Melanie Cole, MS (Host): Welcome to AHN Med Talks, an informative resource for physicians across various specialties as we delve into the latest medical insights and best practices, ensuring you stay at the forefront of your field. I'm Melanie Cole. And today, our discussion focuses on the AHN Multidisciplinary Pituitary Center, and we have two AHN physicians for you today. Joining me is Dr. Jody Leonardo, she's a board-certified neurosurgeon, and Dr. Saira Khan, she's an endocrinologist.

Doctors, thank you so much for joining us today. Dr. Leonardo, I'd like to start with you. Can you give us a little bit of a brief overview of pituitary tumors as they are complex lesions, how common they are, what you're seeing in the clinic?

Jody Leonardo, MD: Sure. Thank you. So, pituitary tumors are extraordinarily common. There actually was an autopsy series done probably almost 20 years ago in England, and they took anyone who passed away from anything and they looked at the pituitary gland. And from that study, they found that one out of three people can have a pituitary tumor or a pituitary cyst. So, they're quite frequently recognized, especially on imaging performed for anybody that gets a headache or bumps their head. So, there are a common incidental lesion that's found, but the differential of tumors that can occur in this area are very broad. So, there's often very complicated tumors and the different type of tumor that can occur within the pituitary gland certainly does range, although the most common is the pituitary adenoma.

Melanie Cole, MS: Thank you for that. And sticking with you for a minute, Dr. Leonardo, give us a little brief overview of what the AHN Multidisciplinary Pituitary Center really entails and why did you see a need for this type of a program? How did it come about?

Jody Leonardo, MD: So, this clinic came about, it's been running here at AHN since probably 2016, 2017. And the reason we started it was because it's very difficult for physicians to track down other physicians and other specialties. And because these pituitary tumors are located in the pituitary gland that's adjacent to the optic apparatus, and the pituitary gland itself is in charge of secreting the hormones that basically govern our body, it's very difficult for one physician to manage these on their own.

So in my opinion, the most important relationship that I can have is with our endocrine colleagues. And so when we started, we invited our endocrine colleagues to come join us in the clinic. And that has been a phenomenal experience for the patients. But even more important for the patients, it's so helpful for us to talk together and compare from our different specialties, our opinions, and how to best treat people. So when we see the patients and meet the patients, we can give them the best care upfront.

Saira Khan, MD: I wanted to add to that, that I think Dr. Leonardo and I feel so strongly that this center of excellence that we're building and have built over these years really does a three-pronged approach. It helps patients, the care is better, the collaboration between multidisciplinary teams is better. Patients get to see two doctors in one visit. Often their MRI is done the morning of the visit, so it's really streamlined. Some of our patients drive several hours to come to see us. And so, they know that they're getting a direct answer as opposed to seeing two separate doctors over several months.

I think we do a lot of education. We do grand rounds. We do a pituitary tumor board. So, I think for the community, we know these tumors often present in the ER or they present to PCPs' offices. And so, those doctors then get educated on where do you send these patients? And how do you recognize pathology when you see it?

Melanie Cole, MS: Dr. Khan, thank you for telling us about this combined clinic and the fact that you both are from different specialties. As physicians, what do you see are the best benefits for physicians? And as you're speaking to other providers, when you're telling them about the clinic, why is it so important for these patients, but also for you physicians as you're treating these patients together?

Saira Khan, MD: I think the collaboration, it's really the best part, we learn from each other every day. I learn from Dr. Leonardo. I hope their team learns from us. We have residents and fellows in our clinic often. And I think sometimes in the times of EMR and really busy clinics where sometimes you can't get appointments with a specialist for several months. In our clinic, the patient sees me first, Dr. Leonardo second, and we sit in the same room and we pull up the images together and we pull up the labs together and we talk. And so, the patient before they leave the office visit, they have a very clear answer about what's going on. And I think as a patient that would give me a lot of peace of mind, and as a doctor, that would give me peace of mind the care isn't delayed and there's no miscommunication between teams.

