Colorectal Cancer and Wellness with Dr. Cindy Kin

March is Colorectal Cancer Awareness Month! In this episode of Scrubcast, host Rachel Baker interviews Dr. Cindy Kin, an associate professor in Stanford University's Department of Surgery. Dr. Kin delves into her choice to specialize in colorectal surgery and shares insights on the increasing trend of colon cancer in younger patients. She discusses the importance of early detection and elaborates on her research to improve patient outcomes post abdominal surgery through 'prehabilitation.'

Dr. Kin also talks about her role as the Director of Wellness at Stanford and her efforts to improve the well-being and work-life balance of fellow physicians. Only a few months in, she has already kicked off several new projects. She explains “Tell Us About It;” a new program developed in conjunction with our Quality Improvement team.

Rachel Baker: [00:00:00] Welcome to Scrub Cast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today, we're speaking with Dr. Cindy Kinn. Welcome to the show. Thank you. Dr. Kinn is an associate professor in our Division of General Surgery's colorectal section.

Colorectal surgeons are some of my favorite people, because out of all of the surgical specialties, you chose butts. Tell us how you made that decision.

Dr. Cindy Kin: Well, obviously I came for the butts, but I stayed for the guts. So actually, um, I chose colorectal surgery because I looked around at all the surgeons and mentors that I had.

And I said, you know, I really like. Many, many types of surgery, many different specialties. And I think I would be happy doing many of them. So I looked at their lives and I looked at, you know, [00:01:00] who of these people seem like they're really involved in their family lives, their kids lives, who seems like they have hobbies outside of work.

And it seemed like the colorectal surgeons had very You know, balanced lives where they had their work and they also had, you know, full participation in what was going on with their families outside of work. And they also had often a third thing that they were doing, you know, whether it was running or cycling or, you know, other hobbies.

So I felt like, you know, these are people that I really felt like I connected with. They also don't take themselves too seriously, which I enjoy. It's hard to have like a God complex when, you know. You have a job like I do, so I like being around people who don't have that kind of complex.

Rachel Baker: I think that's a fantastic answer.

I think, uh, people should really look at the [00:02:00] lifestyle of the, you know, specialty that they're choosing. There's definitely a big difference between colorectal and trauma. Well, so March is Colorectal Cancer Awareness Month, and in 2021, the U. S. Preventative Services Task Force, which is a very long name, issued a recommendation that colorectal screening should start at age 45, which is five years old.

Sooner than previously recommended. I'm wondering, are you seeing more younger patients with colon

Dr. Cindy Kin: cancer? Yes, unfortunately we are. It's, um, a, not just a national trend, but it's, um, been seen in other countries as well. Which is an interesting trend from a research standpoint, but it's also, you know, very concerning from a public health standpoint.

And often younger people with colon cancer present with sort of more aggressive disease than patients who are older. Who present with colon cancer. We're not sure why that's happening, but the suspicion is that there's some sort of external [00:03:00] Exposure or environmental factor that hasn't been elucidated yet.

Rachel Baker: Got it. Well, so I just had my first colonoscopy a few months ago PrEP was awful. What would you say to a patient who is staring down that giant jug of human

Dr. Cindy Kin: Drano? Okay, so I think I also had mine done because I was like, I can't be the colorectal surgeon who, you know, right.

Rachel Baker: We can't be recommending this if we haven't done it

Dr. Cindy Kin: ourselves.

Exactly. And so one of our nurses in the O. R. recommended this little trick to me, which was have a half of a lemon, you know, a cut half of a lemon. And. Lick it, chug, and lick it again, to just kind of get rid of that icky taste. Yes. Yeah. Yeah. But otherwise, it's just, you know, stay near a bathroom and, you know, good luck.

Yes. [00:04:00]

Rachel Baker: What if you're under 45 and concerned? Um, what symptoms might people look out for?

