David Raubach: Well, I want to thank you for joining us on today’s episode of the Cancer Project podcast. We are very privileged to have Dr. Shannon McDonald with us today. Dr. McDonald recently joined the Southwest Florida Proton Therapy Center as their senior medical director. And I’ve got I think the the first half of our podcast is going to be me just reading your bio here. So, prior to joining Southwest Florida Proton, McDonald was an accomplished associate professor of radiation oncology at Harvard Medical School. She served as the director of base of skull service, the director of the sarcoma service, and proton therapy liaison at Massachusetts General Hospital to provide this therapy for patients at Dana-Farber and Boston

David Raubach: Children’s. She was also at Mass General the director of breast radiation oncology, course director for radiation oncology at Harvard Medical School student clinical clerkship. And this goes on and on. She has She has run numerous clinical trials for proton radiation and is the clinical chair of RadComp, the most prominent randomized trial studying proton therapy for breast cancer. So, needless to say an extremely accomplished physician. But, I do want to start with a much more important question and ask you how Franklin’s doing. Your dog. [laughter] The most important question.

Dr. Shannon MacDonald: Franklin is doing great.

David Raubach: important question. How’s Franklin? He’s [laughter] crazy.

Dr. Shannon MacDonald: He’s uh looking forward to a summer of boating and

Dr. Shannon MacDonald: he has uh enjoyed his time in Florida. So,

David Raubach: Yeah, you said I I think when we were at a conference a couple weeks ago, you know, you’re still kind of going back and forth a little bit between Boston and Florida. And I said uh I asked you where you considered home, and you said, “Well, home is where the dog is.”

Dr. Shannon MacDonald: Yeah, I forgot about that. And it’s true. Home is where the dog is. So, um

David Raubach: Yeah, so the dog’s in Florida.

Dr. Shannon MacDonald: The dog’s in Florida, home is here, and the dog’s going to get on a plane with me, his first jet ride, uh which is a a real dog plane, uh on Saturday to go

Dr. Shannon MacDonald: go back to Boston and and and summer in Boston, so.

David Raubach: Okay, and what kind of dog is it?

Dr. Shannon MacDonald: Uh a mini golden doodle, but a kind of a big one. He’s 34 lb, so.

David Raubach: Okay, yeah, that’s super cute.

Dr. Shannon MacDonald: on a regular plane. And he’s he

David Raubach: Although I consider him a

Dr. Shannon MacDonald: Oh, right. a dog that gives service and love to many people, he’s not technically a service dog, so.

David Raubach: Not officially a service dog. What is a a special dog plane? I don’t think I even knew that that existed.

Dr. Shannon MacDonald: So, I didn’t know they existed till we came down here. Um we drove him down, and that’s hard a hard drive, and uh so

Dr. Shannon MacDonald: we found a couple of a jet, it’s called I think it’s JSX, and it allows you to buy a seat for yourself and a seat for your dog at a at a cost of a first-class seat, probably.

David Raubach: Yeah.

Dr. Shannon MacDonald: and fly with your dog of any size, so they can be, you know, 110 lb, and you can get them a seat on the plane.

David Raubach: Oh, that’s amazing. I’m definitely not telling my wife about that. [laughter] [gasps] We will have dogs with us on trips. [laughter] I’ll let you know how it goes Saturday.

Dr. Shannon MacDonald: They only fly in from certain cities to certain cities, so I have to fly into New York and then

Dr. Shannon MacDonald: drive from New York to Boston, so.

David Raubach: It’s not that convenient. Okay, got it. And so the And then the picture I saw of him, he’s on a boat, so he enjoys boating?

Dr. Shannon MacDonald: He He does enjoy boating. He doesn’t like cars, but he loves the boat, so.

David Raubach: Yeah, uh that’s fun. Um and then the dog behind you, who’s the dog behind you? Is that a

Dr. Shannon MacDonald: This is um actually a lion dog. So, it was

David Raubach: Oh, is it? Okay.

Dr. Shannon MacDonald: It’s a local um artist from Naples, and uh and I want I want him to paint Franklin. Franklin’s a golden doodle, but I loved this

David Raubach: Okay, yeah.

Dr. Shannon MacDonald: I loved the colors of this picture,

Dr. Shannon MacDonald: and um I treat children in pediatrics, too, so it seemed like an appropriate piece of art for my office here, so.

