Where Lung Transplant and Health Policy Meet

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, Chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease. My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Sumita Khatri, MD:

Hello everybody, this is Sumita Khatri. I'm the guest host of this podcast for both Respiratory Exchange and Respiratory Inspirations. It is my immense pleasure and honor to welcome a very good friend of mine, somebody I don't see as much as I'd like to see, because, well, you're changing the world, Dr. Valapour. I'd like to introduce you formally, and then what I want to really do in this podcast is to have people get to know you. Like the person behind the curtain who helps things happen in the transplant community and how you got there. So, if that's all right with you, I'm going to start by introducing you, and then we'll get started. How does that sound?

Maryam Valapour, MD:

That sounds perfect.

Sumita Khatri, MD:

Perfection.

Maryam Valapour, MD:

I'm excited to be here with you as well, Dr. Khatri.

Sumita Khatri, MD:

Awe, thank you, Maryam. And you know what? Call me Sumita, I'll call you Maryam.

Maryam Valapour, MD:

Sounds perfect.

Sumita Khatri, MD:

If that's okay with you?

Maryam Valapour, MD:

That seems more natural to me too.

Sumita Khatri, MD:

Doesn't it? Yeah. So, Dr. Maryam Valapour is the Director of Lung Transplant Outcomes Research here at Cleveland Clinic. She has practiced as a lung transplant physician for 20 years and truly is a prolific researcher in the field, with grant funding not only from NIH and the Department of Health and Human Services, but also foundations such as the Cystic Fibrosis Foundation. So, in addition to completing a fellowship in pulmonary and critical care medicine, she also completed a fellowship in bioethics and health policy at Johns Hopkins and has a master's in public policy from the University of Minnesota, all of which is helping her redefine the field of transplant medicine. And I remember when we first met, I think it was in the kitchen, I think we finally sort of first met, and I said, I like public policy, and you're like, I do too. And I'm like, well, you are way ahead of the game here, as usual.

So, welcome. Thank you for being here.

Maryam Valapour, MD:

Thank you so much for having me. I'm delighted to be here.

Sumita Khatri, MD:

Thank you. You know, we will get to some of the scientific and medical side of things in a minute, but you know what, I know that many people who listen to this podcast are also young trainees, medical students often, pulmonary fellows, and they're also wondering, you know, how can they make a difference in this world. I do see that in this next generation. So, that's why I'm going to focus a little bit on you. Is that all right?

Maryam Valapour, MD:

Absolutely.

Sumita Khatri, MD:

Okay. So, I'm just curious, what motivated you as a young person, either in childhood, to do what you're doing and to pursue medicine?

Maryam Valapour, MD:

So, I would say I think of life as these big events that change the course of our lives and then smaller events that confirm we're on the right path or result in course correction.

And in my case, I would say the defining event of my childhood was being a refugee, a religious refugee from Iran, which is how I ended up in the United States. I was 10 years old, and this is 1979 and that's how I ended up in this country.

And undergoing that kind of persecution of religious minorities really, I think, made an impression at that time in that I made two observations that I think have held true, even 40 years later.

And that is that misinformation and a misinformed population is dangerous. And which was what really made me fall in love with science and education, because I was convinced if people knew better, they would do better.

And there was a rationality to the discourse in science that I just found comforting. And the other observation was that policies and societal rules really are very impactful. In fact, they can change your life overnight. And that's probably how I ended up in this intersection of science and policy in my career. And I still think that holds true.

Sumita Khatri, MD:

Wow. That's truly fascinating. As I'm listening to you, I'm getting chills because, you know, these are inflection moments in people's career, and they're imprinted. So, what you did is saw and felt what you saw and felt and turned it around to the opportunity. And so, we are so sad that you had to leave your home country and- and face that, but then on the other hand we're so grateful that you're here.

Maryam Valapour, MD:

Well, I mean I consider the US my home country. This is where I've grown up and, yeah, I consider both countries as instrumental in who I've become. But I think this is how being a physician-scientist makes sense to me, because I get to think about how do I make a system better so patients in need at their most vulnerable period in their lifetimes, can access care in a fair system?

