Jun 17, 2022
Dr. Shannon Westin discusses the topic of climate change in the operating room with Dr. Anaeze Offodile and Dr. Elizabeth Yates.
The guest on this podcast episode has no disclosures to declare.
Dr. Shannon Westin: Hey everybody! Welcome back to JCO After Hours, a podcast where we get a little bit more intense, a little bit more specific about articles that are published in the Journal of Clinical Oncology.
My name is Shannon Westin, and it is my honor to serve as the social media editor for the JCO. I'm an associate professor at the University of Texas MD Anderson Cancer Center and a gynecologic oncologist.
Today, we are going to be discussing a really exciting paper which was published in the March online JCO. It's a Comments and Controversies piece called, “Prescriptions for Mitigating Climate Change-Related Externalities in Cancer Care: A Surgeon's Perspective.”
I have several guests with me today, none of whom have any conflict of interest.
The first is Dr. Anaeze Offodile, who is an assistant professor in the Department of Plastic Surgery, as well as in the Department of Health Services Research at the University of Texas, MD Anderson Cancer Center. He also serves as the Executive Director of Clinical Transformation at MD Anderson. He is the senior author on the paper, so he will have a lot to offer here.
But we're also accompanied by Dr. Elizabeth Yates, who has the title of clinical fellow in surgery at the Brigham and Women's Hospital in Boston, but tells me she's a rising PGY 4 resident, which makes it even more impressive that she is already published on the role of the surgeon in climate change. And so, we're so honored to have her with us today to share her perspectives as well.
Welcome both of you. Thank you for being here.
Dr. Anaeze Offodile: Happy to be here.
Dr. Elizabeth Yates: Thanks so much for having us.
Dr. Shannon Westin: So, I'm definitely someone that has been interested in climate change for some time, and living in the state of Texas, does what I can to rally the political climate here. But I was really intrigued because I never really thought of it in terms of what we do in the operating room.
So, I'd love for each of you to give just a little bit of background on your careers and how you kind of got involved with this idea of climate change and environmental sustainability here in the operating room and in medical care? Do you want to start, Anaeze?
Dr. Anaeze Offodile: Liz can start first.
Dr. Elizabeth Yates: Absolutely! So, I actually came at it from an interesting perspective, I have always been interested in issues of resource distribution and disparities. And when I was in medical school, I started to think about these issues pretty deeply, especially because my younger brother was at the University of Michigan at the same time as I was, studying Environmental Science for his undergraduate and kept nagging in my ear about this problem of climate change and why I wasn't thinking about it as a doctor.
And with my kind of ongoing interest in disparities, I came to realize and become compassionate about the role that climate change will play in driving the existing disparities that we see both nationally and globally. And I realized that nobody was really talking about it yet, at least in the surgical field.
It had started to permeate some of the medicine and subspecialties, but really, there wasn't a conversation in our world yet. It became all the more relevant to me because I did see this dual relationship where not only do the downstream factors of climate change, like heat waves and major storms, impact our patients' access to care and their outcomes, but on the flip side, we contribute to climate change, because the delivery of surgical care, particularly in high-income countries, is so energy intensive and so wasteful. And so, I felt like if any clinician has a role in this space to really lead and change the narrative, it would be us as surgeons.
Dr. Anaeze Offodile: It’s really interesting to listen to Liz’s journey to this issue, which affects all of us. I came at it from the micro level, bottom-up level. So, when I was a fellow about four years ago, under the mentorship of Nancy Perrier, we launched and have since scaled, I don't know if you're aware of this, Shannon, so the 'Know Your Costs' program.
For the audience, this is a project at MD Anderson where we really try to minimize cost variability and waste in the operating room by providing a feedback tool to surgeons that sort of made them more conscious about the spending directly attributable to disposable supplies, implants, devices in the OR.
One direct outcome of the project that we found was that actually narrowing the variability in these disposable instruments, supplies implants surely had no impact on the outcome, but also got sort of the cost structure of what we do in the OR down. So, that's the value-based care proposition.
