Oncology Times

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Joe’s Career Blog
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Wednesday, June 22, 2016

We each have personal views on the health of clinical oncology practice and we often hear from prominent members of the cancer community on the issue. But we seldom see in print the views of those in the trenches.

 

I have asked some oncologists in private practice whom I know and judge to be thoughtful and open-minded to provide their personal views for this column. They represent practices of all types and sizes and from all regions of the country. I asked them to use the SWOT analysis format (Strengths, Weaknesses, Opportunities, and Threats). I suggested no particular topics, but only to give their personal views of the current state of clinical oncology practice in the U.S. today. I did not include duplicates and to fit in the space I could not include every comment or very similar opinions; the texts were lightly edited to fit the format.

 

This is an update of a similar request I made in 2004, the results of which were published in my column in the September 10, 2004 issue. Most of the original responders agreed to provide new opinions for this column, which represents a rough approximation of the evolution of concerns and improvements in oncology practice over the last 14 years.

Strengths of Clinical Oncology Practice:

2004

  • Opportunities for personal growth and service to the community;
  • Doctors' general good will and willingness to collaborate and learn;
  • The most robust medical scientific community in the world;
  • Explosion of knowledge and technology, promising new drugs;
  • The shift to targeted, relatively non-toxic therapy;
  • The silent revolution of the introduction of effective adjunctive therapies to improve quality of life, like anti-emetics, potent bisphosphonates, growth factors, and pain therapy regimens;
  • Strong national organizations and networks, such as ASCO, ASH, and NCCN.

2016

  • Excellent patient care and strong reputation of oncologists;
  • Excellent payer contracts in our area;
  • Greater integration of end-of-life care into clinical practice;
  • Enhanced utilization of Advance Practice Providers;
  • Treatment value-assessment efforts by ICER, ASCO, NCCN, MSKCC, et al;
  • Opportunities for personal growth and service to the community;
  • Tremendous increase in understanding the pathogenesis of cancer and new chemical biology to develop new highly active therapeutics;
  • Development and deployment of good oncology EHRs and chemotherapy order-entry systems;
  • Patients, as always, are compelling and deserving of our efforts
  • The science is amazing—and the improvement in outcomes, at least for a minority of patients, is heartwarming;
  • Acceptance of evidence-based medicine in medical oncology;
  • Exponential growth of computing capacity.

 

Weaknesses of Clinical Oncology Practice

2004

  • Too much money in the system leads to physician excesses and unreasonable expectations of patients, often avoiding or postponing difficult decisions;
  • The rising costs of cancer therapy are not sustainable, no matter how much they squeeze the docs;
  • Technological advances have increased the cost of care, further straining the system;
  • Failure to come to grips with rationing health care (e.g., millions of dollars for separating conjoined twins while American children go without routine health care);
  • Pharma--and the public--conspire to use the flashy new drug with the greatest financial impact, rather than that with the greatest medical impact;
  • Politicians have explicitly protected big Pharma (in the Medicare Modernization Act!) from competitive pricing, so they and CMS put the oncologist in charge of rationing care as prices skyrocket (it is unclear who the MMA benefits, besides politicians in an election year and big Pharma);
  • Failure to take responsibility for the rising cost of treating patients with metastatic disease; embracing very expensive agents that provide statistically significant, but clinically marginal benefit and little, if any, survival benefit;
  • Lack of any system of care (read the IOM report on the "Quality Chasm…");
  • Treatments known to be ineffective are given far too often;
  • Public dissatisfaction with the process of care;
  • Complex data presented by hurried physicians is difficult to understand and retain;
  • We oncologists too often think we are entitled to special treatment (compensation) just because [of our station in life]--if someone starts looking at what we get paid, it won't stand up to the light of day—this just isn't right;

