International Medicine

Cultivating a career in global health with a worldwide impact.

What is The Clinical Excellence Podcast?

The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.

[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Rachel Masch talking about international medical work.

[00:00:11] Dr. Masch: Lots of people use their vacations or volunteer their time to do some work abroad, but it's hard for sustainability or to keep it going over the years because one really needs to carve out, if one's going to do it on a regular basis, carve out a space for that and find funding for it, which is two things that are difficult to do.

[00:00:36] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast, sponsored by the Bucksbaum Institute. On this podcast, we speak to patients and doctors about all aspects of excellence in clinical medicine. I'm Adam Cifu, and today I'm joined by Dr. Rachel Masch. Dr. Masch is a clinical professor of obstetrics and gynecology at the Icahn School of Medicine at Mount Sinai. She's also the chief medical officer of Basic Health International, BHI, an organization with a mission to eliminate cervical cancer globally. Her research focuses on finding novel, affordable, and accessible screening and treatment methods for cervical cancer in vulnerable and underserved populations.

Rachel, thanks so much for joining me today.

[00:01:19] Dr. Masch: My pleasure, Adam. Great to be here.

[00:01:21] Dr. Cifu: Yeah. So career paths in academic medicine often combine patient care, research, education, advocacy, and you've definitely been active and successful in kind of all those, you know, traditional areas during your career. What I think is kind of less typical about your career, is your work outside of the United States. You're the chief medical officer of BHI, which does work really all over the world, but before I ask you about that work, how did your career end up kind of going in this direction?

[00:01:55] Dr. Masch: Yeah, it was somewhat circuitous, as maybe many of our careers are. I actually was... In college, I was an international relations major.

[00:02:05] Dr. Cifu: Okay.

[00:02:06] Dr. Masch: And I had no thought of being a doctor at all. International relations is history and political science and language and I actually thought I was going to be a diplomat and with that in mind I spent my second semester of junior year abroad in Geneva and I spent a lot of time with diplomats and I realized that more power to them but oh my goodness, I don't think I can do that. But while I was in Geneva, I also worked at the World Health Organization, and I came back to my senior year in college and decided to go for it and started taking all of the math and science requirements that I needed. So instead of taking, you know, the interesting things that one waits to take in their senior year once they finished all the requirements, like the history of Chinese papermaking, all those sorts of things, I was taking intro to bio and organic and inorganic chemistry and physics and all of those things, which I actually ended up really enjoying. And I think that what I considered myself to be a mature student, which, of course, looking back, one can sort of laugh at that but I did all of my prereqs and then got into medical school and... But always had that international relations bent in mind. And so while I was in medical school, I was able to get a scholarship to do my pediatric rotation at the Karolinska in Sweden. I worked in India, where I met another esteemed physician, that would be you.

[00:03:39] Dr. Cifu: I caught that.

[00:03:42] Dr. Masch: And in residency did work in American Samoa, and I was always trying to find out how I could bring the global world to my local work and vice versa.

[00:03:53] Dr. Cifu: So it's interesting listening to you, I mean, it sounds like your decision to go into medicine was, you know, much like all of our decisions to go into medicine, but you really had an idea that you would do kind of global health even at that point. Is that true?

[00:04:09] Dr. Masch: Yeah. I mean, I think that that was... The medicine itself was so interesting to me, but I realized there was really a way to combine my love of the global world and how important it was to me to bring care of some kind, whether it was, you know, diplomacy, which was not where I was going, but now healthcare to people around the planet. It wasn't... I never really thought about it in just the solely local context.

[00:04:38] Dr. Cifu: Great. I'm going to skip to my fourth question to cheat a little bit before I get into the details of what you do. And I'll still ask you later about kind of advice to people who might want to, I don't know, follow your career trajectory. But in the people who you do work with, either Americans involved in global health or people from other countries involved in global health, speaking of the physicians in particular, most people you feel like have a background similar to yours or are they people who found this, I don't know, let's call it a vocation kind of later in their career?

[00:05:15] Dr. Masch: Yeah. So I think that many people who are involved in global public health find, have to find a workaround because there's so much in American medicine particularly, there's so much about increasing volume and generating revenue and sort of the time and the money needed to be able to do this is not always easy to find.

And so lots of people use their vacations or volunteer their time to do some work abroad, but it's hard for sustainability or to keep it going over the years because one really needs to carve out if one's going to do it on a regular basis, carve out a space for that and find funding for it, which is two things that are difficult to do in a revenue-driven model like we have in the United States.

[00:06:06] Dr. Cifu: Yeah, that's definitely been my experience with my colleagues who seem early in their career to often do this as instead of a vacation, I'm going to country X to do this work. And then maybe later in their career, once they're a little bit more established and can, you know, get people to start putting some money in the direction when they end up getting sort of deeper, which does feel like a missed opportunity and kind of time lost early in a career and energy early in a career, you know, maybe not being focused on what the person's real, I don't know, enthusiasm is for.

