We continue our series of “OncoDaily Dialogues”. This effort by OncoDaily focuses on highlighting key figures in oncology, featuring their achievements, difficulties, and significant life learnings.

In this session, we’re privileged to welcome a distinguished oncologist from Costa Rica, professor Andrés Wiernik, the CEO of the Hospital Metropolitano Costa Rica and the Medical Director of the Hospital Metropolitano Research Institute.

Dr. Wiernik is a specialist trained in Internal Medicine, Hematology, Medical Oncology and Bone Marrow Transplantation. He studied medicine at UCIMED Medical School (Costa Rica), carried out his training in internal medicine at the Hennepin Healthcare System (Minnesota, USA), and his specialization in Hematology, Oncology and Bone Marrow Transplants at the University of Minnesota. During his training, he completed internships and fellowships at Harvard University (USA), the Karolinska Cancer Center (Sweden), the University of Turin (Italy), and the Peter MacCallum Cancer Center (Australia).

From 2014 to 2017, he was a member of the board of the Minnesota Society of Clinical Oncology, and has been named as one of the ‘Best Doctors’ in the area of ​​Medical Oncology and Hematology of the State of Minnesota (2016, 2017 and 2018). He has also been selected as a “Rising Star” in the field (2018, 2019) by the Minneapolis-St Paul Magazine.

Dr. Wiernik is licensed to practice in the United States and holds Board Certifications in Internal Medicine, Hematology and Medical Oncology.

In addition to his administrative roles and specialist of the Cancer and Hematology Center of the Metropolitano Hospital, Dr. Wiernik continues to periodically treat patients at the Hennepin Healthcare System where he used to lead the Breast Cancer Committee. He is also an assistant professor of medicine at the University of Minnesota and UCIMED Medical School. His work as a teacher in the field has been recognized with a great number of awards.

Throughout his academic career he has published in prestigious medical journals. During his training at the University of Minnesota, he was the lead investigator in the development of an immunological therapy for the treatment of acute myeloid leukemia and myelodysplastic syndromes, which is currently under clinical trials.

Dr. Wiernik is a member of the College of Physicians and Surgeons of Costa Rica, and holds an MBA from Chicago Booth Business School. He is a member of the ASCO International Affairs Committee and ASCO’s International Quality Steering Group.

Our host is Dr. Roupen Odabashian, hematology/oncology fellow at Karmanos Cancer Institute in Detroit, USA. Beyond his clinical practice, Dr. Odabashian possesses an unwavering passion for delving into the intricacies of healthcare policy, regulations and Oncology. He understands the multifaceted nature of cancer as a medical condition and acknowledges the various stakeholders and regulatory bodies that influence the delivery and administration of cancer treatments. In alignment with this commitment, he has joined OncoDaily, where he plays a pivotal role in conducting interviews with Leaders of the Cancer world.

You may view the previous series through the link below:

OncoDaily Dialogues #1 – Harout Semerjian / Hosted by Roupen Odabashian

OncoDaily Dialogues #2 – Piotr Wysocki / Hosted by Roupen Odabashian

About OncoDaily 

OncoDaily was founded in 2023. It is a US-based oncology media platform, which features the latest news, insights, and patient stories from the world of oncology. Within a short period of time it became one of the leading oncology media platforms globally.

OncoDaily gathers content from various sources, including social media posts from renowned oncologists from all over the world, news from oncology societies and cancer centers, patient and survivor stories, and career-related information for professionals.

The mission of OncoDaily is to empower patients, survivors, and professionals with the knowledge and inspiration they need to fight cancer. The motto of OncoDaily is “Cancer doesn’t take a day off – neither do we”.

Follow the transcript below

RO: Welcome to another episode of OncoDaily. Today, we are honored to have Dr. Wiernik with us. Originally from Costa Rica, Dr. Wiernik is a distinguished figure in the field of cancer care with an impressive educational background from institutions like UCM in Costa Rica, Karolin Cancer Institute, University of Chan, Peter Mallum Cancer Center, and the University of Minnesota. He’s known for his commitment to patient-centered care. Dr. Wiernik has a profound expertise in cancer immunology and immunotherapy. And now, without further ado, let’s jump in. Alright, welcome, welcome. Thank you for being here today.

AW: Thank you so much. It’s such a pleasure. I’m honored to be here, thank you.

RO: So, I want to start by the first question, and I want to understand more about you. Why did you choose a career in medicine, and why specifically oncology among all the fields that are in medicine?

