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Transcript56 lines
- [00:06]
A
Hello and welcome to Blood, Sweat and Smears, your Macheon Diagnostics podcast with tag team hosts, including Our medical director, Dr. Brad Lewis, senior director Bjorn Stromses. That's me. And other guest hosts. We hope you find these podcasts interesting and informative. Thank you for listening. And away we go.
- [00:27]
B
Hi, my name is Bjorn. Continuing our series 5 questions posing 5 questions to physicians in and around the disease areas we work in. Today we head north to the land of 10,000 lakes and lutefisk.
- [00:39]
C
Oh, no, you can't talk about lutefisk. It's disgusting.
- [00:45]
B
It's disgusting. I apologize on behalf of my people. We are joined today by Dr. Kristen Evans, Associate professor in the division of Pediatric bone and Marrow Transplantation at the University of Minnesota. Thank you for Joining us today, Dr. Evans.
- [01:02]
C
Thank you for inviting me, Bjorn.
- [01:05]
B
Absolutely. Please step aboard our long ship of exploration. I'm really leaning into it as we get into five questions. All right, so.
- [01:18]
C
Is that appropriate?
- [01:19]
B
I think so. Nordic Viking. We're tapping into the Viking heritage here. Okay, here's our first question. As you look at what you do today and then look back at your medical education, what do you wish you would have learned more about?
- [01:35]
C
Great question. Medical education. That was a while ago, to be honest with you. I have a friend whose kids like to say, was that in the 1900s? It was not for me, not quite that long ago, but it was a while back. I feel like things that commonly come up are like, did we get enough about how to talk to patients, listen to patients? And I feel like actually my medical education did a pretty good job at the direct patient interaction pieces. And our fields, a lot of breaking bad news and expectation management. I think what really would have been helpful, and this is going to be very based on what I do in my career, and not everyone would need more of this. I think business sort of things, finance things, kind of the business of medicine plays such a larger role in every day that I hadn't expected. And that can be like my individual research projects, right? Like managing a budget, grant funds, like spending down a grant before the money goes away. The time it takes to get something reimbursed is way different than. Than I would expect when I buy something on a credit card and pay for it.
- [02:54]
D
Right?
- [02:54]
C
Like, that's the. The turnaround time is so different. And so I think on that level, having more training and that would be great. But I think as a field, we really need to have expertise in business and finance, helping us move forward in some of our newer therapies so one of our, I would say, really big hurdles in cell and gene therapy right now is how to take these really fascinating novel cellular therapies that are so much less toxic than what we traditionally do in stem cell transplant and make them affordable and available to patients in an equitable way.
- [03:35]
D
Right.
- [03:36]
C
Like not everybody has cash on hand that they, you know, I have a disease, I'll pay whatever it takes. Like that's not, not where most people are. And some of the price tags on gene therapy product may start at 3 million and that's not even paying for like hospitalization and delivery and everything around it. And then you get into a rare disease and you're developing these therapies for handfuls of patients. You just lose the economies of scale there.
- [04:02]
D
Right.
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C
Like you're, it's not like dealing with heart disease in adults. So we really need experts that can help us devise platform approaches that are financially viable for the field as a whole. And that's not something I'm going to be doing personally, but it affects me that we don't have those people like invested in this area. And I think someone who has the medical background and a business background, there are people like that and I think they can really be helpful. But gosh, even on the little day to day, smaller grants type stuff, like really understanding a little bit more about business and finance I think would be helpful.
- [04:39]
B
Yeah, I can see that and I've heard similar comments. All right, so question number two. Pediatric BMT seems an area with some stunning wins and rather heartbreaking losses. So how do you manage moving between those extremes?
- [04:52]
C
That's accurate. I would say that the ups and downs are, I mean there's a lot of in the middle, but those ups and downs are pretty, pretty steep. So I think going into the field, I think having that experience and seeing how you personally handle the wins and the losses and how you frame them for yourself is important to know you can handle those challenges. For me, it's a lot about perspective taking and kind of staying grounded in my own everyday reality. Like my relationship with my family, my husband, my kids, they'll kind of bring me back to reality. I always joke, like when my kids have something that is like a crisis in their life, it is the most minor thing compared to what a given patient is facing.
- [05:39]
D
Right.
