Episode Transcript
Welcome to OlympusTalks, the podcast that brings you to the forefront of medical technologies as we explore advancements in innovations in GI. This 8-episode series features talks with healthcare professionals, patients and Olympus subject matter experts. Listen as they dive into various aspects of GI health focused on improving patient outcomes through better best practices. Stay tuned for conversations designed to educate, inspire, and inform.
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Dr. Julie Yang is a paid consultant of the Olympus Corporation, its subsidiaries, and/or its affiliates. The positions and statements made herin by Dr. Yang are based on Dr. Yang’s experiences, thoughts, and opinions. As with any product, results may vary and the techniques, instruments, and settings can vary from facility to facility. The content herof should not be considered as a substitute for carefully reading all applicable labeling, including the Instructions for Use. Please thoroughly review the relevant user manual(s) for instructions, risks, warnings, and cautions. Techniques, instruments, and setting can vary from facility to facility. It is the clinician’s decision and responsibility in each clinical situation to decide which products, modes, medications, applications, and settings to use.
Hi everyone, this is Tom Salemi of DeviceTalks. Welcome back to the OlympusTalks podcast. We're going to be exploring the relationship between clinical application specialists and healthcare providers, and to help us understand the role of the CAS. We're speaking with Rich Burde. He's Director of Marketing for EUS. Rich, welcome to OlympusTalks.
Thank you Tom. Happy to be here. Yes, I'm lucky enough to be able to manage a large team of clinical applications specialists at Olympus. The team supports EUS and EVIS procedures. They're all board-certified sonographers that, you know, go into our customers and they may go into a demo, they may do an in service on our equipment. You know, their job is to educate on the safety and efficacy of Olympus equipment, EUS and EVIS. And the support that they provide to our gastroenterology and pulmonology community is invaluable, and I think you'll see that today by the relationship that Dr. Yang and Melissa have and the support that she's been able to provide over the years.
Yeah, Dr. Yang said at some point, nd you'll hear in the podcast, having a CAS like Melissa makes a world of difference, turning average into amazing. So, it seems, Rich, that these folks really develop a, can develop a, real strong bond and probably become good friends over time.
Yeah, I think you'll enjoy what you're about to hear. Thank you.
All right, great. Well, it's always wonderful to unpack these important relationships in MedTech. Let's start this episode of the Olympus Talks podcast.
Dr. Julie Yang and Melissa Elliott-Walker, welcome to the podcast.
Hi. Thanks for having us.
My pleasure. So I’m excited. We’re going to be unpacking the relationship between clinical application specialists and physicians who are working with Olympus. And I know you two have worked together in many cases for a long time, so I’m really looking forward to understanding the benefits of these relationships. But before we get into that, we always like to understand or know who our guests are and learn a little bit about their backgrounds and how they got to where they are.
Dr. Yang, Julie Yang, how did you decide on a path in medicine? What brought you into this great field?
Well, you know, sort of the cliche answer. I really like science and the noble cause of helping people. And so it was a marriage of two interests that was really a natural fit for me.
Was it something that you had held onto since you were a young person? Did you have a stethoscope when you were six?
No.
Say someday?
No, no. I’m actually the first medical physician in my family. But again, it’s just sort of like a natural fitting. You know, life is always about what are you good at and what really drives you, and also figuring out what you’re not good at and steering away from those things. And so it was just a natural calling for me.
That’s great. And you’re a gastroenterologist. How did you decide on this specialty.
Yeah. So it’s interesting. There’s so many great medical specialties out there, but again, it goes back to what are you good at and what really makes you happy. And so I’m a proceduralist, and so I like doing things with my hands, and I do like seeing the benefits of what I can do, whether that’s an immediate thing or in the long term. But I definitely like that relationship of seeing what your procedure skills can be applied to a person.