AW: Okay, so that’s a long answer, but I’ll try to be to the point because I’m very passionate about what we do as oncologists. But, um, so I grew up in Costa Rica, which is a very small country in Central America, you know, between Panama and Nicaragua. It’s a country of about 5 million individuals, and there are a few things about Costa Rica that are peculiar. Number one, we don’t have an army; it’s one of the only countries in the world without an army. And we have a strong democracy in Latin America, and we Costa Ricans are very proud of those things. So I grew up in a very safe environment, and I was blessed by growing up in Costa Rica, which is a beautiful country. But at the same time, I grew up in a very small Jewish community in Costa Rica because my grandparents were Holocaust survivors. So, despite the fact that I grew up in a very safe place, I grew up hearing the stories of what my grandparents had to undergo when they were in the concentration camps. So from a very young age, I had this seed in my mind that, despite the fact that we were privileged to be born in a country like Costa Rica, we needed to make an impact. So later on, during my high school years, when you start thinking about what you want to do in your life, I knew that I wanted to be in a profession where I could have a lot of impact, and it was very obvious that becoming a physician and pursuing a career in medicine was the right path. So that was really what led me to that. And then the oncology part is not something that became obvious from the very beginning. I’ve always been blessed that, unlike many of us that sometimes think, ‘Ah, I don’t know what I want to do,’ I’ve always been very career-oriented or goal-oriented from a very young age. So I didn’t know exactly what career I wanted to pursue later on or what specialty, but I knew that I wanted to be in a specialty again where I could have a lot of impact as a person. And also, taking care of really sick people, I knew I wanted to deal with that. And then, you know, there’s always luck, and in my case, what happened is I started medical school here in Costa Rica, and we actually do our intern year as part of our med school. So during that year, I actually went to Children’s Hospital here in Costa Rica, and I was just selected to go to the oncology ward, and I worked at the leukemia program at National Children’s Hospital here in Costa Rica. So I needed to learn about pediatrics, but I learned it in hematology there at Children’s. And you know, my mentor at the time, the professor that I worked with, who is now a very close friend, when I finished, she said, ‘Oh, Andrew, you’re going to be a medical oncologist. I have no doubt about that,’ which I thought was very kind of her. But at the time, I was already thinking about going to the United States, and I actually at the time was thinking that I was going to go to the U.S. to do cardiovascular surgery or transplant surgery. I felt that I was looking for that opportunity to have a lot of impact, and at the time, I thought that that was the case. My second rotation was OBGYN, and since I was thinking about doing surgery, I asked, ‘Well, what do you do more surgery in? OBGYN is probably surgical oncology, you know, sorry, gynecology oncology, because they spend a lot of time in the OR, and nobody wanted to take that rotation because you had to be in the hospital like at 5:00 in the morning. And since I wanted to be in the OR, and I wanted to take care of patients, I didn’t mind, and I had a great experience. I did that also here in Costa Rica. And then after that, I went to a medical school called USIM that has an exchange program with a hospital in Minnesota called Hping County Medical Center, which is now part of Henip Helker, and it’s a university-based hospital. It’s one of the hospitals that is part of the University of Minnesota. So I went there, and I had to do internal medicine first for three months as part of my exchange program. And when I got there, they said, ‘Oh, these are the options. You need to choose.’ And there was the option of doing medical oncology there, and at the time, since I had done it in OBGYN and I had done it in pediatrics, I thought, ‘Well, I’ll do that while I’ll wait for my surgical rotation. Finally, I’ll get to do the transplant part.’ But at least, you know, I think I’ll enjoy that. And I had, you know, an amazing experience. I worked with a who, a person who later became my mentor. There were two of them. One was a physician who still works there, his name is Doug Rous, and also Mick Belzer, who were medical oncologists there at the time. And Dr. Rous, you know, later became not only my mentor, actually, he became my boss, and he was the one who later on hired me to be part of the practice. And we’re very close friends now. I adore him. But long story short, it was a very eye-opening experience coming from a country that we have a public system here in Costa Rica that has a universal healthcare system. So all my exposure to medicine prior to going to the U.S. was as part of the system, which is a very good system but has a lot of limitations. And I really enjoy the academic rigor that U.S. internal medicine and hematologists and oncologists have. So that was at the time something that I thought, ‘Ah, I think I really like this.’ Later on, I actually went and did my surgical oncology rotation, and I didn’t like it. So I actually had to go back and ask the internal medicine group there if I could actually apply for residency there. So that’s my short answer of how I got there. But obviously, I think that medical oncology as a field, we’re so blessed because we’re meeting individuals in their most vulnerable time. So the impact we can have on those people and those families is something that is so tangible immediately, and you can do that multiple times a day. So I think that there’s no field that I identified that gives me that opportunity and that privilege. The other part is, you know, like many of us, I’m a big nerd, and I like to study a lot. So later on, I pursue a career in academic medicine and research. But even nowadays that I’m no longer doing translational research, I’m doing clinical research, but you know, the field makes you, you have to read all the time. You know, yesterday I actually saw a patient, and there was a paper just published in the New England Journal of Medicine that I can apply to that patient. Yeah, so we need to always study, and I like to study. I like reading and learning. So this field alone gives us that. So I always, when people ask me that question, I always say, ‘Well, the impact is right there.’ The second one is the academic, the knowledge that you need to keep up with. That’s something that I love, and I like to pursue. And the third is what I take home. And what I mean by that is, well, when I go home, and I’m with my family, my wife, my kids, my parents, my relatives, oncology keeps me in a very basic place. It gives me perspective. When you’re dealing with people that unfortunately are suffering so much, and some of them are unfortunately actively dying, then you know, you take that home, and you say, ‘What’s really important in your life, and how do you want to pursue your life, and what is it that you want to do?’ So I’m always, you know, oncology brings me to that core. So that’s what I take home, and those are the values I try to bring back and think about what are we doing, what impact are we having. So it’s a kind of a deep question, but deep answer, but I hope it’s the honest one.