David Raubach: Yeah, yeah. Well, that’s a good segue uh and uh so I do want to ask you about that. I mean, you you’ve treated a lot of breast cancer patients and you’ve treated a lot of pediatric cancer patients. So, talk a little bit just to kind of lay the groundwork for our discussion about telehealth and this very interesting legal case that you’re part of. Talk about your interest in pediatrics. I know that that that was something that you wanted to do straight out of residency.

Dr. Shannon MacDonald: Yeah, so so my my main interest in protons actually

Dr. Shannon MacDonald: came from being a resident in New York and sending all of our patients to Boston for proton therapy. So, when I was a resident, I went to Mass General and when there were only three proton centers in the country because I wanted to see where we were sending our kids and learn more about it. And I became very interested and fascinated with proton therapy. I decided that was what I wanted to do and I wanted to treat children. And um Jay Loeffler said, you know, we have a job, but it’s not peds, it’s the breast service. But if you want to take this, I’ll shift you over to peds when I need when something becomes

Dr. Shannon MacDonald: available. So, I joined MGH in 2006 and less than 2 years later a peds position became open, so I shifted over, but I didn’t leave breast. And then because I was always interested in peds, I was getting referred very young women with advanced breast cancer, so I had been treating patients in their 20s and then treating kids with protons and I thought, you know, why not use this for young women with breast cancer, especially when they’re you’re treating the internal memory nodes. So, the two first patients I treated off clinical trial were in their one was in her 20s and one was I think 31 and they both had positive internal memory nodes. And shortly

Dr. Shannon MacDonald: after that in 2010 opened a locally advanced breast cancer trial and and that made it so that I never shifted out of the breast service. I just, you know, that kind of thing.

David Raubach: You were locked in at that point cuz it was a great indication

Dr. Shannon MacDonald: I I still think it is and I think there’s select cases patients with breast cancer that benefit a lot. But my passion has been peds. I developed an interest in skull base and chordoma as well. And so for pediatrics I’m I’m actually just started a term as the chair for children’s oncology group and that’s still a major major interest of mine as is protons which is why I came here

Dr. Shannon MacDonald: to start a proton center. So yeah.

David Raubach: So So the interest in peds was that something that you knew because you went to medical school at Loyola in Chicago? Is that I mean did you know all the way back then that you wanted to do pediatric radiation oncology or how did that come about?

Dr. Shannon MacDonald: No. So you know I started my career thinking about becoming a nurse or a doctor and then went then decided it was going to be a doctor. I thought I would do infectious disease and was fascinated by that and then kind of thought you know different different fields were more interesting more interested in anatomy surgery and found the field of radiation

Dr. Shannon MacDonald: oncology. And it was probably my mentor Bernie Donahue at in in my residency that really made me find my passion for pediatrics and I never lost that. I love the kids and I love their their parents and I think the parents are as much your patients as the children are and I think that that just something I was drawn to and it may have been a mentor or it may have been just what what I would desired to do but that’s kind of how I found pediatrics. So it wasn’t until residency that I thought of pediatrics.

David Raubach: So one of the things you know I’ve worked at a in the proton therapy space for about 15

David Raubach: years now and obviously seen a lot of kids come through the proton centers that I’ve been at and it’s just a different um I don’t know there’s just something different about a child coming in with cancer. It’s just a different dynamic and and one of the you and I have a mutual friend Dr. Matt Ladra who trained under you at MGH and then we hired him in Knoxville. And I I asked him a a couple different times, you know, how do you do this? How do you How do you get through a day where you’re treating children with cancer? So, I’ll ask you that same question. How do you, Dr. McDonald, just get through the

Dr. Shannon MacDonald: the challenge emotionally and physically and mentally of treating kids with cancer? So, I think one one thing to think about is that it’s always better to be on the physician’s side than the patient or parent’s side. Um right. I, you know, I had a sister who had a very ill child and I’m and and and that may may have maybe that drew me to it a little bit, too. Um but um but I think that just knowing that you can help them and make it a little bit better is really rewarding. Uh I think that giving we give them such great care. So, I love like really diving in and making sure everything’s perfect and

Dr. Shannon MacDonald: right. And I think it’s much easier to do that with children than it is to do sometimes with with adults and it’s like respected. Um so, it’s so, it’s um it’s it’s, you know, that that part is is very rewarding. And then I do think there’s a part where you just you can’t you can’t bring carry it with you all the time, right? And and and feel sad all the time. So, that’s a skill you have to develop because I do think it’s hard to stop thinking about certain cases sometimes that are really challenging or really sad. Um and just try to accept that you’ve maybe made it a little bit better. You’ve done everything

Dr. Shannon MacDonald: you can to to make it a tiny bit better for that family. And it and that’s really meaningful and rewarding.

