This week’s vault comes from our first episode with Shira Zelber-Sagi. She and Ken Cusi joined us during US Thanksgiving Week 2022 to discuss nutrition and behavioral issues related to MASLD. The episode’s original writeup explains:

Surfing the MASH Tsunami hosts its first episode dedicated to nutrition and NASH with distinguished guest, Prof. Shira Zelber-Sagi. Alongside this rich discussion are Ken Cusi, Jörn Schattenberg, Louise Campbell and Roger Green.

This final conversation starts with Jörn recalling Shira's statement that “diet is every day.” He notes that for patients whose serious medical issues are related to poor diet and lifestyle choices, behavior and diet can play an integral role in improved patient self-care and overall health. Roger highlights that a combination of medications and self-management can be a powerful, reinforced and effective treatment solution. This leads Shira to provide a step-by-step vision of how to work with patients on improving bad habits. In the end, she notes, clinicians and leaders need to appreciate the importance of policy in supporting clinical goals. The conversation continues with the group discussing what Louise calls “fun facts” about common unhealthy foods. For the final question, Roger asks the panelists for one piece of advice to be utilized by providers seeking to push behavioral change in their patients. Surf on for their key takeaways.

This final conversation focuses on shared experience and holistic MASLD support programs. It starts with Tom suggesting that shared experience is a pivotal factor in patient support groups and patient-based supportive care. He goes back to viral hepatitis, where many of the patients had common background challenges related to the disease. In viral hepatitis, patients who have been treated successfully become integrated into the care community. Nothing like that happens in MASLD at this time. Louise comments this would be particularly useful due to stigma around the disease, stigma that successfully treated patients have overcome.

Louise points out that Michael makes extensive use of shared experience video, such as this month, when he has invited patients to follow him on a "30-day glucose challenge." Michael says that he gets unsolicited notes about how helpful the approach is, along with diet recipes. He agrees with Tom that a viral hepatitis model might provide help here.

Mike discusses the idea of metabolic disease support programs that take a more holistic approach and place MASLD in a broader, multi-disease context. Shire likes the holistic approach as well, including a focus on mental health. Tom agrees with the basic approach, commenting that the multitude of possible issues is what makes MASLD so tricky.

As the conversation wraps up, two final themes emerge: (i) physicians needs to be actively curious in exploring each patient's needs if therapy is to succeed; and (ii) joint goal setting is an excellent strategy to drive incremental changes in behavior.

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss ways that socioeconomic and psychological issues impact the dynamic of the physician-patient consult, and, as a result, often patient adherence to therapy.

This conversation starts with Shira asking Tom whether he addresses diet with his patients and, more importantly, whether he does so in the context of socioeconomic challenges, such as not recommending food that is too expensive for the patient. Tom says "Yes" to the first part, about diet and nutrition discussions and encouraging all patients to adopt a more healthy lifestyle, but, he says, not enough about socioeconomic issues. He feels that may be changing, though, based on the increasing discussion of food insecurity at conferences. The two agree that sensitivity in the topic is growing and needs to grow more in the years ahead, and also that while they are tailoring their discussions to address these issues, they can do more. Shira has begun to simplify her recommendations: fewer foods and less preparation time. Tom agrees this is a good idea.

Tom notes that he is focusing more these days on unemployment, social isolation and what he describes as social "unmet needs." He cites figures that 80% of the patients in a liver clinic have unmet needs and that improving social engagement can affect health. Mike asks whether the providers consider mental health, particularly given how important behavioral support is to treatment. Does Shira or Tom recognize mental struggle when the patient is sitting in front of them? Tom says this is an excellent question and identifies the three items patients in large studies say they seek in this realm: (i) education, (ii) reduction of stigma, and (iii) better psychosocial support. Mental health challenges are linked to unmet needs which, again, are linked to poor liver health. Tom believes the UK system does a good job of identifying this issue at the primary care level. Shira agrees this is important and, in her case, involves using quiet, probing questions in a sympathetic tone.

Louise asks whether Tom or Michael have observed MASLD-specific patient support groups in their regions. Both report that there are liver support groups, but nothing yet as specific as MASLD.

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss strategies and questioning styles that can improve the dynamic of the physician-patient consult.

This conversation starts with Tom stating that having multidisciplinary treatment teams would provide tremendous benefits in terms of being prepared for patients and fully responsive to the issues they are likely to raise. Jose agrees but adds that many countries have only a few nurses and no ability to create these kinds of teams.

