could actually be seeing patients and gaining reimbursement for the practice.  Tammy Triglianos: An additional comment on team-based care. I work with a physician where we alternate visits, and I think that has really worked well in establishing a relationship with patients. We both have very high touch points with the patients, very involved, and patients feel like there's that team that's always available because always one of us is usually available. Dr. Stephanie Williams: How long did it take you all, all three of you, to develop that relationship with your physician colleagues to work tightly in a team? Todd Pickard: That's really a great question, Stephanie, because I think one of the strengths of the relationship is that level of trust and comfort and not really to view it as a hierarchical relationship, but really a team. We're there for each other. And you know, that depends, you know, there's personalities involved, people's previous experience, you know. If you've only had great experiences with APPs, probably trust them right away. If you've had difficult relationships with APPs or teams that didn't work well, it may take longer. I'd say the best approach is for both the APP and the physician to really look at this as, “How can we accomplish our work together that provides the best quality and the highest level of safety for our patients?” And really just set the expectations of ‘this is a trusting relationship where we work together, we support each other, and we're willing to talk about where the limits of our knowledge are. And for both of us, that's when we get consultations with other folks, and so we just approach it from this perspective.' And of course, you know,over time, that just strengthens and grows. And when you have a really good, strong, trusting relationship, that's where the real power of the team comes into play. Wendy Vogel: I like what you said about trusting. You know, the AP has to trust in the physician to be able to go and ask questions and to be mentored, and vice versa, too. I think we play to each other's strengths. If my strength is talking about hospice to a patient that needs to change trajectory of course, then maybe that's what I do better. And there are other things that another team member would do better, but feeling comfortable and saying, “You know, this is what I do good,” or, “Hey, I need help with this. I don't do this as well as I would like to.” Dr. Stephanie Williams: Tammy, anything? You said you work with one physician. How did that develop?  Tammy Triglianos: Right now, that's my current setup because of volumes, but I have worked with a team of physicians as well, which, when you're an APP working with a team of three, four plus physicians, that can kind of get a little bit tricky, people fighting for your time. I think being in parallel clinics has helped establish our trusting relationship because all day long, you're with that person navigating care together. We've been together probably 14 years, so that's really dipping back into my memory bank of the beginning of our time together. But I think it's what Wendy was talking about is just approaching each other with questions or, “Hey, why did you do that?” Or “Help me understand this.” And I think our approach to each other wasn't, “Why did you do that?” But, “Help me understand your thoughts on this.” Or “Can I talk through this with you to make sure I'm on the right page.” And how that response came back, then I think that has helped develop a trusting relationship.  Dr. Stephanie Williams: You both bring up excellent points because there still exists that power gradient between the physician, the advanced practice provider, and a staff nurse or an infusion nurse. And it's really important to overcome that so that people are comfortable in terms of taking care of the patient, to give the patient the best possible care that there is. Todd Pickard: Yeah, I mean, I think this is a great time to really just highlight the fact that there's a lot of misinformation and misunderstanding out there around APPs, what they can, what they can't do, what they will, what they won't do. In some corners, there's this fear that APPs will go rogue, and that will harm patients. And really, that is an irrational fear because when we are trained, we are trained very clearly about when you reach your own limits, that you are required and obligated as part of your professional practice to find that support, find those resources, get consultations, work with your team to understand so that you serve the patient. And I think it's really important that folks remember that with this respect and trust and accountability, because asking for help is not a failure. Asking for help shows a successful dynamic within a team so that the entirety of the team brings to bear their expertise, their knowledge, their skills, and their judgment. And when the team doesn't know what to do, that's when you've got to reach out to your consults and your other resources. So I think that's an important thing to remind everybody is that we're all here trying to do the same work, and it doesn't do any good if you spend a lot of time wondering, “What's Todd up to today?” So I think it's important to realize and for us to kind of dispel those kinds of myths. Wendy Vogel: I think, despite a social media post by one of our well-known medical associations that will remain unnamed, we don't think that healthcare is a game. We are absolutely serious about this, and we love taking care of our oncology patients. This is something that we're trained to do and that we want to work together as a team. Great thoughts, Todd. Dr. Stephanie Williams: In terms of actual practice in the states that you're at, are there any restrictions, either statewide, institution-wise, on what you can and can't do? Tammy Triglianos: I think a big topic that comes up a lot is signing treatment plans or antineoplastic treatment plans. And I don't know across the states, but in my state, that is not a state restriction. But not allowing APPs to sign antineoplastic treatment plans is more of an institutional restriction, and that varies. Recently, I was able to work with a team of people to update our policy to allow APPs to sign antineoplastic treatment plans and how it works at my institution, they go through a privileging process, so essentially it's an opt-in privilege. So, APPs can obtain approval to sign treatment plans, and it is restricted to cycle two and after. So the treatment plan initiation and signing the first cycle is done by the physician, and APP can place the treatment plan and get it teed up. But it actually is signed by a physician for cycle one, and then an APP is now allowed to sign beyond cycle one. We have a few guidelines like they have to be in their subspecialty practice and be manipulating treatment plans that are cosigned by the physician initially and have certain subspecialty training. So, yeah, I'm excited about this update to allow APPs to practice to the top of their license.  Todd Pickard: Stephanie, this is such an important concept and one that we have hit upon in all of our podcasts. And really, the limits of APPs outside of physician preferences are really state laws and institutional policies. And so, the answer to your question is ‘yes, and it depends on where you are'. So, for example– Tammy gave an example of what's going on in her institution. In my institution, all chemotherapy plans must have a double signature, whether it's initiated by a physician or a pharmacist, or an APP, and that's a safety and quality check. And so everybody just needs to understand, again, limits generally are only in state laws and institutional policies rather than what APPs are trained to do or what folks will reimburse for. And so, really, that's where you have to do the most detailed examination is: what state are you in and what does your institution or your practice say? Generally speaking, most states allow teams at the local level to kind of figure out what they want to do. Sometimes they'll limit a certain medication, like a schedule II drug or a certain other medication. Institutions sometimes do the same thing. But the good news is, if it's not explicit in state law, you can change institutional policy and physician preference all day long.  Wendy, what's your experience been?  Wendy Vogel: Oh, I totally agree. I think it's important for APs to know who's setting the institutional policies and for physicians to know this as well because it may be someone who is not familiar with what the AP role could really be. What do they know about the advanced practitioner? We mentioned that earlier. But I think it also brings up a very important gap that we've seen in oncology, is what's the training of the AP to be able to write anti-cancer therapy orders, and it's a wide variety. There are very few, for instance, nurse practitioner oncology certification or graduate programs. Most of us are trained in a generalist level as a family nurse practitioner. PAs, as you said before on this podcast, you are trained at a generalist level, and we get a lot of our specialty education on the job or through other advanced education. So we're coming into this at all different levels: brand new APs, brand new to oncology APs, and we've seen a gap at the educational level across the US is not the same.  One of the things that APSHO has done to relieve this, and I'm so excited to be able to share with you guys, is we've just recently launched the APSHO Cancer Therapy Prescribing Course. This, I think, will set the benchmark that we've just talked about and bridge this gap, and allow APs to really practice to the top of their licensure, as Tammy mentioned earlier. It's a very comprehensive online, self-paced course providing that advanced education to prescribe cancer therapies and to manage that hem/onc patient throughout the treatment trajectory. It does not just include the cancer therapies but other things we need to know as APs, like: what kind of drugs do we give with the cancer therapies, what are the standards of care, what do we do in clinical trials? And so just all this that we need to know, and I hope this will bridge that gap, if you will, for this education.  Dr. Stephanie Williams: Excellent points. I think it also requires physician education to know and understand what advanced practice providers can do. And I think an advantage to our younger generation physicians is that they are now growing up in institutions where APPs are normal, as opposed to older physicians like myself, where we really do have to learn what can be done and what can't be done so that we can trust what everyone is doing there. Todd Pickard: Are we normal? Yes. But what you really mean is that we're present. It's really about interprofessional education, and I think there's a lot of importance of that concept. If we're going to be delivering care in teams, we should be trained in teams so that you grow up side by side and so that way it does seem normal. I'm working in a team; where's the social worker? Where's the APP? You know, where's the pharmacist? Because that's how you trained, and that's how we really deliver care. That's the honest truth. No man or no woman is an island in medicine. We all work in teams, whether we recognize that or not. And so I think it's great when you hear about folks that are actually training side by side because it just dispels some of this anxiety, some of these misconceptions, and you're just used to the team being around, and it's like, “Okay, where's my team?” And then it doesn't become unusual. It's just normal. Wendy Vogel: Yeah, we're all sitting here nodding our heads together. You all can't see us, but we're all nodding. So, Stephanie, I really want to know, how do you educate your colleagues who might not be as receptive to the idea of an advanced practitioner writing cancer therapy orders? Dr. Stephanie Williams: I have to tell you, it's difficult sometimes, Wendy, or it has been difficult in the past. The problem becomes not so much a “do you know what you're doing,” problem is how does the reimbursement - I hate to say this – how does reimbursement figure into all this? If I let an APP see half of my patients, who gets that money? And then the other thing is just how do I efficiently use an APP? And we are trying, and  ASCO through the Clinical Practice Committee, to try to get out there and reach out to practices, particularly rural practices, to help them understand the role and the value of advanced practice providers. And I think it's going to be a reach-out effort, leading by example, showing people that this is the way we can do it and we have to do it this way because we need practitioners out there to take care of patients. Todd Pickard: I want us to all pause here because what you just talked about is critically important. And we all know this is part of medicine, whether we like it or not. But reimbursement, how we get paid, and productivity, how we are recognized for what we do, are concepts that sometimes get mixed up. So when you're talking about reimbursement, APPs are reimbursed just like physicians for everything that we do. Depending on who's paying the bill, they may reduce that reimbursement. So CMS reduces generally to 85% of the physician fees. Medicaid is all over the place, depending on your state and the third-party payers, like the commercial insurance, that's based on whatever you've negotiated in your contract. Sometimes it's a little, and sometimes it's the same. So APPs get reimbursed, period. What level they get reimbursed compared to the physician's reimbursement is really up to a lot of different factors.  But productivity, I think that's the thing that we really get hung up on is, well,who's going to get credit for this work? And guess what? The beauty of that is you get to decide. Every practice, every institution makes up those rules. And so, you know, the take-home message here is, don't confuse reimbursement with productivity. Reimbursement is a lot of external factors that are either statutory, or they're contractually negotiated. But productivity is an internal accounting, and you can use team-based metrics. Who's to stop you from saying ‘we reward and recognize both the physician and the APP in these teams.' They both get credit, and they both get productivity measurements and recognition. And so I think that's where we really need to drive home the message is it's not about setting each other up as competitors. It's redesigning our internal productivity measures so that it's collaborative and that all the work that's being done by the entire team is being recognized and rewarded. Wendy Vogel: A lot of what we do, as Stephanie referred to earlier, is not reimbursable. All those peer-to-peer reviews, we don't get paid for that. None of us do. Calling patients back, liaisoning with the nursing staff, and answering their questions through the triage line, so much of that is vital to supporting a practice, and you can't do it without all that, but it doesn't appear on the bean counter's metric sheet. So how do we do that? I don't have the answer to that. Tammy Triglianos: Yeah, and I think in oncology/hematology, there's a lot of frequent touch points in between provider visits, and that doesn't equate to money, but equates to high-quality care, to have access to skilled providers to help manage all the complications, and, you know,in between stuff that happens between provider visits. Dr. Stephanie Williams: Wendy, there have been changes now in terms of who can enroll and write treatment orders for patients on cancer clinical trials. Could you go over those changes with us and how APPs can now fully participate in this process? Wendy Vogel: So there were some recent changes to CTEP and then now allowing APs to sign clinical trial orders. This is huge because it really makes the process of getting patients their drugs in the infusion suite much quicker. We don't have to track down a physician to sign those clinical trial orders. The AP can do that. And so this process is made much smoother. I think we'll see a lot of other cooperative groups and institutions follow suit with this. And I think this was a real demonstration of the AP's quality of care and the safety of AP prescribing and being able to have this privilege. Todd Pickard: Well, this has been a fascinating conversation today, and I would like everybody to have a final say. What's your take-home message today about what APPs can and can't do. And Tammy, we'll start with you.  Tammy Triglianos: Thank you. This was a great conversation today. Happy to be a part of it. Know that APPs with supportive, appropriate training, and, you know, I just have to shout out to Wendy and APSHO for the chemo prescribing course. I think this is huge for bridging a gap. Lots of education programs don't have oncology subspecialty, and this is such a comprehensive course that bridges a gap that I think will be huge. And I hope every oncology cancer center adopts, incorporating this to elevate the education and offer some subspecialty education to our oncology APPs. Kudos for all the team-based care and physician and APP teams out there that are really working hard to care for our cancer patients. Todd Pickard: Wendy, what are some of your final thoughts? Wendy Vogel: I have to agree with Tammy. I'm really excited about the APSHO Cancer Therapy Prescribing Course. I think that we can, together as a team, really make a difference in cancer care, playing to each other's strengths, and I think that would be my takeaway is: how can we better play to each other's strengths? Todd Pickard: Stephanie, what about some of your final thoughts? Dr. Stephanie Williams: I think working with APPs is critical to the success of any medical practice and to any physician who takes care of patients. Todd Pickard: Well, I appreciate all the insights. And just as a reminder, APPs and physicians, generally speaking, can decide whatever they want that is best for the practice, best for their patients, and delivers high-quality and safe care. Just be aware of your state regulations and find those institutional policies that are holding you back. Good news on the institutional policies - you can change them just like you can change your productivity metrics and models. So the good word is APPs and physicians can work in amazing teams, and we have all the power at our disposal to do so.  Well, I want to thank you to my co-host, Dr. Williams, along with Wendy and Tammy, for joining our discussion today and sharing all of your experience and highlights into the services that APPs can deliver. It's clear that APPs and physicians working together in teams are vital to a strong and efficient delivery of our team-based care.  Well, until our next episode, thanks, everybody, and take care. Thank you for listening to the ASCO Education Podcast. To stay up to date with the latest episodes, please click subscribe. Let us know what you think by leaving a review. For more information, visit the Comprehensive Education Center at education.asco.org. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions.   Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