And in doing this work as I dug more into literature, I learned as we so highlighted in the article, my co-authors and I, that actually the perioperative environment is a major driver of waste in the hospital setting. I think that recognition certainly led to this work, which we're very glad that JCO looked upon favorably to champion.
Dr. Shannon Westin: Yeah, I love 'Know Your Cost'. My fellows make fun of me, because I always take the electrosurgery devices, they're the cheapest. And they're like, ‘Oh, you're using the Costco version!’. And I'm like, ‘You know what? We're reducing costs. So, just hold it a little bit longer there, and you're gonna be fine.’
So, I was really struck by one of the first sentences out of the gate in your commentary that the healthcare industry accounts for roughly 8.5% of total GHG emissions in the United States, the most in the world in per-capita and absolute terms, I mean, to me, that was so eye-opening within the first few sentences.
What are some of the other major takeaways that you hope that readers of the JCO get from this piece? Anaeze, I think we can start with you and then I'd be interested to hear your perspectives as well, Liz?
Dr. Anaeze Offodile: So, I will say, a couple of high-level, and I can touch on the sort of specific prescription that we put forward, but I think the big takeaway is, one, is healthcare has a certain moral imperative to keep our contributions to sort of environmental sustainability, greenhouse gas emissions, to control that, there's a moral imperative to this work, right?
One, climate change effects are differential. So, the vulnerable populations, like Liz said, tend to suffer the worst. So, when you think about communities and countries in the global south, they bear the brunt of this, not industrialized nations.
And number two, our activity directly maps to greenhouse gas emissions. And as surgeons, the relationship is much more direct. So, carbon-intensive procedures like the robot, the perioperative environment, and the supplies, the waste, and the supply chain that sort of feeds into that.
So, those are the things high-level that I want to call out. And many ways this paper is intended to start a conversation that will be ongoing amongst the community, the academy, and I'll say in both surgical and medical respect: to what extent do we take ownership of this problem and contribute to the meaningful solutions of the problems? And I can certainly talk about some of the recommendations we put forward, but I think that's the key takeaway.
Dr. Elizabeth Yates: Yeah, as not an author, but a reader of this paper. I really thought it summarized the high-level ideas, and really did serve as a conversation starter in the best way.
What I really liked, and I try to strive for in my own work at our hospital, and we implement sustainability initiatives, was the perspective that you took coming from more of a cost-saving perspective initially, because I think people have a misconception if they do ever think about sustainability and care delivery, that somehow quality has to be compromised for sustainability - to go green, you have to do less - and that's not necessarily true.
And you really highlighted a lot of opportunities in the four domains you emphasize in this paper about how you can change the way your system works, or the choices you make, for the devices you use or the energy supply, without actually compromising outcomes for patients, that we can maintain a high level of quality that makes them smarter choices for our systems to also be more sustainable.
And then a lot of the time there are cost savings. It could be a triple win but we just need to put more time and effort into the surgical world thinking about these issues.
Dr. Anaeze Offodile: Liz, thank you so much. What we tried to articulate was, there is no trade-off between planetary health and value-based care and high-quality care. I think those two are actually synergistic, and certainly mutually reinforcing. So, that's the one thing we tried to do. I'm glad it came out to push forward.
Dr. Shannon Westin: I was joking about our bipolar use and such, but that's really what I'm trying to teach our fellows is that you can do the right work with an instrument that doesn't cost as much. And in this case, the robot is perfect. I was reading that as a robotic surgeon who also does laparoscopy and I thought, ‘Gosh! When I'm making these decisions, this is such a trickle-down effect.’
And so, I really do think that I'm interested in strategies to offset those things. Because sometimes, for us in gynecologic oncology, the robot is a superior tool as far as visualization and also surgeon back pain and such. But you really have to understand that trade-off or what else you're impacting.
So, I guess, what can we do with the framework of this piece in mind, what can the clinical care providers really do across the country to meaningfully address climate change and improve overall healthcare sustainability?
Dr. Anaeze Offodile: So, I will talk from the surgical perspective and maybe I'll point to Liz for a broader outlook on this, but we touched on four main buckets or domains of sub-activity.
