Alicia Morgans: Hi, this is Alicia Morgans, Associate Professor of Medicine and GU medical oncologist at Northwestern University. I am so excited to have here with me today, Dr. Stephen Williams, who's the Medical Director for High-Value Care and the Chief of the Division of Urology at the University of Texas Medical Branch in Galveston, Texas. Thank you so much for speaking with me today.

Stephen Williams: Well, thank you for inviting me to speak with you this evening.

Alicia Morgans: Wonderful. So, Stephen, you have recently been named one of the directors or, you'll have to tell me your true title, but you have a leading role in your center in trying to help understand some of the challenges and address some of those challenges in light of the COVID-19 pandemic that certainly is affecting Galveston, Texas, and the rest of the world. Can you share a little bit, first of course, can you give us your real title, but can you also then share a little bit about what you're experiencing in Galveston, both in your clinical outpatient setting practices and then what we're thinking about in terms of inpatient surgical concerns, and what you're doing?

Stephen Williams: Absolutely. I think these are historic times that we're going through. And one of the things that I've surrounded myself, both at my institution as well as internationally is, the beauty of medicine is people are really used to coming together but really finding their underlying passion. One of the things my institution has appointed me as the COVID-19 Employee Health Task Force Team Leader. So otherwise, it's basically a czar position to help tackle this, but particularly for underlying healthcare providers. And for me, that really hits home, not only from the standpoint of protecting our patients, which is very important, but also those who are on the frontline every day. And when I say healthcare providers, this is all employees. So people who are working in the cafeteria, people who are cleaning our hospitals, that I think quite often we take for granted, and then going all the way to physicians and so on and so forth. And of course, our nurses who are doing an amazing job. And I think we are now really appreciating, really the teamwork that comes together.

From the clinical standpoint, at most institutions and myself being a urologist, we are adhering to the American Cancer Society ban on all elective procedures at this time. And one of the questions I always am proposed is, what are elective procedures and what are the classifications for those? The CDC has a list of what they would quantify on levels of severity, but also the American Cancer Society has provided some useful information, and our colleagues in the UK have provided some useful categorization.

I think also, too, is our clinics across the United States, and I have colleagues obviously that are in New York and elsewhere, as much as you're familiar with, but we have specifically shut down our clinics to only have telehealth appointments, and only emergent or urgent procedures, which are very few and far between, are allowed to come to clinic to have procedures. We still, believe it or not, have a robust transplant team, and they are taking their own necessary precautions. But those patients sometimes have stents that are in place, and we're trying to push those out as much as possible. But sometimes, to avoid any complications that they may have, those are types of procedures that we may do.

But I think it's coming together and really working as a team and as a health system to optimize the delivery of care to our patients. My field is particularly in urologic oncology, and having those discussions with our patients and determining what is in their best interest, and really balancing the risks and benefits, not just from the procedures anymore or the treatments we give, but from the COVID-19 exposure.

Alicia Morgans: I completely agree. I think one of the more challenging things actually for clinicians is thinking through what is a critical procedure? What is a critical surgery? What is a critical office visit, need to see in person type of experience? I think in medical oncology we face this frequently around ideas around chemotherapy because that's something that we both need to see someone have lab work and then deliver that in person.

But in your setting, you have a special interest in bladder cancer among other things. There are bladder cancers that, one, we may need a TURBT to really diagnose it, even if we see something, or especially when we see something really concerning on CT. How are you dealing with that?

And then two, when you find muscle-invasive bladder cancer, some of these are really aggressive tumors, and everybody, patients and physicians alike I think have concerns about timing and trying to have those removed. I don't expect you to have the right answer, I don't know that there is a right answer, but how are you doing this in Galveston to try to balance the risk of cancer against the risk of COVID-19?

Stephen Williams: Sure, no. That's a great question. I think one of the things, first is, as you gave a great example, as muscle-invasive bladder cancer, and what we have at our institution, and had before this COVID-19 concern is multidisciplinary clinics. And I think one of the great things, if you will, to have had that already as a part of our care and management of diseases such as bladder cancer, is the involvement of our radiation oncologists, medical oncologists, and urologic oncologists to preemptively have already had discussions in regards for treatment options. And I think as you have seen in the social media, and different concerns and policies, I think it's putting everything in together in the context of the patient, but also to the environment.

Because where I am in Texas, we're going to hit our peak likely in May or a little thereafter. But my colleagues right now that are in New York, I would bet no one would be considering at all doing any type of an invasive procedure, especially a radical cystectomy. And I think it has to be placed into that context.