RO: No, it is actually the honest one, and it touched me in many points. I think I do share with you lots of commonality.My grandparents also immigrated after the Armenian Genocide, and it’s been a roller coaster for me from one country to another. And having that feeling that you have an impact on people’s life, it’s what gives you the self of fulfillment, which is something it took me many, many years to figure out, right? Because you can make money in any profession. It’s not always about the money. You can make a much higher income if you go and work in investments, real estates, or other things. But I think that self, the feeling of fulfillment, and whatever you are making is valuable. I think that’s very important to have on a day-to-day basis because otherwise, it’s just going to be very tough and challenging and boring life. And I think you brought up a very important point, and thank you for bringing that up. I still sometimes struggle with it. And because like you see patients in their most vulnerable points of life, and you see patients who remind you how blessed you are that you have your health and your family have their health. And you go back home remembering the core values. Cancer doesn’t know an age. This week, it’s been a roller coaster in the hospital. Like, I’ve seen many patients in their 20s, 30s with cancers, and that makes me a bit guarded, thinking, ‘Oh, wow. I have my health. I’m very blessed.’

AW: Yeah, and again, I agree with you 100%. The other way I see this, you know, and thank you for sharing a bit about your background, but I was born in a privileged situation by just being in a very safe family environment, you know, and being in a country like ours. So I understand many times when people unfortunately come from backgrounds that are very challenging, and that’s really their drive. To me, it was a bit different. The drive was really, since I didn’t have to worry about so many things, then it’s my responsibility to make 110% of what I have, you know what I’m saying? So since we are so privileged as physicians and oncologists and being the position we have, it’s not enough to give your 90%. We need to give 100% to our patients. So that also is the reason why pursuing an academic career was important to me because I didn’t have that in Costa Rica. But I said, ‘Well, if I’m going to do this, I have to be 100%, 110% good at it. Otherwise, it’s not worth it.’ And that’s really what led me later on to pursue opportunities abroad. And now, you know, I came back to Costa Rica to try to give back and actually to have a broader impact, different than we typically have when we’re dealing with a one-to-one patient-physician relationship.

RO: Dr. V, you have a diverse educational background, and you studied and trained in several countries. And I had even a hard time counting them from one country to another, from one part of the world to another. First, I think my question is, why? And then, how has this experience shaped your approach to patient care?

AW: Yeah, so the first one, you know, why? Again, because despite the fact that, you know, Costa Rica is a very good place to live, I didn’t have opportunities to do any research, you know, to study in-depth immunology, molecular biology. That was not part of my curriculum. So it was very obvious to me that if I wanted to pursue a career in the United States, which was my original goal, I needed to, you know, raise that bar and pursue education in order to achieve my goal. So I share a bit about that exchange program, which was my first interaction with U.S. healthcare. But later on, after, you know, I went to medical school straight from high school, which is kind of what we do here. I became a physician at a very young age. I think I was 22 or 23 years old, probably similar to you, and I was already an MD. So I had a lot of time to say, ‘Well, maybe I’m not ready to pursue residency, but I want to be very competitive and making sure that I’m the best doctor I can be.’ So then I applied to a program which was also an opportunity in the United States. I went to Boston and spent a year at Dana Farber as part of an exchange program. And it was through Brigham and Women’s, and I spent some time at Beth Israel as well through the Harvard program. And then it was really leading the academic world to the highest. And I really enjoyed the people that I was working with, and I had a mentor there whose name is Wayne Morasco. I’m always very good at making sure that those people get the credit because they were the ones that pushed me. And Dr. Morasco, at the time when I finished my rotation, I would follow him everywhere, probably sick of me, you know, because I wanted to learn, and I had a lot of energy. And he said, ‘Andrew, you know, you’re a good student, you have good grades, but you need to spend time doing research if you want to be an oncologist.’ So later on, what I did that weekend, I went home, and I started applying for, you know, he actually offered me a position to be there, but I wanted, I didn’t want to burn my J1 years and all these visa issues. So I thought, ‘Well, I’m 22, 23 years old. I can go anywhere.’ And I asked him, ‘Where should I go if I’m not going to stay in the United States?’ And he said Sweden. So I went home that day, and I actually went online and started sending emails to many places, many labs at the Karolinska Institute. And I think I sent like 60 emails, you know, describing who I was and that I was willing to go and spend time there, and I wanted to apply for fellowships for programs there. And I was so lucky and blessed that only two people answered. Of all the emails I sent, one said no, and the other one said, ‘Well, tell me more. What the hell are you thinking?’ And that was a gentleman by the name of Ral Gisling, who happened to be at the time, I think, the director of the Karolinska Cancer Center. And Ral had a lab there in tumor immunology, which I knew nothing about. But he was very generous and accepted me first as an observer, and later on, you know, I stayed there for quite a bit of time learning about tumor immunology. And this is around 2006. So, you know, all these immunotherapy things that we do today in the clinic were not really there at the time. You know, there were still dendritic cells, and I actually had a couple of projects where I was writing phase one and phase two protocols using dendritic cell vaccines at the time. But, you know, it really again opened the world to that opportunity. But I knew from the very beginning when I went there that I wanted to do residency. And before I went there to Sweden, I had already been accepted to go to Minnesota for residency. So then I returned to the States, but I kept that relationship with Dr. Kling and his lab. And again, he was so generous that every time I had elective time, he would say, ‘Andrew, would you come back to the lab because we need to finish some work?’ And then he also connected me with a program at the University of Turin that at the time was doing a project in DNA vaccines specifically for animal models that express HER2. And this is around 2008, 2009. And then in 2010, I knew that I was going to stay in Minnesota for fellowship. And I really loved the tumor immunology world already. I had learned experience, and I had already some, you know, I really enjoyed the translational research world. So that year, my third year of residency, I had time, elective time. So I emailed, I wanted to learn about CAR-T engineering, which at the time, you know, CAR-Ts were not around. So I had the privilege to work with a gentleman called Michael Kersha, who is a PI at Peter Mack in Australia. And Dr. Kersha actually had, he did a fellowship and a post-doc at the NCI with Steve Rosenberg and actually moved back to Australia to develop his CAR-T program there. So I went to Australia and spent time with him working with him, you know, for a very short time, but it was really great for me because I learned a bit about CAR-Ts before they were actually in clinical practice. And then when I returned to Minnesota for fellowship, I worked very closely with Jeff Miller, who happens to be one of the most recognized individuals and PIs in the world of NK cell cellular therapies. So that’s really what led me to these international places and my training, and again, it was because people opened doors for me at the time.