So, one is the OR environment, right? Thinking about the type of anesthetic gasses that we use, thinking about energy efficient lighting, thinking about the heating ventilation AC, HVAC, can we sort of bake in preventative maintenance on a scheduled time, and using things called setbacks.
So, for instance, don't have it run overnight when no one is using the OR. For the most part, there are always emergency cases, but when there's low foot traffic, like nighttime, could we not have the HVAC running during that time period.
So, some things like I'll say, low hanging fruit that we can do in respect to the OR environment. And as we think about building new ORs in new hospitals, let's bake in sort of an environmental impact assessment as you sort of commissioned these new environments. So, that's one.
Number two, the supply chain and thinking about streamlining the disposables, the gowns, the implants that we use, and really thinking about the procurement and sourcing of these things, taking a climate change lens to picking vendors, picking partners, almost sort of requesting an audit for these vendors with respect to how they create these goods that are sort of being engineered for the environment.
The third thing is actually waste. And thinking about sort of the amount of waste that comes from the cost of surgical care – Can we lean more towards reusable as opposed to disposables? Can we think about reprocessing devices sort of like, the world is a circular economy now? Can we think about those types of initiatives with respect to waste?
And the last two are value-based care, specifically thinking about low-value surgical care, really that's another way of saying activity that doesn't track to meaningful clinical outcomes.
So, that activity, if we're to reframe it , creates carbon that worsens our greenhouse gas emissions, but doesn't track to any meaningful benefit to patients' society. So, low-value care, de-escalating that, or de-implementing that certainly could help with our greenhouse gas profile.
And lastly, COVID has been a major force in functioning telemedicine. Can we think about telemedicine in a way that optimizes traffic, and transportation, while keeping cost structure down and thinking about greenhouse gas emissions?
So, those are the four or five main elements that we've sort of proposed in our paper. I'll say pieces of this can be contextualized in a medical context. Waste can be put in the medical oncology lens as is virtual care, and as is low-value practices. So, that's how we thought about it for this paper.
Dr. Elizabeth Yates: It really nicely summed up the categories of areas for implementation. So, I think I'll keep my comments focused, one, on what does it mean to actually implement that kind of work, and then scale back and what can we do, as you highlighted more broadly as clinicians. But as someone who's really started this work, and we initiated what we call 'Watching Our Waste' program across our procedural spaces at our hospital, and working with my mentor, Dr. Winn who’s a vascular surgeon has been really beneficial, because having a clinical voice start to push and champion these ideas, is really meaningful.
And when it doesn't come from the administration or top down, it feels a lot more homegrown, and people accept it a lot more quickly on the clinical side, rather than an eco-green team being purely administrators and people who work behind desks. You know, having boots on the ground, saying that this is important, and champion ways to integrate it into our workflow without compromising efficiency or quality of care has been really meaningful.
And for anyone who's starting these initiatives, I would say the gateway for anyone who wants to really tackle this, I would recommend a waste audit. Just start with your floor, your OR, whatever your clinical area practice is, your outpatient clinic, and see what kind of waste you make in a day.
The efforts you put towards that in terms of meeting your environmental services people, meeting Environmental Affairs, going through the trash, understanding what your use of various supplies is, gives you so much information and such a strong foundation as an easy thing to do as a first step and you'll know where to go from there. It'll really guide your next steps.
And as you scale out, and if you get more involved in this work, what I've come to find is the administrators are looking for a clinical voice. There's the policy being pushed at a national level, to start really looking at healthcare and its carbon emissions, and there isn't a lot of expertise, and making sure that this kind of effort and these policies and the implementation of more sustainable practices align with clinical care is a priority and a growing one at the hospital level. And they need clinical voices to actually understand how this is going to work and move this forward and in an effective way. So, if you're interested, I would just highlight that this is an opportune time to get involved.
Dr. Anaeze Offodile: Can I make one somewhat controversial comment, I hope it’s not that controversial. You know, Shannon, as you think about the demographic shifts in the next 15 years, millennials will be the dominant healthcare workforce and the dominant patient population, right?