But then I also liked medicine and the art of differential diagnosis and really trying to figure things out like an investigator. And so gastroenterology is one of those fields which, again, marries those two concepts very well. And the added benefit of gastroenterology is that you really have a myriad of diseases and a wide spectrum of patients that you can take care of, whether that’s healthy for screening or patients who have cancer and everyone in between, chronic diseases, acute diseases. So it’s really the diversity that really attracted me.
That’s fantastic. And, Melissa, you are a clinical application specialist. And that’s the last time I think I’m going to say all three words. I think I’ll just say CAS from now on because I’m going to mess it up eventually. How did you find your way into this career?
Well, I started an ultrasound a long time ago. I was trained by radiologists back in the day, not a conventional way. And I worked at a hospital for 10 years, 15 years, and then transitioned to an outpatient radiology practice where I managed an ultrasound. Big practice there. And after 10 years in that role, I decided I needed a change. And it was just serendipity that I got a call from a headhunter that I’d been working with for years, helping me find ultrasound techs to work for me.
He called and said, listen, there’s an application specialist job for endoscopic ultrasound in the Northeast. And I said, what’s that? I can’t remember.
That’s not what I was expecting. I was like, expecting a little more enthusiasm.
I was thinking, wow, you know, and I needed a change because I, at that point, I had been doing ultrasound for 35 years. And so it was a perfect fit because both of my girls were in college. And this job at the time, I covered a very large territory. It required a lot of travel. So it was perfect. I had a very understanding husband who knew I needed to have a change and I needed to learn and use my brain more.
And, yeah, so I just jumped in with both feet. I had some amazing training and I worked with a great group of sonographers. We’re all registered, which I think sets us apart from other clinical specialists. We’re registered sonographers, all in different specialties. So I’m registered in abdomen, OBGYN, and vascular. And there’s a physics component to those as well. So it’s a separate board certification for that.
So that’s what gives you the knowledge to come in and work with physicians like Julie and the staff. But really on the physician side, it really gives us that. The physics background, that sometimes I don’t think just because they’re busy with so many things, that’s not something they’re focusing on. And so being able to get in the room with the physician and helping that image look the best it can is really what it’s all about.
What is the role of a sonographer? Because, full disclosure, I had a conversation with someone earlier, and I thought they said stenographer. And I’m like, who’s trying to like, what role would that person have in this procedure? I can’t imagine. What is a sonographer? What does it mean to get certified in that?
So you go to school and you have to take, you have to on the clinical side, there’s a lot of academic part of it, too, but you also have to scan a number of procedures. So whatever specialty it is you’re going to go for, because there’s echo for the heart, there’s pediatric, like I said, there’s abdomen OBGYN. You have to get a lump of, I forget how many hours you have to scan. And then you sit for a board.
So if your wife is pregnant, you want to make sure the person scanning your baby is registered and that they have gotten all those numbers checked off and they had worked with a radiologist. So, really important. Yeah. So that’s what we do. You know, all different parts of the body you can get specialized in. And it’s just like gastroenterology went down that road. So before I did ultrasound in ob GYN and vascular, I was a radiology tech first. So I did. Back in the day, I did upper GI’s and barium enemas and all that stuff. So it was kind of. I came circled all the way back, and now I’m in the GI space again.
So it was a great marriage of the two. Yeah.
You’ve seen every part of a lot of people.
It sounds like I have.
Dr. Yang, just in your practice, I’m curious how much of your week is spent. And it probably varies. Seeing patients in an office setting and how much of it is in a clinical setting where you’re using tools from Olympus.
Yeah, so each practitioner is different, but I have a little bit of a mix of office maybe about a third of the week and then procedures two thirds of the week. But again, you know, that changes between the practitioner and what they’re comfortable with. But I like to see outpatients in the office and then have a deep conversation about that with them about their procedures. And then most of the week, though, is spent on cases and endoscopy.
And how is the specialty overall doing? Not to represent your entire class of physician, but we hear of so many physicians under pressure because it’s a shortage of doctors or other things. How are you feeling about the state of gastroenterology right now?