RO: Wow, it’s very interesting. It never occurs to me that, for me, like when I always think about, okay, so how you can get a residency in the U.S., it’s like always going to the big names. But in your case, you were referred to go to Sweden.

AW: I was referred to go to Sweden because, obviously, well, Sweden has a great reputation. They have an outstanding academic program. The Karolinska Institute has a great name and a great reputation, especially in the field of oncology. And I think Dr. Morasco, you know, he’s also an immunologist, so he knew about the place. But I specifically told him that I was open to going abroad, and so that’s probably part of it. He said, ‘Well, if you’re going to go abroad, I would recommend that you go to Sweden.’ So that’s how I ended up there.

RO: Gotcha, gotcha. Um, so throughout your career, you also received several teaching awards. So you’re combining a clinician, a researcher, and a teacher. I want to understand a bit more about your philosophy when it comes to educating the next generation of physicians and oncologists.

AW: Yeah, I mean, again, you know, some people identify a field, and they’re like, ‘I want to be a researcher,’ or ‘I want to be a clinical physician,’ and some people like the education component. I was again blessed, and I had the problem as well that I like everything, you know. So there are always trade-offs there. But again, when I was in residency and later on in fellowship and eventually in clinical practice in Minnesota, I always worked in an academic center, you know, and with residents and fellows. And I obviously love to teach, and I’m a strong believer that if you’re a good teacher, that means you understand the physiology behind things. If you can explain things, you’re good at it. And I was probably a good communicator. I think that also helps us in oncology, you know. So I like talking to people and relating to individuals. So I was just blessed that I always put a lot of energy. It’s not that it’s supernatural. I always prepare myself when I’m giving a talk or when I’m teaching someone. But I really enjoy that. I think that part of it is because I like it, part of it is because I had terrific mentors. I wouldn’t be in the position where I am without them. So it’s always this, you know, I need to give back as well. Now in Costa Rica, where I am, and I assume we’ll talk about this in a bit, we have the responsibility of what the next generation of oncologists is going to do and what resources they have and how we can pursue that, specifically in countries like mine, where there might be a gap in knowledge sometimes between what physicians are learning here versus in the U.S. or other countries. So I think that that’s where the opportunity is. But now I see it almost as part of a responsibility as providers.

RO: Yeah, yeah. I can’t agree more. I think the best ways of learning is teaching. One of the things that I got, I was exposed to is during my fellowship right now in hematology oncology, like, we have to present like x amount of journal clubs as well as specific teachings in hematology and oncology. And I believe the month that I have that, although preparing for a journal club or a presentation that lasts for an hour takes a full month with the clinical practice, especially in oncology, like you always go to the trials and what the trial showed and the overall survival and progression-free survival. So there’s lots of academic exercise there. But preparing those PowerPoint slides for some reason, it’s much more efficient or much more powerful for me to learn a topic than opening an article from UpToDate or ASH guidelines and reading it. Just preparing the slides by itself, it’s a huge learning exercise.

AW: I fully agree. I still have those Power presentations myself. And what I’ve been doing, you know, years later, you know, I graduated from fellowship in 2013, so almost 11 years ago. It’s gonna be, oh wow. And I still have those presentations that I did during fellowship. And what I do is actually, as new data comes up, you know, I just add a slide, you know, and I continue the story. So I’m, I fully agree. I think that we need that. And now, you know, even when I was a fellow, I mean, access to knowledge is right there. And we need just to keep up with it. But I think, you know, societies like ASCO and ASH, you know, and probably others, you know, are really pushing for this and trying to make knowledge more accessible. Obviously, COVID had a lot of challenges for many of us, but among the positive things, you know, the oncology mentality always seeing the glass half full, you know, is the fact that knowledge is becoming more available, more accessible. Therefore, it’s there. It’s just a matter of whether or not you’re studying.

RO: Exactly, exactly. Um, I was also going through your bio, and I noticed that you pursued an MBA from the University of Chicago. So all this learning, all the universities all over the world, was not enough for you. You still wanted to pursue an MBA. Why, and how’s it helping you in your current leadership role?