But more importantly, and as I've done a lot of population-based research, a large number of patients with muscle-invasive bladder cancer don't receive treatment, over 50%. And I think in this time we really need to embrace our colleagues, which include our radiation oncologists, and aside from trimodal therapy being a valid option, I think this is the time to strongly consider those options, and particularly in this pandemic that we are in.

Also, too, I think, when their patients are considering one definitive treatment option versus the other, utilization of chemotherapy. But also, too, that involves, as you know, different cycles or regimens and trying to see how we can limit exposure. And every time I walk into my facility, and I'm sure you as well, it's really starting to ramp up in regards to precaution measures. You know, we have our temperatures taken, we have our other measures to help protect ourselves around our patients. And I think as we're going to be embarking and as we come into more cases, I think we're going to definitely tighten down in regards to what procedures are deemed actually urgent or warranting aggressive measures.

There is no right answer, but I think, using sound judgment, we have our OR review committee, which is separate from the surgeon that wants to post cases. We adhere to the American Cancer Society and the current guidelines as set forth by some of the societies. There are certain gray areas. SAGES, which is the endoscopic society and laparoscopy, earlier, I think it was this week, indicated no laparoscopy procedures. Then the end of the week, it's a, "Yes, you can do a laparoscopy, however, use controlled measures to minimize the exposure from insufflation." So this is an ever-changing time. And I think really it comes into... And something that I've always loved to do is just collaborate with other people. I definitely don't perceive myself as the smartest person in the room. But when you're able to really have those thoughtful discussions with other providers as well as also the patient, of course, then you can hopefully steer people towards the right decision.

Alicia Morgans: That is actually an excellent answer, when there is no right answer, to work together to find the right answer for each patient, I think is the best answer you could give. And I love that. And really your emphasis on teamwork and on supporting all members of the team, as you mentioned, the folks who clean, the folks who make sure that there's food in the institution. The MAs, of course, who room the patients. The schedulers who help the patients as they check out. Nurses, doctors, everybody, we're all experiencing pretty tumultuous times and all trying to pull together. But it's hard.

And I wonder, because you have this czar position, and are going to be called on to do this, how are you supporting the mental health, the psychological health of those in your institution? And really what advice could you give to others who are listening who are trying after, some of us for weeks that we've been isolated, and really in sort of upended times, trying to maintain some normalcy as we experience all of this?

Stephen Williams: That's an excellent question. And you must have listened into my recent administration meeting because that was a major topic. And particularly with, for example, our employee health have actually turned into psychologists, because obviously the intense anxiety just alone of living in a pandemic, but then the added concern, "Am I exposed?", "Do I have COVID-19?", is not uncommon, as we're experiencing. And really making certain that we are providing, and we have at our institution a hotline, as most do, or access center, that then we could direct our employees to the necessary resources as needed. In addition, our institution, and I'm sure yours as well and everyone's, email boxes are getting full of COVID-19 emails. At least twice a day, we provide real-time data to our employees, and more importantly the changes, and then, in addition, resources for both the physical, I think, maintaining a healthy exercise and getting your mind off of all these circumstances, but mental wellbeing as well.

And I think those are critical elements. And I'm quite amazed at how much effort is being set forth by people assuming rules such as, I guess myself, but more importantly in employee health and our epidemiology, we have an epicenter, that are really taking the lead on a lot of these responsibilities. And I really mean it, like the employee health, those individuals that are nurse practitioners or actually not even in the field, they may be epidemiologists, but fielding these calls and really functioning as psychologists and mental health providers. So it is quite amazing, and I'm at a very special place that has allowed me to witness these things firsthand.

Alicia Morgans: Wonderful. Well, I certainly wish you and your institution the best as you continue to move forward in this and continue to find the silver lining in everything that you do, and continue to get patients and staff and faculty to the other side. Do you have any closing thoughts for those who are listening?

Stephen Williams: I think the most important fact is we will get through this. I think there's no definitive timeline, as we've seen other countries go through this, we're obviously a large country as well. But we are all working together to try to get through this as safe and as fast as possible, but really making certain too, particularly for the healthcare providers, taking care of yourselves, and then also too, minimizing the exposure for when you come home taking those necessary precautions and measures so you don't expose your family members. And I think, taking care of your physical and mental health is very important.

Alicia Morgans: I totally agree. And I thank you so much for your time today. Please take care of yourself and of course those around you, and just thank you.

Stephen Williams: You're very welcome. And you be safe as well.