Dr. Cindy Kin: So, I think any newish abdominal symptoms where Your bloating, cramping, pain certainly are all things that need to get worked up. Bleeding from the anus, you know, blood on the stool. Don't assume it's hemorrhoids. I mean, that's the problem I think with people getting cancer when they're younger is that everyone who sees them, their doctors are like, Oh, it must be hemorrhoids.

Like everyone attributes it to hemorrhoids. And so any sort of symptom like that should be worked up. Um, a patient who comes in. Telling me that they have hemorrhoids and they're bleeding. I say, well, we still need to do a colonoscopy, you know, if we still have to do it just to rule it out. So the assumption should not be that it's something benign.

It should get ruled out first before diagnosing that it's something that's not cancer. So I think early detection is key [00:05:00] because it can make all the difference. For sure.

Rachel Baker: So if the worst should happen, they find cancer and it needs to be surgically resected, you've actually done quite a bit of research on how to improve outcomes for patients following abdominal surgery.

Tell me about prehabilitation and why it shouldn't have the red squiggly line underneath it when I write it out.

Dr. Cindy Kin: It's not a word yet, right? So, um, so prehabilitation is when we. optimize patients for surgery before their surgery. So it's kind of the opposite of rehabilitation, which happens after surgery.

So usually it's a multimodal approach, usually with some physical activity training, like exercise training, nutrition, some centers have added stress reduction. Medication reconciliation, advanced care planning, like there's all these other things that you, we could add, but generally it's nutrition and exercise to an idea is [00:06:00] that we want to get people as fit as they, as they can be before surgery, so that when they're recovering, they can have sort of a faster recovery.

A lot of our patients are older. They might be frail. And surgery could be the thing that kind of tips them over into not being independent anymore, having to live in a facility. And so we want to, for those patients who are at most risk for losing independence and becoming frail, we really want to find ways of improving their strength and nutrition before surgery.

And it's also been shown to improve surgical outcomes. short and long term. So that's really promising.

Rachel Baker: That's fantastic. How do you do this? Do you give them like a sheet? Like when I go to PT, they give me like a sheet with all my exercises on it or uh, is there like a, an app on my phone that I can carry around with me?

Dr. Cindy Kin: Yeah, that's a great question. So that is that is the question of the moment is how to [00:07:00] how do we deliver prehab in a way that people want to do it, you know, palatable. Yeah, exactly. It's not like a medication that you just give someone to put even that's hard for people to take, you know, so, you know, I think in All the studies that we've done and all the trials that have happened in this country and in, you know, in Canada, in the Netherlands, that has been sort of the Achilles heel is, you know, adherence, you know, how do we get people to do what we think is good for them?

So we've tried multiple things from low tech, like giving them like a packet of paper and a box of produce, you know, something sort of low tech like that. And a lot of people really enjoyed that. And we. We've gone all the way up to high tech things like an app that was synced with an activity tracker.

We gave people Garmin watches, um, we helped them download an app. It kind of, you know, the app would give them a little avatar that would cheer for them whenever they finished all their tasks. You know, they would have a [00:08:00] strength exercise for the day. They'd have some cardio, they'd have a nutrition video to watch.

We've also done. Telehealth intervention where patients would meet with a nutritionist and also a physical therapist once a week and had some exercises to do as well. And then our most recent pilot site that we're working on now is a virtual reality based physical therapy for patients who are about to go into breast cancer surgery and then, um, for after their breast cancer surgery.

So, so they go into some, a virtual reality world and they meet their physical therapist there and they kind of go through. Some arm exercises with those physical therapists. So that's our, our pilot study to figure out, you know, are there patients that might benefit from that as well? And we want to make things home based because I think a lot of patients like the home based method, but at the same time, there are patients who need prehab the most, [00:09:00] who tend to be older and maybe less facile with technology.

So that's sort of the tightrope we have to walk is something that's accessible. But also engaging in something that's scalable, but also personalized.

Rachel Baker: Yeah. I mean, maybe it's not a one size fits all approach. Maybe it's different things for different people.

Dr. Cindy Kin: Yeah, I imagine that ideally we have sort of a menu of options that people can choose from, uh, based on what works best for them.