This video features Dr. Catherine Larson-Nath, Pediatric Gastroenterologist, Director of the Intestinal Rehabilitation Program and Director of the Pediatric GI, Hepatology, and Nutrition Fellowship Program at the University of Minnesota. Dr. Larson-Nath interest in nutrition began in medical school, and she shares how she was able to tailor her fellowship for nutrition training. Dr. Larson-Nath incorporates rounds time in the ICU with her multidisciplinary nutrition team on “Weight Wednesdays.” Besides clinical work, she is working on research using ultrasound to look at patients' body compositions to see the impact of nutrition interventions. She credits ASPEN for providing her with mentors and opportunities to grow professionally. She has worked on many committees, including the Certified Nutrition Support Clinician committee, where she was able to advocate for pediatric questions on the exam. She's currently the president of the Clinical Practice Committee, an associate editor for NCP, and is working on the next edition of the Pediatric Handbook. She laughs that it was ASPEN who introduced her to a fellow physician at her university and how it resulted in a new project. Physician Spotlight is a forum for outstanding Senior Leaders, Young Rising Stars, and International Colleagues in the field of nutrition to discuss important topics and ideas that impact patient care. Visit the ASPEN Physician Community at www.nutritioncare.org/physicians January 2023

Elliot is an intensive care nurse practitioner, working at Royal North Shore Hospital in Sydney NSW. Elliot has worked in ICU for 10 years, and has post-graduate qualifications in critical care, and a Master of Nursing (Nurse Practitioner) from the University of Sydney. Elliot has sub-specialty interests in vascular access and extracorporeal membrane oxygenation (EMCO). He is a member of the ACI NSW ECMO Advisory Group, runs the ECMO course at RNSH, and is the nursing lead for ECMO in the ICU at RNSH.Elliot has been involved in post-graduate teaching for many years, initially as a Clinical Fellow for the Faculty of Health at University of Technology, Sydney, and now for Sydney Nursing School, Faculty of Medicine and Health at the University of Sydney as a Casual Academic. In this role, Elliot teaches on the Nurse Practitioner Master Program, and has helped with subject redesign.Elliot is also a member of the Clinical Practice Committee for NSW Ambulance Service, where he provides expert advice relating to nursing practice and his relevant areas of specialization. He is also assisting NSW Ambulance with a research project currently, and is a key advisor on nursing matters in general for the organization.Elliot has an interest in research, having been involved in numerous local studies, site co-investigator for a large multinational registry study, and has authored a number of papers related to vascular access and the ICU Nurse Practitioner model of care.

On this episode of Transmission Interrupted, NETEC continues its series on Long-Term Care in the age of COVID by welcoming Dr. Anna Fisher, Director of Quality & Education for Hillcrest Health Services, to the podcast. Dr. Fisher joins host Lauren Sauer to discuss the Long-Term Care Continuum. Topics include the facilities and services that comprise Long-Term Care, and NETEC's effort to develop training and education resources to strengthen the Long-Term Care community.Questions or comments for NETEC? Contact us: info@netec.orgFind us on the web: netec.orgGuestAnna Fisher, DHA, QCP, CMDCP, CDPDr. Anna Fisher, DHA, QCP, CMDCP, CDP, serves as the Hillcrest Health Services health, quality, and nursing services education expert for business lines that include assisted living, memory support, adult day services, in-patient rehabilitation, outpatient therapy, home health care, private duty, telehealth, palliative, hospice, and skilled nursing care. Dr. Fisher is also an adjunct professor in the College of Arts and Sciences at Bellevue University, a board member of the Bellevue Public Schools Foundation, Hillcrest Health Services Foundation, and co-producer of the NET Television program series, Now What?, about elder care and dementia. She continues to serve as a Clinical Practice Committee member, Emergency Preparedness Committee member, and Quality Award Senior Examiner for the American Health Care Association (AHCA) and National Center of Assisted Living (NCAL). Dr. Fisher is also Chair of the Omaha-Metropolitan Healthcare Coalition (OMHCC) Non-Hospital Healthcare Workgroup, a member of the Pioneer Network Artifacts 2.0 Advisory Group, the Nebraska Culture Change Coalition, and the Developmental Disabilities Aging Coalition.HostLauren Sauer, MScLauren is an Associate Professor in the College of Public Health, Department of Environmental, Agricultural, and Occupational Health, at the University of Nebraska Medical Center and Core Faculty of the UNMC Global Center for Health Security. She is an Adjunct Associate Professor of Emergency Medicine in the Johns Hopkins School of Medicine, and the director of the Special Pathogens Research Network.She previously served as Director of Operations for the Johns Hopkins Office of Critical Event Preparedness where she ran the inpatient COVID19 biobank and served on the COVID19 research steering committee for JHU. Lauren's research focuses on human subjects research in bio-emergencies and disasters. Her work is focused on the ethical implementation of human subjects research and navigating the regulatory environment in disasters. Her research has focused on providing healthcare systems tools that facilitate implementation of policy requirements and clinical trials in emergencies.ResourcesInfection Prevention and Control Assessment Tool for Long-term Care Facilities: CDC_IC_Assessment_Tool_LTCF_v1_3Health Department Resources for Long-term Care Facilities: https://www.cdc.gov/longtermcare/resources/index.htmlCMS Infection Prevention, Control & Immunizations: https://www.cms.gov/files/document/qso20-12-suspension-survey-activities-2pdf.pdf(Download .zip) CMS Head to Toe Infection Prevention (H2T) Toolkit

For paramedics, click here for CE credits.  Brought to you by Urgent Admin which is an intuitive one-touch solution that connects in-field clinicians and medical directors in real-time, this episode covers the complex nature of traumatic arrests. ,  Do we treat it the same as a medical arrest?  Do we have different treatment and decision priorities for these traumatic patients?  What makes caring for these patients in the prehospital environment so unique and how does that affect our care of these patients?  We discuss these questions and more with our special guest: Dr.  Rawan Safa @rawansafa93 Emergency Medicine Resident at Washington University Click here to check it out today! Thank you for listening! Hawnwan Philip Moy MD  Gina Pellerito EMT-P John Reagan EMT-P Noah Bernhardson MD References Millin MG, Galvagno SM, Khandker SR, Malki A, Bulger EM, Standards and Clinical Practice Committee of the National Association of EMS Physicians (NAEMSP)., Subcommittee on Emergency Services–Prehospital of the American College of Surgeons' Committee on Trauma (ACSCOT). J Trauma Acute Care Surg. 2013 Sep; 75(3):459-67. Lockey, D, Crewdson, K, Davies, G. Traumatic cardiac arrest: who are the survivors? Ann Emerg Med 2006; 48:240-244. Russell, RJ, Hodgetts, TJ, McLeod, J, Starkey, K, Mahoney, P, Harrison, K. The role of trauma scoring in developing trauma clinical governance in the Defense Medical Services. Phil Trans R Soc B 2011; 366:171-191. Morrison, JJ, Poon, H, Rasmussen, TE, Khan, MA, Midwinter, MJ, Blackbourne, LH. Resuscitative thoracotomy following wartime injury. J Trauma 2013; 74: 825- 829. Kouwenhoven, WB, Jude, JR, Knickerbocker, GG. Closed-chest cardiac massage. JAMA 1960; 173: 1065-1067. Luna, GK, Pavlin, EG, Kirkman, T, Copass, MK, Rice, CL. Hemodynamic effects of external cardiac massage in trauma shock. J Trauma 1989; 29:1430-1433. Leis C. Traumatic cardiac arrest: should advanced life support be initiated?. Journal of Acute Care Surgery. 2013;74:634-638. Keith J Roberts. The role for surgery in pre-hospital care. 2015; 18(2): 92-100. Escott ME, Gleisberg GR, Kimmel K, Karrer A, Cosper J, Monroe BJ. Simple thoracostomy. Moving beyond needle decompression in traumatic cardiac arrest. 2014 Apr; 39(4): 26-32. Martin M, Satterly S, Inaba K, Blair K. Does needle thoracostomy provide adequate and effective decompression of tension pneumothorax? Journal of Trauma and Acute Care Surgery. 2012; 73(6): 1412-1417. Stevens RL, Rochester AA, Busko J, et al. Needle Thoracostomy for Tension Pneumothorax: Failure Predicted by Chest Computed Tomography. Prehospital Emergency Care. 2009; 13(1): 14-17. Inaba K, Ives C, McClure K, et al. Radiologic evaluation of alternative sites for needle decompression of tension pneumothorax. Arch Surg. 2012 Sep; 147(9): 813-8. Ball CG, Wyrzykowski AD, Kirkpatrick AW, et al. Thoracic needle decompression for tension pneumothorax: clinical correlation with catheter length. Can J Surg. 2010 Jun; 53(3): 184-8. Brian Wernick, Heidi H Hon, Ronnie N Mubang, et al. Complications of needle thoracostomy: A comprehensive clinical review. Int J Crit Illn Inj Sci. 2015 Jul-Sep; 5(3): 160–169. Smith JE, Rickard A, Wise D. Traumatic cardiac arrest. J R Soc Med. 2015;108(1):11-16. Leis CC, Hernández CC, Blanco MJ, et al. Traumatic cardiac arrest: Should advanced life support be initiated? J Trauma Acute Care Surg. 2013;74(2):634-638. Jørgensen H, Jensen CH, Dirks J. Does prehospital ultrasound improve treatment of the trauma patient? A systematic review. Eur J Emerg Med. 2010;17(5):249-253.  

