Joel Fish MD, MSc, FRCSC
What is your current affiliation and position?
I am the Medical Director of the Burn Program at the Hospital for Sick Children in Toronto, Ontario as well as an Associate Professor in the Department of Surgery at the University of Toronto.
Please describe your education, work experience and positions held.
I completed medical school at McMaster University in Hamilton, Ontario before beginning training in Plastic and Reconstructive Surgery at the University of Toronto. Following residency, I completed a “Travelling Burn Fellowship” program that allowed me to train at burn centers in Seattle, Boston, and San Antonio. In 1998, I was appointed Medical Director of the adult Burn Program at the Sunnybrook Health Sciences Centre in Toronto and held this role for over ten years before transitioning to the Hospital for Sick Children in 2007.
Why did you become interested in burn care?
Many times when I’m asked why I became a burn surgeon, I often answer this by saying that I didn’t become a burn surgeon – it found me! I had an excellent group of mentors who were practicing as burn surgeons and it was a perfect combination of real medicine and plastic surgical reconstruction that drew me to the profession.
How did you first learn about using laser therapy to treat burn scars?
I had been following the story of lasers and burn scars since I was a Fellow in Boston in the late 1980’s. It was a story that resurfaced at the American Burn Association meeting in 2014, when we had a series of laser experts finally stand up and give us convincing evidence that “scar modulation” was a real clinical phenomenon and that laser therapy was responsible for it. As a result of that meeting, we visited the Shriners Hospital for Children in Boston with Dr. Matt Donelan, in order to see the practical workings and requirements for developing a laser therapy program. Less than six months later, we were able to put together funding and resources and opened our program at the Hospital for Sick Children in 2014.
How has laser therapy changed your practice as a burn surgeon?
The ability to modulate burn scars using laser therapy has improved the way that we treat our burn patients. In the acute phase, our Burn Team would much rather rehabilitate a scar than a skin graft. Although the traditional teaching of secondary healing has often been discouraged, many scars can be rehabilitated using laser therapy thereby avoiding unnecessary surgery. In the rehabilitation phase, laser therapy gives us another modality to influence the thickness and stiffness of symptomatic burn scars. However, the most exciting change for us has been the ability to use laser therapy to treat burn pruritus which can be disabling for our young patients as well as their parents.
In your opinion, what is the most common misconception that patients and their families have regarding laser therapy?
Many of the burn patients and families that we see experience a great deal of regret and often view their burn scars as a constant reminder of the injury. As a result, families and patients are often disappointed to find out that laser therapy will not “erase” their scars entirely. Thus, educating families about laser therapy early on in the healing process is critical in helping to prevent this misconception.
What has been the most challenging part of integrating laser therapy into your practice?
The laser therapy program at our hospital was funded by private donors and was specifically set up to target the burn population. Thus, it has been very challenging to only offer this treatment to patients with scars resulting from burn injuries. Given that there are children that have significant scars from many causes, it is a difficult issue that we deal with almost on a weekly basis.
Why do you think the use of lasers for treating burn scars is debated among some clinicians?
We know that there is a natural resolution of scars which occurs over time – even in the absence of all the treatments that we use. Thus, trying to control and measure the natural resolution of scars to ensure that the result that we see is truly due to laser therapy remains challenging. It is difficult to scientifically prove that laser therapy works and many of the preliminary studies that come out lack rigorous scientific data to change the minds of naysayers.
What advice would you give to a clinician who is just starting their laser practice?
I had a very naive understanding of how to start a laser program and how much there was to learn about the technology when I was first thinking of introducing lasers into my surgical practice. The learning curve in my hands took almost a full year until I understood the power of our lasers and all of the different applications. The actual technique itself was easy to incorporate but it took a great deal of time to become experienced and efficient with the machines. In addition, all of the cases were done in conjunction with the Nurse Practitioner in the Burn Program which provided a constant source of feedback. Although the lasers are simple technical instruments in essence, it took surprisingly more time than I had anticipated until I really felt like a true expert.