Skip Navigation LinksHome > Blogs > Joe’s Career Blog
Joe’s Career Blog
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Tuesday, December 23, 2014

Dear friends and colleagues

I am writing to let you know that I am dying.

I just finished reading Atul Gawande’s book

Being Mortal and realized that I have many of

the symptoms of the patients in his book--therefore, I too must be dying.

 

I am a little sad about this, but to be honest

I knew this was coming and so was not totally surprised.

I learned when I was quite young that all people die,

though like most adolescents I believed deep down

that it wouldn’t happen until I was 110 or so.

But that attitude gradually died soon after I began

going to funerals.

 

Funerals were a big deal in the

Italian-American culture in which I grew up.

Our entire family went to the funeral home (no baby-sitters)

and walked up to the open casket to pay our respects.

The female relatives of the deceased all dressed in black

would be sitting in the front row of the visitor seats

mentally recording who showed up and who didn’t.

 

The women in black resumed weeping when friends visited

the casket and turned to embrace them, now both crying.

The casket was surrounded with a forest of flowers

that gave off a strong sickly sweet scent that often made me feel sick,

so I learned the trick of stealthily leaving the room to get a

few breaths of fresh air in the entrance corridor.

 

On one occasion of escaping into the corridor I noticed a

small room at the back with the door cracked open.

Being nosey I stuck my head in to find a dozen or more

people (mostly men, none of whom had a formal funereal role)

eating from a large buffet of food, smoking and drinking wine or spirits,

but it was the Italian cannoli that caught my eye when I was invited in.

Food and drink were (and are) common at Italian or Irish wakes.

 

Wakes were also an important occasion of reconnecting with distant

relatives and friends that we saw rarely. That and the food and drink

lightened the atmosphere, with eventual laughter in the background

recalling shared funny experiences long before. It also got us up to date

about who else had died or moved in the interim. It was a positive

social event at a time when many rarely travelled far and phone usage

was relatively expensive and used infrequently.

 

My mother would talk at home for days afterward about the news and gossip;

she loved that part of it. It was more effective than Facebook because

one got the information directly from a reliable source with all the gory details,

and everyone hugged and kissed to cement our relationships and love

for one another (my sisters and I aggressively wiped our faces of the juicy kisses from aunts and uncles as soon as possible).

 

In those days, wakes were held for three days (to some, shorter would

have been a sign of disrespect for the deceased).

That was a significant burden for the decedent’s family because after the wake

they still had to go to the funeral Mass on the fourth or fifth day

and then lead a parade of cars to the cemetery.

My father and I usually managed to avoid the multiple days

and the Mass. Enough is enough.

 

I don’t know when the tradition of long wakes died out along with

the shift to a closed casket with a photo of the deceased on a table.

Cremation was unheard of in those days due to some quasi-religious

taboos. My mother nearly fainted when my wife and I said we would

be cremated. Of course, when she died we had a traditional wake

for her as she wished.

 

So that is the story. I hope you don’t mind that I made this announcement

in such an informal way, but times have changed.

And since I have no date certain for my demise, I thought I would

take care of this bit of business while I was still able instead of burdening

my family with trying to contact all my friends and colleagues.

I’ve had a good, productive and overwhelmingly happy life with a loving family.

What more could one ask of life?


Thursday, October 09, 2014

Two years ago I notified five state agencies that I would not renew my medical licenses. I had maintained the five licenses for many years with no reason other than caution; What if I move back to Illinois or California?

 

I casually mentioned this to a friend who said he could never give up his license, even though he, like me, had retired from medical practice well over a decade ago.

 

It was as if he would consider himself a lesser person if he no longer had a license, and not having a license would mean that he would have a lower stature in his profession and, perhaps in society.

 

This got me thinking. Am I less a doctor or a person if I no longer have a medical license?

 

At my peak I thought I was one of the best pediatric oncologists in the world, but I never gave a thought to my license except to pay the annual fee(s).

 

So why did I decide to drop it? Here is how my rationale developed chronologically with the most important first:

 

First, in any profession if one doesn’t practice regularly, the skills honed daily gradually begin to dull and the residents and fellows know more about the current lineup of antibiotics than you do and the nurses start reminding you of important steps in caring for patients. The risk of providing inferior care grows. I did not want myself to be able to return to practice after such a long hiatus.