Today on Insights in clinical nutrition, we talk to Varsha Asrani – Chair of the Clinical Practice Committee and Dr Darcy Holt – leading Gastroenterologist and Consultant Physician from Monash Health. We discuss their careers, the role of the clinical practice committee and their upcoming project work. Email: podcast@auspen.org.auWebsite: www.auspen.org.au/podcast

American Society of Clinical Oncology (ASCO) CEO Dr. Clifford A. Hudis is joined by Dr. Piyush Srivastava, the past chair of ASCO’s Clinical Practice Committee, in the newest ASCO in Action Podcast to discuss the recently released ASCO Special Report: A Guide to Cancer Care Delivery During the COVID-19 Pandemic. Dr. Srivastava was instrumental in developing the report, which provides detailed guidance to oncology practices on the immediate and short-term steps that should be taken to protect the safety of patients and healthcare staff before resuming more routine care operations during the COVID-19 public health crisis. Subscribe to the ASCO in Action podcast through iTunes and Google Play.       The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Welcome to this ASCO in Action podcast brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content and offering enriching insights into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org.   This ASCO in Action podcast is ASCO's series where we explore the policy and practice issues that impact oncologists, the entire cancer care delivery team, and the individuals we care for, people with cancer.   I'm Dr. Clifford Hudis, CEO of ASCO. And I'm the host of the ASCO in Action podcast series. I'm really pleased to be joined today by Dr. Piyush Srivastava, the past chair of ASCO's Clinical Practice Committee. Dr. Srivastava is also a practicing gastrointestinal oncologist, the regional medical director of the End of Life Options program, and the director of Outpatient Palliative Care at Kaiser Permanente Walnut Creek Medical Center in California.   Today, we're going to talk about the recently released ASCO Special Report, A Guide To Cancer Care Delivery During The COVID-19 Pandemic.   Dr. Srivastava was instrumental in developing the report. And we'll speak today about the guidance that the report provides for oncology practices as they return to more routine care delivery. Piyush, thank you so much for joining me today.   Thank you, Dr. Hudis for taking the time to speak with me. Just before we start, I just want to say that I do not have any relationships to disclose. So thank you.   Thank you very much for joining us today. Now, just to provide some context, today as we speak, we're approaching month five of the COVID-19 public health crisis in the United States. We've had more than 2.15 million confirmed cases of the virus and well over 100,000 deaths.   In fact, as we record this today, several of the largest population states in the United States-- California, Texas, and Florida-- are just reporting their largest single-day increases in cases and the health care systems in some of their big cities are approaching the kind of near breaking point that we saw earlier in New York. So the problem is still very much with us.   When the outbreak began, oncology practices nationwide immediately began making operational changes designed to protect the safety of patients and the safety of staff. This meant adjusting to resource shortages that were unfolding and complying with national and state restrictions on elective procedures, among many other things.   Today, communities across the country are in varying states of recovery. And as I just described, some of them actually are probably pausing their recovery right now. Either way, they are facing a real transition in terms of oncology practice. And some are returning to something more like routine care while continuing to be acutely attuned to protecting the health and safety of both patients and staff.   So Dr. Srivastava, could you start us off and tell our listeners just a little bit about what's happening in your own practice and how you have been adapting to the changing circumstances?   Of course. I would be very honored to share my experiences at Kaiser Permanente in Northern California. So at the start of the pandemic, we were very fortunate to be nicely set up to provide care remotely. We've had a very strong existing telehealth structure. So we were quickly able to adapt to the pandemic situation.   Initially, we nearly went 100% remote, with doing all of our new consults and chemo checks via video visits and telephone visits. If a patient needed some more attention, to be seen by a care practitioner, many times that we would coordinate with the on-call physician on site, who would see the patient on the chemotherapy infusion chair.   We also looked as an institution which services we could provide remotely and take off site and so that we didn't need to bring the patients into the cancer center. For example, we activated our home health nursing team to be able to provide port flushes in the home setting.   We also made a very conscientious effort to see what treatments and what procedures that we could postpone or actually decrease the frequency or increase the timing in between events. For example, bisphosphonate administration and port flushes, which we increased to do every three months.   What was extremely eye opening and inspiring to me is a large organization such as Kaiser Permanente was extremely nimble and flexible and was able to respond to the outside pressures. I believe, when I speak to my colleagues across the country, that many people experienced the same things with their institutions. And their institutions responded very flexibly to the ongoing pandemic.   Thanks very much. It's really interesting, I think for me, and I'm sure for many of our listeners, to hear how you adapted but also to compare that with their own experiences. It sounds to me like some of the key features were clear eye on the safety of patients and staff but also having a structure that respected the needs of the clinicians from the beginning. And then, of course, understood that the flexibility overall was a key attribute. And I just think that's something that many people will be reflecting on.   As we hit it from that one in a sense, forgive me, but anecdote, which is how one center, one operation adapted, I wonder if you could talk a little bit about ASCO's role in providing the more general guidance that you helped to develop. Why did this society feel it was necessary to provide guidance at that level?   Yes. So as we are all extremely aware, many individual health care professionals, institutions, and health systems look to ASCO for mentorship when it comes to oncology care. So this current pandemic was no different. I believe ASCO felt a strong duty and a responsibility to partner with the oncology world to ensure the highest quality and efficiency of cancer care and delivery through this pandemic.   Also, the beginning of the pandemic, there was a lack of really clear guidance from federal and state agencies. So cancer care providers and administrators looked to ASCO to help develop their plans of providing care during the pandemic. Now, also opening and ramping up as well, they're looking to us.   I see. So as we think about staff at ASCO headquarters, it's really pretty straightforward on a daily basis. Our decisions to open headquarters, for example, or not are predicated, number one, on the safety of our staff. So when you look at the Special Report, what would you say was the one or the several overarching goals that drove the development of the Special Report?   So when constructing the report, we did very much realize that there are so many varied practices across the country, really around the world, right? For example, we have small rural practices. We have medium-sized private practices. We have academic centers, and we have hospital systems. And all these organizations look to ASCO for cancer guidance and guidance to cancer care delivery.   By no way were we going to be able to solve individual operational care delivery issues for each practice. So the Special Report is made to serve, if you will, as a starting point or a launching pad for individual institutions to develop their own policies and operational adjustments.   So what I would like to do now is maybe just dive a little bit deeper into some of the specific policies and practices that were outlined in the report. And as I look at it, it was really broken down into stages of patient care.   So for example, before a patient even arrives on site, many practices are in a sense pre-screening them or triaging them. What are some of the methods that you have seen put into place and that have been effective that we should recommend to practices just getting open?   So the Special Report lists out very clearly sequential steps to consider in safely bringing patients into cancer centers. And I'll highlight a few of them, which I feel is extremely important. The first step is to actually reach out to the patient well before their scheduled visit to the cancer center. So if we can call these patients and family members well before their visit, we can educate them as to the process that they'll experience when they come into the cancer center.   Allow them to ask questions and to give the reasoning behind or the why to we are doing this. I think that will go a long way. So transparent communication, I think, will reduce anxiety and fear.   I also believe an effective second step was to do a quick check in, anywhere from 12 to 48, 72 hours prior to the actual visit, depending on what your operations would allow, just to check in to make sure that you're screening for the COVID symptoms and the patient doesn't test positive to any of those symptoms.   I may just add also in the first step, when you reach out to the patient well before their appointment, that's also a good time to screen for COVID questions. And then a third implementation can be as a single point of entry.   So when a patient comes into the cancer center, there's one point of entry so that way a temperature could be checked, a patient could be screened again for those COVID symptom questions. And so that when that patient arrives inside the cancer center, there's been essentially three checks and balances of checking for COVID-19 symptoms.   So this provides obviously the safety to minimize the risk of bringing COVID into the cancer center. But I also think an extremely important added benefit is that the staff and providers will feel confident and safe that the institution has done these many different steps to ensure their safety as well and to minimize their risk of exposure to COVID.   I see. So that's one part of this. Now, the implication in all of this is the volume coming through the clinics is likely to be lower. And one of the ways in which it is controlled, of course, is through the reduction of less critical face-to-face encounters and arguably an increase in telemedicine. What are some of the considerations that you think oncology practices should factor into their use of telemedicine in care delivery?   Yeah. That's actually a fantastic question, because telemedicine has really-- well, telemedicine was forced upon most institutions. And the institutions had to really find an effective way to provide care remotely. So it's a very interesting and important topic. For example, I think one thing that I personally struggled with, and I think my institution struggled with is, who is the right patient for telemedicine?   So the report talks about specific patient categories that you can think of that would be easier to provide patient care remotely. So for example, those that are not requiring in-person physical exam, those who may not actually actively be getting chemo treatment, those that don't need any in-office diagnostics. So don't necessarily need lab work tied to that appointment or you don't necessarily need imaging exams at that moment.   Other visits that the report recommends to think about is follow up. So follow up could be done through telemedicine. Or those that are on oral oncolytic treatments. And so it's a quick check in just to make sure that they're taking the medication and the adherence is high could be done by video or by phone.   A couple of things to consider with telemedicine, obviously, is the audio and visual capabilities. And so even in the Bay Area in California, we do have spots that don't have the best reception. And so that can become problematic. So that's something to also think about.   The other sort of counterbalance or countermeasure to this is just to make sure that patients feel that they're being taken care of and they feel satisfied. So in my own practice, I've now adopted that when we finish a video visit or we finish a telephone visit, I let the patient know that I have felt comfortable with the interaction and that I felt that I was able to accomplish the care plan and execute the care plan as needed by the video and phone. But then I ask them, do they feel comfortable and are they OK proceeding this way or do they prefer face-to-face visit.   Yeah. I think that's an interesting observation about telemedicine. I think everybody is feeling their way right now and learning. And we want to be careful not to go too far away from the direct physical encounter since so much can be lost without those subtle cues from body language and classic physical findings as well. Now, coming back once more to the workforce, the report addresses how we maintain a healthy workforce.   And it specifically, I think, gets into questions of testing and scheduling and even dealing with stress. Can you walk through that a little more about antibody testing or saliva or nasal swabs and the frequency and exactly what facilities and practices should be thinking about for their staff.   Sure. And this is an extremely hot topic, and the interesting thing about this topic is it can vary widely just depending on what's available at that moment in your location, what the county is ordaining and what the state is ordaining as well. So there's a bit of variability.   But what the Special Report does very nicely, it lays out considerations for institutions to think about when they are caring for the workforce, both physically and emotionally. So this Special Report lays out some PPE guidelines, and really it's based on what the CDC is recommending.   And as we know, as one of the largest sort of scientific research-based organizations, it's important that we bring the CDC's sentiment forward when we talk about PPE, especially with PPE stewardship as this goes on for some time, we may have some issues with the supply chain.   The other thing the Special Report calls out is to really have institutions make sure that they are putting their health care practitioners in the forefront. So checking in with health care practitioners to make sure that they are not ill, that they're feeling OK, that they haven't been exposed to anybody outside of the medical system. And I think what's really, really special about this report is that it really talks to the practitioner's well-being. I think this is scary for any provider in the front line.   We are also worried about our own health and what we can bring back to our loved ones outside of the medical center. But also, I think all of us as oncology providers are feeling a little disillusioned and a little saddened, because we are not able to provide oncology care like we normally have been.   And so that's a huge adjustment for the oncology provider. And of course, that comes with some moral distress. So the report also calls out for institutions to check in with their health care providers to make sure that their emotional well-being is good and to also make sure that they feel that their family and loved ones are safe at home. So I think that was a really added benefit.   Yes. Really important to acknowledge the importance of all of that to the individuals. And it is not just about narrowly the safety of the surfaces and workspaces they're in, but really in a sense their holistic experience in life. I want to turn to the broad public approach to cancer care and focus on the corners that we cut, if you will, in going into this crisis, the compromises with old ways of doing things that we very quickly adopted.   The report focuses on some of those immediate short-term steps that we took. And I think looking at the effectiveness of that, I can tell you that I asked the ASCO leadership on the staff side and on the volunteer side why those adaptations couldn't just be our new permanent normal.   That is to say, if it was safe enough to do telehealth in April of 2020, why isn't it safe enough to do it forever? So that was the nidus of our Road to Recovery Task Force. And I know you sit on the group focused on care delivery. What do you think we can expect from that effort?   Yeah. And this is fantastic. I am honored to be sitting on the Road to Recovery Task Force, because I think this is an issue that's facing every oncology care provider in the country and, frankly, around the globe. And the task force is composed of a group of really active and very intelligent oncology providers who are putting their minds together collaboratively to see how we can continue to provide cancer care in an efficient and in a high-quality manner moving forward beyond the pandemic.   And as you said very nicely, Dr. Hudis, we have gained several insights through our care over the last few months, and can we harness those insights and continue to practice oncology in a very efficient and high-quality manner?   So the task force is extremely comprehensive. The group is addressing several buckets, if you will, that are very pertinent to oncology care and delivery. So they're looking at health equity. They're looking at resetting clinic and patient appointments.   They're looking at practice operations, telemedicine, home infusion. I know that's something that we've all been grappling with. Financial assistance to practices, which is extremely important when we look at the economy around us.   Quality reporting and measurements. So we want to make sure-- we want to challenge ourselves to make sure that we are practicing the highest-quality cancer care that we can. Utilization management. So that's also extremely important as we are looking at the economy around us.   Psychosocial impact on patients. So this has been obviously extremely traumatic for patients in their very vulnerable state. The task force also is looking at provider well-being, which once again, I can't reinforce how important that is as we go back into somewhat normal operations, whatever that normal may be, but looking at the sort of stress that the providers are feeling in that.   And then ongoing preparedness I think, which is extremely essential, because we just don't know what the virus will do over the next year and what might also come in the future. So the task force is extremely collaborative, extremely thorough. And it is a group of very active individuals on oncology care that are bringing their brilliant minds together to come up with some guidance.   Well, I think that's really great. As we wrap up now, I wonder if at the highest level if there's a single or several major takeaways that you want listeners and our entire community to take away from these recommendations.   Yeah. You know, I've actually had some time to reflect. It's been a very privileged experience for me to be a part of this and to be a listener and to be a learner from all these brilliant minds around me who are putting their heads together to accomplish this. I find that recommendations in the Special Report to be very thoughtful and very comprehensive.   I do hope practices remember that these are actually guidelines to help them develop and change policies at individual institutions. I also hope that oncology practitioners and administrators remember that we're all in this together. And so there is going to be an ever-changing environment.   So I hope that this report is just a start of a collaboration that can be ongoing with ASCO and with oncology providers around the world. I am fully confident that ASCO is a tremendous and a large resource for us in the oncology world to be able to accomplish collaboration and to actually uplift and maintain cancer care during and after the pandemic.   Well, that's really, I think, is nice and as great and complete a summary as one could hope to hear. So I want to thank you, Dr. Srivastava, for speaking with me today. I'm really grateful to you for your time on this whole initiative and the effort that you've put to it as well as, of course, for the time today.   I appreciate it. It has been a great honor. And so thank you very much to you, Dr. Hudis, and thank you very much to the ASCO staff, who do a tremendous job on a daily basis to make sure that we are doing the best we can.   So the Special Report, and later, ASCO's Road to Recovery, are all part of ASCO's larger commitment to providing information, guidance, and resources that will support clinicians, the cancer care delivery team, and patients with cancer, both during the COVID-19 pandemic and then well beyond it.   We invite listeners to participate in the ASCO survey on COVID-19 in Oncology Registry or ASCO registry. This is a project where we are collecting and then sharing insights on how the virus impacts cancer care and cancer-patient outcomes during the COVID-19 pandemic.   We encourage all oncology practices to participate so that we will have the largest possible data set and represent the full diversity of patients and practices across the United States.   I'll remind you that you can find all of our COVID-19 resources and much more at asco.org. And until next time, I want to thank everyone for listening to this ASCO in Action podcast.   If you enjoyed what you heard today, please don't forget to give us a rating or a review on Apple Podcasts or wherever you listen. And while you're there, be sure to subscribe so you never miss an episode. The ASCO in Action podcast is just one of ASCO's many podcasts. And you can find all of the shows at podcast.asco.org.

