Milestones for kids; checkpoint inhibitors and cancer; health care reflections: Upstate Medical University's HealthLink on Air for Sunday, Dec. 25, 2022
Pediatrician Jenica O'Malley, DO, discusses recent updates to developmental milestones for babies and children. Oncologist Merima Ramovic, DO, explains how checkpoint inhibitors treat cancer. And Upstate chaplain Brigid Dunn shares the Schwartz rounds, a program to help health care providers stay connected and grounded.
Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," a pediatrician goes over the new milestones for babies and children.
Jenica O'Malley, DO: ... What's really important about them is they tell us, how is this child doing? How is this child growing, developing and thriving in their environment? ...
Host Amber Smith: An oncologist explains how checkpoint inhibitors are showing promise in cancer treatment....
Merima Ramovic, DO: ... All of the 12 patients -- so 100% of patients -- had a complete clinical response, meaning when they went back in, they did not see any residual disease. ...
Host Amber Smith: And an Upstate chaplain tells about a program that helps health care providers connect.
Chaplain Brigid Dunn: ... The goal is to help us see that we're not alone, that imperfection is part of the human experiment, that we have the opportunity to tell stories that other people will identify with. ...
Host Amber Smith: All that, and The Healing Muse, after the news.
This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, an oncologist shares a promising treatment for rectal cancer. Then, we'll hear how a program called Schwartz Rounds connects health providers with one another. But first, there are new developmental milestones for babies and children, and a pediatrician is here to explain.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Pediatricians use a checklist of developmental milestones to help identify delays in babies and young children. Recently, those milestones got an update from the Centers for Disease Control and Prevention, together with the American Academy of Pediatrics. Here with me to explain the changes is Upstate pediatrician, Dr. Jenica O'Malley. Welcome to "HealthLink on Air," Dr. O'Malley.
Jenica O'Malley, DO: Hi. I'm happy to be here.
Host Amber Smith: I'd like to start by having you explain what developmental benchmarks are and why they're important to pediatricians and parents and caregivers.
Jenica O'Malley, DO: When we talk about developmental benchmarks or developmental milestones, what we're really talking about is what are those key skills that children develop over time that sort of follow a predictable pattern? So, knowing that a child does a certain thing at a certain age, that's something we've known about for a long, long time that parents and pediatricians have observed. And when we think about them, what's really important about them is they tell us, how is this child doing? How is this child growing, developing and thriving in their environment?
So if we start to see that a child isn't doing the things we expect them to, that allows us to kind of say, "Hey, something's going on here. What do we need to do about it?" Sometimes it's education. And sometimes it's a referral to a service, like early intervention, where a child can get different types of therapy to help them make progress toward meeting those milestones. And what we're really thinking about is the long-term trajectory of the child. It's not even just about childhood. It's really about how do they do when they get to kindergarten? From there, how do they do when they get to middle school, high school? What level of education can they attain? And the earlier you can identify a potential problem, the earlier you can intervene, and the better that trajectory's going to be long term.
Host Amber Smith: So it sounds like benchmarks are part of modern medicine. They didn't use these centuries ago, did they?
Jenica O'Malley, DO: Well, I'm not so sure. I think that as long as there's been parents, they've been aware of what their kids are doing. So I think maybe not formally. Around, in the early 1920s is when people started to really pay attention to the science behind development. That's when one of the first books about child development was published. And they really looked at babies in nurseries. So they would just watch the babies. They wrote down what they did, and they tried to come up with what is normal, what are we seeing? And it was very observational. And at that same time was really the development of the field of child psychiatry and a lot of interest in how do babies and children's brains develop. And most of what was documented at that time was all based on observation and just looking at sets of babies, often in nurseries, because at those times, there was big nurseries where all the babies were brought after they were born, and they just watched them and wrote down and started to establish some normals.
Host Amber Smith: So, do you have parents who come to you worried because their baby isn't talking like all the other babies in the day care, or walking at a certain stage? I mean, are parents concerned about this?
Jenica O'Malley, DO: Oh yeah, absolutely. I think it's one of the No. 1 things we see and what parents want to ask about. And what they really want to know about is how is my baby doing, compared to other babies? And parents are very astute, right? Many of them have multiple babies, so they know, "Oh, you know, Joe did this when he was 3, but Tim, he hasn't done that at all. What's going on here?" Or they get together with their friends and they see their kids playing together, and they say, "Well, I noticed, you know, my friend down the street, their 2-year-old is saying sentences, and mine only says one word at a time. So what's going on with that?" It's something people are very concerned about. And luckily we have some great community resources, and we have a lot of resources out there for parents to kind of get an idea of where do their kids fall compared to other kids.
