AHLA's Speaking of Health Law
AHLA's Speaking of Health Law
GC Roundtable: International Health Care
Sarah Swank, Counsel, Nixon Peabody LLP, speaks with Robyn Diaz, Senior Vice President and Chief Legal Officer, St. Jude Children's Research Hospital, and David Rowan, Chief Legal Officer and Chief Governance Officer, Cleveland Clinic, about issues related to health care in the international arena. They discuss what it means to be an “international organization,” international outreach and collaboration, considerations for engaging in international operations, and how international engagement can be rewarding for a health care organization.
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Speaker 2:Hello everybody, and welcome to today's podcast. Um, today I have with me two amazing guests. Uh , my name is Sarah Swang from the law firm of Nixon Peabody in the Washington DC office. Um, I have today with me, Robin Diaz from St . Jude's Children's Research Hospital, and Dave Rowan from the , uh, Cleveland Clinic. Uh, Robin, do you wanna tell us a little about yourself and introduce yourself?
Speaker 3:Sure. Thanks Sarah , and it's a pleasure to be here today. Uh, I'm the Chief Legal Officer for St . Jude Children's Research Hospital. I've been with St . Jude for about 13 years, and I oversee the legal affairs technology transfer compliance, internal audit and government Affairs teams. St. Jude is a specialized teaching hospital and a degree granting institution based in Memphis, Tennessee, which has a group of affiliates at eight other sites in the south and the Midwest, which contains St. Jude co-branded pediatric hematology clinics. We focus on pediatric hematology, oncology and infectious diseases, and we have patients from all 50 states and all over the world.
Speaker 2:Excellent. Thank you Robin. And Dave, do you wanna introduce yourself to the audience?
Speaker 4:Of course. Thank you, Sarah , and nice to , uh, participate with you, Robin and, and , uh, joining all of you. Um, I've been Chief Legal Officer at the Cleveland Clinic for around 28 years. Uh , few changes over that period of time. I have government relations reporting to me. I'm the Chief governance officer as well, and the secretary , uh, the Cleveland Clinic is not surprisingly based in Cleveland, Ohio. Uh, we have 14 hospitals in , uh, other places in Ohio and five in Florida, and some other sites we'll talk about in some international locations. But you'll have plenty of time to hear about that as we go through the program. Nice to participate and , uh, nice to do this virtually. Thank you.
Speaker 2:Excellent. Excellent. Great. So today what we're gonna talk about is international healthcare and you know, we're doing this podcast with the American Health Law Association, but we all know that we have in our careers as health attorneys , especially when you've been in house , we've all bumped into or fully dove into international issues. Um, so that's what we're gonna spend our time talking about today. And I think one of the things , um, I wanted to first start with is th this concept of , um, what, what does it mean to be an international organization? Right? So, you know, there there's two, there's a couple ways to look at it. Um, one is that you may have patients that are coming that are to your facilities that are from other countries. You may be doing work outside of your , uh, outside of the country. You may have, like Dave, I'm sure you're gonna talk about, you alluded to, you may have facilities and , um, arrangements. You may have people have medical students and others. So what does it mean, Dave, what does it mean to you that to be an, an international organization?
Speaker 4:So I think that , um, that it means all the way you've just mentioned Sarah , and I think that it's increasingly international. Like most businesses , uh, clearly we have most of our operations in the United States. Um , but, and I won't go through all the facilities, but I think it's, it's dealing with those patients who come either in virtually or physically into the us . Uh , it's also a lot of research and education efforts that I know we have. And I'm , I know that Robin will speak to it of , of training of people in the United States and vice versa. Um , I think also , uh, when you look at research and then the information internet boom, and then AI and everything that we're seeing the exchange of information , uh, on the research field, the education field has made it a lot easier to read images internationally. It's made a lot easier to, to do consultations , uh, and the world is definitely shrinking. And I think that the interaction with a lot of things, innovation , uh, not just direct patient care, but other activities , uh, makes it an exciting period of time. Indifferent. And we'll talk about the patient care activities in , in a few minutes. I know .
Speaker 2:Yeah. So Robin , what does it mean to you to be an international organization?