In this episode of Thrive Bites, I sat down Dr. Charmaine and we tackled the hard struggle of physician burnout and broke it down bit by bit and chatted about her personal health/mental journey and how she triumphed with her own platform!She has served countless patients, taught resident doctors and medical students for 13 years as Clinical Faculty at St. Joseph Mercy Ann Arbor in Michigan, following Emergency Medicine Residency training at Duke University Medical Center. She has been honored as a nominee for the Golden Apple teaching award by the resident doctors she teaches several years in a row. She is an active member of the Clinical Practice Committee for the Emergency Medicine Physician Group, PC. She serves as a Peer Coach providing feedback on communication techniques for Emergency providers and facilitates talks with healthcare providers about burnout, wellness, and work-life balance/integration. Most recently, Dr. Gregory has had the honor of being a contributing author of the books, The Chronicles of Women in White Coats and Thinking About Quitting Medicine Volume 2.Outside of medicine, her passion to pursue wellness and work-life balance led to the establishment of the virtual greatness and wellness coaching company Fervently Fit with Charmaine, LLC. Wellness, fitness coaching, and holistic nutritional supplementation serve as an extension of clinical service by focusing on preventative methods for health and wellness maintenance. She is also a trained Physician Coach, helping colleagues find meaning and direction when most needed.In addition, she is certified to teach live group fitness classes in an MMA (Mixed Martial Arts) and offers group fitness instruction to colleagues at national meetings.Social Media Links: https://www.facebook.com/CharmaineGregoryMDhttps://www.linkedin.com/in/charmaine-gregory-mdhttps://www.instagram.com/charmainegregorymdhttp://ferventlyfit.libsyn.com/ Please support this podcast to impact others to live better: https://patron.podbean.com/thrivebitespodcast *Interview views are opinions of the individual. This podcast is not a source of medical advice* Copyright © 2020 by TheChefDoc, LLCAll text, graphics, audio files, Java applets and scripts, downloadable software, and other works on this web site are the copyrighted works of TheChefDoc, LLC. All Rights Reserved. Any unauthorized redistribution or reproduction of any copyrighted materials on this web site is strictly prohibited.