Host Amber Smith: How do you advise parents if they have a concern about their child's development?
Jenica O'Malley, DO: Of course, they can always reach out to their pediatrician, but we do have an excellent community resource called Help Me Grow. Parents can reach it by dialing 211. So you just dial 211 and you ask to speak to Help Me Grow. And they can help with all kinds of things, but if you're particularly interested about your child's development, they can assist you with completing a developmental screening tool and giving you the results and connecting you to some resources to. Help sort of promote your child's development, things like story times at the library, activities that are going on in the community. And they're just a really amazing resource. So it's 211 and ask for Help Me Grow.
Host Amber Smith: This is Upstate's "HealthLink on Air" with your host, Amber Smith. I'm talking with Upstate pediatrician Dr. Jenica O'Malley about developmental milestones in children.
And now I'd like to ask you why and how these benchmarks were updated. Do you know what the process was?
Jenica O'Malley, DO: So, I'll go back just a little bit to explain what we're discussing, which is specifically the CDC's milestone checklist. They first came out in 2004, and they were really developed as a tool for parents, pediatricians, educators, other people working with children, day care workers, to have a quick, easy-to-access checklist for various ages of childhood to look at and say, "OK, at 2 months, you should be able to smile, you should be able to lift your head up," and quickly kind of look and see if the kids that they were around were meeting those milestones. And it also included some warning signs. So it would have red flags. If your baby is 2 years old and they're not talking, call your pediatrician, or call early intervention, things like that. They mostly were established from a book. So they looked at a book that is published by the AAP (American Academy of Pediatrics), and that had included milestones, and they put those into lists, and that was kind of the first iteration.
So this was the first update. And what they really wanted to do was make a few changes. So, one, they wanted to make sure that the milestones that they were including had evidence behind them. So they didn't want to just say that at 2 months, a baby should smile. They wanted to make sure that there was evidence that showed that was the normal age for a baby to smile. So they looked at each milestone first to see if it met criteria based on what's, the evidence that that's appropriate. And that has to do with, going through lots of articles. They looked at over 1,000 articles to include, to find their evidence base, so to find the evidence to say that these are the right milestones for the right age. And they actually were only able to include about 30, I think it was 34, articles that they used to collect their evidence.
And the other thing they wanted to do was make it easier for parents and really anyone to understand the milestones. So they wanted to simplify them. And the big thing that they did was to adjust basically the percentile that the children were falling into. So the original milestones that they were using from 2004 was based on what we call the 50th percentile. So that means if a milestone was that at 12 months you walk, it would mean that 50% of kids were walking at 12 months. But it also means that 50% are not walking independently at 12 months. And it kind of they felt like, encouraged people to take more of what's called a "wait and see" approach because they were like, "Well, half of kids walk at this time. You're not. Let's give it a few more months and see what happens," instead of doing intervention.
So for this iteration, what they decided to do was adjust it to the 75th percentile. So for example, walking is one of the ones that they changed. So, it changed from 12 months to 15 months because by 15 months, 75% of kids should be walking. So most kids should be walking. And if your child's not walking at that age, that would be more worrisome than if they weren't walking at 12 months. They wanted to make it so people weren't waiting as long. So you would see someone at 15 months, you would say, "Oh, they're not walking. This is a worrisome finding. We should do more evaluation, do a referral," something like that. And that was the really big change. They did not necessarily change the science of how kids develop. You know, they didn't say, oh, kids are developing in a different way now. They adjusted their messaging to have a different public health approach, I would say.
Host Amber Smith: So, if you do have that child that is in the 25%, that's not walking at 15 months, you as a pediatrician, you then have to think about why that might be. What do you do?
Jenica O'Malley, DO: The first thing you want to do is we always want to ask more questions. We want to look globally at the child. We want to say, "Well, what are the things they are doing in other domains?" So when we think about development, specifically with these milestone checklists from the CDC, they look at four different domains of development. So there's cognitive development, which is problem solving, how do they learn? There is language and speech development, communication. Social, emotional, and then physical skills. Some people may be familiar with the terms "gross motor" and "fine motor." They lumped it all together into sort of physical development. So that's the first thing we're going to do.
