MedEvidence! Truth Behind the Data

Equity Through Clinical Research

• Dr. Michael Koren, Dr. Sara Collins • Episode 359

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Dr. Sara Collins joins Dr. Michael Koren to talk about her journey as a research cardiologist. They discuss Dr. Collins's path through preparatory school, college, med school, and the post-school experience as a cardiologist. They also discuss her role starting a clinical research site in Washington, D.C., and her efforts to leverage the research apparatus to provide equitable care to otherwise disadvantaged and underserved communities. Dr. Collins talks about how there is a racial disconnect in care in spite of the typically good insurance coverage in the D.C. area.

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Announcer:

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Koren.

Dr. Michael Koren:

Hello, I'm Dr. Michael Koren, the executive editor of MedEvidence. And I'm going to be talking to a true kindred spirit of mine, Dr. Sara Collins. Sara, welcome to MedEvidence! And you and I have gotten to know each other a little bit over the last few years because we're both working with a national group called Flourish Research. And as I've gotten to know you and actually study your resume, we actually have other things in common, including how we got interested in research in the first place. So I want to share our collective journey, mostly focused on yours, with our audience and then jump into some of the issues about what it's like being a female in cardiology, which has been sort of a male-dominated subspecialty, and also the great work you're doing to try to reach out to underserved communities. So again, Sara, welcome to Med Evidence and share some tidbits about yourself. Tell us tell us your story in three minutes.

Dr. Sara Collins:

Oh well, first of all, thanks for having me. I'm super honored to be here. I've admired your work, your work in a lot of capacities, but podcasts are new to me. And I think I wholeheartedly agree with the idea of having a casual conversation between colleagues to talk about the important stuff without all the fluff. So gosh, so much to say. How did I how did we get here?

Dr. Michael Koren:

Where did you grow up? Start just with the basics.

Dr. Sara Collins:

Okay, cool. That's easy. I grew up in San Francisco, California, right in the city. So I get to claim the city. And I immediately love still very close to my family. I love them. I don't want to act like I escaped, but immediately after after college, I mean after high school, I went to school on the East Coast for college, and I have never left. I live in DC now.

Dr. Michael Koren:

You went to a very fancy college, I see.

Dr. Sara Collins:

I did. I went to a fancy high school, so that it was sort of an easy trajectory to college.

Dr. Michael Koren:

Okay. Brown University. Yep.

Dr. Sara Collins:

I went to Brown.

Dr. Michael Koren:

Ivy League school.

Dr. Sara Collins:

I loved Providence. It was a small, sleepy town then, not at all what it is now. And had a great time there. And it was pre-med there. And then I kind of followed in my grandparents' footsteps. My grandparents met at Meharry Medical College.

Dr. Michael Koren:

Really?

Dr. Sara Collins:

In a dental school.

Dr. Michael Koren:

Wow. That's cool.

Dr. Sara Collins:

And it was actually the only place I applied to for med school. So I ended up applying. And while I was applying, I did two years of research at what's now Med Star Washington Hospital Center under the tutelage of Ron Waksman, who we who we've mentioned. And that sort of began my research career. I was doing a stent angioplasty model in pigs, carotid cutdowns in pigs, which was was pretty cool at the time. And just sort of in the cath lab all day for two years and learned a lot about interventional cardiology, learned a lot about general cardiology, and I sort of got a whiff of what a certain type of research looked like. And and Ron gave me a lot of autonomy, which was which was really beautiful. And I that's when I really caught the cardiology bug, and in particular, the interventional cardiology bug.

Dr. Michael Koren:

Yeah. Well, that's fabulous. So just a few things on that. One for those of for those of the uh the folks that are listening to us that don't know Ron Waksman, he's truly one of the rock stars of cardiology and well known as a great interventional cardiologist and also a great teacher. So you you got the benefit of that interaction. And I I've certainly enjoyed my interactions with him in the past. But tell me, like, why did you choose cardiology? That's not what women typically do. So give me a little insight into that.

Dr. Sara Collins:

Well, I I'll be truthful here. After college, I really wanted to spend a little time getting to know myself and you know making sure that medicine was the direction I wanted to head. That was sort of the trajectory that was laid out based on, you know, other family members and folks around me that I really, I really respected, but I wasn't quite sure. So I I thought, you know, a good chunk of time working in some sort of clinical setting would help. And the two biggest opportunities were in breast cancer and research and interventional cardiology. And I poked around a bit and folks said the interventional cardiologists were were just tough as nails. And that's and that's what I wanted to do. I just wanted to kind of run with the cowboys. That's kind of my personality. So it was a naive decision at the time. But, you know, as I mentioned, I got this sort of glimpse into interventional as a field, which was, and I, and I love the procedural aspect of it. So that's kind of how that happened.