I mean, I think the state of gastroenterology is great. I think particularly advanced endoscopy is in a really good position. We’ve really made some good strides in the past year, years, not just in the screening front, which is obviously the real crux of what we do, screening for cancers, detecting them early, but really for at least for the platform advanced endoscopy. We really made some strides pushing the envelope of what we can do, not just from the diagnostic standpoint, but really pushing towards therapeutics and being really that in between from patients who would maybe not have to go to surgery or having really have minimally invasive options for their treatment. And so it’s very exciting time.
That’s great. Well, that’s good to hear. Melissa, talk to me about the role of the CAS. How are you engaged with the physicians that you work with? Are you in the rooms with them? What is the nature of the relationship between the two?
A lot of the relationship starts typically with the staff. So especially when a new endoscopic ultrasound program is started, we’re in there with the staff, teaching them how to handle these scopes are very expensive, and teaching them how to set them up properly for the procedure and then being in the room with them when they’re doing their first handful of cases and more. Every need is different based on the facility.
And then my role is to be in the room when there’s a procedure, which is my favorite thing to be in there and just talk shop, talk about what they’re trying to achieve. Why is the patient there loving the history, knowing whether imaging has been done on the patient? I mean, it’s really just all about the patient. Right. So we’re in there for the procedure and then after the procedure, we actually talk about bedside cleaning.
So it’s from beginning. From the moment we walk into the room, before the patient even gets in the room, we’re in there helping set up, making sure we have the appropriate. Appropriate scopes, and then being in there for the procedure. And then after the procedure, too, where they’re helping. Helping clean up.
Wow. So how did? You mentioned you traveled a lot, covered a lot of territory. Were you in one place for, like, a few days at a time, or did you. Were you going from location to location, day to day? What was the lifestyle like?
Yeah, so the first eight years, I covered the entire Northeast. So that was from New Jersey, all of New York, up to Bangor, Maine. You know, New Hampshire, Vermont, Buffalo.
That’s not much.
So in that, for those eight years, I would say, okay, line up cases. I’ll be there for three days.
Yeah.
And then I probably won’t be back for a while. And I was always booking many weeks out to get that. Those chunks of time. But now it’s not like that. Now I still cover a large territory, but I really, everything is, you know, it’s so relative. Right? So now I cover Connecticut, all of New York, Northern Jersey, and I go up to Saratoga Springs. So it’s not overnights. I don’t do overnights hardly at all now because I can drive really anywhere and get back same day.
That’s good.
Yeah.
So let’s unpack the technology a bit, talk about endoscopic ultrasound and the procedures. Dr. Yang, what intrigued you about EUS and what are the benefits of the technology? What do you like using about the technology?
Yeah, I mean, it’s sort of been lucky that I’ve been able to really experience EUS at its full glory and where it’s still going in the uphill. But I always say that EUS is the truth. It’s just something. And how I fell in love with it. But I remember when I was in training, it was a time when EUS was around, and it was mostly diagnostic, but it was still relatively new. And it was more of, why are we doing this instead of getting a CAT scan or. Okay, now I know that we can do endoscopy and get biopsies this way instead of having to call interventional radiology.
But really what it sets apart is that it is the truth. If there’s something on CAT scan, something on MRI, they’re not really sure or they miss it. They just can’t see it, EUS will always find it. That is why once I discovered that in training and I said, wow, it was there all along, whatever it was, that lesion, how could they have missed it? Or how did you not see it? It’s so obvious on endoscopic ultrasound.
That’s how I realized the power of EUS. And then now it’s just I’ve seen the evolution in my 14 years in career that it’s really gone from a diagnostic procedure, which it’s still very powerful to do. We still have. It still plays a role in being the truth. And although cat scan and MRIs have gotten better, we still find lesions and really see the details of things that no one else can see. And that’s really because of the proximity of where we are in the GI tract and, of course, the improvements in imaging technology.
But from there, and going towards therapeutics and really taking us to, you know, being really that foothold of between offering minimally invasive options for patients, it’s just very exciting.