We're going to look and see, is this something that, across the board, the child is not meeting milestones in multiple areas? Or is this isolated to just not walking? And then we're going to say, well, what are some possible reasons for this, and where are they in the development? Because it's a continuum. So it starts with being able to lift your head up when you're on your belly, and then you're rolling, and then you're sitting, pulling yourself up to stand. So how far have they made it? And then we're going to think about, OK, are there medical problems, like physical medical problems, something like a muscular dystrophy or a neurologic disease that just causes them to have an isolated problem with their motor development? And if we're really not finding anything, some people just have a different timeline for development, and it could be in a month or two, that child is going to be walking and running and doing all the things that they're supposed to be. Because as you said, they're in that 25%, so they may still just be falling behind a little bit, but we're probably also going to think about making a referral to something like early intervention.
Host Amber Smith: So even if you do identify a child who isn't walking at 15 months, what do you find if you fast forward 20 years from now? What difference will that make, possibly, in that person's life?
Jenica O'Malley, DO: Well, that is a very complicated question. So, you may find that it made no difference. You may find that they didn't get the help they needed, and then they weren't really ready to succeed in kindergarten, and so they then -- we know that kids who don't succeed as early as kindergarten have lower educational attainment -- so it may be that they don't go on to the best college they could, or something like that. But there's so many other influences on people's lives, right? So this is one thing. And then there could be several other things that push them up or down in a certain direction on their trajectory. Maybe they're a family that's also impacted by poverty, and that is pushing their trajectory lower than someone who's not impacted by poverty. Maybe there's a really, really strong family bond between everyone, and they work really hard to get through things together, and that pushes their trajectory in a different direction. So it's really hard to say just based on one area of development what the long -erm trajectory of a person's life will be just because of how many different influences there are.
Host Amber Smith: Well, can I ask you about some of the other major milestones that you look for? When should a baby start making eye contact?
Jenica O'Malley, DO: Eye contact is interesting. We start to see eye contact very early. It's one of the earliest social type of development you see. So as young as a few weeks of age, some babies will be making eye contact during feedings, a very close distance because their vision is very poor in the first few months of life. So, you will really see that eye contact as early as a few weeks of age, and then you'll start to see it more and more sustained, for longer periods of time, around 2 months of age, and then increasing at 4 months of age. And that's when you're really starting to get a lot of what we call social reciprocation. So I say something, the baby says something back to me. They don't say a word, but you know they understand that queuing of like, oh, it's called serve and return. I serve something and I make a funny face and smile, and the baby smiles and coos, and we go back and forth.And that's all sort of part of a similar line of development, which is really social development.
Host Amber Smith: What about talking or, or saying words?
Jenica O'Malley, DO: I think that development starts earlier than people realize sometimes, too. We are going to start to see some sounds very early on, 1 to 2 months, where they're making some soft, cooing sounds. And then a lot of cooing, we call cooing, around 4 months of age, which is all of those sort of soft vowels, oohs and ahs. And by 6 months, we start to see more babbling, where we are starting to hear some consonant sounds. And that's really, you know, 6 to 9 months, where we're starting to hear the "bu, bu, bu, du, du, du, cu, cu, cu," and around 12 months, you might start to hear meaningful words. Most often that's caregivers, so mama or dada, with the intention of labeling a person.
Host Amber Smith: What developmental milestones happen during the "terrible twos"? And I'm just wondering if there's any developmental milestones during that time period that are not so terrible.
Jenica O'Malley, DO: Well, yes, there's lots of them. So, I think a lot of what gets labeled as the terrible twos is really a lot of that cognitive and problem-solving development that you see. So they're starting to figure out the ways that they can sort of manipulate the world around them. And I don't mean, like, manipulate the way I behave, but just the way that they know their action causes a reaction.
And they're really starting to come to terms with that. At the same time, you start to see that their language is emerging, but it's not fully there. So there's a lot of big feelings they're starting to develop. So they're starting to show this wide range of frustration and anger and sadness and silliness and loveliness and all of these different things, but they don't always have the language to kind of say, "I feel really angry right now," or "I feel really sad." So it comes out the only ways that they know how, which is outbursts or tantrums that we call those things. And those things are not necessarily problem behaviors. They're just the ways that children are kind of trying to figure out how to cope with what's going on around them.