2016

  • Our hospital has a poor reputation, so some patients go elsewhere;
  • Our hospital is trying very hard to buy our practice and, we believe, put us out of business since they cannot control us;
  • Provider burnout is a growing problem;
  • Conflicts of interest, with researchers exaggerating the efficacy of drugs for career and financial benefits;
  • Lack of software interoperability, which stifles patient care and research efforts;
  • Many physicians order all possible tests and treatments, whether indicated or not, whether useful or effective or not, thus raising costs dramatically;
  • EHRs built for general use (e.g., EPIC) are poorly equipped to manage cancer care, thus adding more safety risks and inefficiencies;
  • Oncology is a quintessential multidisciplinary specialty--far too few patients are seen in multidisciplinary clinics where shared decision-making occurs most naturally;
  • The information overload is backbreaking, communication without filters is overwhelming, current systems are overpriced for the lack of smooth usefulness;
  • No link of health care spending to overall spending for a just distribution of goods;
  • Mountains of insurance company paperwork;
  • Care in silos—only beginning to manage total disease trajectory;
  • Economic burden for patients ("financial toxicity") is real.

Opportunities for Clinical Oncology Practice

2004

  • There are enormous opportunities because the "system" is so broken, dysfunctional, and non-existent--e.g., a single electronic medical record that can communicate across all systems and platforms; this is one of many opportunities for the federal government;
  • Use current technology to see how well we are doing and improve  care (e.g., the Quality Oncology Practice Initiative);
  • Better systems of collaboration between community and academic oncologists--many academic centers are creating more community oncologists but neglect development of focused experts to whom one can refer rare or difficult problems;
  • A huge opportunity for improving the quality of care not only in medical oncology, but also in surgical and radiation oncology, diagnostic imaging, and pathology--each has a major influence on quality of care;
  • Improved methods of doctor-patient communication, decision support, and awareness;
  • Better models for management of patients with advanced cancer;
  • Move more toward skeptical, evidence-based oncology to take the high road in the quality, science. and delivery of care.

2016

  • Affiliation with academic cancer centers;
  • CancerLinQ;
  • Greater computer interoperability;
  • Liquid biopsy techniques to facilitate research and the patient experience;
  • Expanded availability of embedded decision-support tools within the EMR system;
  • Oncologists need to be the leaders of care teams. The old model of independent physicians who may or may not call for other opinions is no longer viable--Patients need to know that their doctor is working with other specialists, which is a source of comfort for most;
  • Leverage technology to improve the quality, efficiency, and safety of cancer care, including the incorporation of patient-reported information to inform practices;
  • We can and should figure out how to better include "mid-level" providers, nurse practitioners, and others--we often waste valuable talent by failing to do so;
  • A culture of evidence and cost-effectiveness is taking hold;
  • Drug approval and marketing will be tied to value as well as evidence.

Threats to Clinical Oncology Practice

2004

  • The piece-meal approach to fixing systemic problems--e.g., MMA--results in serious unintended (but foreseeable) consequences for patients;
  • Growing expectations for unreasonably positive outcomes due to hyper-optimism and marketing;
  • Potential for an adversarial breakdown of relations between hospitals and doctors--with money exiting the system, physician purchases of CT and PET scanners, and radiation therapy equipment directly competing with hospitals;
  • Drug costs will price medical oncology therapy out of reach;
  • Ignoring rapidly rising drug costs for all, the inevitable increase in the numbers of those who cannot afford care, and the widening gap between those who can and cannot afford to pay for therapy;
  • Everyone else will police us and oncologists will no longer be the leaders of cancer care; there is a risk that "big brother" will have a greater interest in the bottom line than in the quality of care--oncologists must create and maintain standards of care;
  • Continuously falling compensation may cause early retirements or curtailment of practices, leaving fewer, overly burdened practices-- the public and Congress don't understand that at this rate we will end up with too few resources and providers to give the care expected.

