Interprofessional camaraderie - advancing pediatric leukemia care

00:00:00 Music 00:00:02 Host: Hello and welcome to this edition of Doc Talk. Today we're taking a look at the importance of interprofessional care to improve the outcomes of young people with leukemia, with pediatric leukemia specialists Paul Bowman, M.D. and Kenneth Heym M.D. Dr. Bowman has an illustrious 50 year medical career, 38 of which were spent as a pediatric oncologist at Cook Children's where he became the co-director of Hematology and Oncology, and later the Medical Director of the Hematology and Oncology department, as well as the Director of Medical Education at Cook Children's. Dr. Bowman also pioneered the first pediatric bone marrow transplants for acute lymphoblastic leukemia at Cook Children's, and directed a program focused on quality of life issues for adolescent and young adult cancer survivors. Today, he and his wife Lois, serve on the board of directors at Leukemia Texas, an independent, platinum rated, award winning 501c3 nonprofit organization that supports leukemia patients of all ages throughout the state of Texas. Dr. Heym is the medical director of Cook Children's Oncology Program. As principal investigator for the clinical trials treating leukemia and lymphoma through the Children's Oncology Group, Dr. Heym has helped coordinate the extensive clinical oncology research being performed at Cook Children's. He also leads joint research efforts and treatment protocols with St. Jude Children's Research Hospital in Memphis, Tennessee. In addition to his work in oncology, Dr. Heym has established the Cook Children's Vascular Anomalies Clinic. Welcome to both of you. 00:01:36 Dr. Heym and Dr. Bowman: Thank you. So happy to be here. 00:01:38 Host: So you recently hosted a first-of-its-kind symposium focusing on the importance of interprofessional care to improve the outcome of young people with leukemia. This symposium has been years in the making, can you talk about the vision and how it came about? 00:01:55 Dr. Paul Bowman: The idea for the Cook Children's leukemia symposium first was put forward by me and my wife, Lois, in early 2019. The idea was to make good value out of the proceeds of an endowment that she and I had established in the Cook Children's Health Foundation several years before, and to utilize the funds in promotion of an educational event that we thought would have great value at Cook Children's and to others who came from various places to attend. 00:02:27 Dr. Kenneth Heym: And I think one of the things that involved a great deal of persistence was obviously, with the COVID pandemic hitting at the time, we went back and forth about delays and about whether to go virtual with the symposium. Inside, we really knew that we wanted to have this in-person for a lot of reasons. And so we really hung in there. And we've joked that this is one of the symposia that, you know, has had a four year planning committee meeting across the years. And so, it, it was long in coming, but in the end, we were very glad that we hung on for an in person meeting because I think it it brought that much more impact to the proceedings. 00:03:09 Dr. Paul Bowman: The symposium came at last to fruition exactly three years from the original intended date, which was the first weekend of November 2020. And there was a series of postponements with some initial optimism that the COVID pandemic would abate sufficiently for us to proceed safely. But that did not really come to fruition finally, until 2023, this past fall. The only positive aspect of all of this long wait was that it gave our committee an opportunity to mature and to work together as a team and to reflect upon the focus of the symposium and the mix of local speakers that were being invited, as well as guest speakers from elsewhere. And to make sure that all the topics we thought would be important to our audience could be properly addressed. 00:04:00 Dr. Kenneth Heym: And I think one of the other things I'm sure we'll talk about was the personal feel that this symposium had. And I think everybody was ready for an in person meeting of that type after years of doing virtual meetings. And, you know, one of the things we look forward to in pediatric oncology because the field is fairly small, is getting together, meeting at conferences, catching up, that kind of thing. And, and the kind of networking and learning that really can only happen in person. So I think the fact that we held out for that really added to some of the unique aspects of this symposium compared to some of the other conferences that a lot of the attendees had been to. 00:04:38 Host: So the NIH and other health organizations note that medical symposiums are critical to the advancement of research by providing an opportunity for collaborations that might otherwise not occur. How do you think this symposium is a game changer in how health care professionals will look at pediatric hematology and oncology care in the future? And why? What made it so unique? 00:05:01 Dr. Paul Bowman: I'll chime in first, but I'm sure Dr. Heym will wish to also. We wanted to do some things that were a little different than what other national, international conferences focus on, which is really much, entirely, entirely the science when you go to a symposium or a research conference, which you hear about his the latest research, the clinical trials, laboratory work, and so forth. And we wanted to focus on that of course, but we also wanted to celebrate the progress in leukemia treatments that have occurred at Cook Children's over the last 40 plus years, and to make people aware that the quality of care, the standards of care are as high as they can possibly be, and certainly are ones that we're very, very proud of. 00:05:46 Dr. Kenneth Heym: I think the other thing going along with what Dr. Bowman just said is that, also just focusing on the day-to-day care of the patient, like Dr. Bowman referred to you know, you go to these meetings, and you hear the up-to-date, latest science, which of course we had at the symposium as well. But you also get to see kind of what goes into the day-to-day care of the patients. And I think it also allowed, you know, we were talking about how we learned so much from the speakers, the outside speakers, but also from the speakers within Cook Children's because as an institution gets larger, it's obviously harder for each group to keep tabs on what each … what all the other groups are doing as well. And, so even somebody who has been at Cook Children's 17 years, like I was, like I have been, I still learned quite a bit from some of the other specialties and disciplines that participate in the care of our patients with leukemia, that I didn't even really know how in depth, their commitment and their focus went to the care of our patients. So I think that, you know, symposia are absolutely necessary to keep up to date, also for the networking and the face-to-face interactions that you have. But in this respect, having a day really that was focused to care at Cook Children's, I think it allowed a lot of the people from within Cook, to get a much better idea on the, the commitment and the level of care that we have and that we're delivering to our patients every day. 00:07:05 Host: One of the things that came out of the symposium was an understanding that caring for kids with leukemia is so much more than the illness. It's also meeting their needs and the needs of their families. So much of the time we focus on the acute medical phase, of course, but can you elaborate on the importance of meeting those needs from an extended care perspective? What is the long term impact on patients and families? 