And you see just that is such an age of social development. So learning how to play together. So up until really around 2 years of age, you see kids playing together, but they don't do a lot of interacting together. They do a lot of playing side by side. They do a lot of taking this toy from someone because they want to use it. They don't do so much of that back and forth of "I'm pretending to be grandma, and you're the child."
After the age of 2 and going into 3 and 4, they have this huge bloom in their imaginative skills. And that's a developmental milestone, really, is starting to have that really strong, imaginative play, where they can just carry on a whole scenario without, really, any toys and go back and forth with other kids. I think that's one of the most wonderful things about that "terrible" time of their toddlerhood.
Host Amber Smith: Now, parents like to talk about different phases that their child may be in, all the way up to teenage years where a teenager is going through a phase. But I wonder if that's another way of describing benchmarks.
Jenica O'Malley, DO: I'm sure in some ways it is definitely. The development of memory is a big thing. So, at 6 months of age, we think what we understand is that there's maybe about a 24-hour memory.And it obviously gets progressively longer. So as kids get older, they start to have longer memory, and so they do start to get more attached to certain things, or really latch onto certain ideas. And personality is developing, right? We think babies have almost some innate personality, right? We talk about kids who are more colicky, or what we will say is they're more spirited, and some kids that are just really more relaxed, and some of those personality traits really do carry on throughout almost their whole life. So I think some of it is that kind of development, the development of your personality and preferences, and not necessarily just straight developmental milestones, but just their overall developmental trajectory.
Host Amber Smith: At what age do the pediatricians stop tracking developmental milestones?
Jenica O'Malley, DO: Right now I would say it's very standard that people are going to pay very close attention to how kids are developing through the age of 3. But it's becoming more and more recognized to continue to really follow closely up until about age 5 that we're really looking at those domains closely and that we have a strong recall in our own pediatrician minds of what are the milestones for these ages? Certainly there are kids beyond the age of 5 who are not caught up to their peers that may have a, we refer to as, a developmental age that is younger than their chronologic age, their age in years. And at that time, we start to think like, OK, is this something that's going to be with them forever versus this is something that's gonna be completely amenable to physical therapy during the first couple years of life, or something like that.
Host Amber Smith: Well, Dr. O'Malley, I really appreciate you making time for this interview.
Jenica O'Malley, DO: Great. Thank you so much for having me.
Host Amber Smith: My guest has been Upstate pediatrician Dr. Jenica O'Malley. I'm Amber Smith for Upstate's "HealthLink on Air".
Checkpoint inhibitors show promise in treating cancer -- next on Upstate's "HealthLink on Air."
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." You may have heard about a clinical trial of a few patients with rectal cancer, all of whom saw their cancer vanish after taking a particular drug. The results are encouraging, even though the study was so small. And here to tell us more about this drug and the trial is Dr. Merima Ramovic. She's a medical oncologist who treats cancers, including rectal cancer. Welcome to "HealthLink on Air," Dr. Ramovic.
Merima Ramovic, DO: Hello. Thank you for having me.
Host Amber Smith: So, please tell us about this drug that seems to have worked so well. What's the name of it?
Merima Ramovic, DO: The drug is called Dostarlimab. It is an immunotherapy. Immunotherapy is a treatment that uses the person's own immune system to fight cancer.
Host Amber Smith: I've heard it described as a checkpoint inhibitor. What is that?
Merima Ramovic, DO: Immunotherapy drugs fall under checkpoint inhibitors, and basically part of how our immune system works is by using checkpoint proteins on immune cells. These checkpoints act like switches that need to be turned on, or off, to start an immune response. So cancer cells sometimes find ways to use these checkpoints to avoid being attacked by the immune system. So the immune system doesn't see them, and they continue growing and spreading. So, these medications, they're called immune checkpoint inhibitors. So, they're preventing cancer cells from turning off the immune system.
Host Amber Smith: So this isn't the first checkpoint inhibitor? This type of medication existed before this drug was created, is that right?
Merima Ramovic, DO: That is correct. Some of the more common drugs that are used is pembrolizumab, and nivolumab. They're also known as, their brand names are Keytruda and Opdivo.
Host Amber Smith: And probably people have seen ads for those medications on television.
Merima Ramovic, DO: That is correct. If you have cable TV, I'm sure you have seen an ad for Keytruda and Opdivo.
Host Amber Smith: What are the side effects that are expected with checkpoint inhibitors?