And as you think about awareness, I will say, as you go down in the age levels, I'll say anxiety, apprehension, and more optimism increase as you go down. So, as this population ages into the workforce and the patient mix, I will reckon that they'll begin to demand more of these initiatives from their health systems, both, like I mentioned, first of all, the moral imperative, but also, as most hospitals are the biggest employers in most towns in this country.
So, I think there'll be a clarion call that gets louder and louder and louder and louder. So, in many ways, I think beginning to think about these issues now is probably the way to go. And in many ways feels inevitable to me.
Dr. Elizabeth Yates: There's some great data to back that up. If anyone's interested, the Yale Center - I have no affiliation, this is a purely altruistic endorsement - but the Yale Center for Climate Change Communication has really impressive data that completely backs up everything that Anaeze has just said, he couldn't be more spot on.
Dr. Shannon Westin: So, we need to be focusing on this. And I guess, balancing on that kind of thinking of the upcoming generation, clinicians, and patients, is there an opportunity to build a career that is a balance between climate change and clinical care?
Dr. Elizabeth Yates: I sure hope so!
Dr. Shannon Westin: Liz, this is your thing, right?
Dr. Elizabeth Yates: There better be!
Dr. Shannon Westin: But how do we operationalize this better? Is this something that should be part of the medical school curriculum? Where can we make an impact? Obviously, you all are doing this great work, but how can we get beyond our centers?
Dr. Elizabeth Yates: I think one of the things I've learned in my two, kind of, research years during my residency, and really focusing deeply on this topic, is that there's a real dearth of data-driven work in this space both on quantifying the impacts of climate change downstream on our patient outcomes. And on the flip side, how to make surgical care or medical care more sustainable broadly.
There are methods that are incredibly applicable to this space. One that many sustainability providers will know about is called lifecycle analysis, where you can actually quantify your impact on carbon emissions with different changes in which products you buy, and how you implement your systems.
And being able to produce that kind of data for our clinical providers, whether it be in your outpatient clinic, or in the OR, so you can make more informed choices that align quality with sustainability is a really important next step. And understanding how to implement that kind of research needs a clinical voice. It can't just be these kinds of environmental practitioners who don't have a sense of how clinical care works on a real day-to-day basis.
So, having an increasing number of providers who are interested in this overlap to inform that research, I think, I sure hope, is going to be a valuable contribution to the academic literature because I'm slowly building my career upon it, and it's quite the gamble.
Dr. Anaeze Offodile: No, it's a pretty safe bet, Liz. I think as a clinician, academic or community-based, late early career at this point, so the way I think about moving forward will be one, Liz just talk about scholarship, right? Both empirical data-driven work, as in thought pieces, like the JCO paper that has a policy inclination, I think we need much, much more of it. And there's increasing activity in this space, but nowhere near commensurate with the gravity of the problem. So, that's number one.
I think number two is actually just advocacy, right? In the same way that surgeons are very compelling and effective advocates for gun violence, for COVID, and related science for health equity. I do think there's a huge space for physicians, surgeons, medical oncologists, and primary care doctors in this space from an advocacy standpoint.
I think some of the more productive arguments have touched on the fact that, typically in healthcare, the largest employers, I mean, healthcare is, paid on the year, almost 20% of our GDP, of our economic output, is a huge chunk of US healthcare, so, we have viable legitimacy to sort of have this bully pulpit on this issue. That's number two.
And number three is about clinical practice. I think one thing about climate change is the ultimate tragedy of the commons, right? So, I'm like, how can one person make a difference?
I think if everyone has a position, nothing's going to happen. I think the key thing is that we all begin to move in this direction, as I like to say, ‘Incremental change is not insignificant change.’ There's certainly the proverbial 'burning platform' right now on this topic.
I think as we begin to have our clinical practice, each of us individually be more aligned either from an adaptation standpoint or mitigation standpoint, where we're sort of reducing greenhouse gas emissions. I think that is a huge, huge benefit to us for future generations. So, let's hope with the three main ways practice, advocacy, and scholarship get built into our careers.