00:07:30 Dr. Paul Bowman: This symposium, in addition to conveying information and building relationships for future collaborations, that we want for it to be remembered as a celebration of the progress that's been realized in the success in increasing survival and cure rates in childhood acute lymphocytic leukemia over the last 40 years, from about 50/50, now to over 90 percent, and that we wanted to celebrate some of the special people that have contributed along the way. So, for example, we had a lovely reception hosted by Cook Children's, after the first day, the Friday, which was focused on the care of kids with leukemia at Cook Children's. That reception was followed by an optional tour of the medical center with a focus on the hematology oncology areas. On Saturday evening, the second day, which was the day focused on ALL, the most common childhood cancer, we had a dinner celebration and an event at the Fort Worth Zoo Wildlife Art Gallery, which is a lovely venue and really handled beautifully by them, by the staff there. And on that occasion, we celebrated and honored the collaboration with St. Jude Children's Research Hospital and in particular, the leader of the Leukemia program over there for many years, Dr. Ching-Hon Pui, with whom I had had a close relationship since our days together as fellows and junior faculty. over 40 years previously. We honored a nurse who has been with Cook Children's and anchoring the Midland specialty clinic for 25 years, Julie Jolly, with a special award. And I was very surprised that my dear colleagues led by Dr. Heym gave me an award in celebration of my years of, of supporting the program also. So that was a tremendous event. And the whole thing wrapped up very nicely with a half day on Sunday, and an informal discussion group among the presenters that I think really left the participants with a strong sense of collaboration and the opportunity to be involved in the discussions themselves. 00:09:49 Dr. Kenneth Heym: One, I think what that also does is it gives, it gives you opportunities not only to talk to the outside speakers and get to know them, but it gives the people coming into town a chance to experience the city. The hospital tours were a very popular item. And we got a lot of good positive feedback from people. And, you know, you got comments at the end of the weekend that this was one of the more fun conferences that we've been to, you know, this is one of the more personal ones that we felt that. And so it's creating the atmosphere, obviously, the education is there, the science is there, it's very up to date, technologically and medically. But it also is how you set a tone. And I think that also reflects on the tone set at Cook Children's and the day to day care that we provide the patients. So I think those special events, really were well chosen to highlight some of the unique aspects about the city about the hospital, the medical center, and really gave people a good feeling about just the weekend overall. 00:10:44 Dr. Paul Bowman: I should also mention that we wanted our speakers, both local Cook Children's as well as our guest speakers, to feel special. And so we were able to honor them with a special speaker's dinner on Friday evening, November, the third, which was hosted and supported by the Cook Children's Business Development Group. 00:11:05 Host: Well, and something that kind of comes out of that is like, clearly you had not just Cook Children's presenting, but but speakers and presenters from other other health systems. And so I think, how does that contribute to building those collaborations? And how does that contribute to future care of kids? 00:11:22 Dr. Kenneth Heym: Well, I think that the research collaborations and the consortia that we are already a part of has established relationships, where we were really able to call up the true leaders in the field worldwide, and ask them if they would come and present their research or talk in their area of expertise. And so I think this one of the other things that made many things made the symposium unique, but I think one of the really prominent ones was the fact that we did have a day where we could truly focus on what's going on at Cook Children's. But then we had a day and a half where we were bringing in truly the worldwide experts in the field. And so and with our one speaker, from our neighbor to the north up in Canada, we can say we had an international lineup of truly the experts that are you see in the medical literature, and that are published and are chairing international clinical trials. And so I think through that you're able to bring, I mean, you were not ... the attendees were not lacking for any of the most up to date, state of the art reviews in what's going on in the different fields of caring for children with leukemia. And I think it was able to be balanced with the local kind of homegrown feel about, well, what are we doing here? How do we implement these advances that we've had in the field of leukemia? As well as just kind of that personal feeling of being back together in person, being able to shake hands with people and talk to them face to face, and just give kind of that ... people walked away with not only the increase in their knowledge in ways that they might be able to improve their practice, but I think a very good feeling about what's going on at Cook Children's, 00:13:00 Dr. Paul Bowman: Many of the speakers themselves, who are on the circuit speaking in various prestigious locations in the country and around the world, indicated that they felt that this was an international level conference. 