Jody Leonardo, MD: I agree. These patients can be very complicated. And from a neurosurgical perspective, we as neurosurgeons can figure out, for the most part, when it's structural, when it needs to come out based on imaging. But from the endocrine background, it's really difficult. From my perspective, I've developed a significant appreciation of how much medical knowledge Dr. Khan has compared to somebody that is more surgical based. She uncovers issues with patients that I really wouldn't even think would be that pertinent from a surgical perspective. So, we definitely learn from each other.

 But I think the best thing, as Dr. Khan, mentioned is the fact that we're in that room with each other, talking through things, looking literature up online, and just carrying a conversation. "Well, what's going to happen if we do this? What's going to happen if we do that?" And just really having the time to think about it and make the best plan looking forward and not looking back. It's just a really incredible experience that ultimately I think really makes a huge difference in the care that the patients get. I know there are physicians probably in the audience, and I know most physicians, you put on your to-do list at the end of a clinic, "Oh, I got to call Dr. So-and-so about this patient." And then, that night you're like, "Wait, who do I have to call? What were my questions?" And all of that goes away because you can have these conversations in real time, and it just makes patient care so much easier, so much more enjoyable, and I think just so much more beneficial for the patient.

Saira Khan, MD: We feel so passionately about this, that it's benefited us. Also, the care really is collaborative. We build protocols together. So, we've had post-op management protocols built, how to manage Cushing's patients, how to manage acromegaly patients. And, you know, sometimes in the hospital, surgery and medicine can butt heads about how you think patients need to be managed.

In this case, it's built collaboratively. So, we take surgery concerns in mind, endocrine concerns in mind. And so, really, it reduces error. And it reduces any question of how patients should be managed, and we're all very comfortable. And to that end, our fellows know each other. My fellows know her, her surgical residents know me. My fellows love Dr. Leonardo, but she comes and teaches our clinic and our conferences. So, it's a really nice, I think, joint education.

Jody Leonardo, MD: And it even works out too because we're with a large tertiary care medical center, but we receive a lot of referrals for outside endocrinologists, for us to look at the patients as a team, Dr. Khan from Endocrine, even though they're being sent by another endocrinologist, they want her level of expertise because one thing that we should say, Dr. Khan has specialty training with pituitary endocrinology. She did a fellowship at Hopkins and specializes in pituitary. So, her level of expertise is really significant within the field. And so, even the people and the physicians that are referring to us, Dr. Khan takes over the patient care, the perioperative phase, while the patient is being worked up for surgery, through the surgery, after the surgery. And then, we get the patient back to the patient's own endocrinologist. And so, I feel we've really worked our way into the community in terms of helping other physicians manage their patients during a time when surgery's involved.

Melanie Cole, MS: What great points you both have made and what a wonderfully comprehensive approach. I can hear the passion for what you do from both of you, which is really great for your patients. And Dr. Leonardo, speak a little bit about some of the treatment options that are available through the clinic.

Jody Leonardo, MD: Yeah. So, many patients just need verification that this isn't something that is going to completely derail their life. It's not something that's going to kill them. They just need education. Treatment-wise, there are pituitary tumors that are managed primarily with medication. And Dr. Khan governs the treatment of those patients. And then, there's some patients that may need surgical resection of the lesion or a biopsy of the lesion. So during this clinic, they see both of us, they get educated from both of us. And then, the ones that we decide do need surgical intervention, such as a biopsy or a tumor resection, we speak to the patients about that during this clinic. And then, ultimately, with our team, we have a team of nurses and our physician assistants, we get the patient already prepared and signed up for surgery.

Saira Khan, MD: And I wanted to add that from a surgical standpoint, Dr. Leonardo comes with lots of experience here at AHN and also at Buffalo before coming here with pituitary tumors. And we know through literature that surgical centers of excellence, when you have an identified surgeon who gets most of the cases that come to the hospital, that person's expertise continues to grow and build.