Speaker 3:Sure. I'll echo a lot of what Dave said. Um, we, we do all , all of those things other than having an international facility footprint overseas. So we are really focused on improving the survival rates of children with cancer and other catastrophic diseases worldwide. So we do, as, as Dave said, a lot of training of the workforce in low and middle income countries. Um, strengthening train training programs by developing centers of excellence and offering physicians from low and middle income countries and opportunity to take part in our programs administered in their home countries. Um , we establish a lot of consortia that are focused on advancing knowledge , um, around the globe. And we collaborate with international partners of all kinds. So that might be the World Health Organization, it might be hospitals or foundations in other countries , um, again, in order to share knowledge. And , um, for us it's also , um, about being a degree granting institution here in the us but that focuses on global child health through one of its programs. So we have a master of science degree in Global Child Health through our graduate school of biomedical sciences. And scholars for, for that program are primarily from overseas , uh, conducting research that hopefully they will eventually use to advance cures in their home countries.
Speaker 2:Excellent . It's interesting. So , um, during the PA pandemic, we got to hear the word who a lot, and Rob and I just heard you say who, right, the world , um, health organization. Uh, in fact, I , I think a lot of people were tracking and going on the website of the who when they were looking at let's just a pandemic and looking at the numbers. Um, and then these , these kind of terms like global, global , um, healthcare and, and this interconnectivity about like improving outcomes globally. Um, and so some people that might seem maybe not new, but like things that maybe not was on their radar as much. Is that something that you, that you were already working on and do ? And then do you feel like your organization that became a bigger focus or, or just got more attention
Speaker 3:So I can start? Um, so it was definitely something we were already working on. We, for, for many years had something called an international outreach program, which was , um, focused in certain low and middle income countries in specific regions of the world. And again, the, the , um, focus was humanitarian and it was on advancing cure rates in those countries. And we had our first major collaboration with the World Health Organization in 2018 when we became the first W H O collaborating Center for Childhood Cancer. And we committed 15 million at the time for the creation of the Global Initiative for Childhood Cancer, which is about getting governments involved in building and sustaining local cancer programs in order to increase survival rates. Um, and we have a goal of , um, increasing survival rates in low and middle income countries to 60% by the year 2030 . So definitely something for us that was on the radar before, but has expanded throughout the course of the pandemic.
Speaker 2:Yeah, that's a , that's an amazing initiative, and to hear those numbers is , is really impressive, the impact that your organization's making. Uh, uh, David, do you , did you, let me ask you the same question. You know, in , in involvement in, in global healthcare , I know the Cleveland Clinic is , um, is involved. Do you feel like that that was already obviously happening before the pandemic? It hasn't expanded and has the awareness expanded around it?
Speaker 4:First of all , uh, Robin , those are extremely admirable activities and I applaud you for those and, and I think that the cooperation on international health matters. Uh , Sarah , just to answer your question, I think that there , obviously there was a lot of activity going on before , um, but when you just look at vaccine development and other things that , uh, it really gave people an opportunity to bring to the forefront things that had been thought of or worked on. So absolutely an acceleration of what was there. I'll just go into a couple of other areas that I think that, that , uh, certainly the Cleveland Clinic tried to help , uh, in shortages. It appeared in other countries. Of course, we had our own shortages, which , uh, in supply chain brought us all kind of together to cooperate. And I think that , uh, that also meant that , uh, researchers who have traditionally participated very collaboratively across borders and states and whatever , uh, really came to the forefront in some , uh, I mean testing research, laboratory work. We, they , they would joke that they suddenly had their, their moment in the sun working with lots of other people around the globe. We've talked before, Sarah and and other podcasts with respect to how healthcare institutions in the US really , uh, I mean I'll just say in the state of Ohio and the city of Cleveland came together and cooperated on those things like testing and the like , uh, did so collaboratively. And I think we all had, let's say, other organizations internationally where we tried to help and, and really , uh, cover shortages collectively. Also, I think that if you look at other areas where there've been a lot of collaboration apart from Covid, I mean just look at, we all kinda watch the flu numbers develop in Australia and see is that predictive with regard to the northern hemisphere, I think that there's been a lot more information flow, not just at the research level, but it permeates the institutions a lot more activities . And I come back to the technology, it's much easier , uh, to share information, share results , uh, and the like. And so I think, no question of acceleration and I don't see it going back clearly. It's just an avalanche.