David Raubach: Yeah. Well, it takes a special person to treat pediatric cancer. Um and pediatric cancer is rare. There’s not that many cases each year diagnosed. And so, um and you were you obviously had an amazing team and amazing tools at Mass General and then partnership there with Boston Children’s. Um and so, you had patients that were coming from all over the country to see you there in Massachusetts. Um, and there was one case in particular that led to this lawsuit that we’re going to talk about. Um, uh, and correct me if I’m pronouncing the name

David Raubach: wrong, June Abell?

Dr. Shannon MacDonald: Abell. Yeah, that’s correct. Yeah.

David Raubach: Uh, Abell? Yeah, June Abell. Um, and so at least what the information that’s provided publicly in the case is that this was an 18-month-old at the time who was diagnosed with a a pineoblastoma. Um, and correct, please correct me if I’m getting any of this wrong, but, um, and and that child came to you for treatment uh there and they were from New Jersey and so then they came to Boston to see you. So, talk a little bit more about this particular case and maybe the treatment of this case and why a patient might travel from New Jersey for you for this particular treatment.

Dr. Shannon MacDonald: Yeah, so,

Dr. Shannon MacDonald: um, so June’s case is a case that got highlighted in the lawsuit and, um, and was a an example of a case of a patient from out of state who came for treatment and then in follow-up needed some opinions on MRIs that, um, we reviewed and gave to them and never thought anything of it before COVID of talking to someone after reviewing a scan. And, um, my sort of my advocacy work to advocate for the for telemedicine across state lines to be legal comes from the period of time during COVID when we could all practice telemedicine without any restrictions. Um, and and there all of those rules were lifted. So, when when teleme- if there

Dr. Shannon MacDonald: telemedicine, you know, it makes the most sense to me that to be able to reach patients that are for farthest away who can’t travel. It’s, you know, burden on the family, it’s too expensive, and they want to follow up or or investigate a treatment that’s not available in their state. And proton therapy was an example of that, especially when I started and there were only three proton centers in the country. You know, now we have 48, but there’s a lot of families and and a lot of patients who still need to travel for that treatment. And during COVID, when the regulations about when Zoom became, you know, the way we communicated with a lot of

Dr. Shannon MacDonald: our patients, telemedicine really grew rapidly, exponentially, and we were able to do it across state lines for new patients and for follow-ups. I initially thought I’d hate telemedicine, and I loved it. You know, and it was great for my families to not have to travel, and it was really wonderful for the ones who are out of state to be able to see me legally and in a formal visit and and talk and and follow up after their radiation treatment, or for patients, you know, seeking care for, say, medulloblastoma or rare treatment to be able to from their homes figure out where they were going to go for proton therapy cuz they knew they had to

Dr. Shannon MacDonald: leave their state to talk about it, to get become familiar with a team without having to fly out right away. You know, these parents sometimes have 2 weeks to figure out where are they going to move their whole family, and to be able to meet with someone first was wonderful. And to be able to again to follow my with my patients, I had some that said, you know, I I would have to come by myself cuz I couldn’t afford to bring these are an adults I who I couldn’t afford to bring my husband. So, if I knew if I was going to sit in that room, I’d be getting bad news by myself. Now I

Dr. Shannon MacDonald: get to be with my husband on the video, you know, being able to get with the results with with a loved one nearby. And for, you know, parents, they don’t have to bring their child in and have someone take them aside while you talk about the serious things. The child can just go play in their room and be drawn into the conversation at appropriate times. So, when COVID ended and the restrictions went back into place, it just seemed cruel to me. Like they, you know, that one silver lining of of COVID was sort of taken away for no good reason. You know, it didn’t it didn’t lead to pay you know, patients trying to travel

Dr. Shannon MacDonald: all around the country to get care or didn’t nothing bad happened nothing you know, there were no lawsuits and and and I so I wondered you know, I didn’t understand why and then we also were getting all of a sudden lectures about not speaking to our patients because it’s it’s against the law and we risk losing our license and and it’s really the personal risk of the physician not the hospital risk. Like our general counsels were just we’re just telling the general counsel just telling us what we should do to protect ourselves. So I ended up writing an article about a different patient that got accepted as a prospective piece in the New England Journal