In the latest ASCO in Action Podcast, American Society of Clinical Oncology (ASCO) CEO Dr. Clifford A. Hudis is joined by Dr. Ray Page, Past Chair of ASCO’s Clinical Practice Committee and President of the Center for Cancer and Blood Disorders, to discuss the benefit of drug repository programs solely for oral medications that are maintained within a closed system. These programs can play an important role in helping patients afford their treatment and can reduce the financial toll on the cancer care delivery system, provided that important guardrails are implemented to keep these programs safe. Subscribe to the ASCO in Action podcast through iTunes and Google Play.   The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.   Welcome to this ASCO in Action podcast, brought to you by the ASCO Podcast Network, a collection of nine programs covering a range of educational and scientific content, and offering enriching insights into the world of cancer care. You can find all of the shows, including this one, at podcast.asco.org. The ASCO in Action podcast is an ASCO series where we explore the policy and practice issues that impact oncologists, the entire cancer care delivery team, and the individuals we care for-- people with cancer.   My name is Clifford Hudis, and I'm the CEO of ASCO, as well as the host of the ASCO in Action podcast series. For today's podcast, I am really pleased to join once again Dr. Ray Page. Dr. Page is a past chair of the American Society of Clinical Oncology's Clinical Practice Committee, he is the President of the Center for Cancer and Blood Disorders where he also serves as a medical oncologist and hematologist, and he's a great and good friend of ASCO's.   Earlier this year, ASCO released a position statement on state drug repository programs outlining the society's support for such programs solely for oral medications and provided that they are maintained within a closed system. ASCO's statement also makes recommendations to help ensure that these programs are implemented appropriately with sufficient patient protections in place.   Today, Dr. Page and I will discuss the important role that these programs can play in helping our patients afford their treatment while reducing the financial toll on the cancer care delivery system as a whole. We will discuss the important guardrails that are needed to keep these programs safe. And with that, I want to welcome you, Dr. Page, and thank you for joining me today.   Thank you very much, Cliff, for having me for this conversation today. And I just want to let you know that I have no disclosures for this conversation.   Thanks again for joining us today, it's a real pleasure to talk with you once more. And I want to get to today's subject. First and foremost, what are state drug repository programs? How do they work and what's the purpose?   In its simplest definition, a drug repository program is basically a legal process that allows unused drugs that have been prescribed to patients to be able to be donated and reused rather than thrown away or set aside if it's no longer needed. Its purpose is to offer a practical way to increase access of prescription drugs for patients. And often, this process can offer more timely access to drugs with a negligible financial impact for the patients. And this was a program that has managed at the state level, and it's subject to individual state laws and State Department of Pharmacy rules and procedures.   And these kind of programs are of exceptional importance to cancer patients who are constantly challenged today with getting affordable access to vital drug treatments for their disease, and these issues are described very well in ASCO's 2017 position statement on the affordability of cancer drugs. And this has all been on the radar of ASCO's State Affiliates Council in recent years where our state society presidents and their executive directors have shared model state legislation to advance these kinds of drug donation programs in their individual states.   So Ray, before we go any further, can you tell me, what does this actually mechanically in practical terms look like at the level of a practice or from the perspective of a patient or a pharmacy? What actually happens physically with product in the context of a repository?   It really varies from practice to practice and state to state, but Cliff, I can tell you that I see this in my own practice absolutely every day in my doctor-patient interaction. And this is really what's gotten me personally intensely interested in pursuing and establishing laws in Texas to allow for pill donation. Because ideally, we would like to have that transaction between the doctor and the patient of being able to get unused drug for those patients where the drug's not used anymore.   And so there's many reasons why in the office, these people don't need the drug anymore. They could have progression of disease that requires new drug, or alternatively, they could have completed their treatment regimens that may have resulted in a cure. But oftentimes there can be interval dosage adjustments due to side effects and toxicities where they just need a new prescription.   And lastly, I just have to mention a little bit about the negative impacts of the pharmacy benefit managers in this world, and I'll refer our listeners to our previous podcast that we did together a few months ago just understanding the global concerns of the PBMs, but however, I'll just say that their drug distribution process oftentimes contributes to the tremendous cancer drug wastage that we have in the United States.   Well, I mean, picking up on that, if readers take a look at ASCO's position statement, they'll see that we identify there the fact that appropriately-implemented drug repository programs can help address some of the cancer drug waste, And if I remember correctly, this was quantified by researchers in New York at Memorial Sloan Kettering Cancer Center. I think they found an estimate of about $3 billion annually.   The question is, exactly what causes this waste? And you alluded to the fact that you see this in your practice as well, but I just want to be really clear and in a practical sense, this waste is that a patient is dispensed-- I'll say, for argument's sake, 60 pills, and has progression of disease or a toxicity-based dosage adjustment and comes back for a routine office visit and still has, for argument's sake, 20 of the pills leftover. And the goal here is to essentially recycle those pills back into the supply, is that right?   That is correct. And so that's the basic mechanism. And as practicing physicians we see this issue all the time, where for the reasons that I explained, there's always unused pills that we don't need anymore. And if there is a mechanism by which we can safely transfer that drug to somebody that can actually use it and need it, there can be substantial positive impact with that for our patients.   And is it only a financial benefit, Ray? Or are there non-financial benefits as well that this repository programs can somewhat mitigate?   Yeah. Well the financial impact of this is huge. The Americans are paying over $61 billion a year in out-of-pocket expenditures for drugs, and drug abandonment can have serious effects on a patient's health leading to hospitalizations, extensive health care cost, and even death. And the British Medical Journal reported an estimated $3 billion in leftover cancer drugs are discarded in the United States every year, and that's truly a tragic impact on our society.   But also, outside of financial, in 2015 the Environmental Protection Agency estimated that about 740 tons of drugs are wasted just by nursing homes every year, and obviously this can't be good for our environment, and we've all heard reports about many of these discarded drugs ending up in our water systems. So redistribution and enabling access to these unused drugs can help alleviate some of these problems that go outside the finances.   Well thank you for that. I mean, high out-of-pocket expenses have been for a long time a serious concern for us at ASCO, and you've I think touched on how this can help reduce them. My question is, are there any pushbacks from patients or providers with regard to these programs? I mean, I can imagine that there might be some bureaucratic overhead that might represent a challenge for small practices or maybe there's some risk associated with it, but I'm just guessing. Is there any clear objection to these that we should be thinking about and possibly working to mitigate?   In general, in my interactions with my patients, most everyone has negligible concern about getting a donated drug for immediate use. There should be informed consent and disclosure, obviously, but the patients generally trust their physicians recommendations and are truly interested in just getting the opportunity to get access to the drugs. From a patient's perspective, I generally think that their greatest concern are just getting quick access to the oral drugs so they can get started on their cancer therapy as soon as possible, often to alleviate active symptoms that they're having, and to alleviate some of the fear of just not getting access to beneficial drugs.   And the physicians I think share that same sentiment of the patients, but in addition, physicians have concern and desires and assurances that these donated drugs are indeed safe for re-distribution.   And Ray, is that what the informed consent would allude to? I was sort of wondering when you said informed consent. In a sense, is there anything different in the informed consent versus what would but with any other cytotoxic prescription, for example? I mean, is there really a way to describe the potential risk or the changes in the risk that there might be some loss of purity in a substance or substitutes? Or-- I'm just trying to figure out what the consent really ultimately conveys.   At least through some of the mechanisms that I'm familiar with that we've developed in Texas is basically there's just a disclosure form that the drug that was in possession of the patient, that they just sign a disclosure that they haven't tampered with it, messed with it, they're stored properly, those kind of things to create those assurances. And then the patient's just given a basically informed consent that they're aware that this transaction has been through a patient and outside the pharmacy.   I see. OK. I mean-- so it sounds to me like we're just, in a sense at a societal level, trying to basically make it clear that there's a theoretical risk of some loss of control, but it's, from a practical point of view, not particularly high, right?   Yes. And I think many oncologists across the United States have just had those experiences with patients in the office that maybe don't have the financial resources, they're looking just for access to drugs. And if there's drug that's available that's been donated, a lot of patients seem to have no problem accepting the drug. And again, I mentioned that a lot of the patients generally trust their physicians' recommendations in that transaction.   Well, I just have to say, I'm as you're talking, I'm reflecting on my own practice experience over the decades. And even for old and inexpensive drugs, it always bothered a lot of my patients that they couldn't simply give their inexpensive tamoxifen, for example, or aromatase inhibitors-- generic drugs, for that matter-- to somebody else in need when they no longer could use it. I think they just were offended by the waste. And even apart from the financial aspects that you've so clearly described, there is, I think, a real altruistic desire to use these drugs and not discard them wastefully, and it's nice to see that there may be the opportunity for patients to satisfy that need.   I agree with you, Cliff. I think there is a strong sense of altruism with our patients. Without a doubt, I think patients have extreme difficulty taking a drug that they know that they-- that the cost of that-- monthly cost of that drug was, say, $12,000 or $16,000, and that they're forced to discard it or flush it in the toilet or turn it in without it being potentially used by somebody else that may be in need, because they've certainly been in those shoes and experienced that themselves.   As you know, ASCO strongly supports repository programs, but we're very focused on oral medications, and we make the assumption that they will be maintained within a closed system. For our listeners, can you describe the difference between a closed system and open system and why we would be favoring a closed system? What makes it safer?   So Cliff, to define a closed system versus an open system, a closed system is a way to have the spirit of having an overabundance of precaution to assure patient safety. And basically, that allows for drugs that are prescribed to a patient and they bring back in that they have appropriate disclosure and supervision, and those drugs are reviewed by a pharmacist and assured that they're safe and able to be recycled according to state laws and pharmacy board rules.   And that's as opposed to an open system where, say, you have a patient that comes into the office and they got a bottle of pills that are unused and they give them to the physician, and then the physician turns around and redistributes those drugs to the next patient who's in need.   I think for many listeners, and probably for even more of our patients nowadays, when they think of cancer treatment, many people are used to thinking about perennial therapies, infusions and the like. But this is really focused obviously on oral medications. What are some of the oral treatments that have been made available? You indirectly alluded to some in terms of price, but what are some of the specific ones that have been successfully made available to patients through drug repository programs so far?   Great question, Cliff. I'll just emphasize it today. Over 40% of cancer therapies that oncologists prescribed are oral drugs, and we have several hundred experimental oral cancer drug that are in clinical trials. So it's anticipated that as time goes on in the future, we're going to be prescribing more and more oral cancer therapies rather than patients spending all day in a chemo chair getting IV infusions. And that's a great thing for our patients.   But currently, I estimate that there's probably over 100 oral anti-cancer drugs and supportive care drugs that are being prescribed to our patients, and these encompass a wide range of treatments, including your classic cytotoxic chemotherapy pills, hormonal agents, molecularly-targeted drugs, and symptom management drugs. And so each state has a drug repository program, has its own pharmacy rules for that redistribution. And in general, most of these drugs, in order to be available, must be in untampered and in secure packaging such as blister packs.   And so most states require inspection by a pharmacist, and therefore, there's a number of great drugs that may not be readily available for redistribution based on state laws and pharmacy rules that are designed to protect patient safety.   Are there other safeguards or any other provisions you think that state drug repository programs could take advantage of to improve their ability to serve patients? Is there anything else we should be doing, you think, as we gain experience with these programs?   You know, Cliff, I'm very pleased that ASCO came out with this position statement in support of the drug depository program that are being developed by each state. And ASCO has provided a few guiding principles for states to consider in their programs, and I think the ASCO recommendations for redistribution in a closed system is in the spirit of an abundance of precaution to assure patient safety.   However, like I said, this can potentially reduce the availability, but ASCO has made some recommendations to the states to where they want to assure that if they're not in a closed system, that the state and federal legislative address the concerns of drug related redistribution that are not in a closed system, that the surplus medications are administered in a safe, effective, and private manner in accordance with the prescribing clinician's guidance.   And the state should have a liability protection in accordance with their state health regulatory authority, and that includes such things as the informed consent and disclosures that we talked about. And then ASCO and other professional medical organizations should continue to make efforts to educate physicians about the existence and the value of these programs, and then ASCO also suggests that this drug repository program should be implemented and no additional cost, or at least as a negligible cost to the patient.   Ray, I think that's great, and I actually, personally and on behalf of the membership and our whole community, applaud you for your activism in this area. Is there anything else that you haven't said that you would want our listeners to know about or have we pretty much covered it all?   Yeah, Cliff, I think there is just a couple of closing thoughts that I want to convey to you. So first, most states allow the redistribution of pills and blister packs, but not pills that are partially used in bottles as we've discussed. But during the last couple of years and again today, I want to implore to the pharmaceutical manufacturers to package their new, often very expensive anticancer drugs in blister packs.   So studies have shown that packaging in this way usually results in improved patient safety and compliance with taking their pills, but most importantly, if for whatever reason those pills are not needed anymore by the patient, the patient or the prescribing institution can donate those pills for redistribution to a fellow patient with a similar cancer. So it's the right thing to do.   And lastly, most states have some form of drug repository program already in their laws; however, unfortunately, most states do not have the program properly turned on. A few states, such as Iowa and Wyoming and Oklahoma, have successful programs working for the patients, but some states have rudimentary programs that need expansion. And then many states need to update their laws and get their programs working again, and this is not an easy process by any means.   I've been working for many years to get a meaningful Texas law passed, which although not perfect, we got a law passed in 2017. And in Texas in the last couple of years, we have been working on the rules and the forms and the processes, and I'm proud to say that my cancer center in Fort Worth is the first registered provider in the state of Texas, and we are currently working with the University of North Texas Health Science Center School of Pharmacy on this, and we've been collecting donated drugs, and we hope that very soon we'll be the first provider in Texas to re-distribute cancer drugs in the state of Texas.   So again, this is not an easy process, but I encourage all states to dust off and modernize their laws to allow cancer patients the ability to get affordable access to drugs through such opportunities as the drug repository program.   Ray, again, I just have to emphasize how deeply grateful I am and I'm so happy to see that you've taken this on and with so much passion. It is hard to understand an argument against this, and that doesn't make it easy, but it's good to be right and it's good to see the effort that you've put into this and to start to see this success. It really does matter to patients as we have been discussing.   So for those of you who want to read more about this, I encourage you to open up ASCO's position statement on drug repository programs. Also there you can find breaking cancer policy news and more, all of that at ASCO in Action. That's on the website at asco.org/ascoaction, remembering that ascoaction is written here as one word.   And until next time, I want to thank everyone for listening to this ASCO in Action podcast. I want to remind you that if you enjoyed what you heard today, we'd love it if you'd give us a rating or a review on Apple Podcasts or wherever you listen. And while you're there, be sure to subscribe so you never miss another episode. The ASCO in Action podcast is just one of ASCO's as many podcasts. You can find all of the programs at podcast.asco.org.

Dr. Judith Lacey is the Head of Supportive Care and Integrative Oncology at the Chris O'Brien Lifehouse in Sydney, Australia. She is in SIO leadership, where she helps lead the Clinical Practice Committee, and she is involved in research and policy development in Australia. Dr. Lacey has a special interest in medical cannabis research. In this podcast, we discuss how palliative care and integrative oncology coordinate within Supportive Care as an umbrella designation. We also touch on how she and the Supportive Care team at her cancer center have dealt with COVID-19, and how it is impacting health care in Australia.