Speaker 2:Amazing. Cuz I was thinking about technology, I'm thinking about a project I worked on, this is of course it's outside council on a , on a project and being excited because iPads were new <laugh> and that we could imagine like a iPad or a tablet like sitting in another country. I'm sure you were , I can , you're like thinking probably back in the same moments and, and what would that look like because these projects that were , we're trying to move forward were not, not stalled, but they were really hard to, to do because of the technology. And now it , it's like, well, of course not, of course there's technology everywhere, but of course it'd be easier for us to bring that technology to another country. Has that, and I heard David, I hear that theme of like technology. Um, Robin , has that been something that you think has been a catalyst to, to growth in, in being an international organization?
Speaker 3:Sure. I mean , uh, you know, we, we obviously can talk to people all, all around the world through all virtual conferencing , um, capabilities. So that helps with , um, education. It helps with perhaps diagnosis in some contexts. Um, we know many organizations have moved toward telemedicine including , um, in , in the foreign , uh, arena. So, so yes, absolutely, I think it has helped. Um, a and yet there's still lots of value in, in being there face-to-face and, and having that interaction. And so that's been a , a huge challenge during the pandemic, but, but happy to get back to being able to have some of that on the ground con contact, especially in , um, countries where we're trying to get to a point where we, where we, where we have trust and um, we can collaborate with our partners in those countries.
Speaker 2:Yes . Uh , the theme, and David, you brought up this theme cuz we keep talking, I kept hitting audit , which I think is just wonderful that some , a positive out of the pandemic with this theme of collaboration and coordination , um, together. And so it sounds like internationally from your organizations, you felt that not just within your, within your state or even within the country, but even outside of the country is what I'm hearing from both of you. Um, yeah , I think one moment from me that was touching, and I would love to hear yours , um, was actually being on a international call around supplies , um, related to , um, you know, war and disputes that were happening, right. And refugees and hearing people like the same thing we were happening during the pandemic around, like trying to move masks around or p p e in the United States or ventilators. But, you know, hearing, you know, about the, the almost call to action that people felt around , around ensuring that people had what they needed to care for people. Did , did your either I , I'll , I guess I'll start with you, Dave. Did your organization or did you personally have stories around some of this kind of call to action or , or outside of the United States?
Speaker 4:Um , yes, indeed. And I think that it's, while we look back now , uh, it's good to reflect what it was like the first week in or the second week out when we didn't know what was gonna happen. And , uh, so we all had to build in the potential for capacity probably beyond and clearly New York , uh, Detroit, some other facilities, I mean, experienced more than than many others. But I think there was, coming back to that collaboration, certainly we tried to provide personnel and some resources to other hotspot areas because they stood ready to do the same thing back , uh, internationally, we were all scrambling for , uh, I mean things about things now that seem unbelievable that we're trying to get masks and gloves and things like that. Uh , and so sourcing that internationally, I'm sure we, we all had about a hundred stories about people who had access to masks and, you know, as my uncle or somebody else like that. Uh , but it , it's, we came and we evolved and I think that we tried to deal with, it was difficult in an international area with regard to getting supplies to somebody. I mean, it is just overwhelming. Many times it was providing money to the American Red Cross or somebody else because the logistics of trying to ship your own material overseas, although we had some situations like that. Uh , but I think I come back to the information flow and just how people cooperated. Uh , what worked, what didn't work , uh, was pretty amazing. And frankly, it was good to see a lot of the regulatory barriers come down, certainly in the us . Um, and I mean, just take a simple example, ventilators and people figured out how to make it into two operating , uh, one into being able to serve two patients. And really it was, it was relatively easy to get the kind of regulatory approval. Um , but I'm gonna stop at that and hope that we don't have to experience this again very soon.
Speaker 2:Right, right. And , and Robin, like what I know you and I actually even chatted during <laugh> some of these like d discussions around like , um, making sure that for example, children in other countries that were , um, fleeing with their families had what they need. Like what was your organization's response or some of your own personal stories are related to that?
Speaker 3:Sure. The , the best example I have is, is not covid specific, but happened during the pandemic and it was around , um, determining how we help patients who were , uh, underactive treatment in Ukraine following the Russian invasion. So , um, we initially worked with a foundation in Poland to launch something called Safer Ukraine, which was a humanitarian effort to provide safe passage for childhood cancer patients and their families out of Ukraine into Poland , um, where they could be evaluated by clinicians in Poland. Um, and then a, a process determined for figuring out logistically where to triage them to. So they were evaluated in this clinic in Poland and then , um, their medical rec records translated and they were resting and recovering in the clinic in Poland while awaiting assignment to a clinic , uh, perhaps in Poland and perhaps in another country for continued treatment. Um, so the safer Ukraine team, we had a virtual command center here in Memphis, but we also had some team members who were in Poland and they were working with each receiving country's government to ensure coverage of medical costs. And as the program grew, we had assistance from partners in Romania, Spain, Germany, Italy, Moldova, and of course Ukraine and Poland. So it was amazing , um, effort. And we, we did have some Ukrainian , um, pediatric cancer patients who came here to St . Jude as well. So , um, quite an effort and, and just something that was a amazing to watch unfold.