00:13:13 Dr. Kenneth Heym: And they stuck with us for the ... I mean, there were people we asked back in 2019, would you speak at this conference? And then they got multiple emails, we're gonna delay a couple months, are you still willing? Are you still willing? and ever just about everybody that committed in 2019, showed up in 2023. And I think they were excited about it. And we're very, very glad that they did. 00:13:35 Dr. Paul Bowman: We really focused on the therapy, its intensity, the fact that there's a sequence of milestones, but the completion of treatment, whether in some cases, it may be a few months, up to a year and other cases two and a half years or more, does not end the relationship, or the necessity for close follow up and a long term relationship. For a number of reasons. Patients who go through leukemia therapy successfully, may still have very significant consequences of the treatment that they experienced, that require long term follow up and monitoring. We addressed that issue with both the Cook Children's speaker on the subject of neuropsychology, and the recognized risks of potential cognitive deficits and learning problems among leukemia survivors, which are being identified now. What we describe as proactively to try to mitigate some of the consequences by early interventions, and by treatment changes to try to reduce them in the future. One of our speakers also, Dr. Dixon from St. Jude addressed this in terms of the long term follow up studies on populations of patients, showing the risks that they may face years or even decades after successful treatment. So long term follow up and a structured management plan that involves identifying risks before they become harder to manage is a crucial aspect of leukaemia care, which goes on for many, many years. And some of these relationships actually go on for decades, I occasionally get calls from patients who are now not only young adults, but even middle aged adults when we took care of back in the 1980s, who are seeking an answer to a question or guidance and some follow up and so forth. 00:15:31 Host: Sounds kind of like the basis for basis for the adolescent and young adult program. 00:15:36 Dr. Paul Bowman: It's a closely related the AYA, a or adolescent young adult program focuses on the unique challenges of having to confront a diagnosis of leukemia, when you are in the midst of the most challenging maturational growing up phase of, of youth, namely the ages of 15, up to 19 or so, at Cook Children's and somewhat into the 20s, even. So one of our speakers, Dr. Allbritton, marshaled her entire team to give a case-based presentation that really focused on what was a very significant eye opener to the audience, regarding the challenges that exist when an adolescent not only has to face the diagnosis, but deal with all of the social and school and other issues that can be really fraught with risks, even if you're in perfectly good health. 00:16:31 Host: We often think of the really large academic hospitals when it comes to advances in diagnosis, treatment and long term follow up of leukemia. But in a conversation we had earlier, you both mentioned that a lot can be learned from smaller teams, and freestanding systems. What what are some examples of that? 00:16:49 Dr. Kenneth Heym: Well, I think that again, it was number one, in terms of just awareness. I'm gonna start again, the story there. So I think that the way that pediatric oncology exists, we are all kind of collaboratively throughout the country throughout the world, utilizing similar treatment protocols and able to provide patients with therapy that will cure them. I think one of the aspects that can be learned in a unique way from smaller institutions, even though children's is by no means a small institution, but if you consider the non-traditionally academic centers, is how that care is implicated, sorry, how that care is implemented. And really the the personal aspect that we're able to provide. And I think that my eyes were opened, as I mentioned before, seeing just how in depth the different disciplines and ancillary services like nutrition, physical therapy, social work, all these other aspects of care how dedicated and invested, they are in the care of the patient with leukemia. And I think being able to see how you can provide cutting edge, state of the art therapy with a very personal, individualized, family centered approach, not that you can't get that at a larger academic institution. But I think that there are some barriers that go with being one of those types of hospitals. And I think at Cook, we are really able to provide that balance of not cheating our patients out of any of the most breakthrough therapies that are available for leukemia, but also being able to provide it in a way that treats the patient and the family as a whole and really provides care as well as cure. 00:18:30 Dr. Paul Bowman: I'd like to add that a Cook Children's is not a traditional academic hospital, in terms of being situated on a university campus and intimately managed with the university faculty. However, Cook Children's does participate in a broad range of academic pursuits, from medical student education, to research both collaborative and initiated by its own investigators. And I think Cook Children's is stepping up to the plate and fulfilling the responsibilities that come with its growth into a very large and impactful healthcare system. Many people not be may not be aware of this, but Cook Children's Medical Center is the 10th largest hospital in the United States of America for children. Did you know that? 00:19:22 Host: I did not know that I did understand that we are the largest freestanding pediatric system, but I could be wrong. 00:19:31 Dr. Kenneth Heym: Well, in one other aspect to touch on, Dr. Bowman mentioned medical student education. And I think one of the unique aspects about our symposium is that Dr. Bowman from his years as the Chair of Pediatrics over at the UNT Health Science Center, was able to incorporate the medical students into the symposium and I've not been to a conference where medical students played any part. They were allowed to attend. But what we did was, Dr. Bowman assigned a medical student to each one of the speakers who researched that speaker, learned about them, often touched base with them prior to the presentations. And then the medical students actually introduced the speakers. And it was a very unique thing. In talking to all the speakers, they had never had anything like that happen at a conference they'd been at before. And I think it was mutually beneficial. I loved talking to the student who inter ... introduced me. Dhe learned quite a bit, she said, from looking into it and really enjoyed it. And I think it helps to form this kind of basis for how you approach mentors and how important education is to us. So again, I think it's very important to note that, although we may not have a medical school affiliated, or an academic institution affiliated with Cook Children's, we still do participate in medical student education, multi-institution consortia, and are as academically active, if you want to put it that way, as as any other large center. 