Sumita Khatri, MD:

You know, it's interesting that you are so into that system idea. So, you know, just personally I get very attached to people individually. And, you know, on a broad scale, but I think I focus on the person, and you focus on the system and it's like together we can make a difference, you know?

Maryam Valapour, MD:

Let's hope so.

Sumita Khatri, MD:

And so, you know, also when you're in training, was there any sort of patient and/or mentor that motivated you, or somebody you sort of imprinted on?

Maryam Valapour, MD:

You know, it's interesting, when I started at this intersection of medicine and policy, particularly transplant medicine, lung transplant really started in the 1990s, so it's early in this genesis, and when I started there were no mentor figures who were on this path. When I remember talking to someone about what I wanted to do, he was just flabbergasted about the idea of mixing these two things in the arena of transplant. So, I didn't have a mentor whose path I could follow, but that does not mean I didn't have great teachers.

What I did was use what I learned from each person to forge a path forward. I would say the people who probably made the biggest difference in my career are the patients who reaffirmed what I was doing. You know, these kinds of careers take a long time and there's a lot of trial and error. When you talk about your career, usually if you're on a podcast that means you've had some success.

But, you know, there's many years of attempts at things that don't work out. And it's those years where I would see patients and realize what I was doing probably made sense. And I would hope to be successful in being able to help them.

Sumita Khatri, MD:

Yeah. You know, that's very motivating obviously for you, so I see how you see the granular and the system. You know, I also know, and I've talked about this in other podcasts where others are interested in climate change and other things, that it kind of seems more recent that the physician is getting involved in policy.

And I'm thinking about how your presentation you gave to us at our institute, you gave us a sort of arc of politics and science and policy, and it was so fascinating because you are making an impact on that. So, what do you think about the physician public health policy person, and what would you tell them? Like is it important, or isn't it?

Maryam Valapour, MD:

You know, it's interesting that you think of these people as different personalities, different backgrounds, and different interests, right? And I think it might be true that politics may not necessarily appeal to the average physician, just because there's more to politics than policy, right? Policy is the study of how systems can help, or how system impacts society at large. I had a little bout of having an interaction with politics when I was in medical school and I had a summer internship in D.C., and I realized that politics and that level of advocacy was not for me. Because it wasn't always grounded in rationality and data, right?

So, there's more to it than that. But policy is science, at its core you're just looking at how systems can impact your patient population or society at large. So, for me that is a really natural intersection. I came up in a generation when the NIH really emphasized building the physician-scientist cohort, and I think this is a natural output of those efforts by the NIH.

Where, you know, as physician, I see the impact of what I do daily, weekly, monthly with my patients, so not only does it motivate me, but it also grounds my work into something that's useful and applicable to the population.

Sumita Khatri, MD:

You can have an adult conversation about it, right? I mean nowadays I think people may be a little bit swayed from one side or the other and frustrated with politics. But when you are a scientist, which is I think a real genuine grounded honor, honestly, to know how to not just do good science, but to read the science and understand it properly, right?

And that can be a unifier, regardless, you know? And we all bleed when we're cut.

Maryam Valapour, MD:

And change your mind when you're wrong, right?

Sumita Khatri, MD:

Mm-hmm. Change your mind when you're wrong. So, it seems like the hope for the future for policy and healthcare is to use science to make the case?

Maryam Valapour, MD:

Absolutely. And I do think the physician-scientist is uniquely situated to understand both sides.

Sumita Khatri, MD:

Well, we must continue that for sure. So, thank you very much for that. Now, this conversation is so much deeper and meaningful than at the coffee station.

So, I thought I'd switch gears now and talk about the background of lung transplants, because I know we'll get into your policy, but just in general what are the reasons people are considered for lung transplants? For the lay audience and maybe early medical people, like when do you think about lung transplant?

Maryam Valapour, MD:

So, lung transplant I would say is a surgical treatment for our patient population with end-stage lung disease who has exhausted all other medical and surgical interventions. And I say that not because I don't believe in this treatment, but mostly because survival after a transplant is still not where I want it to be. So, I think the way we approach it is that we maximize what we can do medically for our patient population, and when it's time, then we intervene with a transplant. The populations that are mostly in the lung transplant are patients with pulmonary fibrosis, COPD, cystic fibrosis and then pulmonary hypertension. These are the broad categories that make up the vast majority of lung transplant candidates and recipients, but that is the general diagnosis that is in our patient population.