And Dr. Yang, if you wouldn’t mind unpacking your sort of perspective on the roles of the CAS. I know we’ll talk a little bit more about EUS in a moment, but I got Melissa’s point of view as to the roles the CAS’s play with physicians. But how do they help you and how integral are they in ensuring the patients get the care that they need?
Yeah, I think I have a pretty unique experience with CAS’s, and particularly Melissa. You know, we met when I first started as an attending right out of training, and I could immediately tell that Melissa was really special. And it’s really because of the wealth of her experience. She wasn’t just there to tell us which button does what or turn this button on. It wasn’t that. It was much more. And the value of her experience and the way that she can educate all of us, whether it’s me as a physician, my staff, my techs, my fellows, just really everyone in the room.
It’s a very unique role that really no one else can do, because it is that unique experience of knowing the technology for the company, knowing everything about the machine, but also, like she said, the clinical application for it. You know, really being involved in the cases to understand, you know, what am I trying to do here? Where. What am I, what kind of images do I really need to get, or what is the position that I need to be in to really maximize my yield. And so there’s. Those are the subtleties that really get you from just being average to something really amazing.
And so I’ve been lucky to have worked and known with Melissa, but particularly, particularly in my position. So I was saying that we really started a program from ground up, a therapeutic endoscopy program. And it’s challenging, obviously, really going from 0 to 60. And a lot of it has to do with obviously training your staff, making sure everybody in the endoscopy suite is up to date on the technology, what it can do, but also really, it’s the buy in.
Me as a physician or physicians alone can’t be the only ones to say this is what the technology is and what it can do. You know, I think that’s why somebody like a CAS, and particularly Melissa, who has so much experience, can really help, really develop that conversation into something deeper to make everybody in the room understand what we’re doing, why it’s important, and why this particular technology is so significant.
And so that all that conversation and all of that experience together is what really gets buy in. And buy in is what you need so that everyone can be, you know, at their best for their teamwork for their patient.
I want to, that’s fantastic. And I want to unpack your calling EUS the truth and sort of understand how, how it earns that, that reputation in your mind. Melissa, you’ve had a lot of experience with ultrasound. As we, as we joked about earlier, you’ve been doing this imaging for a long time. What is it about the US technology that really kind of lifts it above in the opinion of Dr. Yang and others, other imaging to find the truth and define the things that need to be found to ensure people get the treatment that they need.
Well, like I said, my background was radiology. So when I first started this role, I thought CAT scan, MRI was the be all end all. Honestly, if they didn’t see it, it didn’t exist until I saw EUS and I was like, wow, we’re missing so much stuff. So the difference is that the end of the scope is in the stomach. Let’s say it can be in the esophagus or the duodenum. But the only thing separating that transducer from the pancreas, let’s say, is just the gastric wall.
So the detail is like none other. You just can’t compare it to anything else. Maybe MRCP is getting better there, but it is really the imaging quality and like we said, the technology, the processors, the scopes are better. It’s just the detail is just amazing and it’s really what is the gold standard now for any pancreatic imaging? I mean, if you have a loved one that has anything questionable in the pancreas and your facility does not have endoscopic ultrasound, you need to send them out to where they have that because it’s surprising me and Julie, you can attest to this too. There are still many physicians, you know, that don’t know about endoscopic ultrasound. Where I was, you know, 17 years ago, there are people still there. So I think still we need a lot of education out there to the masses about this technology.
That’s interesting point. Could you follow up on that, Julie? Because I think people, lay people like myself think that it every doctor has the same piece of knowledge and if you talk to one, they’re all drawing from the same experiences. How do you, I guess not to talk about your counterparts, but what don’t they know about AUS that hasn’t convinced, that has not yet convinced them to bring it into their practice?
Well, I mean, I think it’s really more of access to specialty care because again, not everybody has access to endoscopic ultrasound and they might not have access to what endoscopic ultrasound can do. And so I think in general we’ve made big strides in the past years for people to know that EUS is really implemental in cancer staging cancer diagnosis. So I think we’re all up to speed on that. I think where we could do better and where it’s going to go is again talking about therapeutics and what EUS can do.