Dr. Shannon MacDonald: of Medicine and it got picked up by the Associated Press and then my Harvard I learned I had Harvard colleagues at the law school in the school of public health who were working on the same thing and from a different from different angles and um the Harvard Law School ended up having a meeting that was mostly lawyers but a few physicians and and we kind of met to talk about different ways to lobby for these rules to be lifted at least for rare diseases and Harvard Law held a meeting with rare disease groups as well as a lot of lawyers and a couple of physicians. Um I connected with Sean McBride who was a former

Dr. Shannon MacDonald: resident of mine and and getting a legal degree and he said you know, I want to pursue this further. He said I think this this these these rules violate something called the dormant commerce clause which is you know, by stating that medical care is commerce and restricting it between states is not constitutional. So that was something he he thought of and we pursued with the lawyers at Harvard and other institutions and some colleagues at Johns Hopkins and then ultimately Sean sought out a Pacific Legal Foundation. We found them through um through a clerk that was very generous to us and Pacific Legal Foundation listened to our argument and decided to pro bono take on this

Dr. Shannon MacDonald: case to state that it was unconstitutional for two reasons. And the second reason they thought of was it violates free speech. So, there are two lawsuits and the reason there’s one against New Jersey with with June with June another surgeon, myself and and another patient with cordoma in New Jersey and also a a second parallel lawsuit that is led by Sean McBride against California. The lawyers decided to pick out to choose those two states and it really we want to change it for all states, but you because it’s an in-state law, so medicine is controlled intrastate and that comes from, you know, the early days of the Constitution when you’d have to take a horse

Dr. Shannon MacDonald: to go to an out-of-state hospital or

David Raubach: Right.

Dr. Shannon MacDonald: with a message. Um and and they and and one of our arguments too is it’s just not it’s just not well suited. Those rules are not well suited for modern times. You know, we are a country that should offer all of our citizens the best best health care and medicine is becoming more and more complex, so that may not be available in every state and maybe health care shouldn’t be intrastate anymore. It should be interstate. So, so PLF decided to support us. There’s two lawsuits, one that’s against New Jersey and that’s my lawsuit and then the lawsuit that Sean McBride has against California and those went

Dr. Shannon MacDonald: from state courts and were elevated to the third and ninth circuit and they both just heard oral arguments. And the oral arguments for my case were in Philadelphia just before the Supreme Court ruling of Child versus Salazar, which is a lawsuit that is a therapist about transgender change and the Supreme Court voted eight to one that it was a violation of free speech to say that she could not do this. And so so since the free speech piece and the and first amendment was in our case, the my case was was heard oral arguments before that. Shauns McBrides heard it after. And it’s very it’s very interesting to listen into those oral arguments and how

Dr. Shannon MacDonald: different they are because of that ruling.

David Raubach: Okay.

Dr. Shannon MacDonald: And for mine when I I actually went to the to went to it and listened to oral arguments and they were all waiting for Childs vs. Salazar and then after McBrides was after and you know, it really I think gives us a greater chance of being successful in the lawsuits because of the first amendment being held up and Childs vs. Salazar Salazar not just winning in the Supreme Court, but winning eight to one. Because if that’s considered free speech, then um you know, ours ours also is is the falls under the first amendment and is you know, I and and for for the for the counselor,

Dr. Shannon MacDonald: that’s actually the therapy, right? You’re when you’re speaking, that is the treatment. But what we’re trying to argue for is mainly talk talking to a patient and for most specialists, that’s just talking about it and the patient for a radiation oncologist or a surgeon would actually have to come to the state for the therapy to be delivered.

David Raubach: Well, I thought there was a great quote related to that in in the oral arguments from the attorney representing your side. And he said you can’t treat cancer by talking at it.

Dr. Shannon MacDonald: Yeah.

David Raubach: Unlike with mental health issues. And so

Dr. Shannon MacDonald: Yeah.

