Simone’s OncOpinion
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.

Monday, July 10, 2017

About a decade ago, I learned that many oncologists (and interventional cardiologists, orthopedists, and others, as well) earn very large incomes, seven figures and more. Studies of practices then described the evolution of medical specialists from acting as "single agents" (for the patient), to "double agents" (for patient and payer), and now to "free agents" (for themselves). I called the free agents "econo-docs," for whom economics comes first and the doc part last. And now I ask: Are we oncologists like the interventional cardiologists and orthopedists cited in the articles?

It is impossible to deny there are some of us in oncology who behave as if the patient serves principally as a source of revenue and whose practices are focused inordinately, and sometimes obscenely, on the business of medicine. I have spoken with numerous oncologists who can provide examples of (other) oncologists who fit the profile of the "econo-docs."

Econo-docs often engage in behavior that is unprofessional at best and mired in unethical conflicts of interest at worst. A few examples (all of which I have observed) of such behavior follow:

  • prescribing chemotherapy that is clearly futile ("churning");
  • prescribing chemotherapy the oncologist sells to the patient at an exorbitant markup;
  • ordering outpatients to receive costly IV hydration that is not indicated;
  • using software programs to choose among drugs not by relative efficacy and safety, but by highest profit margin; and
  • preferentially referring patients to other specialty services in which they personally hold equity positions that are hidden from the patient and public, e.g., radiation oncology or diagnostic imaging facilities.

Other examples include responding to the pending decline in chemotherapy reimbursement by sending to their patients frightening letters that threaten the use of inferior or more toxic therapy, or indicating to their Medicare patients they may no longer be cared for (featured in the New York Times articles and editorials in March 2004). An informal survey of community medical oncology practices revealed top incomes in a practice often exceed $1,000,000, particularly in large practices in smaller metropolitan areas.

To be sure, HMOs, Medicare, and medical insurance companies have created a perverse system of reimbursement. The system values an appendectomy more than spending hours diagnosing a cancer patient and describing the prognosis, laying out the treatment options, talking to the family, and repeating information the often stunned and distraught patient cannot remember from one visit to the next.

The system has also rewarded oncologists far more handsomely for the purchase and resale of chemotherapy than for face-to-face care of the patient. Yes, the system's incentives are terribly warped. But with few exceptions, the outcry of the oncology community at the unjust reimbursement schedule came only after the lucrative chemotherapy business was threatened.

Should we respond that these econo-docs make up a minority of cancer caregivers and, therefore, should not concern us? Should we ignore them as minor aberrations that one is likely to find in any profession? Or tolerate them as overzealous business types who occasionally step over the line of ethical propriety? Well, let me test the reader's response with related questions.

Is the reader outraged at rapacious business leaders' theft of billions of dollars from ordinary people, while lying and cheating to hide their crimes? That CEO/chairmen vote themselves almost unimaginably rich compensation packages as their companies consistently lose value? That cozy complicity in these shenanigans is practiced by certified public accountants? I am and I hope the reader is. One might argue these professionals committed more serious breaches than the econo-docs and some were engaged in criminal activity.

But the concern here is not for legality, but the much higher standard of professional ethics. As professionals who are entrusted with the care of the sick and who take an oath of ethical behavior, we are held to much higher standards because we care for people at very vulnerable and often dangerous periods of their lives. The behavior of econo-docs has exposed major cracks in professional ethical norms that include actual or potential conflicts of interest.

Most of all, by taking advantage of vulnerable patients, econo-docs betray the public trust; that is what should concern us most of all.

It is true there are some scoundrels in every profession. But the bigger worry is that our silent tolerance, and sometimes admiration, of the econo-docs' entrepreneurial activities may insidiously encourage some of the large majority to cross the line and engage in practices devised primarily for economic gain. The irony is that econo-docs most likely will find a way to prosper even when the rules change; it is the non-entrepreneurial docs who are likely to suffer most and even be forced out of business.

While an ethical profession may be embarrassed by the transgressions of the few, the quiet acquiescence, approval, and participation of the many ordinary, basically decent docs eventually destroys its professional fabric.

Just because our patients like us and trust us does not necessarily mean we give high-quality care that is free of economic conflicts of interest. It is the professional responsibility of each of us and our leaders to be vigilant and take steps to assure ourselves that both, in fact, are so.​

Monday, June 12, 2017

My mother died peacefully about 10 years ago. I wrote a column when she passed (Nov. 10, 2006 issue). It had been only 3 weeks since the diagnosis of pancreatic cancer. It was a memorable 3 weeks not because of sadness, pain, and anguish, but because of the joy of the family being with her in her last days celebrating her long and eventful life with her. She directed the action in typical fashion from the time of diagnosis until the last day. I am reminded of her death and all the accouterments. It was sad, but not sad. I will explain.