So in the community, when people send patients our way, they know that they're getting someone who's done many of these surgeries before. And from an endocrinology standpoint, I have a lot of reassurance that when she does a case, she has not just what she's read and what she's trained, but her own experience over many years to guide her.

Melanie Cole, MS: One of the great things about a clinic such as the AHN Pituitary Center is the help the patients get navigating through the system, because these are complex lesions, as we've said. So Dr. Khan, speak a little bit about some of the team that you work with, and specifically nurse navigators and other people on your team, your colleagues that help the patients to navigate this complex condition.

Saira Khan, MD: I think to AHN's credit what's been really nice about this clinic is the two divisions have really come together to pool resources to make it happen. So, our endocrine standpoint, our medical assistants will be involved calling the patient ahead of time, making sure that we have all of the images available, all of the records available, the appropriate labs available. So when they take the effort to come to our clinic, all of our ducks are in order.

During the clinic, Dr. Leonardo's team, God, their team is fantastic. She has PAs and nurse practitioners. She has nurses that specifically work in the pituitary clinic. So, they get to know the patients really well. So when the patients come back to see us, they're seeing familiar faces who are familiar with the disease process, who know what labs they need and what medications they need, and who can really reassure them. So, I think, overall, I feel very pampered when I come to pituitary clinic because really, it's staffed so well. And I think the people who come there come and help us out, not just because hopefully they like working with us, but also because they feel passionately about that field. They like the patients, they like the pathology that they see. It's a fun clinic. It's really collaborative.

Jody Leonardo, MD: Yeah. You have to get there early to get a seat, because we only have so many working stations in between our residents and our innate team and Dr. Khan's fellows. A lot of people want to attend to be part of the educational experience. The other thing though that's interesting is that the way. And it's been a work in progress over the years, and I think we're kind of finally hitting a good stride. But in terms of the clinical appointments, we take patients in person and we also do video visits with the patients. And that goes into one thing that I learned from Dr. Khan is the importance of being on time, sticking to the schedule. We have the patients for 30-minute time slots, which is a really good amount of time. And they first see Dr. Khan and then they see me on the backend. So, we're attentive to the time, we're attentive to the schedule. We do video visits. So, it works out really well because we have a larger outreach as a result with the video visits, and it's a nicer way to transition the care back to the home endocrinologist and the primary care physicians after the surgeries are completed because the patients don't often have to come in for every single appointment.

Melanie Cole, MS: I imagine it's a very comfortable clinic for the patients that are coming there. And while they're scared and nervous about conditions, you both are making it so much easier for them to learn about their situation and that education that's so important and really having the video visits is a really important aspect.

And Dr. Leonardo, off air, you and I were talking a little bit about the special bond of working together with endocrinology and neurosurgery and why you love working with each other so much. Can you tell us a little bit about that?

Jody Leonardo, MD: Yes. I love working with Dr. Khan because she is the most relaxed, calm, sophisticated, caring person. I feel like I come in and I'm, "Oh this is work to do, blah, blah, blah." and it is just so wonderful because surgeons, we don't work with other surgeons, where everyone's, in a way, in their silos with their own staff. So, it's really awesome to get a chance to work professionally in a clinic with someone as lovely as Dr. Khan, but also someone in a different specialty. So as surgeons, we run our clinics a little bit differently from a medical perspective the whole way they approach the patients is different.

 And even in terms of what Dr. Khan does in terms of taking notes and the labs and all of her, like there is no physician in Allegheny Health Network that can send the amount of myChart messages and take care of all business. She's like this Jedi Knight Master of efficiency organization, and it is just absolutely awesome to watch her work. So, I've learned a lot from a logistics perspective, an efficiency perspective, and just seeing different ways that other people manage their practice. So, it's been an awesome experience.