Speaker 2:Yeah, I have to say it was , um, having, talking to different people in the US who were trying to put efforts together, you had such an organized effort, it really, it really blew me away to , to hear about and , and
Speaker 3:That was , that was because of the relationships we had pre pandemic. So we would not have been able to do that if we'd had no relationships already in the region. But we already had strong relationships in Ukraine and in Poland, and so we were able to react quickly and, and partner with the people who were already on the ground.
Speaker 2:I think what one of the things I'd like to, to talk to as well is like, I know Dave like a lot of how your work also is very , uh, mission driven . So I'd like to talk a little bit about like how these these programs are tied , uh, back to your, to the mission of your organization.
Speaker 4:Yeah, and I'm gonna keep saying Robin, very impressive. <laugh> <laugh> .
Speaker 2:You can do that cuz I agree. Which is why thank you . Right ? Like , I always like to keep connected with Robin, so <laugh>,
Speaker 4:There's nothing like a crisis to break down some of the international barriers. And it's great to see efforts that really help people directly. So again , great. Um , I think that one thing I'll talk a little bit about how we've kind of viewed international operations, and I'm gonna put aside like research education programs which have really gone on for decades of , of educating people coming here and vice versa, which really gave us a lot of found , uh, a lot of connections throughout all areas of, of , uh, the world for people who have those connections, who may want us to then provide some kind of affiliation or something like that, or even build a hospital or run a hospital , uh, overseas. Uh , and I think that what we always try to do is to make certain there's a cultural fit, realizing that we're in a , a different culture, but that , uh, the dedication to quality, patient safety, trying to treat patients of all types with all of our culture values and diversity , uh, that's really at the bedrock. And when we look over what we've done overseas , uh, that when we have provided our name to a hospital, a facility, we won't just do it without having all of the normal due diligence, the protections in place. So there are our cultural values as well as the, the focus on patient safety quality and, and other similar approaches that those are insured. Um , and we also say that if that we're somewhere and it's not working out, we all , we're gonna take our name, our approach, because we're not gonna lend our name just in operation now. Uh , sir , it's okay. I'll just talk about a couple of them. Please do . We have , uh, been in various places in the Middle East and working in gen , uh, conjunction with Moola Healthcare , which is essentially the sovereign wealth fund in a U E E located in Abu Dhabi. Uh, we began many years ago , uh, really around 2005 with respect to a planning project for a hospital in Abu Dhabi, which opened about four years ago. Um , and that was a hospital where we , uh, hired, we don't own the facility, but we manage it. We hired all the physicians, all the caregivers set up systems similar to what we use on an employed model in Cleveland. And that has operated very successfully , um, in very close ties with regard to metrics, quality, patient safety. And so that, that's clearly a , a very significant operation that really gave us the opportunity to transplant our culture using the great resources and the culture that we found in the uae . More recently, we started , uh, and built a hospital in London where we're the owner and we started , uh, really from the ground up, are actually in the basement building a hospital. It took many years, it's now open one year, and in doing so, it was very important to really make certain that we honored the culture of the n h s of the very important part to all British citizens. And again, we brought , uh, our own physicians caregivers, but it's really 90% plus with , uh, UK based physicians and caregivers, nurses, doctors, and other people really using a situation where we, we took the best of, we thought the UK healthcare system and the clinic and really had that kind of approach. And I, I, there are other examples, but I think that you always have to seek out people or locations that your culture is gonna be comfortable or at least honored. And I'll leave it at that for right now. But those are a couple of examples. Those are heavy footprints so to speak. But we have many other ways to connect , uh, through connection programs alike that we might talk about in the future. So I'll leave it at that, Sarah .