First, she declined any therapy or further diagnostic tests and insisted on going home from the hospital. The first week home was a happy one for her as she made preparations. She had no pain or serious symptoms until the end of the week when she became jaundiced, which I had alerted her and my sister to look for. She had the home health nurse take away the monitoring equipment (cardiac pacemaker). When I visited with her the next weekend, I told her she did not need to take any of her medications, which made her very happy. I then told her she didn't even need to take her insulin or test her blood sugar anymore; she was ecstatic. This worried my sister, "What will happen?" I said nothing would happen except she might pee more.

Her home health doctor had visited just before we arrived and because the jaundice was causing some itching, he had suggested that a stent be put in the bile duct via endoscope. She said she would talk to me about it and when I arrived she said, "I will do whatever you say." I knew this was not true, unless my advice happened to agree with her decision, but I called Dr. Chiang (a saint who cared for her for years) and got the details of what would be involved. I then explained to my mother and sister without editorial comment that she would go to the hospital, have anesthesia, have a tube inserted, and they might need to make small cuts to enlarge the orifice, etc. She said, "Why go through all that for some itching? I have had bad back pain every day for years (osteoarthritis); this is nothing." I told her I agreed with her decision, which made her happy. So we got various forms of Benadryl lotion and pills to control the itching, and they worked pretty well.

My sister, her husband, my wife, and I spent the whole day with her discussing her wishes. She was laser-focused on who would get her furniture. She offered it to all of us, knowing we would decline. But following her protocol of tradition, she then wanted to know if any of our kids (her seven grandchildren) wanted any of the furniture, and insisted we call and find out, which we did. All declined except one niece who wanted to restore the "antique" bedroom furniture and another niece who wanted the cedar chest. After the family had its chance, she decided who would get the rest among long-standing neighbors and friends.

I had told my mother she could now eat anything she wanted. She ate ice cream, which she loved but hadn't eaten because of her diabetes, and yogurt every day, until the last few days. As I was leaving that evening to sleep at my sister's house, she said, "Don't forget to bring something for lunch tomorrow." I asked what she wanted and she said, "Kentucky Fried Chicken, extra crispy, dark meat, and all the sides, especially mashed potatoes." I got the same for all of us…a wonderful feast reminding each other of our happy days and especially some of the funny events making us laugh out loud.

Before we left, she asked (ordered?) that her four great grandchildren who lived nearby come to her apartment the next day. She wanted them to open the two piggy banks she had and divide the coins there in front of her. Needless to say, they came the next day. Finding the piggy banks was a challenge; her directions (or memory) were not very clear. We sifted through tons (not much of an exaggeration) of old papers, utility bills, greeting cards, clothing, religious artifacts, etc., and finally located them. The kids (8-12 years old) had a ball helping us look and dutifully sat on the floor in front of her and sorted and distributed the coins. My mother was very happy. She had taken care of the furniture and the coins and she said, "The rest is junk," meaning she didn't care what we did with it.

It was a great weekend for her and for us. She did pretty well for a few days but her appetite declined steadily and she said she was tired. We had arranged for home hospice care. When I returned a few days later, she had declined noticeably and was sleeping a great deal without medications. However, when aroused her memory and mind were as sharp as ever, which remained true until the last 24 hours. I spent 3 days with her and before returning home to take care of some business, I spoke with her and told her I was leaving but would be back. Two hours after I arrived home from the airport, I got a call that she had died peacefully.

We had a traditional wake and she was buried next to her husband and with her baby son who died at 9 months of age in 1943, just as she had planned for years.

In another age, my mother would have been a leader in business. She was bright beyond her meager education. She had the kind of independence, strength of will, and confidence in her judgments that makes good leaders. I see a bit of her better traits in me, my sisters, and my daughters, and I am grateful for that.​

Thursday, May 25, 2017

Like many of you, early in my career I began to face the difficult issues inherent in end-of-life care. I accumulated a library on the issue but saw few, if any, clarifying insights. Most of such literature consists of superficial banter or a misplaced spiritual focus. I learned to go to the Russian writers for in-depth, humane descriptions of suffering and death.