Saira Khan, MD: I'm going to add, also, it is so fun working with Dr. Leonardo really and truly. You know, in medicine, you send someone to surgery, you may never meet the surgeon in person. You may just talk to them over the phone or talk to them through myChart messages. Jody Leonardo, God bless you, you are the epitome of enthusiasm and cares so passionately about her patients.

Like if you send someone to her, you know that not only will she operate very well. But the pre-op visit, the amount of detail she goes into to make sure the patients understand what's going on with their disease, what's going to happen during the operation and after the operation, and what their recovery will be like. I mean, It's not just the rumors of surgeons going in, spending 30 seconds with the patient, and then operating or waving from the door like we used to hear as a med student. Dr. Leonardo spends sometimes even more time than I do in the room with the patient. And I think that reflects a lot of professionalism. She wears a lot of different hats and works very hard in everything that she does very passionately. So really, I mean, this clinic, it's my favorite part of work. I love pituitary clinic days. I hope we can continue to grow it and continue to work together and help more people and continue to learn from each other.

Melanie Cole, MS: Which leads me very well into my final questions, and I'd love to give you each a chance for a final thought here. So Dr. Khan, looking forward, as an endocrinologist, what's your vision for the program? What would you like your colleagues to know, other endocrinologists to know about that communication with the referring physicians and where you see this going for your patients in the future? Give us a little blueprint.

Saira Khan, MD: So, I think what I like about this clinic is I think that this is how medicine was meant to be. Like we weren't meant to just sit in front of a computer all day and not interact with each other. Other physicians in other places, if you do have the opportunity for your patients that are surgical to develop clinics like this, it is a life-changing experience for the patient and for your own personal growth, to ask for that collaboration, whether it's through tumor boards, whether it's through specialty clinic, whether it's through joint conferences or joint journal clubs. We do all of it. And I think that our fellows in both specialties benefit a lot from that.

I think from a patient standpoint, we've now been doing this clinic for many years. We're hopefully going to pull some data and really mine what we've benefited from how the patients have benefited. And then, I'm hoping we grow. We have newer residents and newer attendings who join our clinic that I hope will come in and collaborate with us. Dr. Leonardo constantly has residents that she's training on pituitary disease. So, that's where I think the future of this clinic is.

Melanie Cole, MS: Dr. Leonardo, last word to you. What's exciting in the field as we just asked, Dr. Khan, where she sees the program going, where do you see the future of pituitary tumors and these complex lesions going? What's exciting in your field as far as treatment or novel therapies? Tell us a little bit about what's going on or what you'd like to see happen in the future.

Jody Leonardo, MD: Well, I think with pituitary surgery, it's relatively particularly endoscopic, not transnasal. But with endoscopic pituitary surgery, it's a relatively young field and there has been advances in terms of technology and various image modalities, even for the patients in the clinic, the advent of 3 Tesla, stronger magnets in terms of imaging has made a significant difference.

 So in the future, hopefully, the imaging will continue to improve. Surgically, I think we're going to be a field that's going to be safe. From the robot takeover of the future, I think that these procedures are challenging in the anatomy. Usually, most centers across the country at this point have a team of surgeon and ENT surgeon who perform these surgeries together. So, I don't see that changing. I think with further advances in imaging and OR technology may make the surgery, run more smoothly from those perspectives. And the other thing too is the genetic workups from the pathology standpoint will be helpful. I believe in the future to help target medication and therapy from that perspective. So, I think there's a lot of opportunities to grow and a lot of changes to look forward to.

Melanie Cole, MS: What a very exciting time in both of your fields. And thank you so much for joining us, telling us about the clinic, your working relationship, and sharing your incredible expertise with us today. Thank you again for joining us. And to learn more or to refer your patient to Dr. Leonardo or Dr. Khan, please call 844-MD-REFER, or you can visit ahn.org. Thank you so much for joining us on this edition of AHN Med Talks with the Allegheny Health Network. I'm Melanie Cole.