 

Second, I am retired with a pension and enjoy part-time work as a writer and consultant. These activities are satisfying and far less demanding than a return to practice. Some doctors retire without preparing for some activity to keep them engaged.

 

Third, sustaining a medical license has become more and more complex and demanding. Continuing Medical Education credits are required and, depending on the state, involves more and more work. Some CMEs are not about patient care; one I was required to take was a tutorial on sexual harassment. And I am unaware of any study that demonstrated a strong relationship between CME credits and the quality of an individual physician’s medical care. In any case, the hassle of maintaining licenses at this time of my career became the last straw.

 

I don’t feel that my ego was injured in this process: I still can legally put an MD after my name, I saved some money, and I have enjoyed the increased flexibility in retirement.


Wednesday, September 24, 2014

This is a common reaction at social gatherings

when people learn that I am a pediatric oncologist.

 

I didn’t ask them if they could "do that”

and wonder why they are prompted to say it.

 

Then they try to make me some kind of hero

for “doing that,” which I certainly am not.

 

I’ve tried to avoid these exchanges by just saying I am retired,

but most press on trying to fit this stranger in a pigeon hole:

is he important or not, worthwhile knowing or not?

 

I try to explain that it is simply the profession

that I have chosen and never regretted.

 

In fact caring for children with cancer and

trying to develop better therapy has

given me more joy and satisfaction than I deserve.

 

Even when the cancer wins and we grieve with the family,

I feel privileged to have been a small part of that family

doing whatever little I can to console them.

 

If there are heroes in these stories, it is the children and their

parents who work hard to maintain a “normal” environment in

the face of constant worry and stress, and unpleasant treatments

and side effects. Some families disintegrate under this stress, others

grow even stronger.

 

//////////////////////////////////////

 

I would very much like to hear from you readers of any similar experiences

you may have had -- comment here, or email OT@LWWNY.com


Tuesday, September 16, 2014

Many readers of OT travel a great deal and many are in their senior years as oncologists and academics. This poem arose on a plane and reflects the poignancy of our jobs and lives as we get older:

 

Travel           

The plane has halved the continent at last

Although discomfort from takeoff to now

Still pesters my back and legs.

 

I read and write, do crosswords for a while

But the tedium grinds away my will

I stare at flight screens but

The painfully slow pace is depressing.

 

I must take the long flight because of work

But even that “must” has begun to erode

And I don’t need to work for subsistence,

But I see engagement with

The world narrowing in my 70s.

 

Which is compounded by drifting apart from colleagues 

As we retire, become infirm, and skip professional meetings,

And the authors of published articles and names of seminar

Speakers are no longer familiar.

 

The youngsters are doing what we all did

Slowly taking the reins and leading the pack

And my domestic routine with Pat becomes my Eden.

 

So I suffer traveling to exercise my intellect and to feed

My curiosity about what is new and exciting. But this

Damned flight never seems to end.


Tuesday, July 29, 2014

How do we know that one cancer center is “better” than any other? If we had a cancer diagnosis, should an institution’s ranking in U.S. News & World Report be our standard? U.S. News has virtually taken over the evaluation of cancer programs and centers, as well as universities and hospitals. The ranking is highly publicized and institutions publicize their own ranks, if at a high level. In my opinion, though, such rankings depend too much on the opinion of deans and other academic types, most of whom have no first-hand knowledge of what makes a cancer center good or bad today (i.e., not 10 years ago), or they focus only on scientific eminence, personal relationships, or a long-standing reputation.

 

The result is basically the same old lineup, with small changes back and forth each year. There are centers that are ranked near the top that would never be there if they were they evaluated by a seasoned, knowledgeable group of cancer center leaders. And there are centers that are lower in the ranking that I would gladly choose if I or a loved one got cancer.

 

But the most important failing of such competitive lists is the fact that the evaluations do not measure the quality, efficiency, and value of cancer care, which the public (and most doctors) care about far more than academic reputation. The public and the medical community are often impressed and deceived by terms such as “NCI-designated” or “comprehensive,” which have nothing to do with the quality and efficiency of the care of cancer patients.

