Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Wednesday, August 24, 2016
Some years ago, I splurged and bought "Essential Art House—50 years of Janus Films." This anniversary collection of DVDs contains 50 films released in the U.S. by Janus, which was the major source of foreign and art films in the 1950s and 60s.
Watching the films has reminded me of many visits to small, off-beat movie theaters with sticky floors and one guy who sold and collected tickets, made the popcorn, and probably ran the film. But most of all, I was reminded of experiencing the pleasure, wonder, and mystery of these decidedly non-Hollywood movies (even though some were made in the U.S.). Though I didn't always grasp nuances, the films made me think and often left a lasting impression.
The foreign films with the greatest lasting impact on me were mostly made by Ingmar Bergman.
Because I am a physician, I believe, his single most memorable and thought-provoking film is Wild Strawberries. It was released in Europe in 1957 and had its premiere in the U.S. in 1959 at the Beekman Theatre in New York City. When I watched it at home, it had the same impact as when I first saw it, the difference being that I grasped its themes much more fully, probably because the protagonist is a physician celebrating 50 years in medicine and I was very close to that mark.
One Physician's Journey
The story begins as Dr. Isak Borg, an esteemed professor emeritus of medicine, is preparing to drive from Stockholm to Lund to be honored for his 50-year career. His first words foretell a basic theme, "Our social relationships are limited, most of the time, to gossip and criticizing people's behavior. This observation slowly pushed me to isolate myself from the so-called social life. My days pass by in solitude." His daughter-in-law accompanies him on the drive. He has had an unhappy family life both as a child and as an adult. His wife left him for another man, largely because of his unsympathetic and cold demeanor. And it is clear that his son, who also is treated coolly by his father, is imbued with the same sadness and loneliness.
Throughout the movie, he has dreams of his life. In his first dream, he is lost in a sterile looking city with a large clock having no hands. A horse-drawn hearse without a driver rapidly approaches and when a wheel of the carriage hits a post, the casket falls to the street and pops open. He looks in, and it is him lying in the casket. As the movie progresses, one thinks it is as much about the death of his soul rather than the body that the dream shows him.
As the journey progresses, he and his daughter converse. She eventually tells him, "You are a selfish old man. You don't care about anything, and you never hear anyone but yourself. All this is so well hidden behind your benevolent, kind mask. But you are as hard as stone, even though everybody says you are a great humanitarian person. But the ones close to you know how you really are."
She then reminds him of what he said (and had forgotten) when she asked to spend a few weeks at his house; there was a problem in her marriage (she was pregnant and wanted the child, her husband did not) and she wanted time to think. She reminds him that he said, "Don't try to bring me into your conjugal problems, because I don't care at all. Everyone has his things to think about. I don't have any respect for the pain of the soul; so don't come here to cry. But if you need spiritual support, I can tell you the name of a priest or analyst."
No wonder his wife left him and his son is estranged. But it isn't that simple. As the movie progresses, instead of being repelled by him we gradually begin to feel sympathetic as the doctor slowly faces his past honestly. This is made possible by the magic of the movie and especially by the remarkable acting of Viktor Sjostrom, who plays the doctor. He (and the doctor) were 78 years old at the time.
During the journey his second dream is of a happy time in his youth picking wild strawberries with his first love, Sara. But she ended up marrying his best friend and he never got over that loss. In a heartbreaking scene, the young Sara, as he remembered her, tells him, as the old man, that she will not marry him. Finally, she tells him to look in the mirror. He refuses at first then looks and says, "It hurts me so." And she replies, "You should know why it hurts so much. But you don't, in spite of your science, you don't know anything indeed."
Immediately following his meeting with Sara in the dream, he walks into a classroom like the one he taught in. This is the scene that led me to write this essay. In the scene, Dr. Borg is the student, not the professor, but he is still 78 years old. The professor is giving him a test. He is asked to identify something under the microscope, but he can't see anything. He is then asked to interpret something written on the blackboard, but he does not comprehend the writing. He then is asked to diagnose a woman lying on a bed. He looks at her and says she is dead. The woman promptly gets up and laughs loudly at him. The professor writes down his conclusion, "You are incompetent."
Importance of Humility
But I left out one detail, which has occupied my thoughts more than any other aspect of the film. When he was asked to read what was on the blackboard and couldn't, he was told it said, "The first duty of a doctor is to ask for forgiveness." That hit me right between the eyes the first time I saw it over 50 years ago and the last time I saw it more recently. Strangely, despite many detailed critical analyses of the film over the years, I could find none that considered what it meant.
The statement can be interpreted in many ways; here is my understanding of it. I believe the movie, at its heart, exposes in Dr. Borg (and in us, if we care to look) a devastating lack of humility, even as he is honored and esteemed in his profession by colleagues and the public.
The soul of practicing medicine is a solemn social contract under which patients surrender themselves to us and trust us to do what is best for them. Because of patients' vulnerability and trust, we doctors have a great deal to ask forgiveness for, our relative ignorance, the times we act without charity, and the invasion of patients' bodies with knife or rays or chemical. A doctor without a substantial and persistent sense of humility every day is a poor doctor.
Unlike many of Bergman's movies, which are often unrelentingly dark, toward the end of Wild Strawberries Dr. Borg begins to see and accept his shortcomings and move toward deeper insight and reconciliation—the first steps toward humility and redemption.