AW: Sure. So to continue a bit of my life story, I guess, you know, when I graduated in 2013, I really had to make a decision of what I wanted to pursue. Should I stay in an academic place, a university hospital, or go to the community? You know, I also had this handicap, and I call it like that. You know, I was on a J1 visa, so I needed to do a waiver. And also, the realities are that I felt at the time that despite the fact that I had spent a lot of years in the lab, that I didn’t have the drive to become a PI, you know, in a lab and doing all the work that they do, which I find terrific. But I just, I just knew that in order to do that, I had to leave the clinic. That’s at least how I felt. I know some people are good at doing both, but again, I’m typically very driven, and I felt that I needed to make a decision. So at the time, I decided not to stay in academics, and instead, you know, I was hired to do my first job as a medical oncologist at Hennipin County Medical Center, which is Hennipin Hker today, which again is affiliated to the University of Minnesota, but it’s the county hospital of the Twin Cities, especially in Minneapolis. And it’s a safety net place. And it was, that’s where I did my, I was there. I was a medical student. I did my residency there. I actually was a fellow there. That’s where I met my wife. So it was very obvious to me that I should stay there. And again, this is where I had a lot of my mentors and people that really love the practice of medicine. So I thought it was the perfect match. And to be very honest, I never thought I would be leaving the place. But after a few years in practice, you know, which was terrific, you know, there, we took care of a lot of patients, very diverse. You know, I was at the time, I think only, I think in the entire state of Minnesota, there were only two or three oncologists that spoke Spanish. So I had to take care of a very large Hispanic community there. And we created a Hispanic program. It was a really wonderful place to practice. I, anyone who wants to be hired at Hpin, you should go to Hopin. But at the same time, you know, around 2015, 2016, you know, I felt that I had already, I felt very comfortable as a clinician and as a medical oncologist. So I needed, I started to get that itch. I needed to do more. And a few opportunities became available, you know, actually at the system, you know, to, you know, I was part of the medical executive committee, and I really started thinking, ‘Well, if I’m not going to be able to stay in academics, you know, I’m very comfortable with clinical practice, but I felt that I needed more.’ And I felt that maybe pursuing a career as an executive physician eventually could help me be in a position where I could not merely have that impact one-on-one but have a larger or broader impact or capacity to have that impact. So I started pursuing that in Minnesota. And around that time, you know, I was approached by a group which is where I work now here in Costa Rica, which is a Hare system that at the time was interested in developing a cancer program here in Costa Rica. And I started having discussions here. And then, you know, they offered me to be part of their board just as an advisor because they didn’t know how to develop a cancer center. And I actually was trying to help them develop a cancer service line because I understood the system much better. So long story short, you know, after a couple of almost a year doing this, you know, the program started growing here in Costa Rica, and the opportunity came where I needed to make a decision either I would return to Costa Rica and work with this group or just say, ‘Well, this is becoming huge. I cannot manage it from Minnesota. I need to step away and let them pursue it on their own.’ My wife is also from Costa Rica, and at the time, we already had a child. Sam was born in 2015. So around 2016, 2017, we had to make the decision, well, we’re going to go back, or we’re going to stay in the States. But I knew that if I made the decision of coming back to Costa Rica, I was going to need a lot more administrative skills, which we clinicians typically do not have. So I actually negotiated, you know, that all right, I’ll quit my job in Minnesota. I’ll move back to Costa Rica with my family to help develop the system and develop the program. But I felt that going through an MBA program was going to give me the skills required in order to understand the operations, the administration, the finance behind running a system or a hospital. So that’s what I did. And you know, I actually did it with my wife. So my wife and I went to the University of Chicago, the Booth School of Business. We did the Executive MBA, and that’s usually about two years from 2017 until 2019. So we traveled back and forth for 22 months while my son was here in Costa Rica with grandparents. And then at the time, we were working also here to try to develop the program and the system. And yeah, so that’s really what led us to that. But again, to me, going back to the beginning, it’s always been about the impact. And I think that doing the MBA, especially now in the position where I am, I’m currently the CEO of the hospital. Obviously, I can, I understand the system much better. And obviously, being a physician, I still practice oncology. I see patients almost every day, you know, not as much as I would like to, but I have limited time. But you know, I just, before the interview started, I told you, you know, I think I’m in the perfect world because I can really do what I feel is best for me, which is being in the clinic and being in a position where I can impact society with there.

RO: Yeah, I can’t agree more with that, especially like I think three things that we don’t learn enough about when we are in medical school or even residency. There are finance, nutrition, and entrepreneurship. And we learn how to become good clinicians, and then you grab some skills doing research by observing, serving other people. But to run a hospital, to run a clinic, or to bring a product to life and make a difference in healthcare, you have to learn how to become a good operator. And this is a skill that we lack in medical schools. And that’s what I’m passionate about. I always say, like, for us, if as physicians, if we don’t step up, there will be someone with an MBA background who doesn’t understand healthcare, will be in your position today, and run that system. And there is nothing wrong with people who don’t have a clinical background with an MBA. I don’t have anything against that, but like, you should have the clinical expertise and contact with patients to understand the difference or to balance between profit and good quality of care.

AW: I fully agree. I think that also, when you’re in a leadership position, you know, again, there are different leadership styles, and I’m always with the team that I work very closely with, which are extremely talented. That you know, despite the fact that I did an MBA, I’m not an economist, I’m not an engineer, you know. So you just have to also think, what are the areas where you feel less strong and bring people that can help you with those. So we have, you know, again, we’re in a position where we have a lot of people that bring different value, you know, to our leadership, you know. So despite the fact that I’m not a finance genius, you know, we have somebody who’s extremely good at that. So I think that at the end of the day, you know, at least in our institution here, you know, is about creating a team of leaders that understand the mission of what we’re trying to do, and that we push forward to try to achieve it. You touched base a bit on your leadership style. Can you tell me, like, take-home points, snippets on leading teams, as a person with clinical expertise and an MBA degree, what are the take-home points if we’re going to summarize it in a couple of minutes?