But again, it’s really more of having access to that specialty care.
So is EUS generally seen as a first line of imaging or is it something that’s saved to confirm something that’s been seen through another type of imaging?
I mean, that’s a very good question. It really depends on what you’re talking about. But in general, you know, it’s a, you know, patient care is team care. Right. So it’s one piece of the puzzle that is necessary to get answers for a patient. And so you still will CAT scan, you still might need mrcp, things like that, depending on the disease state, but it’s really just a complementary role, adjunctive role that everyone plays and can answer that particular question.
And so, you know, you still need cross sectional imaging to evaluate for metastatic disease or you may still need endoscopic ultrasound to really detail is this locally advanced disease or is this early stage disease? So all important questions that, that everyone plays a role in, but essential roles are all key pieces.
And Melissa we don’t have an image to show in this podcast and a lot of people are listening just to the audio part, so it wouldn’t help if we did. But give us a sense of what is the difference in what folks are seeing. And Dr. Yang, you can offer as well between EUS and other form imaging. Is it just a clarity? Is it the crispness? But what is the winning difference between EUS and other modalities?
So when Julie was talking about the truth, I think in the beginning, when you’re first training, and you can correct me if I’m wrong, when you’re first looking at an ultrasound image, it looks like a sonar, right? It looks like a weather map. Nobody can walk in their first ultrasound and go, oh yeah, there’s the gallbladder or there’s the pancreas. I mean, it is a different, it’s pattern recognition.
So it is completely different imaging than MRI and CT. So you can’t even compare because these are just shades of gray. Whereas cross sectional anatomy, you could argue that if I showed you a cross section on a CAT scan of a liver and then I showed you the same cross section the following day, you’d probably be able to pick out where it was. EUS takes many, many, many hours and procedures to get good at that pattern recognition because it’s unlike any other imaging.
And you can pipe in there, Julie, if you want to about that.
Yeah, I mean, it’s exactly what you said. I remember when I first saw it, it was like TV back in the day when we had antennas, you know, it’s like black and white and you’re just like, what is that? Is that supposed to be a show? And it’s really hard for a gastroenterologist in training to switch their eye to endosnography because all we are used to is endoscopic images, which, that is a separate training.
That’s the crux of what we do. And EUS, you have to train your eye to these ultrasound images, which is completely different. And so it’s an. And it’s again pattern recognition. But when we start in the beginning, it’s really looking at what normal is and understanding normal. And then after that, you then start to learn what abnormal is. And then that’s how you build upon your training. But the one added thing besides imaging is actually as a trainee, you also have to figure out how you get the images that you want.
So that’s why I tell my fellows all the time, it’s like first you have to know the road and you know you have to know what driving signals are. But then the other important part of driving, or EUS, is knowing how to get your car from point A to point B. You know, the nuances of the curves and nuances of stops and goes, acceleration, deceleration. So all those kinds of skills, which are just, again, muscle movement, muscle memory, that’s a separate training that goes along with EUS.
That’s also very difficult and something that is not natural when you’re just doing endoscopy, regular endoscopy.
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Fascinating. Well, let’s look forward. What opportunities, what changes in healthcare does technology like EUS allow for in terms of diagnosing and helping to manage the treatment of disease? What are some of the areas where it’s currently playing a critical role? And maybe we can then explore maybe where it will be playing a critical role in the future. Dr. Yang, if you wouldn’t mind starting us off.
Yeah, I think recently there’s been a lot of chatter and excitement about EUS and the role in endohepatology. A lot of what we’ve done in terms of endoscopy and the role a gastroenterologist plays is starting from screening for variances, maybe even doing liver biopsies. You started taking that away and doing that endoscopically because the patients were there otherwise for screening or for any other indication for an EGD.