Dr. Michael Koren:

Interesting. So you you did your training in DC. And then did you go into practice from there or what what happened after you finished your training?

Dr. Sara Collins:

I did. So um I was lucky and lucky enough to have my my general and interventional training all at Georgetown slash MedStar Washington Hospital Center. And there was a research track that allowed me to truncate that training. Uh, and so I was able to kind of you know do a lot in a short amount of time and immediately went into private practice. And I've always practiced in small boutique practice settings. That's always been, in my opinion, the best way for me to be able to access my patients at the pace and with the closeness that I really enjoy.

Dr. Michael Koren:

Fabulous. So let me dig into this a little bit more. How did you go from you finishing up your training to ending up working in a research facility? What tell us about that journey a little bit?

Dr. Sara Collins:

So, in so in training, there was a research track for fellows. And then once I got out of training, I was in one small boutique practice. And when I left that practice and moved to a larger practice, I I realized we had access to a huge patient database and patients who would really benefit from some of the technologies that were being studied in different more academic centers. So I was in that capacity, I sort of just, you know, rubbed two nickels together and brought on some colleagues to do a couple of trials in the in the interventional space and the device space. And so that was kind of the transition before Flourish.

Dr. Michael Koren:

Interesting. So you basically became an entrepreneur. You you put on both your business hat and your clinical hat and said, here's an opportunity. This is something that I love doing, and and and just went for it. Sounds like and I'm sure you learned a lot along the way in terms of the infrastructure needed to run research in the modern era.

Dr. Sara Collins:

Absolutely. Not nearly as much as I've learned in the in the last two years, but uh, but yes, it was a it was a it was a peek into this large machine in a much different setting because clinical research is is a is a beast.

Dr. Michael Koren:

Absolutely.

Dr. Sara Collins:

In the best way, but it's completely different.

Dr. Michael Koren:

Understood. So tell us a little bit about the work you're doing reaching out to an underserved population. So tell people you're sort of in a suburb, exurb of DC, and had you end up there and and you guys are doing some fabulous work reaching out to patient populations that may not always get the word about research. So let's talk a little bit about that.

Dr. Sara Collins:

Absolutely. So, you know, the the reason why I'm I'm practicing, I like I said, I live in DC, but DC is is is a huge metropolitan region with a lot of different types of pockets of demography. Uh and I I work in a small private practice with Dr. Barbara Hutchinson. She and it's her practice, and she does a wonderful job of sort of nestling herself inside of these really important, I mean, these communities that could really benefit from all types of of you know good empathetic clinical care and also research. And what's special about I I believe the way that we have been able to juxtapose the type of care that we are giving in the clinical setting with the research is that you know, our patients are not always are not always underserved in the socioeconomic sense. You know, our patient population is very well insured. I mean, honestly, that would has changed drastically since the federal shutdown, since so many people are are losing their are losing their employment. But typically they're not the our patient population is not necessarily underserved in the in the access to research sense. However, they are underserved in the type of care they're getting, which is a true disparity. So, you know, if if I I can just take a self-identified African American population, for example, we serve a large African American population. What is so striking to me is despite high education levels, good health literacy, there's still a disparity. And that's really baked into the system in a lot of ways. It's baked into in the system in that African Americans can be hesitant to seek care in the same way because of a mistrust that is quite frankly warranted. And they're not offered the care in the same way. So what we try to do in our practice, which is next door to our our clinical research site that Flourish built, is provide that access in a place of trust. So when the message is delivered from your trusted caregivers, because we we truly do care deeply about the patients that we serve, and we allow the opportunity for important conversations, you know. Let's talk about the historical mistrust, let's talk about the mistrust that's warranted because you just discharged from the hospital a week ago and you were discriminated against in the ER there. It's it it's happening in real time, it's not always historic. So you know, I I I firmly believe that the therapies that we are developing in the research setting are incredible and cutting edge and life-changing, paradigm shifting. So my passion, and the reason why I'm doing this is to make sure that everyone has equal access to those therapies in the trial phase.

Dr. Michael Koren:

Fascinating. So just just for my knowledge, what percentage of your population is black in in your clinical practice?

Dr. Sara Collins:

In the clinical practice, it's about it's about 50%.