 

So what should be done? I believe the cancer center community should take control of the conversation on this issue. The cancer center community should take on the task of developing a realistic, broad-based set of standards for measuring cancer center performance in patient care, efficiency of care, clinical outcomes, and the relative cost of care. This is not an easy task, but it is a critical factor in understanding how good a cancer center is in practice, not in theory.

 

The cancer research of NCI-designated cancer centers (currently 60 that do research and also care for cancer patients) is evaluated by the NCI after they have passed the test of being included in that elite group. The NCI funds such centers to assure a strong research infrastructure that includes an assessment of the cancer research effort of an institution based on stringent guidelines and a peer review process. The NCI reviews each center every five years to ensure the consistency of research excellence. It also grades centers on how well they bring research findings to their cancer patients in the clinic.

 

So one may take the success of an institution’s NCI review process, which regularly grades each center’s research program, as ample evidence of the high quality of research. As good as it is, however, this process does not measure the quality, efficiency, and value of cancer care.

 

Complex and Difficult for Several Reasons

Measuring the quality of cancer care is complex and difficult for several reasons. Patients with the same diagnosis vary a great deal. Cancers have many subtypes, and the physical and psychological constitution of patients also varies. Even the culture that the patient lives in can determine how soon he or she seeks medical help, a critical factor in outcome, and patients’ socioeconomic group may have a major impact on the outcome of treatment.

 

Also, doctors vary in skills and knowledge, and in the face of evidence of better therapy, some are slow to change to the better therapy and continue therapy they have given for a long time and are thus comfortable with. There are many other confounding factors that must be accounted for, but that is a bit less of a problem today as medical information is increasingly digitized and thus more accessible and manageable.

 

AACI?

The Association of American Cancer Institutes, with member from many cancer centers would be a good candidate for leading such a project. It has access to all the cancer centers and their expertise and they are a well-established organization in the cancer community.

 

Experts would develop the model and measures with complete transparency of how measures were chosen and applied. Public information can be gathered independent of any one organization -- e.g., the number of cancer research grants, Cancer Center Support Grant scores, Joint Commission ratings, and hospital evaluations by independent entities. Some measures would need to be developed – for example, clinical outcomes, quality measures, patient satisfaction measured in such a way as to get better data (not Press-Ganey which I believe is flawed because every single hospital I have visited over decades claims a 90+% approval rating). Instead of a ranking of 1, 2, 3, I would have three or four categories like “outstanding,” “excellent,” “very good, and “needs improvement.” Ultimately, the group that collects and analyzes the measures could offer a service to guide a low scoring center to improvement.

 

The data and results from such an effort would belong to the participating cancer centers. Each cancer center would receive a report of how well it performed compared with the other (anonymous) centers.

 

There would certainly be some cost involved, but volunteers could do a lot of the initial spadework -- e.g., health services research faculty. Done right, this could be a source of revenue to help cover the costs of the program. For example, a cancer center that wished to be evaluated would pay a fee to cover the cost of site visits, data collection, etc.

 

The program, run by representatives of cancer centers and other experts, would eventually end up being the arbiter of what a program of excellent cancer care, research, and training should look like. Also, some community hospital systems may wish to be evaluated; they could have their own category (no lab research), and pay for the process.

 

Potential Problems

There are potential problems, of course:

·    Many in our profession often reject anything new out of hand;

·    Conflicts of interest would need to be assiduously avoided; and

·     Accepting support from commercial entities like pharmaceutical companies risks a loss of credibility by academic and other institutions.

 

Nonetheless, I believe this approach should be considered with oncologists leading the pack to develop a system that can honestly advise patients and referring doctors of the quality of cancer care at a cancer center.

About the Author

JOSEPH V. SIMONE, MD
JOSEPH V. SIMONE, MD, has had leadership roles at, among other institutions and organizations, St. Jude Children’s Research Hospital, Huntsman Cancer Institute, Memorial Sloan-Kettering Cancer Center, the University of Florida Shands Cancer Center, the National Comprehensive Cancer Network, and the National Cancer Policy Board.

Blogs Archive