Sumita Khatri, MD:

And if for a family member who, you know, wants to exhaust all options including medical, when is it the time to even consider looking into a transplant, whether you're eligible or not? What's too early? What's too late?

Maryam Valapour, MD:

What I would like to do is take this burden off of families and patients, because this is really an intricate decision, and understanding the details of it is scientifically and medically really quite difficult. There are websites that people can go to, but what I would say is when somebody has severe lung disease, what they should do is make sure that they see a pulmonologist. Now, on the transplant side, we make sure we inform the pulmonary physicians about what the indications are about transplant, and how to think about referring patients to us. In fact, the International Society of Heart and Lung Transplant puts out recommendations for selection of candidates and when to refer. I think it was last year when we published the latest version of that, and it's updated, and I was fortunate enough to be part of that international group. And what I think we've come down to is that our expertise is expanding. We're getting better at taking care of patients. So, rather than limit patients before referral, just refer to transplant physicians. Our criteria change regularly. We're getting better at managing patients, so when you think you're about to exhaust all other options, refer your patients to transplant.

Sumita Khatri, MD:

Yeah, and it seems like if you have other options like as a tertiary or quaternary center, the options that you exhaust may be different than others. And I was just thinking about how COPD has changed so much now, and it used to be lung volume reduction, then we realized pulmonary rehab is just as good if you do a good job. And then now there's valves and all sorts of other things, which really what we're looking at is quality of life. And it's funny, it's like your lungs are always the best lungs, right?

Maryam Valapour, MD:

Your lungs are the best lungs, while they keep working.

Sumita Khatri, MD:

Yes, I wasn't going to sway you away from that, for sure. No way. But it's almost like, when you're thinking of it just like PE. If you thought of PE at all, you should probably get a VQ scan. Same thing, if you're thinking, I wonder if this person is eligible for a transplant as a physician, either as a primary care, if you don't have enough pulmonologists in the area, or if you are a pulmonologist and you don't have the resources, refer early.

Maryam Valapour, MD:

You know, I would say that I'd rather see someone too early than too late.

Sumita Khatri, MD:

Yeah, exactly. So, what do those referrals often look like? You know, in a place like this, for instance, where we get a lot of referrals, is it somewhat systematized, is there a process?

Maryam Valapour, MD:

So, I would say that, you know, we're at the Cleveland Clinic, which is one of the largest lung transplant programs in the world.

And as a result, you know, I feel quite fortunate to work with some of the foremost experts in the field. And as a result, we get cases that are a little bit more complex and potentially have been seen elsewhere and they could not do the transplant for that person, and they get referred to us. So, I would say that should be another point to our audience that just because you were turned down in one center doesn't mean that another center cannot handle your case.

But usually transplant programs know that and when they can't do a case, they refer out to a different center. So, the process is that a pulmonologist or another transplant center will contact us, and the records come to us and then they get just scheduled with all the transplant physicians. We're a group practice and we do have our own patients but are also a group practice and we have a common theme to the way we handle patients.

Sumita Khatri, MD:

Well, it's really reassuring that as a national super specialty, that you all sort of know each other in a way. Maybe not always personally, but you know what each institution's capable of, and you discuss this at meetings. So, it's like once you hit one, you basically have access to all, because they're going to think like that.

Maryam Valapour, MD:

You know, there's only 70 lung transplant programs in the country, and just given how involved I am on the national scene you know; I do know the country.

Sumita Khatri, MD:

Yeah. It's amazing. So, how much sharing is there among them? So, for the medical group, as far as what the areas of expertise are, how is it? Is it in a database, or is it word of mouth? Also, the quality outcomes? Cleveland Clinic's very proud of reporting quality. In the Asthma Center, same thing, how well are we taking care of our patients? So, how is that measured? I know this is still a young super specialty, so how would you like to see it measured?

