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10 Questions with an Otolaryngology Resident

Future Leaders

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Sid Puram, M.D., Ph.D., now a fourth-year resident in the Harvard Otolaryngology Residency Program*, gives insight into everything from his research and daily responsibilities, to his passion for cancer care, to how he handles burnout.

What originally drew you to otolaryngology?

Truthfully, my interest in otolaryngology was a bit of a surprise, as I had always planned to pursue a career in medical oncology. However, after my medical school rotations, it became clear that Otolaryngology/Head and Neck surgery was the right choice. First, my Ph.D. background in neurobiology had led me to aspects of otolaryngology involving hearing, and this was naturally extended upon through my role organizing an FDA-approved study of pediatric auditory brainstem implants with Dr. Daniel Lee. Second, I had a strong interest in cancer and the management of complex cancer patients, and almost every subspecialty within otolaryngology contains some aspect of oncology. Third, and perhaps most importantly, I was impressed by the opportunity to take comprehensive care of patients and really manage an anatomic region of the body. Within the field, there’s an opportunity to be a surgeon if it’s necessary, but there’s also a real open-mindedness to medically managing problems that don’t need surgical intervention. It was a really natural fit.

What do you think is special about the residency program at Mass. Eye and Ear/Harvard Medical School?

It’s an incredibly collaborative, collegial environment. Everyone is fiercely loyal to each other, and you have that really strong sense that we’re going to work together to provide excellent care, with no one person shouldering the entire burden. It really works well and everyone learns, improves and grows. The program has many other great qualities: We have incredible surgical volume, we have Attendings who are really willing to teach and there are really wonderful opportunities to learn.

Describe your typical day.

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On a typical day, I come in around 5:30 a.m. and look up overnight data on patients before seeing them —whether at Mass General (MGH) or here on the 11th floor—in the morning. There’s an expectation to be down to the Operating Room by 7:00 or 7:15 a.m., hence the need to start early to see the patients.

As I transition into a more senior role, I’m operating more or less the whole day and seeing any urgent MGH consults as they come in. I see the non-urgent consults after finishing my operative cases. At the end of the day, we usually discuss the patients as a team, so the day typically concludes with rounds with the team at 6:00 or 7:00 p.m. But the bulk of the day is spent in the operating room.

Do you have any time for research?

I am really interested in research, and I’m working closely with one of our dedicated research residents, Dr. Anuraag Parikh, who initially had less of a formal background in basic science but has really been instrumental to the success of our project. Together, with Itay Tirosh, an extremely talented researcher in Aviv Regev’s lab at the MIT Broad Institute, we plan and work through experiments, analyze and interpret the data, and dictate the direction of the project. Anuraag and I have been lucky to work together now for over two years: one year on the wards and over one year in the lab.

We’re really interested in better understanding two things: 1) Which genes and proteins drive head and neck cancer, and 2) how we might better be able to treat patients’ head and neck cancer with new types of biologic therapy that could potentially eliminate the need for surgery in 50 or 60 years. That would be a dream—to put myself and others in the field out of business. It would be wonderful for patients, but there’s a lot of work still to be done. We are hoping that by separating a tumor into its individual cells and looking at the expressed genes in each cell, a technique called single cell RNA sequencing, we can begin to take the first step towards this goal. We are so lucky to have the guidance and support of Dr. Derrick Lin, Dr. Brad Bernstein, the entire Head and Neck Division, and numerous experts at the Broad as we have gone down this rabbit hole.

Can you describe a moment in your career when you have been especially challenged?

This research project has been challenging. There are many challenges in terms of analyzing the data, making sure we get good quality data and are processing samples adequately. It has taken a year to get the data because we’ve hit little bumps along the road in figuring out how to do different techniques. That was a research challenge I very much underestimated and has informed the way I think about the field of genomics as I move forward.

Can you describe a complex patient or a case that has had a lasting impact on you?