2016

  • Competition from academic centers and large multispecialty groups;
  • Our hospital may receive bundled ACO payments and short-change the physicians;
  • Move to oral drugs with management by specialty pharmacies;
  • Outrageous costs of new drugs;
  • Hyperbole of yet another "Moon Shot" boondoggle, raising smoke-and-mirror promises that will lead to disappointed patients;
  • "Personalized medicine" prescribing before demonstration of significantly improved outcomes;
  • Internet knowledge mixed in with "internet garbage";
  • The piece-meal approach to fixing systemic problems--e.g. MMA, MACRA, CMS Part B Demonstration project results in serious unintended (but foreseeable) consequences for patients;
  • The rapid growth of hospitalists coupled with the reduced need for patients to be hospitalized for chemotherapy has led to a loss of oncology expertise in hospitals--hospitals have become dangerous places for cancer patients!
  • Failure to control drug prices will force many patients to skip the recommended therapy, with unfortunate and unethical consequences;
  • The middle class will be crippled by health care costs;
  • CMS/government will continue to be barred from negotiating drug prices, while Canada, France, England, and others get big discounts.​

So there you have it--a snapshot of the changing status of the practice of Clinical Oncology Practice, with opinions of hope as well as  despair. Many thanks to the contributors for generously sharing their opinions. I welcome your thoughts--please let us know by adding your comment in the online version of this column, or by emailing me at joesimonemd@gmail.com.


Tuesday, June 14, 2016

I have wrestled with the concept of what makes a great leader many times over the years and have written about it before, but I never grasped the essence satisfactorily. Changes in leadership are common in academic medical centers, hospital systems, and government agencies. Having observed such changes many times in my career, a recent experience once again has made me ask myself what makes a good leader of these organizations and, better yet, what makes a great leader.

Leadership matters and it matters a lot. This statement would seem to be a no-brainer; however, it is common to see leaders chosen irrationally. This is true of business, a medical practice, a hospital, an academic institution, or a government agency. Books on business success, including leadership, seem to be everywhere. While books on leadership of non-profit organizations, particularly those in health sciences and health care, are almost non-existent, leadership qualities are shared in all industries. There are many faulty reasons for choosing a leader. Here are three.

  1. Longevity: A dean may choose a faculty member to chair a department mainly because he has been with the organization for a long time. He is a nice guy, easy to get along with, and works hard. However, he freezes when having to make an important decision. That slows progress and healthy development of the program. This is especially damaging when he is extremely reluctant to fire or transfer anyone, so he puts the brakes on progress, which can endanger the morale of the team.
  1. Scientific Excellence & Fame: It is a common, in my experience, to see a very good scientist with a huge bibliography appointed to a departmental chair when she has no leadership skills. She has no vision for developing and improving the department, she is not a good recruiter, and she has an imperial attitude toward those in lower rank. This situation often causes long-term problems among the faculty.
  1. Lack of Leadership Experience: A candidate is hired despite his lack of experience in successfully leading a group of colleagues. Leadership is a talent that is partly or mostly in the person from childhood. That talent can be improved with experience. It is my own bias that most leaders have a history of leadership in families, school, church, Boy Scouts, or other such community or social organizations; absent that beginning, becoming a great leader is possible, but very difficult.

Models of Good Leadership

There are several gurus of management that have addressed this subject. One of my favorite sources of business management wisdom is Peter Drucker. This legendary sage understood and clearly described the features of running successful businesses. He is famous for believing integrity and high ethical standards are central to good business practice because it is the right thing to do, but also because it is good for the long-term health of an organization. Here is an excerpt from his work.

"What would I look for in picking a leader of an institution? First, I would look at what the candidates have done, what their strengths are—you can only perform with strength—and what have they done with it? Second, I would look at the institution doing the hiring and ask: 'What is the one immediate key challenge?' I would try to match the strength with the needs. Then I would look for integrity. A leader sets an example, especially a strong leader."

Drucker then quotes a famous and successful business leader and asked what he looked for in a leader. The man responded, "I always ask myself, would I want one of my sons to work under that person? If [the leader] is successful…would I want my son to look like that?" Drucker then concludes, "This, I think, is the ultimate question." And my favorite comment by Drucker, "Effective leaders delegate, but they do not delegate the one thing that will set the standard. They do it." Another well-known management expert, W. Edwards Deming, also held this last principle.

Deming is best known for being the American consultant who revitalized Japanese industry after World War II. "It is the responsibility of management to discover the barriers that prevent workers from taking pride in what they do. Rather than helping workers do their job correctly, most supervisors don't know the work they supervise. They have never done the job." Deming goes on to say that such supervisors often use numbers or quotas as the only basis for judgment, without understanding the nature of the work.