Speaker 2:Yeah, so I guess one question first of all, now Robin and I get to applaud you and now you know why you're both on this podcast, <laugh> Robin is gonna applaud you. Um , and I'm too , um, so, you know , um, w I guess one of my questions for you haven't like worked on, most of my program programs have been more virtual, right? And I really like what Robin said about the connections you have and how you grow. You think about where maybe your medical students are, where you have touches on , um, research and you, you use those connections. I think also you , I'm hearing you do say is also the , you also do look at culture and fit and mission and, and , and often those, they , if they, if it goes well, they align , um, sometimes it's need too, right? There's a need and you have to decide, like you said with your due diligence. I'm just wondering with, with all that, what do you think some of the biggest challenges are when you're like in your experience having, having , having, I know you personally have gotten on planes and done things and done negotiations save cuz you and I have chatted about them. But like, what are , what are some of the biggest challenges that you , you think you faced doing, doing this work or, or going into these other countries to develop these kind of programs or, or brick and mortar?
Speaker 4:So I think I'll , I'll make this a generic, not speaking about either one of the particular projects specifically. Yeah. Uh , but I think that as you , uh, I mean, you have to be very aware of some of the bedrock issues and really have a team approach to looking at opportunities because there are always , there are a lot of opportunities where people want you to manage a hospital or a facility or something like that. So that you need to have a team that's savvy about tax issues. You need to know what the medical malpractice environment is. You need to know a lot of other obviously , uh, the cultural issues that are going to be there. Uh , but you have to have that team of teams with the HR people and the like. And because there , there are so many hidden costs or reasons to, you know, be careful. But if you've got a team that's familiar with them, it , it helps you look at transactions or potential transactions and say, this is not gonna work or it's got a chance to work. Um, and just to take one simple matter, I think that medical malpractice risk, I mean, I know that we've got a captive insurance company, which lets us really look at opportunities really anywhere around the world. But then you have to think about, okay, how is a caregiver treated in that particular country if something goes wrong? Um , and in all the things lawyers do regard to negotiating deals, choice of law, arbitration, that kind of thing. Uh , I think that one of the things that I've done where it's at least really a greenfield opportunity is to seek out, it's not gonna be that you're gonna find an international health lawyer sitting over there in one of those countries, but occasionally you do. But I I typically, when it's a greenfield, when I say I , obviously other people are doing this too , uh, internally, but find an international corporation and just kind of sort out what it's like to practice and might be totally outside of healthcare , but just people that you can sit down and talk with and what's it like to be a general counsel ? Where are the key issues and like to sort those things out. And I mean, then obviously , uh, as we've talked, Sarah , I , I like to negotiate mm-hmm . <affirmative> , I like to do those deals. Um , but these are ones you need to realize that you're not gonna be able to nail everything down because I mean, telemedicine is developed in some countries, not in others . And I've always found that, that you need to have that governance mechanism to anticipate the problems and work through them to make it survive and thrive. And it's, it's, it's interesting. It's exciting. And uh, I think that it depends on what country you're in. It just does <laugh>, which is kinda so ob obvious.
Speaker 2:Yeah, no , it's obviously, yeah. When you're advising somebody that one place you might have very detailed laws. Another places it , you're telling someone, well, there is no law, or it may be a diplomatic initiative and not a, like a black and white regulation that we're , you can hand somebody and say, this is what you, this is your path forward in this country. So , um, so Robin , I'm gonna turn to you now. Do you wanna comment on any of this ? Of course . I hundred questions for you too, but
Speaker 3:I'll just chime, chime in on what you were just saying, Sarah . Um, an ad that, that's not necessarily intuitive to healthcare providers or scientists, right? They, they and , and , um, they're, they're frustrated by it, right? Because I , in, in the context that my organization, they're trying to do humanitarian work and , um, there are all these obstacles in their way. So, so it , it's very challenging to get them to understand that yes, the laws in each country really do vary , um, sometimes dramatically. And they're rapidly changing. I mean, if you think about just the privacy realm, how quickly laws are changing , um, how many countries have their own privacy regimes now, it's, it's a lot to stay on top of. Um, geopolitical risk is another thing we're , we're having to think about a lot , um, you know, new hotspots sort of , um, appearing all over the globe and, and figuring out what what do we do to keep our staff safe in those environments? Um, and then the, the cultural issues around negotiation have been , um, very interesting for me. If you, if you even think about arbitration or mediation provisions and mechanisms and how they're handled in each country. And , um, I mentioned earlier that we have this global alliance, well, we have 244 healthcare institutions now, part of this global alliance in 70 countries. And as you might imagine, a lot of those would, those entities would like for their countries , um, for , for the governing law to be in their country , their country, and the venue to be in their country. And of course, we can't do that, right? We can't , um, we can't expose our organization to , uh, practically every jurisdiction around the globe. And so it , it , it's, it's challenging to hold the line on that and, and to figure out if there are circumstances where we might make exceptions and, and be willing to bend on those things. And so , you know, it's a, it's a negotiation each time and trying to be really respectful of that organization's circumstances and the, the structural and cultural , um, scenarios that they're dealing with.