Dr. Michael Koren:

Okay. And yeah, there's a lot of areas in DC that have majority black populations, as of course you know. So tell me how you present the value proposition of research to patients, particularly those who may have trust issues based on historical misdeeds.

Dr. Sara Collins:

It's a complex conversation, and sometimes it's it's two or three conversations. Um sometimes I I begin the conversation by explaining why I'm involved in clinical research, which is the science, which is the purity of that sort of scientific pursuit. But it's also to provide access to these novel therapies that you would get if you went to an academic center. If you go to Hopkins, you're getting offered a trial. Also in in cardiology, we haven't quite figured out how to package these conversations the same way they have in the cancer space. No one blinks, you know, blinks an eye when they have a new cancer diagnosis and an oncologist offers them a trial. It's just not even a consideration. However, you know, cardiovascular disease is far more deadly than than cancer to a certain extent. And we don't have those conversations. So the first thing is I sort of explain why I'm in it, and I'm in it for that reason. I want my patients to have access to the latest and greatest. And then I talk to them about what it means to be in a clinical trial. You know, it's it's not so bad. You know, it's it's actually kind of great.

Dr. Michael Koren:

It's fun, people actually like it.

Dr. Sara Collins:

People really, people really like it. Yeah. You know, forget the compensation, which is in and of itself uh uh, you know, getting care that's that cutting edge and and and high level with all those touch points with that's outside of the insurance system is pretty great.

Dr. Michael Koren:

Yeah.

Dr. Sara Collins:

But a lot of people really start to nerd out about the about the science.

Dr. Michael Koren:

Yeah.

Dr. Sara Collins:

They really enjoy that. Like I said, our patients are very well educated, so they ask a lot of really great questions.

Dr. Michael Koren:

I love that.

Dr. Sara Collins:

Yeah. And so I I think it starts by, you know, to just just a long that was a long answer, but it's it begins I begin with just uh saying why I'm in it,

Dr. Michael Koren:

yeah

Dr. Sara Collins:

and then finding out, you know, how how I think any particular trial could be helpful.

Dr. Michael Koren:

Well, your enthusiasm is infectious. I I want to join your trial just by talking to you. So that's that's fabulous. But that gets to one of the value points, which is that people want to feel connected. And in the clinical trial world, because it's an intense experience, they get that feeling of connection with you and your staff. And quite frankly, I still practice cardiology. We're so pressed for time in the clinical setting, in the insurance-driven setting, that it's really sometimes hard to not just go down an algorithm and not connect with the patients. So you have you clearly have a skill to connect with patients, and I would think that's a big driver for your patient population to do more research and have a really intense experience.

Dr. Sara Collins:

I hope so. And then we've got an incredible staff, which really just extends the message that Dr. Hutchinson and I sort of initiate in the in the set in the in the office. Our our staff, we really have at this point solved for culture. We have everyone in our on our staff is is brilliant and and absolutely experienced, but they get the why. And so they extend that conversation to our participants, which is really pretty incredible to watch.

Dr. Michael Koren:

I love that. I love that. So, what what are the future plans for your site? What what do you see in the next five years?

Dr. Sara Collins:

Oh, sky's the limit. So, you know, at this point, because we were a de novo site, you know, built from scratch and Flourish's first de novo site, there was a lot to learn. We continue to learn, and you know, I even as an investigator, there's a ton for me to learn, obviously. When I attended your investigator training last year, I was, you know, all ears. So many cool conversations and the case studies just blew my mind. Environments like that are really important for all of us to participate it in. So I hope that Flourish continues to offer that to folks who are interested. But we want to really continue to hone in on putting out a good quality data product. That's just incredibly important, making sure that we're crossing all of our T's and dotting all of our I's, but also expanding our therapeutic areas outside of you know cardiovascular outcomes trials and cardiometabolic and lipoprotein(a) to I'm hoping we could expand to sleep medicine. Dr. Hutchinson is board certified in sleep. She's my co-medical director. And clinical practice, she's board certified in sleep medicine and a brilliant practitioner and principal investigator. So I'm, and we have we have two sleep labs next door. So I'm I'm hoping very much that we can expand into sleep. And other therapeutic areas I think are are incredibly interesting, or all things around, you know, memory and and Alzheimer's as well. So I like to start with those two and then see how that how that goes.