Merima Ramovic, DO: So most patients tolerate the medications really well. Some of the more common side effects that we see could be tiredness, maybe an upset stomach, maybe a rash. Some people can have more severe side effects, like severe diarrhea. It can affect your lungs. But generally, it's well tolerated.
Host Amber Smith: Can all patients take checkpoint inhibitors, or are there any contraindications?
Merima Ramovic, DO: Not all patients can be treated with checkpoint inhibitors. Patients who have autoimmune disease or who have suspected autoimmune disease, such as multiple sclerosis, rheumatoid arthritis, lupus -- we typically do not treat those patients since it can make their disease a lot worse. And of course, patients who have had a severe or life-threatening side effect to the checkpoint inhibitor.
Host Amber Smith: Now this study that took place at Memorial Sloan Kettering Cancer Center, the researchers presented the results at the annual meeting of the American Society of Clinical Oncology in early June (2022), and it was widely covered by the national media. Have you had patients ask you about this new medication?
Merima Ramovic, DO: Yes. I get at least a patient a day who asks about this medication.
Host Amber Smith: How do you explain the research and its significance?
Merima Ramovic, DO: So, the clinical trial looked at patients who have locally advanced rectal cancer, and those patients had what's called mismatch repair deficient cancers. So what is mismatch repair deficiency in a tumor? Well, our DNA, which holds our entire genetic imprint, has a system in place that is called DNA mismatch repair, which corrects any type of mistakes that have happened during DNA replication, when our DNA divides. And, defects in this mismatch repair can lead to what's called microsatellite instability, MSI. So there are patients that have lot of defects, and they're called MSI high. And then there are patients' tumors that are MSI stable, so that they don't have it. So when it comes to rectal cancer or colorectal cancer, not a lot of patients have mismatch repair deficiency.
So in this study, they had 12 patients who had locally advanced rectal cancer who had the mismatch repair deficient tumors. And what they did is, they gave them Dostarlimab once every three weeks for a total of six months. And the plan was to follow them, to follow the treatment by standard chemo, radiotherapy and surgery. And patients who had complete clinical response after completing six months of Dostarlimab therapy, would then proceed without chemotherapy and surgery. So, to backtrack a little bit, the typical treatment for locally advanced rectal cancer is chemotherapy with radiation, followed by surgery. So in this study, what they wanted to know is can we give patients immunotherapy and maybe avoid chemotherapy and radiation and surgery? So that's what they set out to find out. So what they saw was quite remarkable, that all of the 12 patients -- so 100% of patients -- had a complete clinical response, meaning when they went back in, they did not see any residual disease. So those patients ended up having a PET (positron emission tomography) scan, endoscopic evaluation, a digital rectal exam or biopsy -- and none of the patients required chemotherapy, radiation therapy or surgery.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Merima Ramovic. She's a medical oncologist who treats cancers, including rectal cancer. We're talking about the results of a study from earlier this year showing some remarkable, well, beyond improvement -- would you use the word "cure," Dr. Ramovic?
Merima Ramovic, DO: We typically don't use the word "cure" until patients have been without active cancer for five years. We typically say "in remission" or "no evidence of disease."
Host Amber Smith: Hearing about these patients, though, who saw their cancer vanish while they were in this trial, as a medical oncologist, were you surprised to see 100 percent?
Merima Ramovic, DO: I was surprised, but quite happy about these results. This means that for some patients, we may be able to avoid chemotherapy, radiation or surgery.
Host Amber Smith: So the drug Dostarlimab, at this point, has it been FDA approved so that a physician like yourself would be able to prescribe it, if you thought it would help your patient?
Merima Ramovic, DO: We are able to use this drug, yes.
Host Amber Smith: Let me ask you, how common is complete remission in someone being treated for rectal cancer. Do you see that often?
Merima Ramovic, DO: So our goal when we set out to treat patients with rectal cancer is obviously cure. Most patients, or many patients, are cured. However, at this time when I sit down with a patient, and I tell them the plan, there are no predictors that I can use or markers that will tell me patient A is going to be cured, and patient B will not be cured.
Host Amber Smith: So there's no way to predict how the treatment is going to work?
Merima Ramovic, DO: There is no way to predict.
Host Amber Smith: At this point, does treatment usually include radiation, and surgery, and chemotherapy of some sort, or medication of some sort?