David Raubach: Talk a little bit about because I think that that’s important and and maybe let me

David Raubach: step back. I just wanted to hit on two things. So if anybody wants to look up this case, they can look up McDonald vs. Auto F. Sabondo as the defendant and you can pull all the information on the case. And as you mentioned, it was initially filed in state court, went to federal court, was actually dismissed initially on That was May 28th, 2025. And it seemed like, from what I read, there was a little bit of a standing issue where the judge was maybe saying, “This seems like an issue that actually needs to be tackled by the legislature, not by the courts.” But then obviously you guys appealed, and it’s currently with the third circuit

David Raubach: right now, and you mentioned the oral arguments. But I do want to mention because there were four legal arguments that your side made. One was And there were Basically, the argument was that the New Jersey Licensure Statute violated the US Constitution on four different grounds. You mentioned the dormant commerce clause, the privileges and immunities clause, the First Amendment right to free speech, and the parents’ due process rights. And so, the dormant So, let’s let’s maybe hit on each of those. So, the dormant commerce clause um What Tell me what What What’s the premise of of that?

Dr. Shannon MacDonald: So, the dormant commerce clause is this principle that states cannot unduly burden interstate commerce even when Congress has

Dr. Shannon MacDonald: not acted.

David Raubach: So, maybe in your own words, what What’s the premise of this dormant commerce clause as it applies to your particular case?

Dr. Shannon MacDonald: So, saying that it puts like undue burden on the family to have to travel, to have to pay for hotel, to have to pay for flights. And it also puts some burden on the doctor to, you know, probably more burden to feel that we cannot help someone if they’re not physically in our state. So, that’s the burden. So, it it’s putting undue burden on the patient mainly, but also the physician. And you know, just thinking about we have patients who fly and get hotels. We also have many patients who are driving

Dr. Shannon MacDonald: distance but will drive across state lines and sit in a parking lot in their car

David Raubach: Right.

Dr. Shannon MacDonald: for a telemedicine visit. And I think most of us the doctor we almost I’ve had patients tons of patients do that. I’m sure you have as well.

David Raubach: And you know, I had it. They drive across the border from Kansas to Yeah. right across the border and they’re at the rest center in Oklahoma.

Dr. Shannon MacDonald: Yeah. Yeah. To call the doctor, right? I had I talked to one pediatrician in DC before before Virginia just DC and Maryland had this compact that allows them to practice and her patients would share information about the best parking lots to sit in to

Dr. Shannon MacDonald: do their telemedicine.

David Raubach: Right. Right. That That imagine that Reddit thread.

Dr. Shannon MacDonald: Yeah. So So that’s what I

David Raubach: that’s the dormant

Dr. Shannon MacDonald: Yeah, dormant dormant commerce. Yeah.

David Raubach: Okay, is this undue burden undue burden on the doctor undue burden on the patient especially and states cannot place this undue burden. So then the second one was this privileges and immunities clause which basically states that um states can’t discriminate against citizens of other states in fundamental economic activity. So was this one of your main arguments? Was this a secondary argument? What was the thinking behind this discriminating against citizens of other states with the privileges and immunities clause?

Dr. Shannon MacDonald: Yeah, so I think that’s um it’s a little similar

Dr. Shannon MacDonald: to the dormant commerce clause in a way and that was added in by Pacific Legal Foundation as well but I think just as you described it it just wanted to you know, ensure equal treatment across state lines and across states for all citizens. So if a service is available in another state, it’s not fair or equitable to a for another patient to have to put more effort into getting that treatment because it’s not available in their state.

David Raubach: Okay. So I’m going to hit the parents due process and then come back to the First Amendment because I think that’s kind of the To me, that’s the most fascinating angle of this case. So, the the fourth

David Raubach: legal argument was this parents’ fundamental rights to due process. Parents have constitutional rights under substantive due process to direct the medical medical care of their children. And so, the plaintiffs argued that New Jersey interferes with a parent’s ability to obtain care from the specialist they believe are best for their child, especially in life-threatening pediatric cancer cases. So, maybe if you can talk about the importance of of parents being able to in a case like this seek out second opinions, multiple opinions. Why would a Why would a parent leave New Jersey for a case like is represented or the two cases, I guess, that are represented in this particular lawsuit?

Dr. Shannon MacDonald: Yeah, so at the time, you

Dr. Shannon MacDonald: know, when there was no proton therapy available in New Jersey, they had to leave for a young young child to get that therapy. The other patient in the New Jersey case had to leave for someone with expertise in surgery for skull base chordoma, which is a very specialized type of surgery. And this doesn’t just apply to cancer, it applies to, you know, metabolic disorders, mitochondrial disorders, things that are usually rare diseases where there does not where there is not expertise in every state. So, that’s just that law is just it’s pertaining to the the the fundamental liberty interest of providing and making medical decisions for your child. And that

David Raubach: Right.