So we have access to liver biopsies. Us guided various yeast screenings that we talked about. But now, especially with the rise in metabolic steatohepatitis, really trying to get an understanding, a better understanding of EUS and trying to understand the role of liver stiffness and evaluating for cirrhosis. Usually what we did in the past, before that, we would just look at the liver edges and see if it was sort of lumpy, bumpy, nodular.
So that would be suggestive of cirrhosis. And that’s what the radiologists do when they look across the sectional imaging as well. But we have shear wave contrast now that can play a role. And I would love to hear what Melissa has to say about those technologies.
For Melissa, I’d love to hear as well. What is liver stiffness?
Normally, normal healthy tissue is soft and elastic and bounces back, you know, when you press on, doesn’t feel rigid. And so currently there isn’t a screening tool for liver disease. And people can walk around with normal liver function tests and still have liver disease. So I think we need to get better at that. So shear wave measurement is a function that it’s been around for many years in radiology, where you do it trans abdominally.
But you can imagine we’re doing this a lot of times on patients that are obese, and it’s hard to get a good representative image. So by using the scope with the ultrasound transducer and using shear wave endoscopically, like I said, we’re right up close to that part. We don’t have to go through adipose tissue or maybe hit a vessel. We can see where we’re sending. It’s called a push pulse that comes out of the transducer.
It creates a wave, and we actually just measure the speed of that wave. And the faster the velocity, the stiffer the tissue. So it’s just basic physics. And so we are hopeful that we’re going to have a scoring system for this, because right now there is a scoring system with a device that’s called Fiberscan, it’s called a medivir score. And F0 would be completely normal, and F4 is cirrhosis. And we want to be able to tell patients, listen, you’re F2, you’re on your way to F4.
Start eating a salad. So you want to start, you know, counseling these patients before you can’t reverse things. So that’s where I think shear wave. Because I think right now patients are having fiber scans because you don’t need to be sedated. And any technician can learn how to place this probe and get a measurement, and you can repeat it frequently. The issue is that we’re dealing with patients who are obese, and it’s hard to get an adequate reading. So I think they’re getting.
When it’s in those higher F2, F3, it’s not as accurate. So I think by getting closer to the part with an endoscope, with the EOS scope, it’s going to give us a better reading. So that is what we’re hoping to get, a scoring system using the EUS scope. And then that way, if a patient is coming in for an EUS for another reason, we can screen them while they’re there. Right. So while we’re here, we’re just going to take 10 measurements. Right liver lobe, left liver lobe, whatever our parameters are going to be, and that will be part of the written report and just say, okay, we scanned your liver, you’re normal or you’re not.
So I think that’s. That hopefully will be in the very, very near future. That’s what we’re hopeful for.
That sounds very beneficial. I think people respond. I think people respond well to numbers and to rankings into understanding data. So that’s, that’s certainly. I could see that really making a difference.
All right, well, this has been a fascinating look at a really promising technology and an important relationship in healthcare. I appreciate you both for joining us on the podcast.
Thank you so much.
Thank you.
All right, well, that is a wrap. Thanks so much for joining us on this episode of the OlympusTalks podcast. Thanks, of course, to the participants of this episode and to our corporate partner, Olympus. In our next episode, we’ll do a deep dive into Olympus EVIS X1 endoscopy system and Olympus mission to support early detection. For more episodes of OlympusTalks, go to OlympusAmerica.com/podcast and of course, we’d love you to subscribe to our DeviceTalks Podcast Network and also connect with us on LinkedIn. I am Tom Salemi, Editorial Director of DeviceTalks. Please also connect with Kayleen Brown. She’s the managing editor of DeviceTalks and put this entire episode together.
So once again, folks, thanks for joining us on this episode of OlympusTalks. We can’t wait to bring you our next episode. Take care, everybody.
Potential complications that may be associated with endoscopic ultrasound include, but are not limited to, the following: sore throat, infection, bleeding, perforation, and/or tumor seeding (when EUS-FNA or FNB is performed).