AW: Sure. I’ll try to say maybe two things right away. One is, you know, be humble. You know, again, very young, you know, I’m 42 years old, and you know, and there’s people again in our team that have a lot more experience than I do in our institution, you know. So you know, if you think you know everything, you know, you’re so wrong, you know. So that’s the first one. The other one is again, you know, learning to work as a team, you know. And I strongly value that, you know. I think that that’s really important, and understanding the strategy as we continue to grow. And what we do here is we basically, our mission is to provide affordable healthcare access to Costa Ricans, you know, because our country, unfortunately, through the public system, doesn’t have enough capacity to take care of everyone, you know, right now. So we’re trying to develop access to care through many different initiatives. But you also have to have that drive, you know. And I think that you have to be passionate. That’s the other thing. You need to love what you’re doing every single day.

RO: You touched base also on the healthcare system in Costa Rica. I would really appreciate if I can understand more about it. Could you provide me with, like, a 30,000-feet overview of the healthcare system and how it’s structured and how it’s funded?

AW: Yeah, very straightforward. You know, we’re blessed to have what’s called a universal healthcare system here, you know. All of us pay for it, you know. And therefore, we all have the right to have access to care. It was based a bit on some of the Scandinavian systems, you know, with the big difference, you know, that unfortunately, we don’t have the budget, you know, in order to pay for all the cost of healthcare here, especially in the last several decades, you know, there’s been, unfortunately, a lot of struggle, you know, for many individuals to access the system. There are, unfortunately, a lot of waiting lists, you know, to have access to, let’s say, even basic things like mammograms or follow-up scans, you know, etc., you know. A colonoscopy is actually sometimes over a year before people can have access to care if it’s not an emergent situation, you know. So we belong to the private sector, you know. But again, you know, despite the fact that we’re a private company, we have a very strong social mission. So from the very beginning, you know, the mission has been, well, what infrastructure can we develop to develop? Initially, it was a hospital, then it became a network of clinics, and now our system provides care in over 125 sites in Costa Rica because we have different things in the system, you know. We have our own health plan. We have labs. We have pharmacies, etc. So the system, you know, is again, trying to provide access to care. And every day, our mission is, ‘Can, how can we lower the bar and make it more accessible so more people can actually come to the system if they need to?’ So that’s really how we work, and that’s how we interject with the government, which obviously does a great job, you know. The quality of care in Costa Rica, in the public system, is actually very high, which is a good thing. That’s a blessing we have, you know. So again, you always have to, there are two ways of looking at it. Oh, you know, there’s a lot of problems. We just see there’s a lot of opportunity. Costa Rica is small. People are highly educated. The distances, you know, people don’t need to travel hours to receive care. So we need to find ways to try to help the country, you know, to provide care. So that’s really how we operate here.

RO: So are both sectors available, like private sector and public sector?

AW: Yeah, they’re both available. You know, right now, there are countries where people can jump from one to the other. We don’t have such a formal relationship, you know. The government doesn’t have programs that, you know, patients can jump from one system to the other. But I’ll just give you a very brief example. In 2018, we started the breast cancer program. I think that our group right now probably, we diagnose close to 20% of all breast cancer diagnosis in the country happen in our system. Wow, that doesn’t mean that all those women receive the entire care with us, but because they were able to access, let’s say, a mammogram and ultrasound, get a biopsy if needed, and we provide all of that within a week and give them the results with an IHC, then those patients can say, ‘Well, you know, now I have a diagnosis.’ So we can shorten that diagnostic interval, and those patients now can go back to the public system and receive care, let’s say, in oncology. But if they had to do all of that diagnostic part through the system, you know, it might take them months, if not longer, you know. So again, you know, the mission has always been, where is the need, and let’s, what are initiatives that we can develop to help in where the system is lacking? Thankfully, the system is not lacking in providing chemotherapy or treatment directly, but on the other side of the spectrum is also survivorship care. You know, those patients, you know, I recently saw a patient that, you know, she had a scan done. I want to say in April. I saw her about two weeks ago. We’re in November, you know. And she had a scan done in April, and it has not been reported. She had it done in the Wow, you know. So those are the problems we have, you know. So our system, our model has been, and I say this very proudly, a great opportunity to kind of close those gaps where we can. So yeah.

RO: Gotcha. So the private system is helping as a guidance for the public system to detect those people who need more emergent care if I’m saying it correctly.

AW: You could say it that way. I mean, I also think that way, but it’s not that we’re helping. It’s just that, unfortunately, patients don’t have an option, you know. And the question is, can they afford it? Because private care is also expensive. So we’ve been, for many years, you know, our health is very accessible. It’s about $12 a month for the principal person, and then each individual family member pays $6 a month. So when we’re talking about a health plan, you know, it’s not hundreds or thousands of dollars, you know, to be part of a plan. Therefore, those type of initiatives have helped, you know, especially people in middle-income families of Costa Rica, you know, that before, they said, ‘Well, I need to receive care, but I cannot afford the private sector.’ So that’s where we have been able to fulfill a need. But despite what we’ve been doing over the last 10 years, the reality is that there are still people in Costa Rica that cannot even afford, you know, to come to our system. So we’re now working really hard. How can we develop some system even for those that have very low income, you know, because they also obviously need care, you know?