Dr. Shannon MacDonald: that So, that

Dr. Shannon MacDonald: is the piece that it kind of falls under. So, there’s other like education and other things for your children. And I think that that was put in because we for the New Jersey case, the the patients are minors and they’re children.

David Raubach: Okay, got it. So, then free speech, very interesting. And I think what’s What’s interesting is that what you all are arguing is that what you’re doing when you’re having a conversation with the patient is actually speech. You’re not I I don’t know if this is the right technical term, but you’re not treating the patient. So, you’re not touching, feeling, operating on, delivering some type of therapeutic remedy. It’s just a conversation. So, explain why

David Raubach: that difference is important and why you why you would say that this is speech and not shouldn’t be construed as uh a as medical conduct.

Dr. Shannon MacDonald: Yeah, so I think that this was again something that PLF came up with. Um Shawn and I Shawn and Brian I did not think of it. We thought it would end up not being the strongest, but because of Childs versus Salazar, it’s turning out to be one of the strongest argument. And and specifically because Childs was the speech that was the treatment and therapy. Whereas we were trying to argue for not necessarily that type of we we’d love to see that also be legal across state lines. You know, that

Dr. Shannon MacDonald: during COVID many many children and adolescents, especially those in college, couldn’t find a psychiatrist or psychologist because there’s a huge shortage and they would have greatly benefited from continuing post-COVID to be able to see a therapist by telemedicine across state lines. And um and so so we agree that that’s reasonable, but for most of for what we were discussing and what we were writing about and speaking about and arguing for was really just to inform a a family of a certain therapy that was available um and not delivering that cancer therapy cuz the the patients in these lawsuits are mainly cancer patients. And um and so we were we we wanted to say that you

Dr. Shannon MacDonald: know, we’re not we’re not get we’re not treating them. We’re just informing them. And you are allowed to educate, but not do a formal visit and you can’t make a the you know, but the state laws um in New Jersey and California and and most other states they consider giving medical advice or you know, diagnostic advice or reviewing a scan and giving an impression of that to be practice the practice of medicine. Um and yet we are really on these on these video visits typically either speaking about a therapy that the family would then have to travel to receive or in follow-up speaking to them about things they’ve had done at their at their home

Dr. Shannon MacDonald: institution. So I think that that the speech it’s it was arguably something we did before COVID having no idea that that was practicing medicine, right?

David Raubach: Did you ever think of it before COVID? Oh, I’m calling this patient back who called me, where are you? What state are you in? Oh, if you’re in Massachusetts, I can tell you what I think of your scan, but if you’re somewhere else I you I can’t or if you’re calling me to seek out an opinion on do I need to travel for proton therapy or not? I may say no for that disease, you know, I think you’ll be better suited staying at home with the social support of your

David Raubach: family. It it there won’t be any benefit or yes, I think you know, this is a real clear indication and it would be a reason to travel if you’re capable of doing that and and that was speech that we we we you know, we called back patients all the time before COVID and didn’t think Oh, where are you? I I can’t I can’t tell you you know, what to do because you’re in the state

Dr. Shannon MacDonald: lot at the proton center?

David Raubach: Yeah. Oh wait, you’re in New Hampshire? Can you drive 10 miles and then I’ll talk to you?

Dr. Shannon MacDonald: Right. And you know, even

David Raubach: Yeah, are you on vacation? you go on vacation, you travel for

David Raubach: work, you call your doctor, imagine them and this does happen now. They they sometimes call you back and ask you where are you and say, oh, I’m sorry. I can’t give you advice. Please go to the ER for something that I could have told you to do in 5 minutes or prescribed for you in 5 minutes. So it’s yeah, but those are speech things that I think we’re done before and I think it was it was a now you know in retrospect a very valuable thing to put that in the lawsuits as well.

David Raubach: Well, and I think one of the things that I’ve noticed just again working in oncology for many years is that you

David Raubach: develop this trust with a doctor. And so in this relationship and especially an example with radiation oncology where a patient’s coming for multiple weeks for treatment and then there’s years of follow-up and I’m just thinking if I had cancer I want to talk to the doctor that treated me about follow-up. Like that’s the person that I trust that’s the person that I know. We have a doctor here at the proton center in Oklahoma City who retired and then came out of retirement just to see follow-ups. Because his patients wanted to see him and he’s like okay, well I mean I can at least come back in once a week to see my follow-ups and so

David Raubach: I think that relationship element is so critical. Um so So you wrote an op-ed in the Wall Street Journal. Not everybody gets to write an op-ed for the Wall Street Journal Shannon. [laughter] Thank you. That’s a big deal. How did how did that come about? Was that did somebody ask you to do that or did you submit this?