Dr. Gianluca Gambarini discusses dynamic navigation, the Gentle Wave, minimally invasive techniques, bioceramic materials in obturation, reciprocating versus rotary endodontics, favored cleaning and shaping methods, and his current research. Dr. Gambarini:is the Professor; Head of  Endodontic and Restorative, University of Rome, La Sapienza, Dental School; Director of Master in Endodontics an International lecturer and researcher, He is author of more than 480 scientific articles, He has lectured all over the world (more than 500 presentations) as a main speaker in the most important international congresses and many Universities worldwide. has achieved many awards and recognition in his academic career, and is responsible of many scientific projects with national and international grants. has focused his interests on endodontic materials and clinical endodontics. He is also actively cooperating as a consultant to develop new technologies, operative procedures and materials for root canal treatment. He has many patents concerning endodontic technologies. He is member of the Executive Board of ESE  and   Chairman of Clinical Practice Committee. maintains a private practice limited to Endodontics in Rome, ItalyThe Dental Clinical Companion Podcast (DCCP) is provided for general informational purposes only. The DCCP, MounceEndo, LLC, and Dr. Richard Mounce personally have no liability for any clinical, management, or financial decisions or actions taken or made by you based on the information provided in this program. The DCCP is not intended to offer dental, medical, legal, management, investment, surgical, tax, clinical, or any other professional advice. Reliance on the information in the DCCP is done entirely at the listeners own risk.  No guarantees, representations, or warrantees are made with regard to the completeness, accuracy, and/or quality of the DCCP.  The DCCP takes no responsibility for, does not endorse, and does not imply a relationship/affiliation to any websites, products, services, devices, individuals, organizations which are hyperlinked to any DCCP component or mentioned in the DCCP. Third party materials, hyperlinks, and/or DCCP content does not reflect the opinions, standards, and policies of MounceEndo, LLC (owner of the DCCP, Dr. Richard Mounce, the guest, or show sponsors). The DCCP makes no warranty that the Podcast and its server are free of computer viruses or other destructive or contaminating code elements. The Dental Clinical Companion Podcast expressly disclaims any and all liability or responsibility for any direct, indirect, incidental, special consequential or other damages arising out of any individuals use of, reference to, reliance on, or inability to use, this podcast or the information presented in this podcast. http://www.dentalclinicalcompanion.com/   Support the show (http://mounceendo.com/)

Dr. Rod Tataryn describes the etiology, diagnosis, and management of Maxillary Sinusitis of Endodontic Origin. Dr. Rod Tataryn has been in private practice endodontics in Spokane, Washington for the past 25 years.  He is a graduate of Loma Linda University School of Dentistry in 1989, spent 3 years in general practice, and returned to LLU to attend the endodontic residency program, graduating in 1994.  He has served on the Clinical Practice Committee for the American Association of Endodontists, and is on the faculty of graduate endodontics at Loma Linda University. He has published scientific and clinical articles in endodontics and lectures internationally. He is a contributing author to several endodontic textbooks including: The Sixth and Seventh Editions of Ingle's Endodontics, and The Art and Science of Contemporary Surgical Endodontics. http://www.drtataryn.com/The Dental Clinical Companion Podcast (DCCP) is provided for general informational purposes only. The DCCP, MounceEndo, LLC, and Dr. Richard Mounce personally have no liability for any clinical, management, or financial decisions or actions taken or made by you based on the information provided in this program. The DCCP is not intended to offer dental, medical, legal, management, investment, surgical, tax, clinical, or any other professional advice. Reliance on the information in the DCCP is done entirely at the listeners own risk.  No guarantees, representations, or warrantees are made with regard to the completeness, accuracy, and/or quality of the DCCP.  The DCCP takes no responsibility for, does not endorse, and does not imply a relationship/affiliation to any websites, products, services, devices, individuals, organizations which are hyperlinked to any DCCP component or mentioned in the DCCP. Third party materials, hyperlinks, and/or DCCP content does not reflect the opinions, standards, and policies of MounceEndo, LLC (owner of the DCCP, Dr. Richard Mounce, the guest, or show sponsors). The DCCP makes no warranty that the Podcast and its server are free of computer viruses or other destructive or contaminating code elements. The Dental Clinical Companion Podcast expressly disclaims any and all liability or responsibility for any direct, indirect, incidental, special consequential or other damages arising out of any individuals use of, reference to, reliance on, or inability to use, this podcast or the information presented in this podcast. Support the show (http://mounceendo.com/)

In this episode, we're learning more about The Nightingale Challenge. The World Health Organization is calling the year of 2020 “The Year of the Nurse and the Midwife,” honoring the 200th birthday of Florence Nightingale.  During 2020, Nursing Now is launching the Nightingale Challenge to invest in young nurses and midwives as it is essential for improving health and health care globally.  Nursing Now is a campaign to improve health globally by raising the status and profile of nursing.  The Nightingale Challenge offers young nurses an opportunity to be part of a global movement that will equip and empower the next generation to be advocates in health.  AMSN is excited to be able to provide this opportunity to our younger members to assist them in their career growth and to provide them opportunities to expand their leadership skills. GUESTS Summer Bryant, DNP, RN, CMSRN, is a managing consultant for BRG|Prism Healthcare where she serves as a subject matter expert for medical-surgical nursing processes and patient care delivery. She is currently the President-Elect of the Academy of Medical-Surgical Nurses. She is a seasoned healthcare leader with more than 19 years of clinical expertise and nursing leadership experience in medical-surgical environments. She has led teams in a variety of areas to transform performance, reduce staff turnover, and deliver high-quality care and patient service. Dr. Bryant is adept at managing projects and leading people while building a cohesive, collaborative environment and developing nurses and other staff members into leaders.  She has completed research studying the effect of the Lean Management System on unfinished nursing care in a medical-surgical setting.  Prior to serving on AMSN’s Board of Directors, she was a member of the Clinical Practice Committee, member of the Exemplary Practice Task Force, and Chair of the AMSN PRISM Award Task Force.  She is a member of several professional nursing organizations, to include the Academy of Medical-Surgical Nurses, the American Nurses Association, the Kansas Nurses Association, and Sigma Theta Tau International.  Dr. Bryant received three degrees from The University of Kansas, a BSN, as well as a MSN and DNP focused in Organizational Leadership.   Jennifer Kennedy, MS, RN-BC, has been practicing nursing for over 20 years and is Board Certified in three specialties; Certified Medical-Surgical Registered Nurse, Certified Nurse Educator and Nursing Professional Development.  She graduated from Northern Illinois University with her Masters in Nursing Education and currently is an assistant professor at George Williams College of Aurora University.  She has an extensive background in Medical-Surgical Nursing, Pediatrics, Emergency Medicine and Orthopedics. Jennifer is a member of the Academy of Medical-Surgical Nursing national association and currently serves as on their national nursing board as treasurer.   HOST Alissa Brown, BSN, MSN, RN is a clinical nurse educator from the University of Utah Health. She has been working in the health care industry for almost 12 years, and started her nursing career as a med-surg bedside nurse on an Ortho, Trauma, and Surgical Specialty Unit. It was through that experience in the med-surg unit where she discovered a passion for education, and pursued a master’s degree. She is a lifelong learner, and loves to teach.  Born and raised in Salt Lake City, Utah, she's not all work, and definitely enjoys play! She loves to travel, and tries to plan as many vacations each year as she can with family and friends. Alissa loves to read, listen to podcasts, and geek out to documentaries and crime shows on the weekends. She's a total fair-weather fan when it comes to Utes Football, but will cheer in all the right places, or get mad when her husband tells her to during a game. Alissa is looking forward to conversations together on this AMSN podcast!

If you have a fear of public speaking, this episode is for you. If you’re confident when speaking but have a fear in a different area of your life, this episode is for you. My guest’s story of how she went from a self-described fear of public speaking to being an in-demand paid keynote speaker in just 2 years is incredibly inspiring.  Charmaine Gregory, M.D. is an emergency room doctor and speaks to professional groups about burnout. You’ll hear: How Charmaine’s fearlessness and love of the stage as a child transformed into fear How the fear of speaking presented itself when she had to do it Why she decided to conquer this fear What she did first Her journey to becoming a speaker Strategies she used and still uses today to feel more confident and comfortable when speaking   Charmaine is a member of our Master Your Speaking group coaching program. Want to know when enrollment opens again? Sign up for the interest list at https://www.speakingyourbrand.com/mastery.    → Download the free checklist to prepare for your next speaking engagement at https://www.speakingyourbrand.com/129.    This episode is part of our Confidence Series, episodes 127 through 131. About My Guest: Charmaine Gregory, M.D. has served countless patients and taught resident doctors and medical students for 13 years as Clinical Faculty at St. Joseph Mercy Ann Arbor in Michigan, following Emergency Medicine Residency training at Duke University Medical Center. She has been honored as a nominee for the Golden Apple teaching award by the resident doctors she teaches several years in a row. She is an active member of the Clinical Practice Committee for the Emergency Medicine Physician Group, PC. She serves as a Peer Coach providing feedback on communication techniques for Emergency providers and facilitates talks with healthcare providers about burnout, wellness, and work-life balance/integration. Most recently, Dr. Gregory has had the honor of being a contributing author of the books, The Chronicles of Women in White Coats and Thinking About Quitting Medicine Volume 2 and Doctoring Better. Dr. Gregory faces her fear of public speaking by speaking publicly on topics of burnout, wellness, fitness, work life integration, and night shift life. Outside of medicine, Charmaine’s passion to pursue wellness and work-life balance led to the establishment of the virtual greatness and wellness coaching company Fervently Fit with Charmaine, LLC. Wellness coaching and health content sharing serve as an extension of clinical service by focusing on preventative methods for health and wellness maintenance. She is also a trained Physician Coach, helping colleagues find meaning and direction when most needed. She is the host of the Women in White Coats and Fearless Freedom with Dr. G podcasts. About Us: The Speaking Your Brand podcast is hosted by Carol Cox. At Speaking Your Brand, we help women entrepreneurs and professionals create their signature talks and gain more visibility to achieve their goals. Our mission is to get more women in positions of influence and power: on stages, in businesses, on boards, in the media, in politics, and in our communities. Check out our coaching programs at https://www.speakingyourbrand.com.  Links: Show notes at https://www.speakingyourbrand.com/129 Connect with Charmaine on her website at https://www.ferventlyfitwithcharmaine.com/. Listen to Charmaine’s podcast “Fearless Freedom with Dr. G.” Book: “The Chronicles of Women in White Coats” Book: “Alter Ego” by Todd Herman Download the free checklist to prepare for your next speaking engagement at https://www.speakingyourbrand.com/129.  Join the free Speaking Your Brand community at https://www.speakingyourbrand.com/join/ or text the word SPEAKING to 444-999. Get on the interest list for the Master Your Speaking group coaching program at https://www.speakingyourbrand.com/mastery.  Sign up for a Strategy Session at https://www.speakingyourbrand.com/strategy. Create your signature talk or TEDx talk. Get all the details at https://www.speakingyourbrand.com/coaching.  Say hi to me on Instagram and Twitter: @CarolMorganCox. Subscribe to the podcast on Apple Podcasts and leave a review! Related Podcast Episodes: Episode 66: Mastering Your Speaking Style and Stage Presence Episode 118: Push Past Your Speaking Plateau Episode 119: Deconstructing a Keynote: Writing, Preparation, and Delivery Episode 127: Developing Confidence in Public Speaking