RO: Yeah, gotta. So something similar to Medicare and Medicaid in the U.S., but the Costa Rica version, I guess?

AW: So, but again, without federal funding, we don’t have any funding.

RO: Yeah, fair enough. In your opinion, how does the quality of cancer care in Costa Rica compare to other countries that you’ve been through?

AW: I think, and I say this proudly, despite the fact that I did not train here, so I’m not, I hope I’m not as biased, but when I returned to Costa Rica, one of the things that I encounter, which is a very positive thing, is that oncologists are very well trained. So physicians, you know, they pursue excellent training through the public system. You know, they’re, you know, they’re very academic-driven, you know, like many other places. You know, they always attend the big meetings. They’re always learning more. So I think the doctors and the human capital is there. I think obviously the challenge is not necessarily in our case, you know, it’s not necessarily that the providers don’t have the knowledge or the training. It’s actually accessing the treatments, you know, and the cost of care, specifically cancer drugs, you know, which are so expensive. So many doctors have experience, let’s say, or they know about a lot of the molecular drugs or the immunotherapy drugs, but some of them have never used them because the public system might not offer them, you know. So that’s really the challenge. So that’s really the reality of how Costa Rica operates. So the biggest challenge that faces oncologists is giving patients access to the appropriate treatment if I’m saying it correctly.

AW: Yeah, and I think that’s true obviously in the public system but also in the private sector because you know when I meet patients, you know, you have to be very careful because obviously, we follow NCCN guidelines here, as an example, or ASCO or ESMO guidelines, you know. But whatever it says on the guideline, I might not be able to offer to my patient because they might not afford it, you know. I know there are resource-stratified guidelines, but again, those guidelines have limitations in countries like us because we might have access to a few things, not others, you know. So but to, and again, we need to personalize care at the end of the day. And there might be patients that might have private insurance, and they could afford care, but when I have to take care of patients that do not have private insurance, you know, I also have to be very respectful and not offering them treatments that, unfortunately, they won’t be able to get through us or through the public system. So that’s where you need to find the right balance and be very careful and very ethical about, you know, what, which is the way you can. I always tell my patients, ‘I’m not here to treat you. I’m here to help you.’ And but what I mean by that is we’re going to try to figure these out. I’ll give you examples. For this breast cancer, you know, that’s been the area where I’ve been focusing the most clinically. And many times, you know, we talk about neoadjuvant therapy, you know, and all these things. But here, the decision is, some, ‘Well, yes, I would like to give her neoadjuvant, but what if, you know, the system is not going to be able to get her the right drugs?’ And actually, in order to get, let’s say, neoadjuvant treatment, she might have to wait, I don’t know how many months. So as an example, for let’s say luminal A localized or locally advanced breast cancer where sometimes you would like to probably shrink the tumor so patients can undergo breast conservative surgery, sometimes we cannot offer that here, and we have to elect pursuing surgery upfront because at least we know those patients can have surgery. Otherwise, you know, they might actually develop metastatic disease if we just keep waiting for the neoadjuvant therapy. So those are the type of decisions we have to face here sometimes that are challenging. And I’m sure they’re not exclusive to our reality for many.

RO: No, they are not. No, they are not. I completely agree with you. I think it’s similar to other countries. We were talking about earlier about my interview, Dr. Vaki, and it’s very similar there. And I also trained in Canada. In Canada, it’s completely a public system, so there is no private healthcare sector unless in some parts of Quebec, part of the, the Quebec part, the French part of the country. But it’s interesting because like in Canada, we do have, I think it’s also different economics of the country. We do have access to most, if not all, most of the treatments, as you said. And it’s a question that always comes to me. I experienced the fully private healthcare system in Canada, and I’m experiencing around the, sorry, the fully public, and I’m experiencing the extreme end now in the U.S. where it’s mainly private. And you experience also a mix of both. Do you, how do you envision, there is no perfect healthcare system, but I would love to hear your opinion, like if you want to restructure the healthcare system in a perfect world, how do you envision is the best way of funding healthcare?