Dr. Shannon MacDonald: No, I think I you know I I did a little bit of narrative writing in the perspective piece in the New England Journal was first and then since it it got some some press from the Associated Press it made me a little bit more interested in writing for lay media. So I actually took a narrative writing

Dr. Shannon MacDonald: class at Harvard Medical School I was there and wrote this piece kind of during that class and and then it it almost got into the New York Times which I and then it did get into the Wall Street Journal which was great and and I just you know wrote sort of passionately about my feelings about these laws and why they should change and why they need to be adopted for modern medicine and I it was a while ago that I wrote that piece, but I think that two of the things I felt like strongly about is that VAs and veterans get to do it. They can have a medical license in one state and practice

Dr. Shannon MacDonald: anywhere. Um another thing that made me passionate about it is I was speaking a lot on it and everyone said, “Oh, the IMLC, it’s so easy to get licenses.” And I said, let me tell you about my experience with the IMLC to get just seven licenses. I had to get fingerprinted three times. I had to take multiple tests. It took me 2 years to get, you know, like or almost 2 years to get one of the licenses. They trickled in and by the time I had all of them, I was a year away for or a year and a half away from having to renew the first one I got. And you renew them every

Dr. Shannon MacDonald: 2 years. And someone did a study pre-COVID. The costs are still there, right? It’s the same cost and it’s 90k a year it for you for those for all of to get licensed in every state and then you have to renew every 2 years and the burden of the paperwork alone is probably the full-time a full-time job for a few admins. And and and you know, often the doctors are faced with doing this by themselves. So that that was one thing. And then the other thing is the Sports Clarity Act of 2018 allowed physicians who were usually orthopedic surgeons, but other physicians as well who traveled with college or national sports teams to practice medicine

Dr. Shannon MacDonald: across state lines. So they were free to practice anywhere with only one license and I thought you can do it for, you know, Tom Brady on the Patriots. Why can’t you do it for a child with a brain tumor? And that’s what so that’s what I wrote in that I think that’s what I wrote in that article and few more few other things perhaps.

David Raubach: Well, no, you did. I was going to I’m glad you brought that up because I was going to bring that up. Essentially, you know, if if if we’re talking about what’s the headline, the headline is NFL players get exceptions, but cancer patients don’t.

Dr. Shannon MacDonald: Yeah.

David Raubach: Right. I mean [laughter] And

David Raubach: it’s and so there the point with that is that there is a precedent for making exceptions for example for unique situations. We know these NFL players are traveling around the country. They’re allowed to communicate with their orthopedic physicians uh across state lines. Why not for something like cancer? I mean, that seems like such an obvious additional exception that could be made.

Dr. Shannon MacDonald: Yeah.

David Raubach: But it’s But it does sound like what you’re what you’re potentially hoping is the outcome is that the rule This is precedent-setting to just change the rules across the board. Is that Would that be accurate? Like this This isn’t just about an exception for cancer patients.

Dr. Shannon MacDonald: It is. It is. And again, I

Dr. Shannon MacDonald: think the Charles versus Salazar ruling and the fact that it was supported like bipartisan support from for that. And one thing I didn’t mention before, but the free speech it was not just conduct speech, like what you know, what what you what is done, but also um one of the judges made a comment about viewpoint speech. Like you should be able to share your viewpoint about something.

David Raubach: Right.

Dr. Shannon MacDonald: So, I do think that it’s the right thing in our country to be able to help patients across state lines anywhere in the US that needs a therapy that’s not available in their state and not burden them to make them travel, but to be able to

Dr. Shannon MacDonald: to give to give them advice from the comfort of their own home and not, you know, and not make a patient who happens to be in a state that doesn’t have that service travel and place that burden on them.

David Raubach: So, I I’m curious. I mean, when you put yourself out there in a lawsuit, you know, there’s obviously two sides to every case. Have you received some pushback from being such a public advocate for one particular position?