Maryam Valapour, MD:

Well, we're not young enough where we're not graded. The scientific registry of transplant recipients, which is the scientific arm of the US transplant system - that is the organization with which I'm associated - I kind of oversee the analysis of US transplant data. For that organization, one of its major tasks is evaluation of transplant outcomes. That's for all organs for every institution, and those report cards you would call are public. They are put out quarterly by the SRTR, maybe with a little bit more frequency to the individual transplant centers where they must evaluate, you know, they look at their outcomes. But transplant programs are evaluated based on what happens to their patients on the waiting list. And that's compared to what other centers’ outcomes are. For patients on the waiting list.

Then their transplant outcomes are also evaluated and then survival as well. So, at every instance, data is gathered. Transplant is one of the most regulated systems in healthcare. And at every step, not only is it evaluated, but it's reported out to the government, to the individual transplant centers and it’s available to the transplant population.

In fact, when we see patients in clinic, we are mandated to show what our outcomes are compared to other transplant centers.

Sumita Khatri, MD:

Well, it's important, you know? Who likes to be graded? But actually, that's what keeps us honest, right?

You hope to meet those grades.

Maryam Valapour, MD:

I mean I call it grading, kind of tongue in cheek because, you know, we're evaluated, but it was not meant to be used that way.

When it initially started, I don't know how many decades ago, it was really used because when this was a new field, all transplant was new field, and centers were wondering how they were doing. And you didn't even know if you were doing a good job or a bad job. How long should my patient live? How fast should I be at removing patients off the list? And so, this method was developed so that you're compared to each other. So, that's really the easiest way.

Sumita Khatri, MD:

And you lift each other up in a way.

Maryam Valapour, MD:

Right. So, you lift each other up and in scenarios where you're not doing well, we offer ways that they can evaluate their own programs.

Sumita Khatri, MD:

Got it. You know, I'll get back to lung transplant in more detail and policy and all that in a second, but, you know, many people, probably almost everybody knows somebody who's had a kidney transplant, let's say.

And then I've seen a heart transplant among friends and close friends, and they do well for so long. So, I was just wondering, so kidneys were first, right, in the '60s.

Maryam Valapour, MD:

The '50s.

Sumita Khatri, MD:

Oh, '50s even. Okay. And then heart was next, I believe, right? As far as solid organ goes. So, can you - for the lay person who kind of gets a heart transplant, somebody has a heart and then they start remembering things, you know? So how is kidney and heart, where are they compared to where we are and how is lung transplant different than that?

Maryam Valapour, MD:

Oh, now you're going to make me admit that we're not the best in survival.

Sumita Khatri, MD:

It's hard. It's hard.

Maryam Valapour, MD:

I would say it's very hard. Kidney has the best survival outcomes.

It depends on if your organ comes from a diseased donor or a living donor, but their survival is in the decades, somewhere, on average of I would say 12 to 20 years.

And the numbers are just much bigger, and they started in the 1950s, so they have more experience. But kidney transplants are quite successful. The problem with them is that they have such a huge wait list.

Other organs are in the middle. Liver, heart they have decent survival, and then we end up with lung transplants. Our lung transplants survival, we're getting better and better with short-term survival. Our long-term survival has plateaued some.

And we average about six to seven years. Which is not where I want to be, but it's at least something, when you think about the end of life. And about 20 percent of patients live longer than 10 years.

Sumita Khatri, MD:

That's wonderful.

Maryam Valapour, MD:

So, I always make sure I say that to someone who sees me who's considering transplant, that long survival is possible. I've had a patient who was alive for 25 years after a lung transplant. So, it's possible. But I would say as a population they have a lower survival compared to the other big organs.

Sumita Khatri, MD:

So, I'm sure that just like in asthma, we want to be able to predict what the course of your asthma for the rest of your life will be based on history. Is there, kind of shifting a little bit to more to now, what should they expect, what are you trying to do to understand how to predict so that this can improve?

Maryam Valapour, MD:

So, we've talked about how my interest is in policy. But, again, policy has its own science, and a big component of making systems that are responsive to patients is understanding the trajectory of patients. And that's where the quantitative science part of my life comes in.

Sumita Khatri, MD:

What does that mean?

Maryam Valapour, MD:

What is quantitative? It is measuring and then predicting what's going to happen to patients.

Sumita Khatri, MD:

Better than the weather I'm hoping?