I think the hardest patients are those whose cancer is, unfortunately, progressing. One patient in particular had chemotherapy and radiation for laryngeal cancer, the standard approach for most of these patients. Ultimately, that failed and his cancer came back. So we did what we usually do from a surgical perspective: He had a laryngectomy, a procedure to remove the voice box. Although he did well for about two years, this patient was thereafter admitted to the oncology service with a recurrence of his cancer and was about to start on palliative chemotherapy and immunotherapy (the latter which is more or less a heroic measure to see if the cancer responds). At that point, there was little to be offered from a surgical standpoint, and I felt a real sense of frustration over my inability to meaningfully improve his care and the conditions that arose from his cancer’s progression.

Here at Mass. Eye and Ear, a lot of the patients do very well, and we get to see them five, ten years out in clinic, but head and neck cancer still has a very negative prognosis. Being the MGH consult resident and seeing patients come back to the oncology service when there isn’t additional surgical options is very humbling. That has been really eye opening and has motivated me even more to push the research and be excited about it. It would be amazing to develop more treatments so that we would not only help the patients who respond to surgery—which is the standard of care for a lot of these tumors—but we would also have options available to those who do not respond to surgery.

Have you ever experienced burnout? What do you do to make sure you’re not too tired or too stressed?

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Absolutely; I think it’s impossible to not experience burnout on some level as a surgical resident. I think there are two key ways to manage it. It is very important to be able to recognize that you feel burnt out, to realize that the reason you feel tired or down is that you have been working very hard. The second thing is to rely on your co-residents, friends and especially people outside of medicine to help realign your interests and get things back in perspective. The co-residents really help because it’s reassuring to hear that someone else has gone through burnout. It’s not that you’re incompetent or inadequate or not up for the job; it’s just natural to experience that at some point. And, practically, they also help with redistribution of work as needed for people who are having a little bit of a harder time at a given moment. People outside of medicine give you a different perspective, often reminding you that you’re doing something so influential to people’s lives. Yes, there’s a big price to pay with the work hours and everything else but, at the same time, you’re able to have a huge impact on people every day.

Do you have any advice for med students who are interested in pursuing otolaryngology as a field?

Seek out really good mentors in the field, because it is full of really warm and welcoming people who want to see med students succeed and encourage their interest in otolaryngology. Also, try to immerse yourself in the field as much as possible early on. It will give you a better sense of what you’re committing to. I think, as a med student, you owe it to yourself to make sure you’re making the right decision with whatever information you have. There are a lot of reasons to pursue otolaryngology, but at the end of the day, it has to be something that you’re genuinely interested in. Like with any surgical subspecialty, it’s hard work. You have to know that you’re doing it for the right reasons or you will regret the decision.

What do you do in your spare time?

I spend a lot of time with my wife. I like golfing; I like running; I enjoy trying new restaurants and bars. I especially love just going out with friends and dancing or getting drinks on the water on a nice summer night. I find that with the time I have, especially as a resident, there are few interests that I can continue all the time. For me, staying in touch and meeting with people are what really make me happy and separate me from medicine.

I used to have a pilot’s license, but I put it on the backburner during residency. It had become a bit of a chore to just do the bare minimum to maintain my competency, so about a year ago I decided that, rather than take something I love and make it something laborious, I’d just put it aside and come back to it. As I have gotten closer to finishing, I have been getting excited about returning to flying and expanding my skills, so that I can fly in instrument-dependent conditions, which would really open up opportunities to explore the northeast – weekend trips to Martha’s Vineyard and Nantucket await! With a small prop plane, you can get to the Vineyard in 37 min with a breath-taking landing straight over Katama Beach.

What are your long-term goals?

I want to do basic science research about 50 percent of the time and have my own lab. The other 50 percent of the time would be purely clinical with maybe two days in the OR and one day in clinic.

I definitely envision myself being in an academic place, both because of the lab interest and because I really enjoy teaching. I’ve gained so much from my mentors and teachers, especially those at Mass. Eye and Ear, and I would love to pay some of that forward. I really like teaching because I find that taking someone else through a case and seeing them learn and grow and seeing how they think of things—which might even change the way you do things—is a very bidirectional learning process. So I definitely want to stay in an academic hospital and continue doing that.

*While Dr. Puram is currently a PGY4 otolaryngology resident, this interview took place when he was in his 3rd year of residency. As a result, some of the daily activities and responsibilities he describes reflect those of his 3rd year of residency.

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