00:20:54 Dr. Paul Bowman: We had tremendous interest among the student groups at Texas College of Osteopathic Medicine who are pursuing their interests in pediatrics in oncology. And so with the help of their leaders, I was able to recruit 23 students, one to match with each of our 23 speakers, of whom there were 12 from Cook Children's, and 11 from the outside institutions that we invited. 00:21:20 Host: So if I understand correctly, this symposium really shone a light on the multiple disciplines that go into treating kids with leukemia today, including genomics, pharmacology, pharmacogenetics, multiple therapies, etc. How so? 00:21:34 Dr. Kenneth Heym: Well, I think just by involving and allowing presentations from these different disciplines really shone a light, like I've never been to a leukemia symposium, where physical therapists spoke, and at the importance of physical therapy while patients are undergoing therapy, things like that. So I think it certainly opened the eyes to just how much care and how many different people are involved in the care of each leukemia patient. You know, acute lymphoblastic leukemia is the most common cancer that we see in childhood. And so this is our largest number of patients, and each one of them is cared for in this multidisciplinary way. And so I think the symposia symposium did shine a light on just how much goes into it both the day to day care, but also from the speakers talking about the basic science, the pharmacology, having the pharmacists discuss not only treatment, but also how to get availability of new agents, and novel therapeutics, just all the different layers that are involved in treating your individual patient, but also making sure that, as an institution, we can provide everything that's necessary to keep us up-to-date and current. And there are just so many layers to it that you can never really fully get that idea across. But I think the symposium and the ... the variety and the diversity of the speakers really helped to bring that message home. 00:22:55 Dr. Paul Bowman: I think it became very clear to the attendees and the speakers, that the degree of teamwork involved in the care of children with leukemia at Cook Children's is as good or better than is available in many institutions that are known for their academics and their research. But perhaps don't have quite the same recognition that some of these disciplines are really crucial to the care of the patients. 00:23:22 Dr. Kenneth Heym: And I did have one of my colleagues from one of the most highly academic centers in the country for pediatric oncology, say to me, after the day that focused on the care at Cook Children's, that you all really seem to enjoy working together. That came across that the teams really enjoy collaborating on the care of these patients. And I think that goes a long way. 00:23:44 Host: So caring for kids with leukemia, or any serious diagnosis can really take its toll on the patient's families. And that family includes the medical team, because members of as you just mentioned, the care that goes into the kids and the whole team. And so because members have both spent a lot of time together and in making hard decisions together, how difficult is it to navigate this and how beneficial are support groups? 00:24:11 Dr. Kenneth Heym: I mean, I think it's crucial, you know, families will tell us in the two-and-a-half years that they're being treated, that they see us more than they see their family, more than they see their cousins and their aunts and uncles. And so you really do form this relationship with them that ... one of the reasons why I went into pediatric oncology is because of that relationship. It's not short term. It's not just a few visits attacking a specific problem. It's really a long-term kind of long-haul relationship. And as Dr. Bowman pointed out before, not just while the patient is on therapy, but for the years after they complete therapy. And so I think it's crucial to not only provide, obviously the medical care, and to treat the patient, and to treat the underlying leukemia the best you can, but it's providing that support for every decision that comes up, every hiccup or obstacle, because no patient sails through therapy without a complication. And, and you know, the parents and the families know, that any day, an infection or a complication that comes up could turn into something huge and something that they can't recover from. And so, I think it's forming that relationship over time. It's one that's built on trust and collaboration, much like the collaboration between the other disciplines within the institution. And, you know, you just, it's something that people hear that you're a pediatric oncologist, and the first thing out of their mouth is, 'Oh, bless your heart.' 'Oh, it must be so hard.' But it sounds really weird when I say this, but it's a beautiful thing to be a part of. And part of it is that relationship and the bonds that you make, even when things don't go the way you want it to. 00:25:41 Host: So Dr. Bowman, as one of the key founders of the Leukemia program at Cook Children's, how have you seen care change over the years, and what have been some of the greatest breakthroughs both in medicine, but also in the delivery of care, not only here, but across the board? 00:25:56 Dr. Paul Bowman: Care for kids with leukemia, of course has grown in complexity, as we have learned more from our successes and our failures over the years. And there's been a tremendous amount of refinement in treatment based upon what we've learned about the responses to treatment, the risks for what's called relapse, which is treatment failure, and the underlying biology, or the underpinnings of what makes diseases behave in certain ways in certain patients. Fundamental to all of this, of course, is the research that is involved through collaboration in what are called clinical trials. When I first came to Cook Children's back in 1982, the infrastructure was just barely in place to be able to get clinical trials underway. And one of the things that helped that helped us gain a reputation for meeting a high standard of care, was the official launch of clinical trials in ALL and AML, the other acute leukemia in children, in 1983, no 40 years ago. So we built upon that and enhanced our reputation through rigorous participation and meeting the standards of the cooperative groups. And along the way, we had the opportunity to learn so much from our participation, to