The greatest leader in American history was, in my view, Abraham Lincoln. A book that focused on his leadership and political skills cemented this view and, of course, on aspects of his personal character that shaped him (Lincoln: A Life of Purpose and Power). Lincoln's integrity, vision and bedrock principles were combined with uncommon political skills, which enabled him to navigate skillfully the most difficult and treacherous times of our country. He devoured information from all sources and sent aides into the field to obtain first-hand information that helped him make astute strategic decisions. He was an uncommon leader who brought political enemies into his administration because he believed they were the best people for the jobs. This book is the best I have ever read on the subject of leadership.​

Leaders With Vision

In my experience, it has been clear the ill effects of poor leadership, at any level from CEO to department head to housekeeping, insidiously permeate an entire institution. This invariably leads to inefficiency at best, and at worst leads to falling dominoes of lost opportunity or catastrophe. Effective leadership is often subtle but direct, nuanced but clearly understood.

What makes great leaders is not a secret. They have grace under pressure, which means both courage and character, while they remain focused on the important aspects of an issue in the midst of chaos. Great leaders repeatedly articulate a consistent, simple public vision by example, conviction, and actions. If the troops don't know what is expected of them, what direction is set or what the leader values most, that is the leader's fault.

However, this vision must be backed by public acts, not just words. There are many opportunities to demonstrate one's vision, both subtle and overt. Whom the leader hires, fires, and promotes sends the most effective signal, but smaller acts can indirectly express his or her values. Great leaders take satisfaction in the success of team members and try to hire people who are better than they are.

I end with two qualities that help distinguish a great leader from a good leader, especially in the not-for-profit world. First, though the great leader remains confident in her final decisions, she must have humility in sufficient measure to mitigate arrogance and promote active listening to those holding other views. Second, she knows that at some time she will be asked to compromise her basic principles. If her values cannot be sustained because of the environment or trustees, the great leader may choose to lose favor, be fired, or quit over a key principle. If the position or stature or pay means so much that the leader will not put her job on the line for a core value, she is no longer free and has taken a step onto a slippery slope. Great leaders start with the mindset of holding core values and principles dear, no matter what the cost. 


Friday, May 27, 2016

I am at an advanced age (80) and, though there are disadvantages (I can no longer throw a good forward pass to my grandsons), one of the things I enjoy about my age is that young and old physicians often ask me for advice on career issues. I enjoy that opportunity, which brings me back to my own questions and challenges.

When I was in medical school and for a couple of decades afterward, I and many other physicians before and during their formal medical training, were avid readers of non-technical books about medicine in various formats like biography, essays, and fiction. I wrote about this in a very early column and came across it by accident recently. Although some students and physicians still read about the best values of being a doctor, that practice does not seem commonplace. So here is my small effort to help revive such reading.

A few of these books had a profound and lasting impact on my thinking and values so that even today, decades later, I have vivid memories of the issues, triumphs, and difficulties they addressed. My top three such books: Microbe Hunters by Paul de Kruif (initially published in 1926); Arrowsmith by Sinclair Lewis (1925); and Aequanimitas by Sir William Osler (1904). Don't let the age of these books spook you…truth and passion about our profession never dies.

Of course, the impact of books depends not only on the topic and skill of the author, but also the frame of mind of the reader at that specific time. All three fed my burning idealism, an unformed mixture of saving mankind, practicing medicine with utmost skill, and satisfying my scientific curiosity. These and other books helped move me gradually from seeing medicine as the fantasy depicted by Hollywood in the Dr. Kildare movies to seeing medicine as a vocation, a noble calling.

Microbe Hunters describes the work and the environment of scientists and physicians who explored, opened, and illuminated the world of microbiology. Written for the general public with flair and suspense, a bit like the Western paperbacks of its day, it also has scientific heft and accuracy. I first read it as a teenager when my favorite sections were those describing the work of Louis Pasteur, Robert Koch, and Paul Ehrlich; they still are my favorites. I was and am inspired by the struggles and perseverance of Pasteur and Koch, who laid the foundations of microbiology and its application to curing human disease. Ehrlich strikes a special cord in me for his pioneering search for antibiotics and for essentially establishing the field of chemotherapy. This was dramatized effectively in the 1940 movie, Dr. Ehrlich's Magic Bullet, starring Edward G. Robinson.