Rachel Baker: To me, the healthy diet And exercise seems logical, but I'm the type of person that is going to do everything in my power to improve my health odds. Are there patients who just look at you askance and say I have cancer doc I plan on eating ice cream and binge all six seasons of the sopranos

Dr. Cindy Kin: Yes, and I relate to that. I definitely relate to that. I think that it's very overwhelming to have a diagnosis Where you need surgery to fix it It's [00:10:00] extremely overwhelming. And, and it's, it's not just mentally and emotionally, but also logistically patients often have so many appointments and scans and labs and they're traveling from far away to come here.

So it is really challenging for people to add another thing. So definitely people have. We're very used to rejection. We don't take it personally, but we get it. You know, people get really overwhelmed and, and I think that a lot of it is timing, you know, when you're asking patients. It's like a bad idea to ask someone to do prehab when they're in the middle of chemo, for example.

And I think that It can be pitched to people in a way that's like, it's not that we are going to make you do anything. This is just a resource for you. Yeah. So that when you, when you are ready to do something, if, if, if actually getting ready in a proactive way, decreases your anxiety, then this is here for you.

But yeah, we definitely get lots of [00:11:00] rejections. And I think, you know, we actually just did a study where we interviewed people who rejected us and thankfully they, they agreed to be interviewed. Um, but a lot of them said, you know, it's overwhelming or that adopting a healthier diet is actually really hard because I have kids at home and they're not going to eat, you know, this food, peanut butter and jelly.

Exactly. So they're like, I can't cook extra food for them and for me. And so I think getting the family on board is really important, like having some family alignment. The key with nutrition is you don't talk to the person, necessarily the patient. You talk to the person who's doing the grocery shopping and the cooking, you know, um, but I think getting family involvement is key.

And then also, you know, we have some patients who are already doing their own regimen, you know, so they often say no, and that's fine. You know, they're, they don't really need. Um, but yeah, I think that's, that's definitely one of the biggest challenges, but that's what makes it fun. [00:12:00]

Rachel Baker: Well, so you're clearly interested in the health of your patients, uh, but you're also interested in the health of your fellow physicians as and educated by your new role as the director of wellness for our department.

Why did you decide to apply for the role?

Dr. Cindy Kin: Well, so, you know, I, um, I never, you know, I have to say I never thought of it as my thing and then someone talked to me about it was like, this is your thing. And I thought about that. And I said, Oh, yeah, you're right. It is kind of my thing. I really always enjoyed talking about health and always felt and knew that.

Your own personal health is key to being able to perform well at work. It's key to having a positive, you know, sort of work environment around you because all the relationships that you form and all the interactions that you have with people is so related to how you're feeling about yourself and How you feel physically and [00:13:00] emotionally.

So I think all those things are interdependent. Yeah. So the more I thought about it, the more I was like, Oh yeah, I actually believe in this. I really think it's important and I want to spend time doing this. And so it made sense. And I think that there's a role for bringing in lifestyle medicine into wellbeing for physicians because so much of our Um, I think that our own lifestyle because we're physicians runs counter to what we would advise our patients to do, you know, like not

Rachel Baker: drinking water all day, because then you'd have to be in the middle of surgery,

Dr. Cindy Kin: basic things that humans need, hydration, you know, sleep, nutrition, social interaction, pillars of good health, you know, that we advise for our patients.

And so why should we. do less for ourselves, you know, yeah,

Rachel Baker: definitely. Well, you've only been, I think in the position of for a couple of [00:14:00] months, but you've already hatched a few projects in conjunction with our quality improvement team. I usually think of QI as like, Oh, our tuna of our times. Um, so how does QI.

intersect with wellness. Tell us about the projects that you've been

Dr. Cindy Kin: doing. So how does QI intersect with wellness? I think that the more efficient things are, the more predictable things are, the more control physicians and everyone in the, in the ecosystem of healthcare has over their lives. And, and part of.