Speaker 4:Sir , I might just jump in and find what Robin is saying about your, the care we call a lot of our employees, even the lawyers, caregivers. Um , and I think that, that, I mentioned before a team of teams. We have an international and global patient services group , so they specialize in, in this. And we have , uh, a couple of lawyers who, I won't say embedded, but I mean, they are, they're just like tax people , just like HR people. So they're, they're there to spot the issues from day one. I think that dealing with , uh, our caregivers , uh, I use that term for everybody is that it's all of those things. You're going to be safe. You're going to know who to call. You've got communication links , you've got that geopolitical, something goes wrong that, that we've got your back so to speak. And then just the little things that people come with, they're going live overseas or be there that you have trained people who have been there or whatever. That's really important. And I think that, as Robin said, I mean, what we, and you know, Sarah , we all try to break down the barriers so that the researchers and the educators and the , and the the clinicians can do their work collaboratively knowing that we do have, we've been there before. We've got the systems in place to protect them . And if something goes wrong, if it , I mean, in some cases it's an auto automobile accident, but if it's in a wrong place, you need to know that we've got somebody that they can call. And it , it really, it's, it's that , uh, international operations group, and I'm sure you do Robin as well, who they're there to take that call no matter what time it is.
Speaker 2:Yeah , that's, I , that's amazing support for people. Um, and also just the, the concept of , um, caregiver being used so broadly, Dave, including us lawyers, is <laugh> . It's pretty remarkable, honestly. Um, especially the , maybe, especially as lawyers, that's my lawyer joke for the day. No , um, <laugh>, although I , I, I think the three of us actually might have that true philosophy, like in our hearts actually think that we are trying to care for people and are , I always think it's like I'm caring for the people that care for people or caring for the people that care for people that care for people. And that's, I think what I think, I believe knowing both of you drives you as, as well. Um, so I guess one question I have also is like, personally like this work, like what has it meant ? I'll start with you, Robin . What has it meant to you or how has it like fit into like what , you know, we always think of like our career path, like what drives us in and what interests us? Like how has this work fit in international work fit into to , to that vision of yours?
Speaker 3:So , um, I love being a health lawyer because I love feeling that I facilitate the provision of, of high quality care. My, my assistance to healthcare providers helps ensure that they're providing high quality care. Um, and so thi this is no exception, right? Um, we as , as we learn more about how to improve care in other countries and we try to break down barriers to high quality , affordable treatment, I, I feel like I , I can contribute to that and, and, and maybe in some small way, right? Hel help patients in , um, low and middle income countries survive a pediatric cancer diagnosis that they might not have , um, survived years before. And so , uh, I , I feel like as a lawyer, I'm doing humanitarian work while working for a company. So it , it's, it's a pretty amazing experience and , um, something that I think is valuable for our whole team.
Speaker 2:Excellent. Dave, how about you? What are you, how does this work fit into like your vision of what you wanted to do as an attorney? And how does , how does it fulfill you personally?
Speaker 4:I think probably Elise , I'll just say you have to be in the right place at the right time, a little bit of luck, and then hope that you're doing something you really like to do. Uh , one thing at the clinic, I've been given really the, the ability to recruit what is a great team of lawyers who work really collaboratively with their clinical research counterparts and education. So I think I, I hire well and delegate better so that , I'd like to say <laugh> , so and so, it's a great team, including on the international side because way we're organized with subject matter experts, meaning the international lawyers have the special, they know how to deal with particular tax issues and a like , but they call upon , uh, HR people, they call upon other people within the organization, both lawyers and otherwise to put it all together. So I think that , um, I did some international where I was with a large law firm, so I had done some international negotiations. It's really interesting and I, I hope both of you remember what the Aaron curtain was, at least from maybe when it was already down. But I got to go right after, not with the clinic, but right afterwards. And seeing developing economies and working , uh, on projects was always fascinating. And I got to do that at the clinic. I mean, it's, it's a great place to work. Um , you get to be a, a counselor. I think we all want to be in a , I think we all want to be in a position where you're a lawyer, but you're also counseling on projects. And when you do that, you're part of a team that protects the reputation, the culture of the organization. And in the international field, just like, I mean, if you're doing a deal in another state that learning those local issues, learning what's important, bringing the people together, working collaboratively and, and again , uh, delegating because they're great lawyers who work on these things now day to day . But I've been able to work on transactions over my career, and that's what I like to do. And , um, there's clearly a great group of people who have developed skills and, and taught me lots of different things. So you gotta be lucky.