Shira states that every physician should learn the principles of motivational interviewing. The key to this is asking open questions that allow the patient to respond fully without feeling judged or steered in a specific direction. This enables the patient to share unhealthy behaviors, which they might not do if the physician admonished them in advance. Tom agrees with the positive tone, saying that so much of the physician's role is all about trying to enthuse the patient to take control of lifestyle factors.

Along a similar theme, Mike notes the importance of tailoring care and questions to the individual patient. He points out that while 10,000 steps/day might be a goal, for some patients, it will feel so unattainable as to be demoralizing. Shira points out that an open question would start by asking the patient what goal is reasonable, and Jose follows by sharing an example of a patient who "hated" all exercise. José found a way to motivate the patient with simple, timely reminders that this was for the liver, and that the liver would be appreciative. Louise adds that changes in activity if the patient can define them as "fun."

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to discuss some of the key dynamics shaping the physician-patient consult.

This conversation starts with Mike asking Tom whether he reviews the patient's history before the visit. Tom says he does so because he considers preparation vital to a successful consult. That said, Tom notes the importance of being responsive to the conversation rather than using the chart review to decide the outcome of the visit. He provides some empathetic detail about how important the visit is to the patient and, as a result, how important that he be responsive as well as prepared.

José agrees, provides more color, and notes what she considers the most important question a physician can ask a patient: "How are you feeling today?" To José, asking that question just one time a year can change he entire dynamic of the relationship.

Tom then notes the scarcity of time and the double-edged demand this creates for each visit: plan in advance to use time as productively as possible, but once the patient is in the consult, give it all the time it needs.

After José makes a point about the importance of using language precisely, Louise joins the conversation to describe the consult as "like speed dating," with both sides having a scare few minutes to make a relationship that will be pivotal to the patient.

Co-chairs Shira Zelber-Sagi and Mike Betel and panelists Tom Marjot and José Willemse, all from the EASL Congress session "Patient Experiences in Clinical Settings," join Louise Campbell to provide an overview of issues in physician-patient communication.

The conversation itself has two elements. It starts with first-time surfers Tom Marjot and José Willemse introducing themselves to listeners. After that, Shira starts by discussing the EASL Congress session within the context of a broader collaboration called "EASL Patient Synergies." This program led to the creation of the Patient and Advocate Forum as the EASL Congress, which led to this program. She says this year's program "worked" in developing "very interesting and fruitful and open dialog between patient and patient representatives and physicians," focusing on unmet patient needs and the roles various providers can play in addressing these. Mike shares one of his key takeaways: how fearful patients are when approaching physicians and how little information they share.

Mike recalls a comment Tom made during the session that if a patient ever told him, "What you just said hurt me or made me feel bad," that would have more impact on him than, as Tom puts it, "an entire weekend at a stigma workshop." Tom describes three levels at which to address patient stigma. Two of these, public policy and patient advocacy, are well known, but the third, improving direct physician-patient interaction, may be more vital and is underappreciated today. If patients provided direct feedback to Tom when Tom was communicating poorly, he says, he could adjust with the very next patient. Today, though, he doesn't get that kind of feedback.

Jose sees this as a two-way problem. Yes, most patients are fearful and do not share what they are thinking with the provider, but the reverse is true as well. When a patient shares feelings with a provider, the provider may not be equipped to handle it. She makes this point about provider insensitivity or failure to listen with two powerful vignettes.

Tom recalls Jose telling him in Milano that when the physician turns off the computer screen, it changes the entire dialogue with the patient. He has begun to do so, and it works! Jose makes a couple of points about this. First, simply asking that patient, "How do you feel?" and engaging with the answer makes the patient more satisfied with the visit. Second, this speaks to the idea that physicians do not realize how important they are in the lives of their patients.

00:00:00 - Surf's Up: Season 5 Episode 23
During SurfingMASH's wrap-up interviews from the EASL Congress (S5 E19), Louise Campbell and Mike Betel mentioned a session Mike co-chaired on challenges in provider-patient communications. Today, the other co-chair, Shira Zelber-Sagi and panelists Tom Marjot and Jose Willemse join Louise and Mike to return to this topic.

00:13:34 - Discussing the EASL Congress session
Shira describes EASL Patient Synergies, a broad collaboration to develop open, solution-centered dialog focusing on what patients need in working with providers. Mike shares a key takeaway.