benefit our patients as well as patient populations as a whole. One of the most important things that we learned was that we had a lot of tools, that is chemotherapy drugs that were becoming available in the 1960s and 70s. And we had to learn how to use them more effectively, with a better balance between response and side effects. This is something that's continuing to date with drugs that we've used now for 50 years or more. Back in the 1980s, we began to recognize genetic features in leukemia cells that were different from one patient to another that had a bearing on their prognosis and response to treatment. This began the concept of what are called risk groups that is being able to determine either at the outset, or not too far into therapy, what a patient's likelihood was of being successfully treated or not. This is one of the greatest advances the refinement of treatments based upon what the patient's disease has in store for us if we don't tailor it to the needs of that individual. We've learned how better to use bone marrow and now stem cell transplants effectively. There's been a tremendous improvement just in the last few years in immunotherapy techniques, which Dr. Heim can elaborate on much more than I can since it's becoming now a key aspect of treatment, a modern treatment for kids with leukemia, supportive care, that is getting them through the rigors of the intensive aspects of therapy and having them come through it in the best possible shape, better antibiotics, better blood component safer approaches to treatment, other things such as critical care. When I first came to Cook Children's, the ICUs did not were not fully staffed with critical care physicians, that gradually changed and a variety of other specialists came into play that were crucial to the success of our program and helping deal with potential and established side effects. And of course, the study of late effects. That is the things that happen as a consequence of leukemia treatment, which may be recognized during therapy, or even several years later, has allowed us to look back and to tailor treatments according to a patient's needs more effectively than if we weren't studying those. One of the most important areas is the fact that radiation therapy was part of the treatment protocol programs for children with leukemia, dating back to the 1960s and 70s. And with our collaboration with St. Jude hospital in the last 20 years or so, we have learned that radiation therapy is necessary only for a very small reduction of kids with leukemia, therefore protecting them from the others from the consequences radiation therapy that include long term effects on growth and cognitive function and development and so forth. 00:30:13 Dr. Kenneth Heym: I think the change over the years, as Dr. Bowan said, has not only been viewed at Cook Children's, which is just in the 17 years that I've been here has just grown exponentially, not only in size and scope, but also in the way that we're able to provide more individualized care. But as he was saying, as well, just the the movement, worldwide, from the toxic type of therapy that was given initially, you know, when patients aren't surviving, you'll try anything to get them to survive. And then once you get a disease to the point where prognosis is excellent, and the majority of patients are surviving, then the goal is to see if you can back off on your therapy a little bit, reduce that risk for those long term problems. And that's where immunotherapy and cellular therapy has started to play such an important role. And just in the last few years at Cook Children's, our immunotherapy and cellular therapy has exploded in terms of what we're able to provide for patients both at diagnosis, but also when they relapse and the outcomes are not as good. And so it's changing and growing so quickly, that it's just a very exciting thing to be a part of. 00:31:22 Host: In an earlier conversation that I had with both of you, you talked about the new relationships that formed during this symposium that kind of focused on the art and science of medicine and teamwork. And what comprehensive care is, can you share a little about that? 00:31:39 Dr. Kenneth Heym: Well, I think that at the symposium we were having throughout the day, especially the the Cook Children's Day, I was having colleagues from different institutions across the country come up and say, Hey, I'd like to, can you put me in touch with this person, I'd like to talk more about what they're doing and how they're implementing things like that. At first, I wanted to make sure they weren't going to try to offer them jobs and take them away. But I think that, you know, again, we were all used to going to these conferences where a researcher talks about this new gene that was discovered or the impact that it's going to have on treatment. But really, this was kind of like a nuts and bolts like how do you implement all of these advances in the day to day practical care of the patient. And I had some colleagues from very large institutions say, Well, we have not been able to make a team that specifically addresses this, for example, after the adolescent young adults discussion. Someone came up to me and said, We don't have a team like that we don't have this multidisciplinary approach that finds these adolescent patients, regardless of their diagnosis, to address the specific needs. And so I think that I know for a fact that a lot of our pharmacists, physical therapists, nutritionists have started conversations with patients with people who attended the symposium, really trying to seek their advice on what are what are ways that we can bring what you guys are doing a Cook Children's to our institution. And I think those are going to be relationships that not only help address those specific issues, but build future relationships. So if another institution is saying, well, we want to do this study on the impact that nutrition is having on patients with ALL, they're going to remember the talk that was given by Rachel Hill that was incredibly well received, and they're gonna say, Cook Children's is an institution that we want to collaborate with. And I think that's where, over the years we have built so much of our reputation is through these collaborations with the Children's Oncology Group with St. Jude with other smaller consortium that we've been a part of as well as elite groups, such as a group called tackle, which is therapeutic advances for childhood leukemia, which is a group of about 30 institutions worldwide, focusing on novel breakthrough therapeutics for patients with previously incurable leukemias and lymphomas. So I think it really and that's also one of the huge benefits about meeting in person, because you