Speaker 2:<laugh> , um, Robin, do anything you'd like to add to what Dave just said?
Speaker 3:Um, I , I'll just say that we, we all have something similar in that we have , um, an international affairs and compliance practice group. We also have a separate privacy practice group. Um, our operations are a lot smaller than, than Cleveland Clinics, so probably different sized team. Um, but absolutely it's important to have those, those people with that subject matter expertise who are, who are seeing the volume regularly. And so , um, know, know how to spot those red flags and also have the contacts in the right departments, like, like Dave said, know when to go to hr, when to go to the benefits team , specifically how to coordinate with payroll , um, with respect to, say, an employee who is working overseas for some period of time. So, so just people who have those connections and know how to, how to spot the right issues.
Speaker 2:Yeah . And the , um, what , what I'd also like to talk to about , um, also is the concept of people coming to, to you all. You are both at organizations that are known in the, in the United States, but are are internationally known as well. And I just wanted to hear a little bit about your, your experience and, and with your organization related to that. So, I don't know, Robin, if you wanna talk a little bit about your organization as a internationally known organization , uh, where people come from, other countries to seek care , uh, in , in , in , on your , in , on your actual property.
Speaker 3:Sure, sure. Um, so we , we don't seek that out because again, our goal is to , um, help increase the capacity to care for children in their home countries. But we certainly do have , um, international patients and a lot of international consult activity mm-hmm. <affirmative> . So , um, pre pandemic, so FY 19 numbers, we had 125 accepted international , um, pediatric, mostly cancer patients. Uh, f y 22 was much lower, of course, because the pan , because of the pandemic, so it was 64 international patients , um, consult activity remained high over a thousand international consults each of those years.
Speaker 2:Oh , wow. So how about you, Dave? What was some of the , some of the in , uh, international , um, your inter interaction with international patients and especially , um, coming maybe to, for example, to the United States to seek care?
Speaker 4:Sure. I mean, I think that tying back to what , uh, ley Robin and I have both talked about, as with regard that educating , uh, physicians, researchers, whatever, they go back to their home countries and then they became, become a natural place for additional education efforts, but also working on , uh, tertiary quinary significant cases. So in our case, we, we do have those outreach efforts, our global patient services. I think that we like to state that I think we, we are patients in any, maybe, maybe every two year , 185 countries. So I mean, we, we draw from a, a large catchment area. Obviously some countries a lot larger , uh, but we do have , uh, outreach efforts in several , uh, countries around the world. We also have, from our, the sites I've mentioned before and other locations that, that patients will travel. Obviously, covid , uh, affected that. Um, and I think we've all seen that kind of come back. Um , I think that, again, coming back to the internet and internet searches and clinical trials, all kinds of things , uh, it's a natural approach. We do, for example, in Florida , uh, we attract patients from South America, central America, but also patients from, we've got a facility in Canada, and because of the, the laws there, we, we can only do certain things, but , uh, Canadians like to go to a warm climate for the winter. So there are a lot of people who go down to Florida and use our facilities there. Uh , but it , it's an important area for us because I think that it also gives us , uh, the opportunity to work with , uh, clinicians , uh, from those countries who develop relationships. And I'll say also , uh, with, I mean in London and Abu Dhabi in other locations, it's, it's a two-way street with regard to information and techniques. And I think that will only increase as you see , um, uh, the ease of technology and some of the exciting new , uh, therapies and certainly genetic research and like that , that there's a lot of information flow both ways between the US and pickier location and plus all the metrics with regard to diagnoses and alike , that, that when we look at ai, we will delve too much into that, but, but the world is changing with greater healthcare and the broader catchment area of data, you know, the better your ability to diagnose and treat.