Alexander Solzhenitsyn's Cancer Ward is a masterpiece that provides insight into the fears, strengths, and weaknesses of people under enormous stress because of cancer. Fyodor Dostoyevsky is a master at describing how people like us deal with their sins and challenges, and especially the value of lives, particularly in The Brothers Karamazov.

However, for the purpose of this column, the best source is the shortest—Leo Tolstoy's masterpiece, The Death of Ivan Ilyich, published in 1886. This novella in my little yellowed-page Bantam Classic pocket book edition (that I got for $1.35 in a used bookstore long ago) is only 99 pages long. It is a tour de force of artistic compression—the impact of a novel from what is essentially a long short story.

Tolstoy describes a 40-something man, Ivan Ilyich Golovin, an accomplished attorney who rose to the position of high court judge. Ivan Ilyich (I use this name format as Tolstoy did) develops a slowly progressive, ultimately fatal disease. Despite the radical changes in medicine since his time, Tolstoy would need to change none of the human essentials if he were writing it today; his description of this "worldly careerist" describes features of many of us professionals today. Ivan Ilyich is successful by societal standards. He has married "correctly," has two attractive children, and has achieved substantial professional stature. He had a good life, took pride in his work, moved in the best social circles, and derived great pleasure from playing whist, a card game similar to bridge, with his friends.

One day, shortly after being appointed to the high court, he fell and banged his side. It was sore for a couple of days then subsided. Later, he noticed a small lump in the area that was mostly painless but it remained tender to the touch. But the discomfort gradually became annoying to him and his disposition worsened, leading to frequent arguments with his wife. Finally, his wife insisted he see a doctor. Here is Tolstoy's acidic description of the visit to the doctor:

"The whole procedure was just what he expected, just what one always encounters. There was the waiting, the doctor's exaggerated air of importance (so familiar to him since it was the very air he assumed in court), the tapping, the listening requiring answers that were clearly superfluous since they were foregone conclusions, and the significant look that implied: 'Just put yourself in our hands and we will take care of everything…' [Then] the doctor said: such and such indicates that you have such and such, but if an analysis of such and such does not confirm this, then we have to assume you have such and such…and so on.

"To Ivan Ilyich only one question mattered: was this condition serious or not? But the doctor ignored this inappropriate question…one simply had to weigh the alternatives: a floating kidney, chronic catarrh, or disease of the caecum…and in Ivan Ilyich's presence the doctor resolved that conflict brilliantly in favor of the caecum, with the reservation that if an analysis of the urine revealed new evidence, the case would be reconsidered."

Over several months, the aches changed to pain that became progressively worse. He began to lose weight and developed a bad taste in his mouth, bad breath, and a poor appetite. Despite repeated visits to doctors and multiple medications, he was on a downhill path.

If Ivan Ilyich had ever thought about death, it was never his own, it was always removed from serious concern. Death happened to others and required expressions of sorrow and condolences that caused brief and unwelcome interruptions in the comforting routines of a busy life. In fact, Ivan Ilyich never deeply examined his life, his only focus being on the physical aspects. He was an opportunist, a "man on the make," in society and his profession; metaphysical issues were of no interest. His professional authority led him to believe he was special.

Even though he sometimes acts like a pompous boor, in some ways Ivan Ilyich becomes a sympathetic character because we can glimpse a bit, or more, of ourselves in him, because Tolstoy uses him to express his own fear of death and because of Tolstoy's graphic and heartbreaking description of Ivan Ilyich's suffering.

What sets this narrative apart from most treatments of death in the artistic and medical literature is that everything is described as seen and experienced by the dying patient. The viewpoint is personal and specific instead of generic, making it more poignant, and Tolstoy's artistic genius creates the mood, intensity, and relentless clarity of a dying man…it is hard to watch, but hard to look away.

There are several circumstances illustrated by Tolstoy's story that will be familiar to most doctors and nurses.

Ivan Ilyich says this can't be happening to him…it was only a little bump, after all. We are familiar with denial and the attempt to apply reason to what doesn't lend itself to reason. He also points to his living an exemplary, if unexamined, life and the injustice of this happening to him. The application of justice is, of course, also fruitless. He is tormented by the lack of an answer to "Why me?" He simply cannot grasp the reality of dying.