Merima Ramovic, DO: Standard treatment for rectal cancer is chemotherapy along with radiation. So the chemotherapy allows the radiation to work better. So it it's a radiation sensitizer. And the radiation prevents or is supposed to prevent a local recurrence. This is usually followed by surgery, and then by additional chemotherapy. Sometimes we give chemotherapy with radiation, followed by chemotherapy, followed by surgery.
Host Amber Smith: So if larger trials are done with more patients of this Dostarlimab, and treatment standards change, would that potentially mean that patients could avoid radiation and surgery in order to have rectal cancer treated?
Merima Ramovic, DO: That is correct. We need to continue following, and they are following, these 12 patients to see how well they're doing. When the study was published, some patients were followed as long as 25 months, so a couple years out. But we still need more work. More work has to be done.
Host Amber Smith: Would the drug potentially be used for other cancers beyond rectal cancer? Or is it designed just for rectal cancer?
Merima Ramovic, DO: This drug, potentially, can be used for other cancers.
Host Amber Smith: Do people who are newly diagnosed with rectal cancer, or any type of GI cancer, do they typically undergo genetic testing of their tumors?
Merima Ramovic, DO: There is different types of genetic testing. So there's genetic testing in patients who have a strong family history of cancer, where we suspect hereditary syndromes. So that's one type of genetic test that we do. The best example is the BRCA mutation for breast cancer patients. So there's that genetic testing.
And then there is molecular testing, where we look at the genetics of the cancer itself, of the cancer cells themselves. We do do testing on all stage 4 cancer patients, and almost all stage 3 cancer patients. There's some exceptions here or there.
Host Amber Smith: So you would need the results from that testing before you could say whether Dostarlimab might help somebody, is that right?
Merima Ramovic, DO: That's correct.
Host Amber Smith: Well, I know that you're excited about the results of this drug trial. What do you say to the patients who come in and ask about whether it could be an option for them or their loved ones?
Merima Ramovic, DO: So, when I first meet with patients and their family or friends in the exam room, I typically review the findings, the imaging, and I come up with a treatment plan. If the mismatch repair testing hasn't been done, I will order that. And the turnaround is pretty quick. So the treatment decision is made in the beginning, before we start treatment.
Host Amber Smith: Well, that's good to know. Thank you so much for making time for this interview, Dr. Ramovic.
Merima Ramovic, DO: Thank you.
Host Amber Smith: My guest has been Upstate Medical oncologist Dr. Merima Ramovic I'm Amber Smith for Upstate's "HealthLink on Air."
Next on Upstate's "HealthLink on Air" -- health care providers connect through Schwartz rounds.
From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."
Health caregivers have a regular chance to share their thoughts and feelings about their work lives through a program called the Schwartz rounds, which Upstate has offered for several years.
I'm checking in today with Brigid Dunn. She's a chaplain from Upstate who's the coordinator of the Schwartz rounds.
Welcome to "HealthLink on Air," Chaplain Dunn.
Chaplain Brigid Dunn: Thank you, Amber. It's a joy to be here with you.
Host Amber Smith: The Schwartz Center for Compassionate Healthcare, I know, is a national nonprofit that was founded in 1995. Can you tell us why it was created?
Chaplain Brigid Dunn: It was created by a gentleman named Kenneth Schwartz, who was a lawyer in Boston, and he came to a terrible diagnosis of terminal cancer when he was 40 years old. It was a terrible irony because he was a healthy person. He was a marathon runner, and there he is with cancer.
During his 10-month ordeal of being treated, he was motivated to help the health caregivers who helped him. He said even a gentle touch made a big difference. So he wanted to leave a foundation, a legacy, where he would care for the caregivers who made the unbearable bearable for him.
Host Amber Smith: I know that Upstate is a member. Do you know how many other hospitals and health organizations are members of the Schwartz Center?
Chaplain Brigid Dunn: Throughout the world, there are approximately 500, in the U.S. And Canada in the UK and Ireland and in Australia and New Zealand. Actually there are three in Syracuse alone who are members, too. It's an amazing program.
Host Amber Smith: Let's talk about what is the Schwartz rounds? How does that work? It's called Schwartz rounds because it comes from the Center for Compassionate Healthcare, right?
Chaplain Brigid Dunn: Yes. We have them at Upstate six times per year, in October, November, December, and then we take a break, and it's February, March, April, or sometimes, May, depending.