Speaker 2:Yeah. Well, you know, Dave , you just talked about all my favorite subjects and <laugh> , you already knew that. You just talked about all my favorite subjects, AI, innovation, all the positives that are coming out of , out of the, what was happening before the pandemic. But really I think it allow , you know, it's exploding even more because of the scientific innovations that happened, but also, like you said, some of this collaboration that's happened , uh, internationally that naturally had to happen during a pandemic. Um, well, I think one other question I have , um, before we start wrapping up here is to ask you if you've had any surprises in doing this work. And , um, I'll just throw it out there to see if <laugh> and like off of this , any surprises in which you can talk about on a podcast, I can always turn , we can turn the record off and talk about the other ones another time, <laugh> . Um, but , uh, anything that surprised you in this work?
Speaker 3:Um, you know, I, I think just the complexity of the global landscape being a, a US trained and initially US focused health lawyer , um, we think our laws are incredibly complex and, and of course they are. And, and we have our, our , our 50 states , um, to look at. But it , it , it's a just a whole other level when you start operating , um, in multiple countries and, and having to absorb the variety of legal structures , um, that, that exist in those countries. Uh , and so , uh, the, the way I look at it is you're never too experienced , um, or, or too high up in your organization to learn and to grow. I certainly had a learning curve when I first started working on these international matters, and, and now I love it because it's constant change. Um, a always something new for, for me to experience.
Speaker 4:I think that one thing we haven't talked about, but is a real benefit is as you work, you also attract people from around the world to work within your own, your four walls. And that, that is an enriching experience, both with respect to their expertise and alike , but also just it's a cultural opportunity to really exchange. And international facilities really take people who have experience being worldly and alike . So I think it's, it's a lot of fun. Um , I think that, yeah, lots of experiences that, that , uh, I think it's good to jump into a negotiation of foreign country where you don't know anybody and you get to learn the team and done correctly. We all have ones that have been done correctly and some that we tuck away and say, that didn't work out real well. But you really, if you are working on something that's gonna survive, you're gonna build those relationships. And that's, lawyers are a key part, in my opinion, blending together other teams, and I mentioned before, the governance, so that it will survive, thrive, that I think you can really play a role passing on those personal relationships to the, the next generation or whatever. And then there are a lot of humorous stories, which we'll say for another day.
Speaker 2:<laugh>. Um, so I guess I'm gonna, I want you to see if there's one thing you'd like to leave the audience with, something that we haven't talked about , um, that you'd like to leave the audience with. Um, I'll start since I started with Robin. I'll start with you, Dave. Is there something you'd like to, to tell our audience?
Speaker 4:Well, I think it's probably self-evident from this group that it's in an interesting, it's exciting, it's fun. Um, I think one thing that, that Robin touched on before with regard to just data, data requirements, and if you look at intellectual property and what's changing, I, I think it's a very exciting area if you want to blend international along with an expertise and in all the, the , the hipaa like rules that develop around the world and even within the states . So I think that it's, it's an opportunity. Uh , all or most emerging countries or emerged countries have looked and said their healthcare systems have to be better. And the US is not the only example, but the US healthcare system is really an example that they look to , uh, take the best of or work with. And so I think it's a real opportunity. I think one has to be very respectful of what, no matter where they are , but it is something that the US can export and import knowledge from . Mothers, so exciting area to work in.
Speaker 2:Robin, what would you like to leave the audience with?
Speaker 3:Uh , I'll just build off of what, what Dave was saying. I think another related really , um, interesting area for, for career growth, both in the US and and globally, is this combination of , um, health law and technology, and in particular, people who have an acumen for things like artificial intelligence, right? And, and using technology to improve diagnostics overseas. That's a, that's a really important area. Um, there's a , I think a , a lot of room for growth there. And so I i if you, if you love those things or have an acumen for them or, or , uh, an an ability to come to speed quickly on them, I think there's a lot of opportunity for international work that could be very exciting and meaningful.
Speaker 2:Great. I wanna thank David and, and Ramen , I wanna thank you both for joining us today. I, I mean, I, I believe you've been very inspirational both to health lawyers and also to others that are interested in this area to see, you know, w that even in health law, you, you end up in areas that you might not have expected in the beginning of your career, but also the international issues , um, have a lot of different complex components can be very exciting and very fulfilling and mission driven . So I really wanna thank you both for, for joining , um, us in the audience today.
Speaker 4:Thanks Sarah and Sarah , thank you for leading us through this . And Robin , it's been great to , uh, get to know you better and , uh, and what good work you do. So
Speaker 3:Thank you. Thank you both. It's been great.
Speaker 5:Thank
Speaker 3:You for
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