He dreams of cures though he eventually comes to acknowledge the fact that he is dying. He thinks about "the big lie." All around him doctors, family, and friends talk about his recovery and that the next medicine may do the trick. But it is all a big lie. He knows he is dying but nobody is honest with him. He is "trapped in a mesh of lies." This leads to his isolation, his sense that no one understands and he is all alone facing "It," which is what he calls death. Everyone around him is thinking beyond his death: the funeral, how they will get along without his income, will they get promoted when his job is filled, and so forth. He realizes that is what people do, that is what he did, because they are not dying. He comes to understand that, ultimately, everyone faces "It" alone. Near the end, he asks everyone to leave him alone.

Everyone lies to him except Gerasim, a farm boy who is brought in to care for him. He alone understands and accepts what was happening. When Ivan Ilyich thanks Gerasim for his kindness and help, the boy says, "We all have to die someday, so why shouldn't I help you?" By this he meant, Tolstoy tells us, that he did not find his work a burden because he was doing it for a dying man, and he hoped that someone would do the same for him when his time came.

Ivan Ilyich's last few days were horrible. He dreamed he was being stuffed into a black bag and he screamed in pain for 3 days before he died. An epiphany and relief came in the last moments before his death. He finally could admit to himself that perhaps he did not live a "good" life. All those honors and high stations and high society now seemed so pitifully irrelevant at this moment. He comes to admit that he could have done better, an admission of his smallness and an understanding of what is really important in life. Thus, his physical crisis ends at the same time as his moral crisis.

We are fortunate to have a contemporary writer with some of the writing skills of Tolstoy and the same uninterrupted gaze at death. Atul Gawande, MD, a physician and gifted writer has written many books, and he writes regularly for The New Yorker magazine. His article on the topic of end-of-life care is Letting Go, published in the May 26, 2010, issue.

"What should medicine do when it cannot save your life?" He tells stories familiar to any oncologist and most physicians about patients who are going to die because therapy is no longer effective, and how patients, families, and caregivers deal with it. He includes himself among doctors who on occasion recommend treatments they know will neither cure nor extend life with even a modicum of quality. He graphically describes the wrenching challenges for families and caregivers facing death and helplessness.

Gawande's article is excellent and I urge you to read it as well as Tolstoy's novella. I believe both can help us manage patients at this stage with a bit more compassion and truth, but mostly, to spend a few more unrushed minutes with the patient.​

Tuesday, April 25, 2017

This column is one in a series on the importance of leadership in cancer research and clinical programs. Trying to understand leadership, good and bad, has been an endlessly fascinating journey for me. And I am not alone. The shelves in the business section at Barnes and Noble are filled with books on the subject and airport concessions, even in smaller airports, always have such books. The Harvard Business Review reliably prints many articles, universities offer continuing education courses, and celebrities give well-paid lectures on leadership. Why is the subject so popular? The answer is easy: because leadership is difficult and because leadership is so important to any enterprise.

A parenthetical note of caution here about business books: I have read my share and found the majority to be useless. They are filled with simplistic nostrums, are endlessly repetitive, and have an almost total dependence on anecdotes (case studies), which by their nature are totally retrospective and uncontrolled. Only a small percentage of books provide an enlightening synthesis or novel viewpoints, so caveat emptor.

In my own case, an interest in the qualities of effective leaders has been greatly intensified beyond sporadic reading. It helps for me to review my own experience of watching great leaders in action, assessing my own role as a leader of academic programs and hospitals, and through my consulting work, which provides opportunities to examine in detail the work and effectiveness of many leaders in health care.

In an earlier column, I described what some experts believe makes a great leader, or rather, what kind of performance and outcome is apparent in very successful leaders. This is an important distinction. It is much easier to identify an effective leader after the fact than before or during his or her tenure. This raises interesting questions, such as: Are leaders made or born? Can someone be taught to be an effective leader? Can one identify an effective leader beforehand? Are all effective leaders "successful?" I hope to shed a bit of light on these issues from the literature and personal experience.

Are leaders born?

Yes, partly. I agree with Bill George, a former corporate CEO. In his book, True North: Discover Your Authentic Leadership, he expresses in several ways that the core characteristics of leadership, the soul of leadership, cannot be taught. I have come to believe that what is true for most skillful activities is also true for leadership. Not only is one's DNA a major influence, but George points out that personal crises and other life experiences early in life and later also prepare one to be an effective leader.

Although I loved the game, no matter how hard I tried, I could never have been a competitive college football player. I was the wrong size and shape, terribly slow, and had other interests that were more important to me. A friend once told me of a conversation he had with a CEO of a large corporation. He asked the CEO how he could tell if a candidate was likely to be an effective leader. He replied, "Simple, I just asked them what they did in high school." He was making a point that the signs of an aptitude for leadership show up early.