just can't get that kind of relationship building and that kind of connection via zoom or on the phone, it's being able to go up to the presenter after the presentation and shake their hand and say, Oh, that was great. You know, what about this that, and it was just great to watch the conversations occurring in the corners of the room during the breaks, seeing people reaching out, not only again, to address the specific thing that was discussed, but you can tell that there are going to be future collaborations that come out of this. 00:34:33 Dr. Paul Bowman: Sometimes, the knowledge and passion that is evident in one speaker and their approach to their topic is infectious and inspires others. I can there I think there are many examples of that came out of the symposium two that come to my mind immediately are the presentation of Dr. Tristan flat from Kansas City who has been focusing all major efforts on the Management of kids of Hispanic heritage, whose prognosis is not as good as those of Caucasian heritage for a number of reasons. And his presentation was a tremendous inspiration to many in the audience who felt that their Hispanic population needed more specific attention to their unique challenges. Also, not just their socio economic issues that they may face, their access to care. But also the fact that the disease processes in individuals of Hispanic origin especially those who have come from Mexico, may have a different type of biology of their disease, it may make it much harder to manage with conventional treatments that are presently available. Another speaker that was equally inspiring was Dr. Hetzler from Toronto, who gave a just beautiful presentation on the care of kids with Down Syndrome and leukemia. Leukemia occurs with a higher frequency in Down syndrome, children than it does in others. And they have very special needs with respect to their fragility in the face of chemotherapy and the fact that their drug doses need to be altered and their monitoring for side effects needs to be even more meticulous and rigorous because of the risks that they face. 00:36:18 Host: So, Dr. Heym, your presentation focused on the impact outreach clinics have on meeting the needs of patients, families, physicians, and communities, and outlying areas, what … what impact does this have? The amount of collaboration needed for regional coordination of care and keeping the patients’ primary care physicians informed must be tremendous. How is this accomplished? 00:36:39 Dr. Kenneth Heym: Well, this is accomplished by building on what Dr. Bowman started 40 years ago, when he first came to Cook Children's and realized that you can't just count on the fact that the areas and the surrounding areas close to you are going to refer their patients to you. I mean, that's usually what happens. But you're going to develop a much stronger referral base and be able to provide the highest quality care to as many patients if you go out into those communities. And so, you know, the western part of Texas is a very large area, I'm from New York, I was blown away. When I first started working in Texas, I had a patient who said they drove 10 hours to come and see me and I said, Oh, what state did you come from, and they said, Texas, because 10 hours up on the East Coast is, you know, Boston to DC. And so I think being able to go out there and have a presence there. Again, there's only so much you can get from and not to put down talking to those referring doctors on the phone and, and doing things like that. But when they see that you care enough to come out to their community, and do your clinics regularly. You know, if we see 20 patients out in Midland, that saves 20 families five hours each way having to take a day off sometimes come in the night before. So the financial hardship, the social stress, what am I going to do with the other children, that kind of thing. So I think it shows commitment to really trying to relieve some of those burdens on those families, so they can focus on helping their child get better. It also allows us to build these collaborating relationships with the physicians locally in these smaller towns. You know, I was blown away that you know, how much these local pediatricians are willing to take on themselves and how much they're willing to participate in the care. You know, if you're a pediatrician in a big city, and you've got a major medical center, 10 minutes away, you're probably going to have a tendency to refer a lot of those patients and know that you have that backup right there. Whereas a lot of these pediatricians that are out in the middle of very sparsely populated areas, realize that they're the medical care that that patient has locally. And rather than make that family have to come back and forth to the major medical center, they accept so much of the responsibility and are willing to do so many things out there. Draw labs, do exams when the children are sick, supervise us giving chemotherapy, giving blood transfusions. And so it has been an incredible experience to build those relationships with those families. Now, you're absolutely right that that takes a lot of coordination. And I am not even going to begin to claim that I do that. Amy Bales as a nurse practitioner who has been at Cook Children's for longer than I have probably close to 20 years. And her area of expertise is she has really taken over coordinating the care of the patients not only in West Texas, but at our other regional clinics as well. And she has just built the strongest personal relationships with the nurses in the local clinics, the local pediatricians, the staff at the hospitals where the chemotherapy is given. I mean it's an incredible amount of coordination that goes into it, but it is so worthwhile and it is so amazing to see what we're able to do. And I think, at least for me, one of the highlights of the symposium was the panel discussion we had on the care of patients out in the satellite clinics, because we had Amy talking about all that goes into coordinating it. We had Julie Jolly, who Dr. Bowman mentioned before, who has spent all 25 years of her nursing career at Cook Children's at the Midland clinic, and is really an anchor for those patients out there. And then just to add more power to that discussion, we had Dr. Chelsey Greer, who is one of our newest faculty members here. A graduate of the Texas College of Osteopathic Medicine in Fort Worth, but who started before all of this as a West Texas oncology patient being treated for her childhood cancer at the clinic in Midland. And so she was able to talk about the impact it had on her family to be able to have those resources locally, as well as what the relationship with Julie and the staff has been over time. And