Subscribe through iTunes and Google Play. Dr. Joanna Yang and Dr. Robert Daly join ASCO CEO Dr. Clifford A. Hudis to discuss the Health Policy Leadership Development Program (HP-LDP). As former fellows, Drs. Yang and Daly provide insight as to how the program has made them better advocates for their patients. TRANSCRIPT Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Clifford Hudis: Welcome to this ASCO in Action podcast. This is ASCO's monthly podcast series, where we explore policy and practice issues that impact oncologists, the entire cancer care delivery team, and the individuals we care for, people with cancer. My name is Clifford Hudis. And I'm the CEO of ASCO as well as the host of the ASCO in Action podcast series. For today's podcast, I am delighted to be joined by not one, but two of ASCO's rising leaders, Dr. Robert Daly and Dr. Joanna Yang. Both Dr. Daly and Dr. Yang are recent participants in ASCO's Health Policy Leadership Development Program, formerly known as the Health Policy Fellowship Program. This is a professional development program designed to build health policy and advocacy leadership expertise among our members. It's a one-year program where fellows get practical experience working with our policy and advocacy staff and council to craft policy positions and statements, along with other educational sessions on communication, leadership, and advocacy. Starting this year, participants will be able to participate as well in ASCO's Leadership Development Program, which offers mid-career oncologists the opportunity to improve their leadership skills and gain valuable training to set them up to be future leaders in oncology. Dr. Daly and Dr. Yang, welcome, and thank you for joining me today. Joanna Yang: Thank you so much for the opportunity. Robert Daly: Yes, thank you so much for having us. CH: So Dr. Yang, I'm going to start with you. You were an ASCO Health Policy Fellow in 2017-2018. And I want to kick off our discussion by talking about what brought you to the program. Why were you interested in developing special expertise in policy work? JY: Sure. So I've always been interested in health policy. And I had the opportunity to study health policy and health economics during undergrad. But of course, studying health policy is very different than creating or influencing health policy. When I started residency, I saw many ways in which health policy on a national level or even state level affected the patients I was caring for. And I felt compelled to do more. But the issue is that there is never any clear way for me to get involved or even to learn how I could learn how to shape health policy. And that's why the ASCO program is so great. I feel like it came at exactly the right time. I was looking for a way to learn more to develop the skills I needed to influence health policy. And ASCO came out with this structured and immersive experience where I could take the things that I had studied in school, and also the things that I'd seen in practice, and use them to actually have an impact on the patients I take care of. CH: So Dr. Daly, you as well were one of our inaugural Fellows. What prompted your interest in applying for the program, especially given I think you were the first year? RD: Yes. CH: Right, so you took a leap off of the ledge there and said, I'll go first. RD: Yeah, I'm similar to Dr. Yang. I had a real interest in cancer care delivery research during my fellowship at the University of Chicago. And I was lucky enough to be mentored by Funmi Olopade and Dr. Blase Polite. And Dr. Polite was really fundamental and helped developing the ASCO Health Policy Fellowship. And so I really saw this as an opportunity to augment that training but really gain skills in leadership, advocacy, and health policy, areas that I hadn't had exposure to in the past. So this seemed like the perfect program for me at that point in my career. CH: I have to say parenthetically that I'm jealous of both of you, because while I was personally drawn, especially in later years in my career to the policy and advocacy aspects of work with ASCO-- and it truly is the reason that I moved from my traditional academic career to this role as CEO at ASCO-- I never, of course, had the opportunity to be trained and to learn how to do this professionally as you two have. So I am in awe of your accomplishments, as well as the opportunities that are going to continue to unfold in front of you because of this. So given that, and given that this is really the beginning, we hope, of a career with impact, we should talk a little bit about what you actually did. The program, as I mentioned earlier, lasts for a year. And during that time, Fellows worked very closely with our policy staff on a mentor project. So I'll start again with Dr. Yang. Can you talk about the project you worked, what it entailed, what you learned, and where this is going? JY: Sure. So I worked on a two-part project with Alex Chen, who was my co-fellow during the past year. And as you hinted at, the work is actually still ongoing. So the first part was we looked at whether a bundled payment model could work in oncology. And this really culminated in a white paper for us. But the second part of the project, which built on the first part, was really the most fascinating. In the second part, it was really asking, if not bundled payments, then what? And we actually built on some of the work that Dr. Daly did that he'll probably describe in a little bit. But we actually worked on designing a pathway-based alternative payment model. And of course, going into this, I had no experience designing alternative payment models at all. But the beauty of the program is that from the very beginning, Deb Kamin, said, we will not be having you do any work that is not necessary. So all the work that you do is important to ASCO, is important to our patients. And that was really true for our project. So we were able to work with the ASCO staff, and our mentors, Ray Page, and Linda Bosserman, and a whole team of experts to create an alternative payment model that we thought would allow oncologists to prescribe the right drug at the right time, without being penalized by the high drug costs. CH: So I guess, based on that, we really should have started with you, Dr. Daly. But your mentor project was centered around clinical pathways. And I understand that ends up being the foundation for the alternative payment model that Dr. Yang just described. So can you talk a little bit about that process, what you did as an inaugural fellow in this and what you learned as you went through the work? RD: Absolutely. So I was lucky enough to be able to serve on the ASCO Task Force on Pathways. So that was an incredible experience for me because I really got to interact with leaders on this issue, including Robin Zon and Ray Page, who are very active in cancer care policy, both at the state level in Indiana and Texas, but also on a national level. So to be able to gain their mentorship that early on in the fellowship was really a great asset for me. And we were looking at, how do we write the criteria for what constitutes a high-quality pathway? So I really got to see, from soup to nuts, how do you write a policy statement? How do you solicit input from those important stakeholders? So the stakeholders in this case were fundamentally the patients, but also providers, ASCO's Government Relations Committee and State Affiliate Counsel, ASCO's board, the vendors-- get all of their input together to create a policy statement that can really influence change. And then lastly, I played the part of representing ASCO and in discussions with the pathway vendors about these criteria for high-quality pathways. So I learned about the important role ASCO can have on influencing the development of products and services that impact patient care, but also the impact ASCO can have on legislation. So in California, Connecticut, and other states, they started to look at policy around pathways, policies around implementing the criteria that ASCO had developed, so that those pathways that were being used in their state were high quality. So it really showed me the reach of ASCO and the impact of ASCO on patients and providers. CH: That is amazing because it really is a reminder-- and I'm going to come back to this idea-- about how much impact one person and one project can ultimately have. And I think that in these sometimes cynical times, people forget that. I alluded to this before about my own engagement with ASCO was accelerated by my experience as an advocate on Capitol Hill-- again, an amateur to your professionalism. So I wonder if you would reflect on your experience during the fellowship program. I understand you were both frequently called on to join in advocacy meetings on Capitol Hill. And this is with federal agencies, as well as, I assume, with representatives, senators, and their staff. Did either of you have any experience doing this before ASCO took it to Capitol Hill? RD: I had never had any experience doing advocacy meetings. So it was really-- the fellowship really helped me learn how to do that and how to do that effectively. CH: What was the first meeting like? RD: My first meeting was here in Manhattan. It was at the office of Senator Gillibrand. And I was accompanied by Heather Hilton, who is an ASCO advocate and someone who's served on the Government Relations Committee. And I was really nervous. I didn't know what to expect. But we met with one of her health policy staffers and really had an engaging discussion about an ASCO advocacy issue where we really felt heard. We were able to share patients' stories and also deliver data that ASCO had collected to help support our view. So it was really an exciting experience for me. And then I got to replicate that experience on Capitol Hill, meeting with congressional representatives from New York in their offices, but then also, as you said, going to government agencies, which was a different experience as well. So I really got to see a broad perspective of how you can advocate for policy issues for ASCO. CH: Dr. Yang, how would you describe your initial advocacy meetings for someone who hasn't participated before? What does it feel like to walk into that first meeting and begin that first discussion? JY: Sure. I've done that for my friends before. I've described these meetings. And they always say, it's really not at all what they expected. And I think that Dr. Daly's description is exactly right. So you go with your group-- usually it's by state-- to the member's office. And then depending on how much room there is and how many meetings are being held that day, your meeting is either going to be in a conference room in the member's office or even, more frequently, in the hall or any room that's available. And the member is not always there, but one of their staffers is, or sometimes multiple staffers, who are always really young but super, super, super knowledgeable about the issue. Basically, you go around, and you introduce yourselves and then describe the issues that you're here to discuss. And it's interesting because ASCO always does a great job of making you exceedingly well-prepared with the facts. But the truth is that most members and most staffers are most interested in hearing the patients' stories, which is why it's so important that oncologists come to the Hill to have these meetings. I think that no matter how well you try to prepare, ultimately, it really just comes down to engaging with the staffer and finding some area of common ground. And cancer is so common that most of the time in these meetings, I find that staffers or members will say, I have a family member or friend or some other loved one who has cancer. And it's really great that you guys are here. CH: My own experience-- I mean, I'm here to talk to you. And the listeners want to hear from you. But I just can't help but share. When I got involved in this before you all were, the key issue that we were confronting was the decade-long flat-- in dollars-- flat funding of the NIH and the NCI. And my first trips to Capitol Hill consisted of virtually beating on doors and explaining why this was a mistake for the country and for our people, and getting what felt like the cold shoulder. Over and over again, the same arguments seemed to fall on deaf ears. But-- and this is an important "but"-- what I have learned is that repeatedly making rational, evidence-based, and appealing anecdotal arguments, just as you describe, can ultimately move the needle. And it does. And so my personal cynicism with regard to politics and making a difference has gone down, not up, with aging. And I think listeners should think about this. You will never go to a congressional office and change a mind in one quick phone call. But when dozens and hundreds of people do it repeatedly over months and years, we actually do have the chance to positively influence policy and legislative actions and regulations in the United States. And you should forgive me for waxing so poetic. You should be proud that you've committed to doing this early. And I hope you start to see the rewards. So I'm sorry to carry on about my own experience here. But it really is part of what has helped motivate all the staff to get behind this program and launch it and support it. Looking back, I'll turn back to you Dr. Daly. You're a couple of years removed now from the program. Can you identify one or several key learnings from your time as an ASCO Policy Fellow that have stuck with you, that you find yourself coming back to in your daily life? RD: Yeah, I mean, I think what you've just said, Dr. Hudis, about how you can really have an impact is something that I learned during this fellowship. It wasn't something that I had been aware of in the past, because I had never done advocacy work before in the past. So I think what this fellowship really trained me to do is to be an effective advocate. And that is something that I can use in a multitude of different areas as an oncologist. So combining the patient stories that we talked about that are so visceral and so needed when you're trying to get through to those legislators or policymakers that you're trying to reach-- but also backing that up with data, and I think ASCO really equipped us well as advocates to have the data, as well as the personal stories, to influence change. So using tools like CancerLinQ to be able to look at broader data sets and say, we know this is impacting our patients. We can see that. And now we need to think of a solution for change. And I think being involved in helping to create some of those solutions was also really valuable for me. So with the pathways, creating the policy paper, but also serving on committees during that fellowship year on MACRA and other issues, like opioid legislation, that were really affecting our patients, and seeing how ASCO is effecting change in those areas, was something that will stay with me throughout my career. CH: And how about you, Dr. Yang? Do you see any practical day-to-day impact, for example, in your work with patients from your time in the fellowship? JY: Yeah, absolutely. I think because I spent most of the past year thinking about high drug costs, both for chemotherapies, immunotherapies, and supportive drugs, I'm much more thoughtful about the costs that are passed on to our patients. And that can actually be really significant. And one of the things that I do much more often is I ask about cost to my patients when I prescribe medications. And that I really attribute directly to work that I was doing with ASCO. The other thing is that working with patients actually often gives me ideas. So I'll see patterns emerging. And I'll think, we really need to work on a policy that addresses this. And the great thing about the Health Policy Fellowship is that you remain involved with ASCO. So when I see these issues, I'm able to take them back to ASCO and to the committees. CH: Well, speaking of the committees, after you and all of our Fellows complete the one-year program, you were automatically added to one of ASCO's relevant committees. And I think you're both members of the Clinical Practice Committee. I'm curious-- I'll start with you, Dr. Daly-- has your time as a Health Policy Fellow helped you in your work on the CPC, and how? RD: I think, absolutely. It's made me more fluent in the issues that the CPC is confronting, the sort of things like the Oncology Care Model, rural cancer care. I now have a foundation where I'm able to contribute in a way on that committee that I never could have before or without the Health Policy Fellowship. CH: Yeah, I think it's often the case that sometimes-- or I shouldn't say often-- I think sometimes it's the case that people get onto committees and really do have a steep learning curve. It seems like maybe this could have accelerated your start on the committee. Is that your experience, Dr. Yang? JY: Yeah, I think so. I think that the Health Policy Fellowship, that first year is a really steep learning curve. But it does, as Dr. Daly said, provide a great foundation to just be aware of all of the issues that affect cancer doctors and cancer patients. CH: So I'm going to go to a little bit of a speed round, if you will, and ask you both to think about the other members of our community who have not had the opportunity to do this and might not ever have thought about it. Dr. Yang, finishing the program last summer of course-- so it's fresher, I think, for you-- why do you think it would be important for oncologists to be aware of and engaged in policy discussions, rather than nose to the grindstone, thinking about their clinical and research responsibilities on a daily basis? JY: Mainly, I really think that the reason for oncologists to be involved in this is that regardless if you are thinking about it or not, health policy affects you. And it affects oncologists. It affects how they practice. It affects how they are able to care for their patients and the type of care that they're able to provide. And if oncologists aren't involved, their voice is going to be lost. And oftentimes, they're the most important voice for their patients. CH: And Bobby, what would you say to the old version of me, the cynic, who says, this is a waste of time-- I'm not getting involved? RD: Well, I do think it really makes your career more exciting to be involved in health policy issues. It really broadens your view of how you think about patients and how you think about cancer care, and makes coming to work every day, I think, more exciting because you have this other lens that you're looking at issues with. CH: And looking back more specifically, and not intending to turn this into a sales job for the Policy Fellowship-- we only have two slots a year-- but I wonder what each of you would say to young colleagues thinking about this. What's the best reason to get involved in the Health Policy Fellowship at ASCO? I'll start with you, Dr. Yang. JY: I think that if you're interested in quality of care, the costs of care, access to care, then this fellowship is the right fellowship for you. And I think that being interested in those things doesn't necessarily provide you with the skill set you need to actually do meaningful work in that realm. And I think that the fellowship program really does provide you with tangible skills that you can then use to write policy briefs, to hold meetings, to be an advocate, all of which are really, really, really important. CH: Dr. Daly, is there anything you can add to that? Or does that pretty much sum it up? RD: I think that's absolutely right. I would just add the mentorship of the fellowship is really incredible, so getting to interact with the ASCO leaders, like Robin Zon, or Ray Page, or Blase Polite, but also the ASCO staff as well, who are incredible in the policy area, like Deb Kamin. I think I learned so much from being in their presence for a year and just absorbing all of their knowledge that they had, an experience they had. And when I was at the annual meeting just a couple of weeks ago, it was just such a fun pleasure to be there and see all of them and know that those relationships are something that will be with me throughout my career. And they really influenced me. CH: Wow. I think that's great. And I am so proud of both of you and all the participants in these and the other development programs that we offer. I will share with you that from the perspective of the board of directors, these programs really represent the crown jewel, something that the board members take the light in. And you should be proud to have contributed the way you have. So Dr. Daly, Dr. Yang, I want to thank you again for joining me today for this ASCO in Action podcast. RD: Thank you so much for having us. JY: Thank you. And for all of our listeners, if you want to learn more about ASCO's Health Policy Leadership Development Program, please visit us at asco.org and search for "policy leadership." The application period for the 2020-2021 year is now open, and it will be open through the end of September. So there is time to get those applications in. And with that, until next time, I want to thank everyone for listening to this ASCO in Action podcast.  