Can one teach effective leadership?

Only partly and only if the basic soul of leadership is already there, I believe. One can be taught certain techniques and skills through mentoring and graduated experience. But that is a refinement of the basic foundation of good instincts about human nature, character, ambition, and self-confidence. I also believe one can teach, or try to teach, a potential leader that unless he/she gets pleasure out of seeing those being led succeed and get the glory because of his/her efforts, a leadership position may not be a good choice, no matter what other talents are in place.

Can one identify an effective leader beforehand?

This is very difficult and typical search processes often fail to identify the right leader for the specific job. In my view, the best predictor of an effective leader is evidence of effective leadership in the past. This seems to be a catch-22: "I don't know if you will be an effective leader unless you have already been an effective leader. How can one become an effective leader if one never gets the chance?" But this is not as dumb as it sounds. If someone has had experience as a leader, even in a voluntary or relatively minor position, it usually means the person wanted to be a leader and went after the job, or was recognized by others as someone they would like as their leader. If he/she were successful in that role, that provides a degree of greater security in the evaluation.

In my personal experience, there are two top reasons for the failure of leaders. First, a candidate is hired for the wrong reasons, e.g., an outstanding scientist is hired to be chairman of a department or a dean primarily because of a long bibliography and an expansive CV. These are poor indicators of an aptitude for leadership, yet are often the most powerful influence on the decision to hire. Second, the candidate likes the position for its stature and power, but doesn't really like (or understand) the job of leadership. This type often is just a boss or even a bully, but not an effective leader that leads the team to perform at its best.​

Are all effective leaders successful?

No. This is one of the great faults of business books on leadership. Too often, the only measure of an effective corporate leader is an increase in market share or stock price. In academia, it is grants obtained or papers published. Books don't sell if they describe the leader who, despite seemingly insurmountable obstacles, managed to bring his so-so team to a much higher level of performance than expected. Or the leader who inherited a staff ill-fitted for the job, but was able to rearrange the workforce and workflow to help them perform at their very best. The athletic directors of college sports know this well. They often hire a coach who has turned a chronically losing team at a second- or third-tier sports college into one that wins half its games. They recognize the coaching talent despite the mediocre player talent.

In summary, effective leaders are born with an innate aptitude shaped and grown by life experiences and refined by mentorship and experience; all three are necessary. Although not fail-safe, one makes a better bet on a prospective leader who has a record of successful leadership in the past, no matter at what level. Finally, excellent and effective leaders may not be judged successful by the world's standards, but they may have done an excellent job with the resources and conditions provided—and they usually know that in their hearts.

Monday, April 10, 2017

​Changes in leadership are common at government agencies and the academic medical centers influenced by them. Having observed such changes recently, I have begun to ask myself what makes a good leader of these organizations and, better yet, what makes a great leader.

Leadership matters; it matters a lot. This is so whether the organization is a business, a practice, a hospital, an academic institution, or a government agency. Books on business success, including leadership, seem to be everywhere. Typical is the book, Winning, by Jack Welch, the former CEO of General Electric, which became a bestseller. While books on leadership of non-profit organizations, particularly those in health sciences and healthcare, are almost non-existent, leadership qualities are shared in both venues. So let's review what some gurus of management have had to say on the 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 that 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 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 whom he asked what he looked for in a leader. And 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."

He continues, "In human affairs, the distance between the leaders and the average is a constant. If leadership performance is high, the average will go up." And finally, "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. This view was cemented in my opinion by a book that focused on his leadership and political skills and, of course, on aspects of his personal character that shaped the former (Lincoln: A Life of Purpose and Power). Lincoln's integrity, vision, and bedrock principles were combined with uncommon political skills acquired in his Illinois years and with a keen sense of public opinion. These 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 engaged some political enemies in his administration because he believed they were the best people for the jobs.

In my experience, it has been clear that 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 not only have grace under pressure, which means both courage and character, but 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 he remains confident in his final decisions, he must have humility in sufficient measure to mitigate arrogance and promote active listening to those holding other views. Second, he knows that at some time he will be asked to compromise basic principles. If his values cannot be sustained because of the environment, 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 his job on the line for a core value, he is no longer free and has taken a step onto a slippery slope. Great leaders have the mindset upon taking a position of holding core values and principles dear, no matter what the cost.