Maryam Valapour, MD:

I really hope so. I really pray that that's the case with us. So, that is where that part of my science comes in. Where my team and I work hard to understand and build better models, kind of predictive models, these mathematical models, of predicting what the survival is for someone on the list, what transplant circumstances change that survival, and then survival after a transplant. In fact, the allocation systems and organ distribution systems are really based on these models that have been produced.

Sumita Khatri, MD:

Right. So, how often do they look at these models and revise them?

Maryam Valapour, MD:

So, we look at them all the time, I would say. You know, there's science that happens every day in this area. The big shifts in the country are slower to come, right? Because you must change, these models will go in and we get implemented as policy, and then everyone's ranking in the country changes, and access to transplant. The last big one was in 2005 when the lung allocation score system was implemented. Over the years we've made changes to the system, small changes. So, every five years or so you would say there's enough of a push in the change in our patient populations or in our treatments that it's necessary to change the models. The next big change to the system is coming on March 2nd.

We're moving to the composite allocation score system.

Sumita Khatri, MD:

How is that different?

Maryam Valapour, MD:

The way that’s different is that as the science of organ distribution evolves, the clinical aspects of it evolve too, right? So, when we started transplanting, organs could only travel so far. And which is why they could only go so long without getting enough blood perfusion.

And over time, you know, our science has gotten better there, our technology has gotten better, and we're able to move organs faster. And so, the composite allocation score really has incorporated that concept of basically minimizing the impact of geography in organ distribution.

So, an organ doesn't have to be as close to a recipient as in the past, and the boundaries of geography can contract or expand based on other criteria. For example, if you are really very sick on the list, the boundaries of geography are wider for you. You have access to a wider range of organs than somebody who is not as sick as you are.

Sumita Khatri, MD:

So, if it's more urgent for you, do you have a chance to look beyond a certain mile radius?

Maryam Valapour, MD:

Right.

Sumita Khatri, MD:

That does make sense. I mean we have airplanes. I mean, right?

Maryam Valapour, MD:

You do. This then becomes the system component of it. So, every time.

Sumita Khatri, MD:

Don't lose that luggage, right?

Maryam Valapour, MD:

Well, not only don't lose the luggage. For lung we actually go out and get the organs ourselves. But remember, you need to think about every time a team goes out to get an organ, they might potentially not be able to do another transplant for smaller centers. So, you have to move organs in a way where people are traveling for clinically meaningful differences. So, you don't want to make a whole team fly from, let's say Ohio to California, if they could've waited another day for their patient, and the patient in California could have gotten that lung. So, you must think about system efficiency as well as the patient population.

Sumita Khatri, MD:

Wow. So, this is part of what you love, it seems.

Maryam Valapour, MD:

It's part of what I love. Making systems work.

Sumita Khatri, MD:

This is fascinating, and it's so wonderful. I think the timeliness of this conversation is so perfect because you've done this, you've nudged the needle. I mean that's absolutely fascinating.

Maryam Valapour, MD:

With a lot of help, let's just put it out.

Sumita Khatri, MD:

Well, but you're a nudger, we know that, and you've never downplayed your team. You've always lifted them up and given them credit, so that's just something that I know about you. But you are being the face of this and like the spear, is very, very important. Is there anything else you wanted to tell me about lung transplant, or something to know? What's the one thing that's still in your craw about it, apart from the allocation? Is it something like the rejection?

Maryam Valapour, MD:

Well, there's lots of things that bother me. But there's still a big list of things I kind of think about. For patients who access organs, I would say the thing that we really need to conquer is increasing our donor pool. So, that is still the crux of the problem.

I only think about how I distribute organs, because there's just not enough and I work to make sure that we give people access in a timely way. If there were enough organs, I wouldn't need to do what I do, right? So, that's one, I think increasing the donor supply is really essential.

The second for, again, is once people get into the system and get transplanted. Chronic rejection is a major problem in our field. And as you may know that my team also serves as a coordinating center for a 15-center consortium, trying to better understand chronic rejection. So, that's one aspect. The other is really the question, which is a big part of transplant, is who doesn't get access to transplant that should? The disparities in access to transplant is an area that I feel quite passionate about, because this speaks to kind of who we are as a society, right?

So, are we cutting people out that deserve a chance? And that is an area of inquiry of my teams and, I can now tell you that, the National Academy of Sciences recently had a work group and a product that was put out, that's really focusing on that area, thinking about disparities and access to transplant in this country.