Sinclair Lewis's Arrowsmith was dedicated thus: "To Dr. Paul H. De Kruif I am indebted not only for most of the bacteriological and medical material in this tale but equally for his help in planning the tale itself…" I first read this novel during my pre-med years. It traces the career and struggles of Martin Arrowsmith, a physician-scientist in the fast moving, fermenting world of microbiology in the early 20th century. The academic locale is based at the Rockefeller Institute (now Rockefeller University) in New York City, then a world leader in the study of microorganisms and their diseases. I wanted to be Arrowsmith, preventing and curing horrible diseases like plague, fighting the ignorance of peers and the wiles of academic politicians, risking my life to save lives, and tragically and heroically losing my devoted wife to the diseases we fought together in the tropics (the latter no longer seems attractive). It was an inspiring and, yes, heroic way of life.

I was in medical school when I first read Aequinimitas by Sir William Osler and I was immediately captivated. Here was a renowned physician, the first professor of medicine of the Johns Hopkins School of Medicine and one of the founders of the modern era of medicine, speaking directly to me about being a physician, a good physician. The book consists of a collection of Osler's addresses given over the years, many to incoming or graduating medical classes. They were inspiring and made me proud to be a budding member of the profession. But they also were practical, providing advice about how one should behave and what one should value. And most of all, his words rang true, refreshing and clarifying feelings and beliefs that were deeply, if vaguely, held.

The book was an immediate international hit. A section of Osler's preface to the 2nd edition describes the book's reception and intent, as well as his bedrock view of medicine as a calling akin to a religious vocation.

"I have to thank my friends, lay and medical, for their kind criticisms of the volume; but above all, I have been deeply touched that many young men on both sides of the Atlantic should have written stating that the addresses have been helpful in forming their ideals. Loyalty to the best interests of the noblest of callings, and a profound belief in the gospel of the day's work are the texts…from which I have preached. I have enduring faith in the men who do the routine work of our profession. Hard though the conditions may be, approached in the right spirit—the spirit which has animated us from the days of Hippocrates—the practice of medicine affords scope for the exercise of the best faculties of mind and heart."

But Osler's head was not in the clouds. He continues, "That the yoke of the general practitioner is often galling cannot be denied, but he has not a monopoly of the worries and trials in the meeting and conquering of which he fights his life battle; and it is a source of inexpressible gratification to me to feel that I may perhaps have helped to make his yoke easier and his burden lighter."

The title address, Aequanimitas, was given to the medical graduates of the University of Pennsylvania on May 1, 1889, his last day at Penn before leaving for Johns Hopkins.

"…my tender mercy constrains me to consider but two of the score of elements which may make or mar your lives—which may contribute to your success or help you in the days of failure. In the first place, in the physician and surgeon no quality takes rank with imperturbability… [meaning] coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of great peril…It is the quality which is most appreciated by the laity though often misunderstood by them; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emergencies, loses rapidly the confidence of his patients." He describes this quality in more detail and expresses regret that "some among you…may never be able to acquire it. Education, however, will do much; and with practice and experience the majority of you may expect to attain to a fair measure."

He goes on to describe the second and similar desirable element. "…the mental equivalent to this bodily endowment [imperturbability is] a calm equanimity. How difficult to obtain, yet how necessary, in success and failure! One of the first essentials in securing a good-natured equanimity is not to expect too much from the people amongst whom you dwell." He continues that colleagues and patients are full of fads and eccentricities, whims and fancies and weaknesses, "which are not unlike our own."

Another passage also demonstrates the timelessness of his words despite the passing of a century. "I would warn you against the trials of the day soon to come to some of you—the day of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living."

Among the 22 addresses are these titles, "Doctor and Nurse," "Teaching and Thinking," "Internal Medicine as a Vocation," "Nurse and Patient," "The Hospital as a College," and "Chauvinism in Medicine." In the latter, he lists the four great features of the profession of medicine—its noble ancestry, remarkable solidarity, progressive character, and singular beneficence.