Some of the burnout that people have is related to just not having control over your life, you know, and, and thinking, oh yeah, I'm going to make it to dinner. I'm going to make it to that game for my kid, you know, and then having a surprise two hour turnover, turnover time, and then being delayed and then not being able to make it to those things like that really gets to people, you know, if it happens and it happens over and over again, [00:15:00] then it just kind of eats away at At you.

And so I think that those are the moments that we wanted to capture with this new tell us about it initiative where, you know, these things do happen over and over again. And I think what happens is that most surgeons are like, okay, I'm really pissed off about this. I'm fuming. I'm going to vent to somebody or not.

And then they get busy and they go do their case and then they forget about it. And then, and also there's nothing to do, what are you going to do about it? You can't make people move fast. I mean, you can't make the turnover better in that moment. So they just move on because they have to, they have to do their case.

And then. They sort of forget about it. And then the next week it happens again, and you're like, God, this always happens. Like why? And it just makes you more upset. And that is what I think, you know, again, [00:16:00] eats away at people. And so why we created this was so that In the moment, they could tell us about it and that would give us, it's not just or it could be other things.

I mean, there's a probably, you know, many things that I'm not even aware of, you know, that people are struggling with on a day to day basis. And the goal is really, how do we make your day better? You know? And so tell us what's happening when it's happening so that you don't forget. And then we know what's eating away at people so that we can.

Then have a direction of where we're going with our future projects. You know, what are we going to focus on next year? We're going to focus on our efficiency. Are we going to focus on interpreter services or clinic staffing? What is it that we can do to help make people's days better?

Rachel Baker: Well, so for anybody who doesn't know about the Tell Us About It initiative, it's a, we have a badge buddy on our little badges.

Um, and it has a QR code and there's a phone [00:17:00] number. Go And you can either write you're venting, uh, angry typing, or, um, you said the, the phone call they can, you know, actually vent out loud, but then it's transcribed and completely anonymous.

Dr. Cindy Kin: That's right. So, and they can text that number as well. And yes, I guess transcribe is completely anonymous.

Some people have told us who they are so that we can get back in touch with them if yeah, and follow up. Um, and often people have really good insights into what. Solutions or what potential solutions could be done to make this not happen.

Rachel Baker: Well, we are getting close to our time. So I'm going to ask you the same questions that we ask all of our guests on the show.

And the first one is who is a surgeon you admire and why?

Dr. Cindy Kin: I admire Andy Shelton, not just because he's my boss or one of my many bosses, but because he is so [00:18:00] consistent and Efficient in the OR. And he's a very, he's also a very good leader because he is again, so consistent and upfront, you know, just logical.

And, you know, I have to say that whenever, you know, we're talking about cases and if he's not there and we're just talking amongst, you know, a few other of us, we're like, well, what would Andy do? So what would Andy say in this situation? So I think that, yeah, he's just a great model of, you know, a compassionate surgeon who Gets the job done, he's kind, and then he's also a great model of a leader, you know, he's advocates for his team, he's fair, and he's direct.

Rachel Baker: That's fantastic to have such a role model so close to you, that's really very lucky. The second question that we [00:19:00] ask is, what is the best advice you have received in ten words or less?

Dr. Cindy Kin: If you wait to the last minute, it only takes a minute. I'm kidding. That's not, that's, that's just my justification for, for procrastination.

But no, actually the best advice I got is that if it doesn't look right, it's probably not right. Ah, yeah.

Rachel Baker: I feel that sometimes I write a tweet and I go, you know, we're just going to

Dr. Cindy Kin: delete that. Yeah. Yeah. You just have to trust your gut. No pun intended. Yeah, but at the same time, the enemy of good is perfect.

So you have to balance those two things. Balance it out.

Rachel Baker: Yeah, yeah. Well, this has been such a fantastic conversation. Thank you so much for joining us on the show today.

Dr. Cindy Kin: Thank you for having me.

Rachel Baker: And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts.[00:20:00]

Scrubcast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds. And our chair is Dr. Mary Han.