so I think that's something that's, you know, I know, a lot of major medical centers have these referral areas that have some of these kind of smaller 10 areas. But I think Cook Children's really has excelled at its ability to provide the same state-of-the-art care that you would get walking into a major medical center in any major city in the country, to these families that live in these small towns that are five, six hours away. And it all comes down to showing commitment to it. Because it's not necessarily going to be what makes a hospital money. It's not going to be what brings you fame or that kind of thing. But it's building those relationships, that is going to start and then those pediatricians know, I've got a new patient, who am I going to go to? I'm going to call the team at Cook. They've been available to me for years and years and years. And it really goes back to Dr. Bowman going out there, when he probably didn't have the resources to cover when he wasn't here in full in Fort Worth. But going out there taking the charts with him on the plane. And going out there and seeing those patients, meeting all of those pediatricians face-to-face, having lunch with them, going office to office, that kind of thing. And there are pediatricians who still call and ask for Dr. Bowman, just assuming that he's always going to be here as he is. So the West Texas clinics and the satellite clinics have been one of the most rewarding things about my time at Cook Children's. 00:42:01 Dr. Paul Bowman: You know, I certainly echo that a great deal of my professional and career satisfaction came from those travels and getting so closely acquainted with the … with the local physicians, nurses, communities, and building relationships with families and patients that I'll always treasure. 00:42:18 Dr. Kenneth Heym: And the families are so thankful, so thankful. And you know, it's great to visit some of the smaller towns that I may have never gotten to. I can't tell you how many pies and cakes have been brought to clinic over the years. So … but it's just, it's just a warm feeling. Because it means that much to these families. Families who don't have anything, and knowing that they don't have to come back and forth to Fort Worth is a huge relief for them. And they show it. They're so, so grateful for everything we do. 00:42:48 Host: So over the last few years, Cook Children's has developed global health services to work with referring physicians, how has this helped to evolve care for patients who aren't in the immediate area, and may not have access to the care we provide. And that's patients coming in from other states and even in some cases, other countries? 00:43:05 Dr. Kenneth Heym: Right? I think once you establish yourself as providing the level of care that we provide at Cook Children's, you know, word gets out. And it's not just our West Texas catchment area, and other parts of Texas and Oklahoma and New Mexico in places that we've been getting referrals for a long time for things like bone marrow transplant, but certainly, being so close to the border, patients from Mexico – and not only having a lot of those patients here, but over the years, we've developed relationships with physicians in some of the major cities throughout Mexico, both helping them with being a resource for them for the care that they provide. But also being able to help share the care. On certain patients provide second opinions, and also for patients who wind up going back to Mexico knowing that they're going back to an institution that's capable of providing the care. So, you know, the reach has extended because our capability has extended as well. 00:43:56 Dr. Paul Bowman: We had, I think, six, at least, guest attendees from various institutions in Mexico, and I had a very enjoyable opportunity to discuss some cases with them and to exchange information. I know they found the experience very valuable, as I did, too. 00:44:12 Host: What do you think the biggest takeaway for health professionals from the large academic institutions, and the smaller institutions as well, what do you think the biggest takeaway was for them? 00:44:21 Dr. Paul Bowman: I'll just say one thing, and then turn it to doctor Heym.. We are all in this together with a common purpose of trying to improve the lives of children with leukemia. Everyone seeks to achieve the highest standard of care possible. And teamwork is essential whether you're working in a large or small institution. And there's always an opportunity to learn something useful from talking and listening to someone else who shares the same focus as you do in a different part of the country or part of the world. 00:44:57 Dr. Kenneth Heym: I think that's absolutely right. And I think that a lot have the faculty from the larger institutions said essentially that, it's not that I don't know how to say this without sounding a way I don't want to sound, but it's not that at some of these larger institutions, they get in the mindset of well, our way’s the way to do it. And you know, if we can be available to help other, smaller, lesser known institutions do things our way that would be great. I think what they learned is that what we're doing here is … is incredible, it is on par In some ways, even surpassing some of the aspects of the care that can be given, even at these larger places. And so I think they realized, and like Dr. Bowman said, our field is small, we're all very close, we're all have the united goal. And so I think everybody realizes there's something you can learn from everyone. But I think they were very, their eyes were open wide as to just the level of care that we are providing here. And that, you know, taking back to their institutions that, well, we may have the lab researchers and the people making the discoveries and all of that, but are there ways that we can better implement this care on a day-to-day basis? And seeing an institution that's able to have such a good mixture of treatment, that's second to none, but also the way that it is implemented and the way that it's family and patient centered and focused. I think that a lot of the faculty from the smaller institutions got hope that yes, we can do this too. Like they have building blocks for where they may want to go with their different programs and how they can build and they also may have found a partner to collaborate with. Obviously, we have collaborations with a lot of the institutions from which the speakers came. But this really opens the door, and putting, you know, people face-to-face. You know, if we were to get a call from someone from a smaller institution saying, Hey, we're looking to do this, can we talk to your this person who we heard speak at the symposium, we want to help build this program, maybe have them come and spend some time with us. I mean, again, it, it sounds so simple, that this is how those relationships start. But it really is getting people in a room together and just saying, Hey, this is what we're doing. This is what we have to offer, and, you know, whatever we can do to help other institutions. But I think it was just so well received by the people at different levels because of what we're able to do here. 00:47:18 Host So based on feedback you've had from presenters and attendees moving forward, what impact do you hope the symposium has? And do you see another in the near future? 