Dr. Shannon MacDonald: I’ll tell you not really, um which is surprising, but I think that you know, we I I actually have gone another route, too, in the lobbying route with a group at that at Johns Hopkins that’s supported by Bloomberg

Dr. Shannon MacDonald: and includes a lot of the members that I started working on this with at Harvard. And um and and what I’ve learned is that there’s the the I think the state medical boards just don’t want to change, but they’re not they haven’t looked to attack. So, they you know, there these things have been set up for so long that there’s so many jobs in place and finances in place and you know, procedures and policies and we we can’t really even get an answer at like why is why are you resistant? And no one’s like attacking us, but I think it just it will take a a huge restructuring and there’s just a a lack of

Dr. Shannon MacDonald: desire to go through what it would take to to to you know, to update these laws and make it more modern and there is a fear like malpractice and how do you handle that? But again, nothing nothing bad happened during COVID and we did it for you know, we did we did it for a couple of years with everything and we did it for a longer period of time with follow-ups and many states have started to add these exceptions, but no one can keep up with what state allows one consult versus a follow-up versus so it it’s not it’s practically useless for the states to try to allow little bit like little things here and

Dr. Shannon MacDonald: there. It really needs to be more of a I think a federal decision to overhaul it and and to figure out how to how to fair you know, how to how to alleviate the business concerns, how to fairly compensate the medical state boards, how to make sure that they’re able to regulate malpractice and that people are are in place to make it all work or maybe there’s a way to get a you know, a telemedicine license and then pay all states a fee, but not have to get you know, go through the hassle of individually licensing someone in every state. But there seems like there should be some solution and no, I have not received

Dr. Shannon MacDonald: a lot of pushback, which has been great and [laughter] it was my thought that I’m going to have to win a lawsuit when I started this, but I also had advocated for it so strongly and was um really I really believed in it and I have a lot of patients who believe in it too. So, when I was asked to do it, it was really hard to say no it because it seemed like the right thing to do and I believe that.

David Raubach: Well, it’s interesting because you know, you you’re probably used to being the lead author on a paper, you know, it’s the McDonald et

David Raubach: al lawsuit.

Dr. Shannon MacDonald: Yeah.

David Raubach: Uh and a lot of lawsuits especially big transformational lawsuits end up being you know, we colloquially talk about them by the name of the plaintiff. So, this may end up being the McDonald lawsuit for all of time. So, [laughter] it changes the way we practice, which is a good thing. I’m completely in favor of everything that you’re talking about. I’ve seen just how impractical it is and how much of a detriment it is to patients to have to travel. It’s impractical for doctors to go through this licensing process. It takes a long time. There’s an administrative burden. There’s a cost. And in New Jersey and I guess in California

David Raubach: too, I mean you you’re actually potentially literally liable for criminal charges.

Dr. Shannon MacDonald: Yeah. So, fines and 50k, 100k and then you can get thrown in jail.

David Raubach: Yeah. So, yeah, this is serious stuff. [laughter] Yeah. And that’s not just to close Right. Yeah. So, so just to close out on this topic, what is next with this particular lawsuit? So, you had a oral arguments in March. What what are the next steps?

Dr. Shannon MacDonald: So, the the judges in the third and ninth circuit need to render a decision for both of the cases. So, the New Jersey, which is the third circuit, went to the third circuit and was argued in Philadelphia in March is

Dr. Shannon MacDonald: still pending and they were waiting for Charles versus Salazar, which did did have a decision and then McBride versus California was just argued in April after Charles versus Salazar and they’re also waiting for a decision. And it will be interesting to see will they rule the same? Will they rule differently? They might go back to lower courts for discovery. They might end up you know eventually I hope changing the law for everyone. But [clears throat] it would it’ll be interesting to see what happens next. And you know one thing I’ve learned it it’s it’s a very slow process. But in a way I think we were fortunate to have another case in the Supreme Court

Dr. Shannon MacDonald: around the same time we were both going up for oral arguments in the circuit court.

David Raubach: And if you do receive an adverse ruling with the third circuit would you then appeal to the Supreme Court?

Dr. Shannon MacDonald: So I think if yeah especially I think if one rules one way and one rules the other I think an appeal to the Supreme Court may ultimately happen.

David Raubach: Okay. Or and it may be there may be some more back and forth before that or but it’s potentially. Well here’s hoping for a positive outcome before we get to that point. So. Well and thank you for doing this. The Cancer Project podcast is made possible by the Oklahoma Proton Center. A