It's been interesting over COVID because we used to meet live and in person, and we'd offer lunch. And, since COVID, we've been on Zoom, so it's been more convenient for some people. And it's been less personal for most of us who are used to the way that it was done beforehand.
It's an hour. Anyone who attends gets a continuing (medical) education credit (known as a CME). And we take a lot of our ideas from the evaluations that are submitted after each rounds.
Host Amber Smith: So who are the health care workers that typically participate? I'm assuming, doctors, nurses -- what other health care team members are there?
Chaplain Brigid Dunn: It's anyone. We have people from environmental services (the cleaning and maintenance department). We have people from nutritional services. We have chaplains. We have people who are in the C-suite (chief officers), so it's anyone who works at Upstate.
Host Amber Smith: So any of the hospital people, including administrators, anyone who's involved in taking care or making sure that the patient's stay goes as it should.
Chaplain Brigid Dunn: That's right.
Host Amber Smith: Is there an overriding goal? I mean, people are sharing stories with colleagues, but what is the end goal?
Chaplain Brigid Dunn: The goal is to help us see that we're not alone. That imperfection is part of the human experiment, that we have the opportunity to tell stories that other people will identify with. So usually when we have somebody who's a panelist, they tell a story, or all of the panelists will participate in talking about a particular case of a patient and they tell of their experience.
One example is that recently we had one about child behavior and, even self-destructive behavior among children and the, aggression that was experienced by the psychiatrist, by the people who had to come in and clean up the room, by whomever. It was a very stressful situation for anyone who was on the floor.
They told of that experience and that it's easy to identify a patient who's been particularly challenging or a family member who's been upset, understandably, because their loved one is sick, but whose behavior wasn't really helping the situation.
So they can say that in complete confidentiality. Everything that's on that Zoom meeting or that's in that room in the Cancer Center is kept confidential, it's never taped, so they can be assured of that. We're big gatekeepers on who comes into the Zoom meeting, so it has to be somebody who is an employee, no matter what department.
Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Brigid Dunn. She's a chaplain from Upstate who's the coordinator of the Schwartz rounds
Now the Schwartz rounds are not for patients, I realize. It's for employees of the hospital, but do you think there's a benefit for patients knowing that this sort of thing exists?
Chaplain Brigid Dunn: I think there's a benefit in them knowing, yes, that Schwartz rounds is one prong of opportunities that are available to health care personnel, doctors, nurses, whomever, so that they know that the doctors are actually taking care of themselves, too. There's a terrible idea that it's weak to talk about what's wrong. And actually, like I said, it's part of the human experiment to make mistakes. It's going to happen. And we have to be able to discuss that somewhere safe. So I think that patients might not understand what Schwartz rounds is or why or when or where, but I think probably they know that their doctor is taking care of him- or herself, and that's probably reassuring, in some way.
Host Amber Smith: Now, as the coordinator, are you the one who chooses the topic or the theme for that particular Schwartz rounds?
Chaplain Brigid Dunn: No, rarely. I get a lot of suggestions from my advisory committee, comprised of doctors, nurses, case managers, the director of environmental services. They see what's going on and say, "We really have to do this. We have to talk about this. This will help us, help my people on my floor. We need to do this." So we get suggestions that way. And at the evaluations at the end of each Schwartz rounds, we ask please to suggest a topic. And then I go after people who would be good panelists for that.
Host Amber Smith: So you get a panelist lined up for a particular topic, or panelists, you may have more than one --
Chaplain Brigid Dunn: Yes.
Host Amber Smith: -- and then the people who come to the particular gathering, do they have to participate, or do you get some who come just to listen?
Chaplain Brigid Dunn: Many who come just to listen. And that's perfectly fine, but the panelists will speak. We tell them that they really only have to speak for five to seven minutes. Ideally, we have three or four panelists who tell their story for that length of time. And then the moderator will ask those who are gathered if they would like to comment or share, and again, if you're here, you have to remember not to name names when you go outside. And so everybody feels safe.
Host Amber Smith: Can you give some examples of some of the topics over the years that have been popular? Because I know this has been in place for several years now.
Chaplain Brigid Dunn: Yes, we are heading into our 10th year here.
Some of the topics that have been really popular: There was one actually done by my predecessor called "More Than 13 Reasons Why," and it was addressing adolescent suicide. And fortunately it did draw, but unfortunately it's a problem that had to be addressed.