I will end this quick survey of Osler with several of his well-known quotes and biographical information. "One of the first duties of a physician is to educate the masses not to take medicine." "Look wise, say nothing, and grunt. Speech was given to conceal thought." "Live neither in the past nor in the future, but let each day's work absorb your entire energies, and satisfy your wildest ambitions."

A brief, but excellent biography of Osler can be found at www.whonamedit.com/doctor.cfm/1627.html. The site also has quotes, a list of his writings, and a bibliography of literature written about him. The best major biography of Osler is the Pulitzer Prize-winning, A Life of Sir William Osler, by Harvey Cushing, MD.\

I believe there is no better inspiration and influence for medical students, residents and fellows than reading Aequinimitas. But reading Osler—and de Kruif and Lewis—still excites and inspires an old duffer like me as well.

A modern day equivalent of these authors is Atul Gawande, MD, MPH, who has written some wonderful articles on being a better physician: "Cowboys and Pit Crews" was published in the May 2011 The New Yorker, which publishes many of his articles. Several excellent books are "Being Mortal," one of my favorites, and "The Checklist Manifesto," Complications," and "Better."


Friday, May 27, 2016

I attended the 21st annual meeting of the National Comprehensive Cancer Network (NCCN), which met in Hollywood, Fla. this spring. I had not attended since I formally retired from academic medicine in 2001. Because I was one of the founding members and the first chairman of its Board of Directors, Robert W. Carlson, MD, the current CEO, invited me to attend. I was curious for two reasons: 1) I wanted to know how had NCCN had fared in the past 15 years, and 2) its development is a good story in which I played a role. More important, NCCN has become a vital organization because it develops, and updates regularly, cancer therapy guidelines that are widely available in the U.S. and around the world. It has expert panels for each cancer type that meets regularly and describes the degree of certainty and solidity for each recommended guideline based on available data and experience.

A bit of background history will be useful to understand the foundation of NCCN. In the 1980s, Medicare changed its hospital reimbursement system from a cost plus basis to one based on Diagnosis Related Groups (DRGs), later called the Prospective Payment System (PPS), which attempted to control inpatient costs by using the average regional cost for a disease or procedure and the length of stay as a payer benchmarks; this rule was applied broadly. However, specialty hospitals, such as children's hospitals and some freestanding cancer hospitals, were later exempted from PPS because there were too few such hospitals in any region to set a valid average cost and because these centers had more patients with advanced disease.

The original eight cancer hospital exemptions went to Memorial Sloan Kettering, MD Anderson, Roswell Park, Fox Chase, City of Hope, USC-Norris Cancer Hospital, Dana-Farber, and Fred Hutchinson. These institutions were allowed to charge on a negotiated cost plus basis; this gave them a huge financial advantage. Others were added later. Representatives of this initial group of PPS exempt cancer centers met regularly, especially after the general election of 1992.

In 1993, the new Clinton administration attempted to radically change how hospitals were paid. This caused uproar among academic centers of all kinds because one of the provisions in the draft proposal was to redirect patients to community hospitals that were less expensive than academic hospitals. I had been at Memorial for only a year and became deeply involved in trying to deal with the potential changes.

Meetings with representatives of the all the PPS-exempt cancer hospitals were intense as we struggled to focus on a plan. This was not easy. Some felt the goal should be to protect market share. We met with politicians, medical directors of large corporations, and insurers trying to make a case for sending patients preferentially to these well-known cancer centers. We did not get very far. We learned that insurers were made up of regional branches that operated under different laws. A few of us came to believe the attraction of higher quality of care should be promoted. We tried that with medical directors, insurers, etc., but we had a big problem: there was no objective evidence that the marquee cancer centers gave better care or cured more patients than community hospitals.

Nonetheless, I was asked to lead a subgroup to develop a plan around the idea of higher quality and, incidentally, to serve as the first head of the project. Some colleagues and I pitched the idea of the developing cancer care guidelines to the PPS-exempt centers and received mainly a cool reception. This was partly due to the fact that we needed money from each participating center to fund the development of the guidelines. With the invaluable help of Cathy Harvey, DrPH, and Bruce Ross, we managed to get funding commitments from each center via annual dues (I think it was over $100,000 per year) and we drafted a strategic plan.