00:16:31 - Stigma in what doctors say to patients
This section covers the issue of physician saying things they do not realize patients find hurtful. If the patient would share their discomfort, the provider could adapt on the fly. Jose sees this as a two-way problem: patients do not share feeling, but when they do, most providers cannot handle them.

00:19:40 - Sending signals of attentiveness
This section covers the positive impact when the physician does something simple like turning off the computer screen and the reasons why.

00:21:06 - Preparing for a patient consult
Tom considers prior preparation and chart review vital to a successful consult. Panelists note how much more important the consult is to the patient compared to the provider.

00:29:23 - Structural improvements for patient consults
To Tom, multidisciplinary treatment teams provide tremendous benefits in patient preparation and responsiveness, but Jose notes that many countries lack the number of nurses necessary to do so.

00:30:57 - Motivational Interviewing
Shira suggests that every physician learn the principles of motivational interviewing: asking open questions with no emotional valence. This enables the patient to share unhealthy behaviors. The panel agrees, noting that physicians can motivate and that they are most effective when tailoring to the individual.

00:38:10 - Food insecurity as risk factor
Shira asks Tom whether and how he addresses diet with his patients and, more important, he does build socioeconomic factors into the decision analysis. Tom says "Yes" about diet and healthy lifestyle, but, he says, not enough about socioeconomic issues. They agree that awareness of the impact of food insecurity is growing and needs to grow more.

00:41:10 - Assessing mental health and quality of psychological life
The group considers the idea that a large majority of patients in a liver clinic have unmet economic or mental health needs, and discusses what to do to improve social engagement. Tom identifies the three items patients in large studies say they seek. The group discusses the idea that they see liver support groups, but none are MASLD-specific.

00:46:03 - The value of lived experience in providing care
This section explores shared experience as a pivotal factor in patient-based supportive care, similar to viral hepatitis, where successfully-treated patients become integrated into the care community.

00:49:03 - Holistic metabolic disease support programs and wrap-up
Mike suggests that MASLD support programs take a more holistic approach that places MASLD in a broader context. Shira suggests adding a focus on mental health.

As the conversation ends, two final themes emerge: (i) physicians maximize success by being actively curious in exploring each patient's needs; and (ii) joint goal setting is an excellent strategy to drive behavior change.

00:54:41 - Question of the Week
What structural or educational changes do you anticipate will improve provider-patient communication significantly, and will these changes require more from the provider, the patient or both?

00:55:14 - Business report
Information on future episodes plus a shout-out to Indonesia.

In this week's episode, Jeff Lazarus discusses the idea that the MASH community, including patient advocates, live in a "bit of a bubble," where the clinicians with whom they interact are part of the MASH community. Last year's ICER Public Comments session exposed them to an FDA Advisory Board of hepatologists...and it was a very different experience. Last year's conversation notes reveal what happened and the advocates' reactions:

In March 2023, Jeff McIntyre (GLI) introduced a draft report from the Institute for Clinical and Economic Review (ICER) on resmetirom and obeticholic acid for NASH. The Surfers dedicated an episode to expand on the contents, its shortcomings and potential implications with special guests Veronica Miller (Liver Forum) and Hannah Mamuszka (Alva10). In this conversation, SurfingMASH revisits the topic after a public comments session that took place last week. In doing so, patient advocates and friends of the podcast Mike Betel (Fatty Liver Alliance), Tony Villiotti (NASHkNOWledge) and Wayne Eskridge (Fatty Liver Foundation) join co-hosts Louise Campbell and Roger Green to share a range of impressions.

Roger begins by asking the group how the word empathy fits into this discussion. Tony shares that he was upset by the majority viewpoint of 15 featured voting members on a number of different issues. For example, 40% of these voting members suggested that a drug approval would have no impact on a caregiver’s life. Tony asserts the importance behind people needing to be aware of the impact of NAFLD/NASH not only on the patient, but also the families and those close to them. Speaking from personal experience, Wayne shares that he was perplexed on the document's position that NAFLD/NASH is not considered to be a progressive disease. This leads Louise and Roger to insert comments around the pricing and economic analysis surrounding the discussion. As the conversation winds down, Mike returns to the conundrum of the voting results. Listen on to hear why his reaction was, “I literally fell out of my chair.”