00:47:28 Dr. Paul Bowman: There are two types of feedback. Regarding the symposium, there is the informal feedback that I'll ask Dr. Heym to share a bit more, although he's certainly done so already. And then there is the formal requirement of a continue of an accredited continuing education program, to seek feedback from the attendees, both with respect to quantitation, numerically on a scale of one to five, how they assess each component that they attended, as well as to provide constructive criticism and input. So with that preamble, I will say that I have it on good authority that the Cook Children's leukemia symposium was one of the most highly rated, if not the most highly rated conferences that Cook Children's has ever hosted. On the Likert scale of one to five – and every item was, was scaled by every attendee – the average overall score was 4.86, out of five, which is really extraordinary. And accompanying that, a lot of very valuable input was received, much of it positive or virtually all of it, but with a few pieces of constructive input that I think are valuable, that should be taken to heart if there is a future symposium to be to be developed. I do want to mention that the team that put this together, the members of the committee, the event planning group, marketing, and all of the other members from the foundation and physicians, nurses, dieticians, physical therapists, and so forth, they all really stepped up to the plate and just did an extraordinary job in putting this together. And I'm very proud of the opportunity that we've had on behalf of the Leukemia program endowment to have helped support it and provide the initiative behind it. And I'm also very happy that it was so well managed, that we actually had to infuse not quite as much money into it as we thought we would have to. So it was really a positive experience for me and my wife, Lois and everyone who, with whom, I've had any further discussions about it. 00:49:47 Dr. Kenneth Heym: I think also to have our coordinator Danielle running around on the day of the conference nine months pregnant, still coordinating everything not slowing down at all. It was just … and that was another bit of feedback that we got is that it was so well run. It was smooth. The transitions were seamless, even getting the logistics of getting back and forth to the events. The Cook team just did an incredible job doing that. I think that, you know, we certainly think that this is a symposium, or this kind of symposium needs to continue. One of the other things that was unique about it is this did not address one specific topic in the care of children with leukemia. This was a really broad review. This was almost like a board review course, where you could leave this symposium being up to date on what's going on, and all the kinds of different key aspects in treating different populations and patients with leukemia. So I don't think this is something we can put on every year. Hopefully, it won't take four years to plan like it did with COVID. But I do think this is something that every couple of years would be incredibly beneficial. I know a lot of the faculty members said they want their trainees to come, they want their fellows to come because this provides them pretty much a review of everything you need to form as a basis for the care of patients with leukemia. So we had a resounding call that this not be a one-and-done. And I think probably this would be an every few years kind of symposium just because of the broad scope of it. 00:51:10 Host: So is there anything I haven't asked you, either one of you. that you wanted to add? 00:51:16 Dr. Kenneth Heym: I just want to add, and Dr. Bowman won't want me to add this. But I have to add that I think this symposium also served as an incredible monument display of what he has built. I mean, he's, again, not someone who wants to have things like this said about him. But he’s the reason that I came to Cook Children's and the reason a lot of people did. But also, he built this program, this leukemia program and took it in places that we never could have dreamed it would go. And this really, you know, he had his time at Children's end during COVID, when you couldn't have big celebrations, and parties and things like that. And I really think this was the, I don't want to say swan song, because he's not going anywhere. But this was really, in a lot of ways, also a way that we could honor him. And those of us that are still at Cook, still caring for these patients could really show him the amount of gratitude that we have for him, knowing that everything that we're doing right now came from everything that he built. 00:52:19 Dr. Paul Bowman And so that was part of the very personal aspect for me, as well as every aspect of my career. This has been about teamwork, and about sharing. And I'm just feeling so fortunate that I've been able to pass the torch of leadership to Dr. Heym and other wonderful physicians and staff in the hematology oncology program at Cook Children's. And indeed, this was a landmark event that I hoped we would bring to fruition before I retired, didn't quite work out that way. But being a part of it has helped me kind of keep up with what's going on and maintain some wonderful relationships in the process. So I'm very grateful for that. 00:52:54 Host: Well, thank you both for all that you do and all the passion that you clearly have for what you do. And there's so much more we could talk about on this subject, but alas, time does not permit so I do hope we can do this again and cover some more topics. Thank you both for being here today. It's been really a pleasure. 00:53:13 Dr. Paul Bowman: Pleasure for me too. 00:53:14 Dr. Kenneth Heym: Thank you very much. 00:53:15 Host: We're so glad you could join us today. If you'd like to learn more about this program or any program at Cook Children's, please visit us at Cook Children's dot org. Want more Doc Talk? Get our latest episodes delivered directly to your inbox when you subscribe to our Cook Children's Doc Talk podcast from your favorite podcast provider. And thank you for listening