We later realized we could not pull this off with volunteers only and needed a full-time leader and staff. NCCN then hired Bill McGivney, PhD, and, after a slow start, the program began to take off. McGivney started the annual NCCN meetings in Florida, which were highly successful and provided some income. He also promoted disease-specific committees of volunteers from the participating cancer centers. Becoming a member of these committees became a coveted post. After I left Memorial in 1996, NCCN continued to do well and became a reliable national and international source for cancer care guidelines, which were offered free of charge and, eventually, were published in many languages. The NCCN became the primary trusted source of treatment guidelines globally.

Fast forward to 2016. NCCN had its largest ever turnout of attendees this year. More than 1,200 registrants filled the Diplomat Hotel. In fact, the NCCN cannot return to that venue after many years of going to the same place because the attendance had grown so much that the expected attendance was too large for the Diplomat and the meeting would be moved to Orlando in 2017. One of the more interesting things I observed by schmoozing and chatting round the coffee pot and posters is that this annual meeting seems to attract a larger proportion of oncology nurses and other non-MD cancer caregivers than ASCO and other large meetings. That is a very good sign since nurses provide most of the care

This year's agenda looked rather familiar with the specifics differing because of advances in the science and the evolution of caregiving. As usual, the speakers of the presentations were experts in their field and presented clear data and opinions, with the usual precautions against stretching the results too far.

I wish to describe two sessions that were unique for me compared to past NCCN meetings, and a very welcome change. The first presentation on the first day was on palliative care, a topic absent from the meetings I attended years ago. The presentation was followed by a panel discussion on the matter. I heard many compliments from those who attended that session. It is a topic that has too long been ignored because many doctors do not want to give bad news to patients and their families that stopping cancer therapy (no effective drugs available) and switching to treatment of the patients symptoms, physical, spiritual, and mental.

My only disappointment was that it did not go far enough. Care of cancer survivors is often neglected and the oncologists too often do not follow the patient after therapy has stopped to offer help for a variety of common problems, such as psychosocial, mental, family disruption, etc. I also believe NCCN should consider having guidelines for managing the care of cancer survivors.

The second example was the keynote session on the second day of the meeting. Its title was "Cancer Care in an Election Year." There were six experts in politics and political policies, two were also practicing physicians and one was a member of Congress. It was a lively, erudite discussion from a panel equally divided politically. They knew and respected one another and did a wonderful job of describing the difficulties of improving health care and controlling its cost. I have never heard a better discussion of the topic. These were smart, deeply engaged experts who really cared a lot about things like out-of-pocket costs of care, which many cannot afford; the risks and potential rewards of bundled payments (doctors and hospitals must negotiate on who gets what); and many other important issues.

My snapshot view of NCCN in 2016 instilled in me the confidence that it had evolved favorably in the recent years and seemed to be on the right track.


Thursday, April 7, 2016

 After many of my lectures, especially to those who are still in medical training or in early or mid-career, I mention the integrity and sanctity of work. I am passionate about this issue, which is why I wrote this column about 10 years ago.

In a short play, titled The Stonemason, author Cormac McCarthy has encapsulated the irreplaceable gist of a profession practiced correctly and with honor. This applies to every profession, whether medical or the "dirty hands" type. I think the lesson it teaches is even more relevant today in our ever-changing medical environment and is especially appropriate for a medical and nursing audience; we deal with lives and the stonemason deals in buildings.

The play is set in Louisville, Kentucky, in the 1970s and is narrated by Ben Telfair, a stonemason whose father, Big Ben, and his grandfather, Papaw, are also stonemasons (papaw is a common name for a grandfather in the South.) It is a masterfully written story of a family faced with the acute problem of Ben's wayward nephew, Soldier, who is in trouble with the law.