- [05:40]
C
But I can't hold them to the same sort of ruler. It's just different. And for them it is important and I have to like bring myself back to recognizing that and respecting that. I think one of the things that really helps with the wins and the losses is just being very realistic and honest with patients and families going into all of these things and managing those expectations, including my own, There are definitely times where I have in my head that, oh gosh, this kid's in great shape, Disease status is wonderful. We have a perfect donor, this is going to go smoothly and then it doesn't. And so I think recognizing all the points of difficulty or, you know, failure even, and knowing like what a tenuous situation it is and just approaching that realistically is really kind of what keeps me in a sane place with, with processing grief and losses. But yeah, some of, some of the losses in particular hit really hard and they stick with you. But on the other hand, I have, you know, a lot of really cool patient interactions where there's a huge, huge win. Like a diagnosis that someone who's had a disease for 10 years and nobody's diagnosed something, and I happen to be in a meeting and hear something that sounds similar and suddenly we figure it out and then, you know, change treatment course. And here someone's been sick their whole life and then you change that for them just by being in the right place at the right time and open to thinking about it or like a new treatment that comes on board in a, in a case you think really has no options and no realistic long term hope, and you give it a try, knowing that it might not work, but it does. So the field's always changing and that's, that's what I think keeps us in transplant in a hopeful spot. The longer you're in it, you see patients doing better and better, but then managing those expectations for the times when something, something comes up along and just knocks you off course again. Because it's hard, you know, you're dealing with people. So losses are quite big sometimes.
- [08:01]
B
Well, we've dealt with life and death. So now we move on to the really important question, which is more fun and why the complement cascade or the clotting cascade?
- [08:13]
C
The cascades that you row on are better or fishing? I don't know. You're a fisherman. Do you get much fish around cascades? Or they stay away from the rough water?
- [08:23]
B
Oh, sure. No, they. No, they need the rough water.
- [08:25]
C
Yeah. Right. Okay. So that is better than the complement cascade or the clotting cascade. And I would catch no fish and it would still be better.
- [08:34]
B
Are they real?
- [08:36]
C
Yeah, they're real fish. Fish. Compliment or clotting?
- [08:40]
B
Yeah, compliment or clotting.
- [08:42]
C
So clotting. I once tried to consult and by once, as if it's in the past. It might have been a few months ago, trying to consult a hematology colleague in the workroom next door when one of our patients had a clot. And I was laughed at and reminded that I all you too are a hematologist. I'm like, yeah, but I really don't like coag. And he said, yeah, I also really don't like coag. And he's like, but nothing has changed since your training. I'm like, still a low vinoxin anti 10a levels. He's like, yeah. I'm like, okay, fine, I'll do my own consult. I don't really love either of them. I interact a lot more with complement. Clotting. Yes, we inflame our patients, but we also obliterate their ability to make platelets. So clotting is a little less frequent unless they're like crazy sick and we've really screwed up. Complement and thrombotic microangiopathy. I mean, that pulls the two together. I think I'm going off course other than fishing, which I would like to be good at, but I don't know anything about more interesting processes. Thymopoiesis. Yeah, T cells.
- [09:56]
D
Right, right.
- [09:58]
C
Skid. All the ways you can get severe combined immune deficiency. Like, those pathways are so fun. Telomeres. Telomere maintenance, sheltering complex proteins. Come on, Bjorn, this is good stuff.
- [10:14]
B
There's a lot to. To be excited about is what I'm getting.
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C
Right, right.
- [10:18]
B
Neither compliments.
- [10:18]
C
DNA repair. I mean, gosh. And you ask about complement and clotting.
- [10:25]
B
There's a lot there. I know. Those are. Those are where we live most of the time.
- [10:28]
C
No, I understand, I understand. I think when I took Humong boards and was doing. Doing like a review course, something in the clotting cascade had changed since I had learned it, and I was livid. These are set in stone things. It's like the Declaration of Independence, right? These truths. But no, I think they're real. Will they change again? They may. Will I learn that? I probably won't. And I'll probably Google it. No. Just kidding.
- [11:03]
B
There we go. All right, question four. So we met at Nicer a couple of years back was a bit of an introduction to me to immunohematology. So when you think of immunohematology, where does that fit into the medical landscape?
- [11:19]
C
It overlaps so many things and. Okay, so the immune system is derived from the blood forming cells.
- [11:28]
D
Right.
- [11:29]
C
So they're inextricably linked. Immuno and heme.
- [11:33]
D
Right.
- [11:34]
C
In my field in transplant, one thing that's really cool about immuno disorders or immunohem disorders is that because they come from those blood forming cells, we can treat and I dare say cure problems in that area by stem cell transplant.
- [11:50]
D
Right.