Dr. Shannon Westin: Yeah, not to get into a total mentoring conversation here but Liz, there's a huge opportunity for policy and through our own home organization, ASCO, there's a policy fellowship, there are lots of opportunities that I think that you'll find your academic career could be supported by. So, just a little off note.
Dr. Elizabeth Yates: I’ll preview the recruitment.
Dr. Shannon Westin: So, we'll talk about some inspiration as we close this conversation. You guys have kind of peppered this throughout, but maybe just summarize a little bit, what are you doing in your own practice, as well as in your lives, like out of hospital lives to contribute to these efforts?
Dr. Elizabeth Yates: I try to live my life with a perspective of sustainability kind of in every aspect, but with an informed perspective because I really do believe that quality of life, just like the quality of care, does not need to be compromised in order to be green.
And so, being really informed about what choices in your life and your actual career have a true impact, and an impact that can scale is really important. So, do I try to buy the least plastic that I can? Certainly. Do I kill myself to be completely waste-free? I do not.
I try to amplify the need for these kinds of interventions across my own little local network, both socially and wider in my own career. And as I've started to pull this into my workplace, I was apprehensive about what the kind of reaction was going to be from pushing a sustainability perspective. I've been really pleasantly surprised and impressed with how many people in our workplace already, like me, are doing what they can at home, and just don't know how to start in the workplace, especially in a hospital.
And so, being that champion, and having that voice to start, wherever you are, whether it be a small project or a big policy initiative, whatever you can take on, I would say is kind of the inspirational next step and as you see the reaction of your colleagues, I hope, like me, you will continue to be inspired to do more.
Dr. Shannon Westin: Great! Anaeze?
Dr. Anaeze Offodile: So, I'll lead off with a plug. I read this book called The Uninhabitable Earth by David Wallace-Wells. And I thought that book is the most compelling argument that we just think about climate change. It really created a sense of urgency within me. It came out about two and a half, maybe three years ago – compelling read. So, I'll just sort of start off with that.
There are many sources that are available now, I think the National Academy of Medicine, they have a grand challenge and a national collaboration on decarbonizing the US healthcare sector, and they have a bunch of resources on their website. So, I'll certainly point many people to that.
What I do in my day-to-day life and the way I've thought about this is what behaviors can I entrench in the long term. I think human beings, physicians, in particular, I'd say, we're high resistance pathways, old habits tend to come back to the surface. So, I've really focused in the last few years on embedding certain climate-sensitive practices in my life that I hope to continue moving forward. So, one of them is a) I drive less. Now, it's not super easy in Houston, Shannon, as you are aware, but I happen to live near the light rail. And for the last nine months, I've been taking the train in, every morning to work to and fro. That allows me to zone out. I put a podcast on, ASCO podcast, After Hours.
Dr. Shannon Westin: Love it! Love it!
Dr. Anaeze Offodile: So, that's one. Number two is just easy. My purchasing choices have a climate lens. So, in many ways, you could say what you buy reveals your preferences like nothing else. So, when I buy a new radio or a new TV, I look for the sticker that says EPA certified. It's a little thing but it's something that I'm able to maintain for the last 2-3 years now. So, I'll say, being informed, changing my commuting habits, I curtail my spending habits, also like the ways I'm just really embedding this into my daily life.
Dr. Shannon Westin: That's great! I think there are so many great resources that you guys have mentioned, so, I hope our listeners will check it out.
I will put a plug in. I love to compost. It’s super easy to do, and you can use it to grow food and beautiful flowers. And so, that is something that my husband and I have been doing for years now. So, another simple little thing. I mean, you can get everything online. It's magical.
So, alright guys. Well, this has been incredible. I have so enjoyed getting to chat with both of you and I hope our listeners have the same feeling. Just as a reminder, this article can be found online in the March version of the JCO, “Prescriptions for Mitigating Climate Change-Related Externalities in Cancer Care: A Surgeon's Perspective.”
Many thanks to my guests, and you all have a great day. I hope to see you next time.
Dr. Anaeze Offodile: I’m happy to be here. Thank you so much for having us.
Dr. Elizabeth Yates: Thank you so much!
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