AW: I’m gonna be very honest. I find a very hard time answering that because you need to understand a lot of the realities of the different countries we’re talking about. I don’t think that a model that works in Costa Rica might be something that you can extrapolate easily to other countries if they have different socioeconomic, cultural, political characteristics, you know. So obviously, there are, and I’m not an expert in this, obviously, there are people that study and do this for a living, you know. But since I’ve been able to practice in the U.S., as an example, I’ll actually give you the other side of the coin. You know, we all recognize that we, we even think about cost in the U.S. When I practice there, nobody’s asking me, ‘Well, doctor, what is the cost of my treatment?’ Very, very few questions. And we don’t, as physicians, we don’t even think about it. In this part of the world, when I meet with patients, one of the first questions that comes to the table from the physician, sorry, from the patients and their families is not about, ‘What’s my stage? What’s my prognosis?’ It’s, ‘What’s going to cost me to receive care?’ So people are extremely sensitive to this, appropriately because they need to make decisions. And that’s obviously, you know, it’s great to be in a position where we don’t have to think about that, but somebody’s paying for it in the U.S. or somewhere else. Trust me, you know, we all know that. And so I think that there’s always, you know, two sides of the coin. Um, again, talking about Costa Rica, which is obviously the country where I practice and where I have more knowledge, I think that Costa Rica’s system is good, you know, because we have that safety net, you know. So again, you know, that’s great. And again, the quality of care in the public system is terrific. I think the country is just struggling to, you know, as healthcare cost is rising, you know, and we have a limited budget, you know, appropriately, the government has to make decisions on how can we provide care. And sometimes they have to decide, well, if I’m going to accept a therapy that costs hundreds of thousands of dollars after several months, you know, what could the government do with that money is probably treat or open clinics or, you know, open capacity for other medical conditions. So it’s very, you know, it’s very challenging from an ethics perspective as well. So I feel it would be disrespectful for me to tell you, you know, my, you know, I don’t have an answer, but even if I did, you know, because I think that each country is different, you know. We provide care through actually here to a lot of patients from Central America. You know, we have patients that cross the border to receive care here in Costa Rica. We have a program with Nicaragua where a few patients can actually receive radiation there. So they come to Costa Rica, and they get chemo radiation for cervical cancer, head and neck cancer, and then they go back. You know, one aspect that I think is, I want to bring this up, you know. Yeah, this is something actually we’re writing a couple of papers through ASCO and JCO and the Journal of Global Oncology that are going to be coming up. But is how can we use research to, you know, as a venue to provide care? So we started a research institute is called the Metropolitano Research Institute. We’re an SMO, a management organization. We started this in 2020 during COVID. Great year, a year, you know, to get it started, you know. And now we have, you know, the staff is terrific. We have about, you know, 12 people working fully dedicated to research, clinical coordinators, and all of that. And we trained almost 50, 60 of our staff, you know, in all the best practices, etc. And now we have over 20 clinical studies that, you know, we can offer to the Costa Rican population. So they can receive care through clinical research, you know. Um, and I think that’s a model that obviously is difficult to scale because we depend on what type of studies come to countries like ours. But the impact we’re having through a clinical research program is outstanding because we can really bring patients that there’s absolutely no way they could receive the care they’re receiving unless they were part of a clinical trial. And I’m not even talking about those that are getting treatment through the treatment arm. I’m even talking about the placebo arm because those patients otherwise might not get access to care at all. And I could spend hours telling you about how many patients we’ve screened for a clinical trial that at the end were not able to enroll, they failed screening, but because of part of that screening, they got their biopsy and their staging, and now they can go to the public system and get care. Oh wow. So I think that we need to, you know, and those are the things I think we need to focus on. You know, I can’t change the Costa Rican law or policies, you know, which obviously we all need to get involved. But in my world, you know, those are the type of things that we can truly do to bring value and to bring access to care. And I think that that’s something that can be replicated, you know. And especially we as oncologists, you know, through our associations, we can create policies in order to bring more research to this part of the world.

RO: That’s very interesting. You can pursue research at the same time you can provide care for patients in need. That’s a very interesting insight that I never thought about because like I’ve never been in that part of the world. But like, it’s a great way of looking at it. Also, you’re advancing science at the same time. Like, it’s a win-win situation for everyone.

AW: Indeed, you know. So again, I think that the biggest, I’ll be very honest, I mean, the biggest challenge we have to grow the program now is convincing sponsors to come to Costa Rica or countries like ours to do research. And we have the quality. We have the, you know, we have the SOPs, you know, and not only us, other people doing that here in Costa Rica and in the region, you know. So we need, you know, people to look into, you know, this as an opportunity, you know. And convince them, you know. It takes time, you know. I’m not very patient, as you can see. Sometimes momentum, but there is lots of energy. I can see that for sure. I can see lots of energy and lots of passion. I love it.

RO: Alright. I don’t want to take more of your time. It’s almost 5 o’clock. My last question, so what advice do you have for early career oncologists?

AW: Oh, god. Um, I think that again, you just have to pursue what makes you happy. And that sounds very simple, and excuse me if I say the word dumb, you know. But you need to sometimes step back and say, ‘What is making me happy? What’s important to me? And where do I see myself, you know, in the next five years, 10 years, etc.?’ And then once you, it’s always not, I guarantee you, it’s never going to work the way you thought. But as long as you can start thinking about what is my next step. And I think my story is an example of that. You, if you pursue that with your heart, then the doors will open. It might not be the doors you were thinking, but the doors will open. And as long as you’re very passionate and you work extremely hard for that, you will get somewhere. It might not be where you want it to get specifically, but in hindsight, I think that having that open mentality and focus on what’s important is at the end what matters independently of if it’s in this hospital or that institution, etc. And the reality is that you can always change, you know. As I mean, this is not a contract, you know. We’re just making decisions as we go. So I think that my personal experience, you know, I’ve learned from that, you know. And I always, you know, after a few years where I’m in a position, I said, ‘Well, am I fully content here, or are there certain things that I still want to pursue?’ And you know, we always keep learning.

RO: Sweet. Thank you. Such a pleasure. Thank you so much. I appreciate it. I really appreciate your time, and it’s been a pleasure. I learned a lot, and I’m sure everyone who’s listening to this also will learn a lot today.

AW: Thank you. Such a privilege and an honor to be part of this. Thank you for inviting me.