Sumita Khatri, MD:

Oh, gosh. I mean it's still an issue for asthma, which is relatively easier. But it's not. So, yes, I'm glad that that is you must put a marker in the sand about this for people to know that it's important. And to pursue it, and then other people like you will join the fight to make that happen.

You know what also fascinates me? I think you talked about that National Academy of Sciences, but NIH, you know, NHLBI is 50. So, lung regeneration is the next frontier as well.

I hope to be alive and be a clinician scientist still while that becomes possible, don't you?

Maryam Valapour, MD:

Me too. Me too. Wouldn't that be great?

Sumita Khatri, MD:

Hopefully sooner than later. But that's exciting that they've made it a priority as well. I think people probably have figured out what you're like and of course I'm really excited about what you do.

You talk about your team, and I know many of your team and a few are peers, but many are mentees. And you have lifted them up amazingly and they've been on podcasts with you, and they're just thriving. So, I just wanted to say with this robust team of multi-institutional, multidisciplinary partners, you've overseen a large team, multi-institutional as I said let's start with how might others describe your leadership style? And then if it is parallel or counterpoint, how would you describe your leadership style?

Maryam Valapour, MD:

Should I start with what I think I do?

Sumita Khatri, MD:

Well, of course you'd go with what you think first. Yeah, you just rearrange that. Go ahead.

Maryam Valapour, MD:

You know, I think as a leader, and I use that term, I don't even know what that really means. But I think people think of me as that. When I walk into a room, they kind of look at me to think about what to do next.

And I think of my role as being the person who communicates what our shared vision should be. I think that's essential for what I want to do, and how to move forward. Every day that I wake up I think about how we make things better and how do we make the future become a better place than today. And that really requires creating that shared vision. The next thing I do is I find the best people I can. I really try to find people who are smarter than I am and the best people with the best skillset and help develop areas where they need to develop. So, then they can become my partners in this.

You know, I think it's interesting how when I first start working with someone, there's a lot of communication about what we should be doing, how can we advance this work, methods, all of that. But it takes about a year or so, and after that I don't have to talk about why we're here and what we're doing. It's baked in, and then I have a partner. And as much as people talk about me mentoring, I didn't even know this would happen, it is how much you learn from the people you mentor or your mentees.

Sumita Khatri, MD:

They open your eyes in a way.

Maryam Valapour, MD:

They open your eyes and you understand where your issues are, and you learn, there's a whole team that I work with who are way smarter than I am, who know, there are things that they all know how to talk to me and make me understand things, but what I do is provide a cohesive vision.

Sumita Khatri, MD:

Yes. You're the overseer of all of this talent.

Maryam Valapour, MD:

So, how would they see me, you're going to have to ask them.

Sumita Khatri, MD:

Maybe when they first started, it's different than two years later.

Maryam Valapour, MD:

I would say that you could say that I'm uncompromising in our commitment to the work. And I do care about them individually, I frankly care about myself individually as well. But as for the bigger picture, work is more important and while everyone is seen as an individual, when we come to work, it's for the work.

Sumita Khatri, MD:

Absolutely. And there is a tendency for very ambitious people to want to row ahead and row in their own direction. That doesn't work in a job like this. It has to be everybody bringing their skills and rowing together.

Maryam Valapour, MD:

This is very hard work and it's multidisciplinary, it's interdisciplinary, and it's moving policy forward and getting everyone on the same page in the country. And to do that, we all have to be on the same page. And appealing to that, I found, works.

Sumita Khatri, MD:

You know, I've always appreciated the way you articulate your vision and your clarity, and I can see why you would be that person people would look at to see, okay, what's the big picture, again? Where are we going? How do we course correct?

Maryam Valapour, MD:

And we try not to get confused about that. You know, sometimes you can get distracted and as I've gotten older, I get less and less distracted. Now I'm pretty clear. You know, we have finite careers and finite lives and I'm very clear about that.

Sumita Khatri, MD:

Yeah. I think life experiences and also our personalities become clearer as we become wiser.

Maryam Valapour, MD:

It's the best part of aging.