The play has a number of important layers, but the soul of the work, and the reason I read it over and over, is Papaw, the 100-year-old stonemason. His passion intimately weaves the sanctity of work and craftsmanship into a single fabric with spiritual wisdom about what really matters in life. He reminds me of the craftsmen who built medieval cathedrals with pride of craftsmanship and with an acute sense of the nobility and sanctity of their work.

Ben recognizes the knowledge and wisdom Papaw offers and he avidly tries to soak it up before Papaw is gone. When he realizes what a remarkable and unique resource his grandfather is, he says, "Oh I could hardly believe my good fortune. I swore then I would cleave to that old man like a bride." Neither Big Ben nor Soldier places a high value on Papaw's views of stonemasonry and his exacting standards.

During the course of the play, Papaw relates through Ben's narration what he knows and how he feels about stonemasonry, and not coincidentally, about life. He also is speaking to us about how one loves and respects his work: the truth of it, the wholeness of it, the essence of it. For Papaw, how he approaches his work is inextricably linked to how he views the world, how he treats others, and how this is all intertwined with his basic faith.

Here are excerpts from the play. While Ben and Papaw are working on a farmhouse, Ben the narrator speaks about stonemasonry:

"For true masonry is not held together by cement but by gravity. By the stuff of creation itself. The keystone that locks the arch is pressed in place by the thumb of God. When the weather is good we gather the stone ourselves out of the fields. What he likes best is what I like. To take the stone out of the ground and dress it and put it in place. We split the stone out along their seams. The chisels clink. The black earth smells good. He [Papaw] talks about stone in a different way from my father [Big Ben]: always as a thing of consequence. As if the mason were a custodian of sorts. He speaks of sap in the stone. And fire. Of course he's right. You can smell it in the broken rock. He always watched my eyes to see if I understood. Or if I cared. I cared very much. I do now. According to the gospel of the true mason God has laid the stones in the earth for men to use and he has laid them in their bedding planes to show the mason how his work must go. A wall is made the same way the world is made."

There are physicians who have the same respect, almost reverence, for their patients and how to put them back together. Perhaps for them it is because the mystery of their lives is held together "by the stuff of creation itself" and deserves—no, demands­—professional and personal respect.

Ben continues, describing the essence of the work. "So. It's not the mortar that holds the work together. What holds the stone trues the wall as well and I've seen him check his fourfoot wooden level with a plumb bob and then break the level over the wall and call for a new one. Not in anger, but only to safeguard the true. To safeguard it everywhere…I see him standing there over his plumb bob, which never lies and never lies and the plumb bob is pointing motionless to the unimaginable center of the earth four thousand miles beneath his feet. Pointing to a blackness unknown and unknowable both in truth and in principle where God and matter are locked in a collaboration that is silent nowhere in the universe and it is this that guides him as he places one stone over two and two over one as did his fathers before him and his sons to follow and let the rain carve them if it can."

Ben then talks about seeing samples of Papaw's work, some of it 80 years old, while driving in the region. "…in a thousand structures I've never seen a misplaced stone… . The beauty of those structures would appear to be just a sort of a by-product, something fortuitous, but of course it is not. The aim of the mason was to make the wall stand up and that was his purpose in its entirety. The beauty of the stonework is simply a reflection of the purity of the mason's intention."

Papaw and Ben feel a passionate responsibility to their profession and for its integrity. They believe what they do matters not only for the quality of the wall they build, which can be seen by all, but also for what cannot be seen, what almost no one will know or understand or value. They do things right out of respect for their profession, their craft and, most of all, out of respect for themselves. The characters who disdain such values, Big Ben and Soldier, are chronically unhappy and unfulfilled and find it hard to love unconditionally. They make excuses for their unhappiness, their impatience and the short cuts taken in their work and in their lives. For them, too, their jaded and cynical views of work are of one piece with their views of life.

The message is clear: Integrity in one's work and a passion for doing the right thing and doing things right are an inseparable part of what we love and value, of what brings happiness. Medicine is the same. Doing the work that we love is a privilege and a blessing; doing it with the same integrity and passion for truth as Papaw is the way we respect our patients, our profession, and ourselves.

I recommend that you read The Stonemason, because I cannot do it full justice.

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.