Let me ask you specifically about BHI, Basic Health International, what is the mission, and kind of in general, how does it operate?

[00:06:52] Dr. Masch: So BHI has a mission to eliminate cervical cancer globally. And we have offices in... We have people who are in the New York City area, we have offices in Pittsburgh and in San Salvador, El Salvador. And our work actually started in Central America, but now we work globally in many places around the world. We're very involved in research and have a lot of funding from the NIH, the National Institutes of Health, and the NCI through the Cleveland Clinic, which is where our founder and president actually lives and works.

We also have philanthropy and foundational grants to do some of the work that we do. So we do a lot of research in what we call secondary prevention of cervical cancer. So primary prevention is vaccination and secondary prevention is screening and treating pre-cancer, which is really successful in preventing what happens next, which is invasive cancer.

So in secondary prevention, that's where our areas of expertise and that's where our research has focused for both screening and treatment modalities, where we work with industrial partners and engineers and entrepreneurs who can have the ideas. We have ideas, and then we meet with engineers to try and create those ideas, and then we test them and validate them in all the ways that one does that.

It's been really exciting to try and bring these technologies to people who really need them because really cervical cancer is entirely preventable and we know how to do it. It's really just about having people have access to those modalities so that they can get screened and treated early before the disease becomes invasive. So there's a lot of research, and then we also do education and training of local providers of all levels. So not just physicians, but mid-level providers as well to try and again, to increase access to these different technologies.

And then implementation. So we do a lot of work with... Once we have tested this, validated it, how do we implement it to get it to the most people, to help the most people that we possibly can?

[00:09:09] Dr. Cifu: It's so exciting sort of hearing about the model because I think, you know, maybe this is my old cynicism coming through, whenever I hear about people saying, "Oh, we're going to rid the world of, you know, TB, malaria, river blindness, whatever," you know, I'm like, wonderful, but good luck. But cervical cancer, you know, is something when you think about what we do in the United States, you know, anybody who ends up with cervical cancer, you feel like it was a failure, right? And so, this is one area that you listen to and you say, "Boy, you know, this should be achievable," right?

[00:09:47] Dr. Masch: Absolutely. And the World Health Organization actually put out a call to action to eliminate cervical cancer by 2030, which is really a lofty goal and is defined as less than four per 100, 000 people with cervical cancer. That's considered relatively low levels of disease. So that's, you know, seven years away, six, six and a half, six years away. So we have a lot of work to do, but it just goes to show that we... It's really trying to figure out how to get what's needed to the people who need it.

[00:10:24] Dr. Cifu: It sounds like a big part of the job, and maybe this goes back to your, you know, work in Switzerland at the beginning of your career, you know, I always kind of imagine this, you know, let's say global health work, in general, being medicine plus working with, you know, in a sensitive, productive way, people at each location you are at. But the way you talk about it, it's a lot more than that, it's not only research, but it's almost, you know, working with engineers and developing, you know, both hardware, software, and relationships to make this all work.

[00:10:59] Dr. Masch: Yeah. And it's been really interesting because, you know, the engineers know how to make the things, but they don't... The things that they make don't always work in real-time and in the way that they want it to because they just don't have that clinical acumen to say like, "This is a great idea, but it's too short or too wide or way too uncomfortable, or this gets in my way and I can't see, and this is never going to work." So it's the combination, the industrial academic partnership has been really, really interesting. And the exchange of ideas between us about what's... We're like, "No, this needs to be smaller." And they're like, "But we can't heat something that small. We don't know how to..." You know, so it's like, "No, you have to do that." You know, and they're like, "Well, no, this is how it..." You know, so just trying to find the union of where we can have a product that actually works in the field for the end user, and then testing it and making sure that, you know, people with a lot of expertise, you know, like anything, people who do them all the time are very capable, but we want them to be in hands of people who don't necessarily have that same extensive decades-long of experience and training, so...

[00:12:15] Dr. Cifu: Right, and I think a lot of people are used to that sort of interaction between, let's say, you know, surgeons or interventionalists and device makers, but in that case, you're always talking about, "Okay, we're going to use this, you know, in an operating room in the United States that we're used to." And it sounds like not only are you saying, you know, we need the device perfectly designed, but we need it to be transportable and able to use and function basically anywhere.

[00:12:45] Dr. Masch: That is a big part of what we do is getting not only equipment but screening tests that can be done, what we call point-of-care so that we can get the test done and give the patient their results at the same time because what we have found in many places is the loss to follow-up with a multistep process. So everyone says, "You do pap smears, right? That's how you're going to prevent cervical cancer." But pap smears across the world have shown not to be effective in resource-poor settings because it takes so many steps. You come and then you have to, if your pap smear is abnormal, you come back, you get a colposcopy, you get biopsies, and if those are abnormal, then you come back, you have an excisional procedure, and if those... And then once that pathology, if it's cancer, you need to go one place, if you seem to have gotten it, then you come back in 6 to 12 months for another test, and it just... That kind of multistep process is really not possible. So, see and treat is sort of the mantra, so we want a way to diagnose people who are at the highest risk for getting cervical cancer and treating the pre-cancer immediately so that they can get it done all within one day. And that seems like, "Oh, that seems obvious, that's good," but actually making that happen is much trickier than one might imagine.