Sumita Khatri, MD:

I totally agree. I totally agree. And so, you know, back to the why, there's going to be a couple questions I have. One is, is there a patient or a situation particularly that you remember that keeps you inspired? I know you care about all of them in total, but one that you still remember, some interaction that empowers you and motivates you to continue this life's work?

Maryam Valapour, MD:

I would say, yes, it's true that all patients ring with you in a certain way and motivate you and help your course correct. I do have to say, I think when, I don't even remember how old I was, I was a young faculty member in my 30s at the time, and I would say my career had not fully taken off. It was a hard time, and I was applying for grants, not getting them, just the usual difficult young life issues. I had a patient, a very young patient in her 20s, with cystic fibrosis, who died. I think she wasn't ready. And she couldn't access transplant because of the kind of infection she had. I think she really has stayed with me.

It's interesting, I've seen a lot of patients over the years, you know, it's a long career now, but the fact that we didn't have adequate treatment for her, and we couldn't list her for a transplant, just has stayed with me. And, I have to say, that is somebody I probably think about at least every few days.

Sumita Khatri, MD:

Wow. Who knew she inspired you in a way that others are being helped. I mean I'm not going to tell you how to think, but that's, you know, that's motivation.

Maryam Valapour, MD:

And, I would say that of course you enjoy the successes, right? But I don't know how people are normally wired, but I think physicians remember when they couldn't help. That's kind of our professional Achilles’ heel. That we just remember people we couldn't help. And I think that person has always stayed with me. Sorry to be depressing.

Sumita Khatri, MD:

No, no, you're not, you're not depressing. I think what we do need to do is take what can be very sad and depressing and flip it. I know I had a very severe asthma patient who, I think her family said, lived longer than she would have if she hadn't been taken care of by our team. And I'm going to have to live with that too. You know, people shouldn't die of asthma, but she did. So, you know, I think of her often too. I have a little cross that she made with a reed on my bookshelf and look at it every day.

So, lastly, word of wisdom. What are the words or if there's a phrase that you have, I mean I'll share mine with you just so that, you know, like mine's, find the largest platform where you can make a difference and pay it forward. I've done that for women leaders, you know that.

Maryam Valapour, MD:

You have.

Sumita Khatri, MD:

Yeah, I'm quite proud of that. Thank you.

Maryam Valapour, MD:

You should be. We are proud of it too. We are beneficiaries of your efforts.

Sumita Khatri, MD:

Number one, and it's not about me, it's about you right now. So, what are your words of wisdom, or words to live by?

Maryam Valapour, MD:

I would say there's not, you know, I tend to meditate, so there's a lot that kind of informs my behavior and my conduct, I would say. But in the Bahá'í faith there is this concept that work done in the spirit of service is equal to worship.

And I would say I don't formally worship regularly, and this is my way of conducting myself and working to improve things, to just leave things better than I found them. And in that way, I always kind of remember that in the back of my mind. You know, work can be challenging. There are days you're not at your best, and there are days that you're frustrated. So, with that in mind, I think it not only focuses on my work, but my conduct when I'm doing that work. And that probably is a phrase that's in the back of my mind at all times.

Sumita Khatri, MD:

So, your life is your purpose. You live your purpose in how you conduct yourself and what you do.

Maryam Valapour, MD:

I try.

Sumita Khatri, MD:

Yes. We all try. Many of us try.

Maryam Valapour, MD:

Yeah. I think one of the reasons I went into medicine is because I thought I was going to be surrounded by people that were like-minded. And at the end of the day, we all are here to help in whatever way we can. That is the core motivation, I think, of every physician. So, I see that with my colleagues, and I try to measure up.

Sumita Khatri, MD:

Yes. Well, I just so thank you for the time you've given us. It's been wonderful. It's like we should've had this conversation a long time ago, but now we're going to have it in a way where so many people will benefit from the knowledge and your philosophy and your drive and your motivation. So, I just wanted to say thank you, it's an honor and pleasure to call you a friend as well as a colleague.

Maryam Valapour, MD:

Yeah, I'm so grateful to be here, and I feel the same way. Thank you for having me.

Sumita Khatri, MD:

Be well.

Maryam Valapour, MD:

Thank you.

Raed Dweik:

Thank you for listening to this episode of Respiratory Exchange Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @RaedDweikMD.