Dr Dale Gardiner is a Consultant in Adult Intensive Care Medicine at Nottingham University Hospitals NHS Trust, UK. Through an interest in ethics, the diagnosis of death and deceased organ donation he has been a Clinical Lead for Organ Donation since 2009. In June 2018 he was appointed national Clinical Lead for NHS Blood and Transplant. Dr Gardiner is chair of Nottingham’s Ethics of Clinical Practice Committee and co-chair in a European deceased donation ethics working group (ELPAT). He served for four years as a member of the UK Donation Ethics Committee until its closure in 2016

Host: Matt Birnholz, MD Guest: Robin Zon, MD, FACP Value-based, patient-centered care has become the destination for all branches of medicine, and is the philosophy driving modern payment reform initiatives like MACRA. But the unique care delivery needs in each specialty challenge the notion that one payment model can serve everyone. And nowhere has this become more relevant than in the field of oncology. Dr. Matt Birnholz joins Dr. Robin Zon, practicing oncologist and vice president and senior partner at Michiana Hematology-Oncology in South Bend, Indiana. Dr. Zon serves as Chair-Elect of ASCO's Government Relations Committee was Past Chair of the Clinical Practice Committee, which alongside other stakeholders at ASCO developed a Patient-Centered Oncology Payment (PCOP) model. Recently, Dr. Zon presented this information at the recent AMA House of Delegates meeting in June. She speaks to the phases of this model, how it can function as a defined APM under MACRA, and its demonstrated positive impacts on oncology care pathways.

Host: Matt Birnholz, MD Guest: Robin Zon, MD, FACP Value-based, patient-centered care has become the destination for all branches of medicine, and is the philosophy driving modern payment reform initiatives like MACRA. But the unique care delivery needs in each specialty challenge the notion that one payment model can serve everyone. And nowhere has this become more relevant than in the field of oncology. Dr. Matt Birnholz joins Dr. Robin Zon, practicing oncologist and vice president and senior partner at Michiana Hematology-Oncology in South Bend, Indiana. Dr. Zon serves as Chair-Elect of ASCO's Government Relations Committee was Past Chair of the Clinical Practice Committee, which alongside other stakeholders at ASCO developed a Patient-Centered Oncology Payment (PCOP) model. Recently, Dr. Zon presented this information at the recent AMA House of Delegates meeting in June. She speaks to the phases of this model, how it can function as a defined APM under MACRA, and its demonstrated positive impacts on oncology care pathways.

Host: Matt Birnholz, MD Guest: Robin Zon, MD, FACP Value-based, patient-centered care has become the destination for all branches of medicine, and is the philosophy driving modern payment reform initiatives like MACRA. But the unique care delivery needs in each specialty challenge the notion that one payment model can serve everyone. And nowhere has this become more relevant than in the field of oncology. Dr. Matt Birnholz joins Dr. Robin Zon, practicing oncologist and vice president and senior partner at Michiana Hematology-Oncology in South Bend, Indiana. Dr. Zon serves as Chair-Elect of ASCO's Government Relations Committee was Past Chair of the Clinical Practice Committee, which alongside other stakeholders at ASCO developed a Patient-Centered Oncology Payment (PCOP) model. Recently, Dr. Zon presented this information at the recent AMA House of Delegates meeting in June. She speaks to the phases of this model, how it can function as a defined APM under MACRA, and its demonstrated positive impacts on oncology care pathways.

Host: Matt Birnholz, MD Guest: Robin Zon, MD, FACP Value-based, patient-centered care has become the destination for all branches of medicine, and is the philosophy driving modern payment reform initiatives like MACRA. But the unique care delivery needs in each specialty challenge the notion that one payment model can serve everyone. And nowhere has this become more relevant than in the field of oncology. Dr. Matt Birnholz joins Dr. Robin Zon, practicing oncologist and vice president and senior partner at Michiana Hematology-Oncology in South Bend, Indiana. Dr. Zon serves as Chair-Elect of ASCO's Government Relations Committee was Past Chair of the Clinical Practice Committee, which alongside other stakeholders at ASCO developed a Patient-Centered Oncology Payment (PCOP) model. Recently, Dr. Zon presented this information at the recent AMA House of Delegates meeting in June. She speaks to the phases of this model, how it can function as a defined APM under MACRA, and its demonstrated positive impacts on oncology care pathways.

Host: Matt Birnholz, MD Guest: Robin Zon, MD, FACP Value-based, patient-centered care has become the destination for all branches of medicine, and is the philosophy driving modern payment reform initiatives like MACRA. But the unique care delivery needs in each specialty challenge the notion that one payment model can serve everyone. And nowhere has this become more relevant than in the field of oncology. Dr. Matt Birnholz joins Dr. Robin Zon, practicing oncologist and vice president and senior partner at Michiana Hematology-Oncology in South Bend, Indiana. Dr. Zon serves as Chair-Elect of ASCO's Government Relations Committee was Past Chair of the Clinical Practice Committee, which alongside other stakeholders at ASCO developed a Patient-Centered Oncology Payment (PCOP) model. Recently, Dr. Zon presented this information at the recent AMA House of Delegates meeting in June. She speaks to the phases of this model, how it can function as a defined APM under MACRA, and its demonstrated positive impacts on oncology care pathways.

Having worked in music therapy for almost 20 years, Annette Whitehead-Pleaux currently works with pediatric burn patients at Shriners Hospitals for Children-Boston.  There she provides clinical services that focus on pain management, anxiety management, reduction in trauma symptoms, body image, improving fine and gross motor skills, and quality of life issues.  In addition to her clinical work, Annette has conducted clinical research on the effects of music therapy on pain.  In 2003, she was awarded the Arthur Flagler Fultz Research Grant Award for her research on the effects of music therapy on pain and anxiety of pediatric patients undergoing medical procedures.  She has an interest in and has written about using music assisted technology into music therapy practice and multicultural issues.  Prior to working with pediatric burn patients, she worked with children, adults, and geriatric individuals diagnosed with mental illness.  Additionally, she has worked with children in special education classrooms and women and children at a domestic violence program.  She has served the New England Region and AMTA since 1997 and currently serves as the Assistant Speaker of the Assembly of Delegate, national chair of the Standards of Clinical Practice Committee, and a member of the Music Therapy Perspectives editorial board.  In 2003, Annette was named one of Thirty Extraordinary Bostonians by the Boston Event Guide.  She was awarded the 2004 President's Achievement Awardby the New England Region for her work on the Rhode Island Night Club Fire Project.   She has a passion for knitting and being a mom.

Having worked in music therapy for almost 20 years, Annette Whitehead-Pleaux currently works with pediatric burn patients at Shriners Hospitals for Children-Boston.  There she provides clinical services that focus on pain management, anxiety management, reduction in trauma symptoms, body image, improving fine and gross motor skills, and quality of life issues.  In addition to her clinical work, Annette has conducted clinical research on the effects of music therapy on pain.  In 2003, she was awarded the Arthur Flagler Fultz Research Grant Award for her research on the effects of music therapy on pain and anxiety of pediatric patients undergoing medical procedures.  She has an interest in and has written about using music assisted technology into music therapy practice and multicultural issues.  Prior to working with pediatric burn patients, she worked with children, adults, and geriatric individuals diagnosed with mental illness.  Additionally, she has worked with children in special education classrooms and women and children at a domestic violence program.  She has served the New England Region and AMTA since 1997 and currently serves as the Assistant Speaker of the Assembly of Delegate, national chair of the Standards of Clinical Practice Committee, and a member of the Music Therapy Perspectives editorial board.  In 2003, Annette was named one of Thirty Extraordinary Bostonians by the Boston Event Guide.  She was awarded the 2004 President's Achievement Awardby the New England Region for her work on the Rhode Island Night Club Fire Project.   She has a passion for knitting and being a mom.