- [11:50]
C
A little control, alt delete to a certain extent we try not to be like super, super aggressive and myeloablative, but enough that we need to, to get rid of the cells that aren't working and replace them and get rid of the immunoheme disorder. But it's interesting, every different program I've been through training at and I've done my training all over every program you'll kind of find what you think of as an immunoheme patient population in a different medical setting. So some places will have like an immunoheme group. It's usually multidisciplinary, but some people will have like that's their main focus and that's what they do. But it might include hematology, transplant, immunology, genetics, infectious disease, rheumatology. So all these areas, some places those patients are followed by one of those groups. So some centers have in their allergy immunology division a really big immunology focus. Some places don't or they don't have immunology at all. And so then those patients kind of fall to whoever's most passionate about managing their care. So it's interesting. And then flip side of things that can go wrong in immunohem you certainly have like the lack of cells or the dysfunction or inadequate function of cells, so risk for infection. But you also have that risk for dysfunctional immune cells or immune dysfunction that ends up lending itself towards autoimmune complications or malignant formation or pre malignant conditions. So it really depends on where a patient pops up, if you know, and where they're managed just depending by different centers. So it's a cool area. I think we all really enjoy it because we interface with so many colleagues with different sort of toolboxes and different approaches to things and ways of thinking about disease and learning from the rheumatologists all the different monoclonal antibodies they use and why and when do they use them. And we come in with our sledgehammers. But is that appropriate?
- [14:06]
D
Right?
- [14:06]
C
So as far as the medical landscape, if it's everywhere, all over the place, Pediatrics in adult land, it's like the forgotten stepchild sometimes. And these patients that have like survived but always had a little something going on and nobody could figure out or suddenly something presents in adulthood. So some of my favorite immunohem colleagues are the adult providers that are really bringing their expertise to these patients that have no home. You know, we need more immunologists for sure. And across the board, peds and adult. So yeah, immunohim is everywhere. I don't think you can get away from it.
- [14:48]
B
It's been very interesting to see some of that up close. All right, so our fifth question. What is the absolute best part of your job?
- [14:59]
C
Best part, Best part, Best part. I love people and I think you'll hear like we're humans are social beings. Some people would argue with that. Some people are like anti social beings. But I thrive on the interpersonal relationships that I have in my job. And that's with all the members of the team that I work with. And not just colleagues or subspecialists, but my nurse coordinator, my pharmacists, my advanced practice providers on the team, the dietitian nurses on the unit, all these people. And then you also have all the patients and their families and who supports them and those relationships and the fact that they're often in these really challenging moments where their whole life is disrupted and they're coming to transplant or cell therapy and we're working to together to make difficult decisions and get them through that. You know, I feel like we become part of the family for better or worse, whether they want us or not. Respecting that and kind of owning that, but also really valuing that is one of the best parts of my job. I think in direct competition for first place, there is the just constant intellectual stimulation. I mean, even just in the last five years, like the growth in, in cell and gene therapy in particular, that will be putting a lot of transplant out of date at some point is phenomenal. In in vivo approaches now is really cool and really all about immunology too.
- [16:42]
D
Right.
- [16:42]
C
Like how do you get something in that you want in and not recognized by the immune system such that it's not rejected? What sort of payload can you get into? What sort of vector? There's just so many cool things happening that on the surface seem like science fiction, but now it's like science non fiction, which is super cool. So yeah, though I think I, I will never be done learning and I that's. I'm all about that.
- [17:11]
B
That sounds great.
- [17:13]
C
Yeah.
- [17:13]
B
All right, so if you're keeping score at home, that is five questions and we have a bonus question, of course, which is what is something you'd recommend? It could be absolutely anything.
- [17:25]
C
Anything. Well, I would not recommend lutefisk We've already established that this delicacy is only for our grandparents of the Nordic type. My grandma loved it and I wish I didn't know what it was before I had tried it, because the concept, but also the taste. What would I recommend? I would recommend knowing that life and your career is what you make it and you never are out of options. So I think as we go through training and each step you're selecting a path, but it feels like you're closing doors to other paths. Turns out you can always, like, open them in some sort of way into what you're doing and pull that interest in. There's just too many ways to take your expertise and apply it across realms that keep you, keep you engaged and feeling like you're making a difference. So I think just never feeling stuck. And that goes for mental health sort of things too. I'm very open and honest talking with people about mental health, and I think everybody has struggles at different times and some people have struggles all of the time. But knowing that you have options and that you don't have to be stuck and that if you continue what you're doing, you've chosen to do that, that that's your choice, I think that's what I recommend, like knowing that you have the ability to make your own choices.
- [18:56]
B
Fantastic. Well, thank you for making the choice to come on the podcast. I really appreciate your time, so thank you.
- [19:04]
C
Thanks, Bjorn. Appreciate it. Have a good one.
- [19:08]
E
That's it for us here at Blood, Sweat and Smears, a podcast produced by Machion Diagnostics, your reference lab and CRO, specializing in thrombosis, hemostasis and rare disease. Thank you for listening and if you have a question or comment or there's a topic you'd like Dr. Lewis to speak to, please send us an email to blood sweatandsmeersachiondiagnostics.com that's M A C H A O N Diagnostics. You can follow Matrion at twitter@mation dx. Be sure to subscribe to stay in the know. Share this podcast with clinicians you think might appreciate it, and we hope you'll join us next time here at Blood, Sweat and Smears.