But that's another thing: that we go there with whatever topic is necessary. So, one of the recent ones was about what's falling between the cracks during COVID? The opioid crisis continues, and how is Upstate addressing that? How are we as a culture addressing that?
Host Amber Smith: I imagine that during COVID we heard so much about how much stress health care workers were under. I mean, we were all under, but imagine, tenfold for someone working on the front lines. So I know you had to move to the Zoom format, but do you think people stayed connected through the Schwartz rounds during COVID?
Chaplain Brigid Dunn: I think we lost a few, and we gained a few that way. Because the CME is still out there. And sometimes people will tune in just to hear a doctor or nurse or colleague that they know who's presenting. So that's a way of getting new people to come. I think it, on average, in person, was usually around 25, 30 people who would come, and it was pretty much the same on Zoom. I would love it to get bigger. I would love that.
Host Amber Smith: You said CME, that's continuing medical education, and nurses, doctors, other technicians, they all have obligations to stay current in their field. So this fulfills some of that?
Chaplain Brigid Dunn: Correct. Thank you. Yes.
Host Amber Smith: Is there any evidence that a program like the Schwartz rounds improves health care for the patient?
Chaplain Brigid Dunn: For the patient, I think it filters down to like what I was saying before, that if there's wellness emphasized in the staff, then that will necessarily produce better results because the staff is healthier, and then they can attend to their patients better. We know that burnout happens because people feel shame and blame themselves because they can't keep up those incredible hours that are expected of them.
And if you're being treated by somebody who's a very tired doctor, then more mistakes will be made. So the urgency that we see for staff to care for themselves, I'm sure does filter down.
I read in JAMA, which is the Journal of the American Medical Association, that there's a price tag attached to burnout of physicians in costs of physicians leaving, having to be replaced, the training, getting them on board, lost hours with patients. It's $4.6 billion per year. It's a terrible cost. But the other cost is people feeling burnout, feeling like they cannot continue in a career, in a profession, that they've trained for years to do.
Host Amber Smith: So, a counter to that to try to help reduce burnout, might be, well, it sounds like health care workers talking about issues that are sometimes really hard to talk about.
Chaplain Brigid Dunn: Right.
Host Amber Smith: What do you see for the future of Schwartz rounds at Upstate?
Chaplain Brigid Dunn: I hope that everybody will know about Schwartz rounds soon and know that they are welcome to participate if they're an employee and that it will be just part of the fabric, just like they know that there's the cafeteria, they know that there's Schwartz rounds to be able to talk about things.
And feel welcomed and not feel anything except, really, pride in their work because it's a huge deal to take care of patients day in, day out. And during COVID we saw -- I usually take a title from the Beatles, and it was called "Eight Days a Week" -- about how there was this ongoing cycle of "I'm leaving work, I'm back to work, I'm leaving work" -- days just melted into each other.
So I want Schwartz rounds to be part of the overall wellness plan that is underway at Upstate.
Host Amber Smith: Well, Chaplain Dunn, thank you for taking time to tell us about it.
Chaplain Brigid Dunn: Thank you so much, Amber, what an honor. Thank you.
Host Amber Smith: My guest has been Brigid Dunn. She's a chaplain and coordinator of the Schwartz rounds at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."
And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.
Deirdre Neilen, PhD: Dr. Peter Cronkright is an associate professor of internal and family medicine here at Upstate Medical University. He gave us a poem that reminds us we have come through medically and socially challenging times before. His poem "Making Rounds" gives physicians, in particular, a reason to hope.
Virus taking hold
Calling the shots
Truth be told
Don't sleep a lot
Distance and hygiene
Where to lean
Times are tough
At rapid pace
Am I ready
For the call
Exposed to all
Long white coat
Serves as shield
Foot of the bed
Stand your ground
While it spreads
So much unknown
Our limits shown
Lots to fear
James McCague is a physician and writer from Pittsburgh. His poem "Contagion" is similarly eerie in that we do not know what disease we are facing.
"The mask becomes you," so he said, and could not see her smile.
"It's probably your eyes," he said, "lips often are disguise."
It was a yellow hospital mask with a center stain of red,
Betraying lipstick she earlier had nonetheless put on.
By now she felt a warming blush extending up her face,
And she wondered if it would peek over the mask's edge
Like an early dawn over a horizon.
And so she stood there, like Juliet on the balcony,
Six feet or so away.
Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," understanding cluster headaches. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.