Dr. Michael Koren:

That sounds uh very ambitious and very exciting. And I'll just comment on one of the things that you said, which I think is super important, is that there is a specific skill set related to being a clinical investigator that's not really well understood by the general public and even by physicians. Yeah, people think, well, you're a doctor, you should know research, but that's not the case. And even during our training, we don't get full exposure to all the nuances in in clinical investigation, especially when you're involved in these large multi-centered trials. And there's always tensions when we have to figure out what's best for the patient while still collecting accurate data while also managing a staff because none of us can do it ourselves. So a lot of things come up, and you you mention our teaching program, which is what we call research grand rounds, and MedEvidence sponsors that. And we invite everybody that's listening to us to take a listen. You don't have to be a flourished person. This is open to all members of the medical community. We get CME credits for it, and we talk about these cases. Every single day, a case comes up that requires thinking through this. And so I'll give you a recent example and I won't give you the answer, but I had a patient come in for an Lp(a) trial that you mentioned. Lp(a), for those of you that are not familiar with that, is what we call the really, really, really, really bad cholesterol. And it's a form of LDL cholesterol that tends to have even more negative prognostic elements than just LDL itself. And it's hard for our bodies to get rid of, and it's also genetically mediated, so you get family concerns that are involved. But I had a fellow physician call me, said, Oh, I hear you're doing Lp(a) study, and I know I have a very bad family history related to Lp(a). In fact, I have a CAC score that's in the worst 5%. CAC score is a coronary artery calcium score, and it's a good indicator that somebody is gonna have trouble with atherosclerotic complications. He was around 50 years old, and he told me, Yeah, I had a heart attack, and you know, I'd like to be in your study. So I said, Well, you sound like somebody that would be really, really good. Obviously, we have a screening process, but why don't you come in and we're gonna figure out whether or not you're the right patient for this, and it sounds like you would be, but this is a placebo-controlled study, so I just want to make sure I understand that you're not guaranteed to get the product, but we will certainly learn a lot about your condition during the course of this, and maybe you'll get it. And he was fine with that. So he comes in again. This is a physician, and he mentioned to me he had a heart attack, but when my staff was trying to find out what the heart attack when the heart attack actually occurred, it turned out that he considered an episode of very severe chest pain that he self-treated a heart attack. So that's a dilemma. Here's a physician who made the decision that he was having a severe anginal attack, treated it with what he had available in terms of aspirin and nitrates, and never went into the hospital. So, is that a heart attack from the standpoint of clinical research? So I won't give you the answer, but these are the kind of dilemmas that we have to face every day. At the end of the day, we have to adjudicate these patient stories into things that are elements of the protocol. And to me, I find this fascinating. These are the tensions about doing research. And in this particular case, there was a lot of implications in terms of randomization and stratification, which we won't go into for this particular talk, but you and I know that these are important elements of accurate data analysis. And again, this is coming from a physician who now is a patient that wants to get into a study. So some fascinating things that we deal with on a day-to-day basis.

Dr. Sara Collins:

Yeah, it's an it's it's tricky. Those conversations are are really incredible to witness, the conversations around questions like that, because you know, what your training provides is not only your expertise, but the expertise and expertise of your staff, but this wide, quite variable range of opinions. Because if there's one thing physicians know how to do, it's be opinionated. Well, we don't always know we know what's right, we we know what's right clinically most of the time, but that is not always the research answer. Um so that's that is the nuance that's really teased out in these conversations.

Dr. Michael Koren:

Well, that's the interesting thing about research. You have to balance doing things right with doing the right thing. And they sometimes are not in the same Venn diagram. And so it can be very, very tricky how to deal with it. But that's part of the skill set of a good clinician investigator. And we cover all these type of things and go into the regulations and going to the history, going to the pragmatic elements, and going to the fact that the safety and the welfare of the patient supersedes all of the other goals of research. And that's part of our ethics, and and we need to sometimes remind our business colleagues about this. So it's uh it's a neat thing that that we do, and thank you for doing it. It's it's super important. And our on behalf of your patients and our community, you do a fabulous job, and we truly appreciate it. Oh, thank you. Any last words before we sign off? This has been a fabulous conversation, and we'll definitely have you back for more focused discussion on one of the many things that we talked about, including maybe Lp(a), and and look forward to you being involved in our research grand rounds.

Dr. Sara Collins:

Yeah, I thank you. Just thank you for having me and thank you for doing this. These conversations are are really cool to be a part of.

Dr. Michael Koren:

Uh Sarah, thank you very much, and and thank you for being part of the Med Evidence! family.

Dr. Sara Collins:

Thank you, Dr. Koren.

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Dr. Michael Koren

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