[00:14:07] Dr. Cifu: So we talked about this a little bit and I was going to ask you kind of what are the greatest challenges for you who to some extent, you know, from your training and from your work in the United States is like a traditional, you know, American academic physician, and maybe besides the funding side of it, which I think everybody can understand, you know, what are the biggest challenges for you working overseas?

[00:14:36] Dr. Masch: I would say, yes, besides the funding and the time, which really has taken some time to carve, figure out how to manage that, working in the local context and having partners on the ground who are invested and able to maintain the program functioning in a way that is productive. I think trying to manage anything when you don't have people on the ground, I've come to learn is much, much harder. So having people invested in the project who are actually living and working in that particular place has been essential to try and make programs run and function and be successful.

[00:15:20] Dr. Cifu: You must get very good at identifying who those people are who are excited about it and are going to stick with it.

[00:15:28] Dr. Masch: Yeah. So it's... When you go, you know, you do sort of have a sense of who can motivate others, who's really excited about the idea but we also work, when possible, with the ministries of health to try and... Because we realized, sustainability is really the name of the game. And if we want to not just have one-offs where we're just seeing this population of patients and then that's it, but if we wanted to actually be sustainable over time, involving the government, the local government, the ministry of health, for example, and figuring out how to make it... Make sure that they're interested, that, you know, this comes from them, that this is something that is a priority for them. And then working with them to figure out how to sustain the program. And it's not just monetary, there's a lot of logistics, there's a lot of training, a lot of education. And all sorts of all of the other things that go into having a successful program.

[00:16:23] Dr. Cifu: So my next question, I hate this question, but I've heard so many of my kind of global health colleagues be asked this, I figure you have an answer and I want to ask you. You know, so many people say, "Oh, God, you know, we have so many problems here at home. And we as a country have invested heaps in you." You know, do you feel okay spending so much of your time and effort on humanity outside the United States, rather than closer to home?

[00:16:52] Dr. Masch: Yeah, and it's true. There's so much work to be done everywhere, but I think lessons learned can be applied anywhere. The United States also needs point-of-care testing, we need to simplify our processes and make it more convenient and make people better able to get the kind of care they need in a way that they can access and that is meaningful to them.

So I think that all of the lessons we've learned can be applied anywhere where access is an issue. And so I feel like... We actually just submitted a grant to do some work here in the States, too, because yes, there's so much work to be done, and I do think that some of these modalities are going to be really useful here in this country, too.

[00:17:35] Dr. Cifu: That's an amazing point because I think there's probably not an effort to develop those here, because you say, "Oh, you know, what's the problem? You know, you call people on their cell phone and then take an Uber back and forth and there are no barriers," but anybody who's actually done clinical work recognizes that that's absolutely not the case and that things that you're forced to develop in other places maybe really do, you know, make things more efficient or more effective, efficacious, you know, here.

And so my last question. You know, for people kind of developing now, we have a lot of listeners who are pre-medical students and medical students and, you know, may listen to this and, I don't know, get inspired. How do you talk to people about... Is it important to think about things during training? Is it important to just, you know, "Focus on the medicine, you'll get to that later." You know, how do you advise people?

[00:18:33] Dr. Masch: Yeah, I don't think there's one right or wrong way, but I think that if there is an interest in global health, getting involved early, trying to join campaigns or programs that are going to places so that you can see where your niche is, what it is that excites you, what you find. Is it a certain disease process? You know, I focus solely at this point in our organization on cervical cancer elimination, but I came to that over time. BHI used to be many things to many people. We had pediatrics, we had internal medicine, we had optometry. So we really honed in. And that was a process over time. But I think that getting involved, trying to go with people who are going on trips, people who have programs around the world, seeing if there's a geography that speaks to you, something medical that speaks to you, but just saying yes and getting involved and really trying to see what it is that interests you. But I do think learning the medicine is also important because that's how you're going to actually help the most people. So having that background is important.

[00:19:44] Dr. Cifu: That sounds like great advice. Rachel, thank you so much. This is really interesting and very different from I think a lot of the things we've talked about in the past on the podcast, so I really appreciate your time.

[00:19:52] Dr. Masch: Yeah, my pleasure, and happy to join you.

[00:19:55] Dr. Cifu: So thanks for joining us for this episode of The Clinical Excellence Podcast, we're sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago. Please feel free to reach out to us with your thoughts and ideas via the Bucksbaum Institute website or on Twitter.

The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.