Tuesday, August 9, 2016
I have written over the years about doctors and nurses, writers and poets, as well as other groups. But I am a physician first.
I have met, worked with, observed, and read about hundreds of physicians in the 50-plus years since I entered medical school. There are many that I have respected, usually for their medical skills, intellect, or efficiency.
Some I have deeply admired, often for their humanity, their view of medicine as a calling and a sacred trust, or for the personal sacrifices they made for their patients and profession. And a handful have stimulated not only respect and admiration, but also a sense of awe and wonder. I would like to tell you about one of the latter, an American physician of my grandparents' generation that I never met, but have read about extensively.
William Carlos Williams was a general practitioner and pediatrician in New Jersey. He cared for a working class, mostly poor, immigrant population early in the 1900s through the Great Depression of the 1930s when house calls were a regular part of each day, and thereafter until his death in 1963. Why he is special, and the only reason I know of him, is that he was also a poet, probably the greatest successor to Walt Whitman as a uniquely American poet. He wrote about ordinary people and everyday things in his community and his practice.
Williams was drawn to the arts at a young age and spent his life as a fulltime physician while trying to be a full-time poet. So he wrote in his carriage on house calls, between patients and after office hours, "stealing" time from his practice and often complaining of overwork and the lack of time for writing. However, despite the urgings of his colleagues in the arts, he refused to give up his practice to write and refused lucrative Manhattan practices.
Listen to Williams talk, first about "The Practice" from his autobiography: "It is the humdrum, day-in, day-out everyday work that is the real satisfaction of the practice of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life. I have never had a money practice; it would have been impossible for me.
"But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives, when they were being born, when they were dying, watching them die, watching them get well when they were ill, has always absorbed me. I lost myself in the very properties of their minds: for the moment at least I actually became them, whoever they should be, so that when I detached myself from them at the end of a half-hour of intense concentration over some illness that was affecting them, it was as though I were re-awakening from a sleep. For the moment I myself did not exist, nothing of myself affected me. As a consequence, I came back to myself, as from any other sleep, rested."
And more about his patients and society: "I don't care a rap about what people are or believe. They come to me. I care for them and either they become my friends or they don't. That is their business. My business, aside from the mere physical diagnosis, is to make a different sort of diagnosis concerning them as individuals, quite apart from anything for which they seek my advice. That fascinates me.
"From the very beginning that fascinated me even more than I myself knew. For no matter where I might find myself, every sort of individual that is possible to imagine in some phase of his development, from the highest to the lowest, at some time exhibited himself to me. I am sure I have seen them all. And all have contributed to my pie. Let the successful carry of their blue ribbons; I have known the unsuccessful, far better persons than their lucky brothers."
And finally, he speaks about his poetry, for which he began to be recognized by literary critics only late in life: "…I have never felt that medicine interfered with me but rather that it was my very food and drink, the very thing which made it possible for me to write. Was I not interested in man? There the thing was, right in front of me. I could touch it, smell it. It was myself, naked just as it was, without a lie telling itself to me in its own terms."
As with medicine, poetry was not a pastime for him, which was made clear in his ever-present red notebook:
If I did not have
I would have died
So we hear a man deeply committed to his profession, his patients, his community, and his poetry. The four are fused, inseparable and interdependent, nourishing and revealing secrets to one another, about his patients and about himself.
Williams wrote many poems, his magnum opus being the book length "Paterson," in which he writes about the city, the times, and especially the people in all their glory and decadence, disease and health, joy and sorrow. His style of writing is not ornate, but direct and tangible, though not necessarily simple or straightforward. In "A Sort of Song" he describes his style, using a metaphorical snake and flower; the phrase in the second stanza (my brackets) is his famous statement on poetry:
Let the snake wait under
and the writing
be of words, slow and quick, sharp
to strike, quiet to wait,
—through metaphor to reconcile
the people and the stones.
Compose. [No ideas
but in things] Invent!
Saxifrage is my flower that splits
He also wrote The Doctor Stories and poems about his practice and patients, some of which were compiled and introduced by Robert Coles, himself a famous physician and author.
As Coles says of them, "…the sheer daring of the literary effort soon enough comes to mind—the nerve he had to say what he says. These…accounts meant to register disappointment, frustration, confusion…or, of course, enchantment, excitement, pleasure…These are stories that tell of mistakes, of errors in judgment; and as well, of
one modest breakthrough, then another—not in research efforts of major clinical projects, but in that most important of all situations, the would-be healer face-to-face with the sufferer who half desires, half dreads the stranger's medical help."
Needless to say, The Doctor Stories, which I have read several times over the years (and that I highly recommend), were the final steps in elevating Williams to the upper level of my pantheon of doctors. He was by no means a saint and often a curmudgeon, but he worked hard every day at his passions, medicine, and poetry. In both his practice and in his art he respected his poor, societally insignificant patients enough not only to care for them, but to listen to them, to study them, to understand them and to write about them in all their humanity.
I am awestruck by his perseverance, sensitivity, artistic talent, and his commitment to the medical profession, which for him was clearly a calling and a sacred trust, as well as the lifeblood of his art. Though he died over 50 years ago, in his stories and poems he still has much to teach us about being a doctor, and about life.
Wednesday, July 27, 2016
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 found it difficult to find clarifying insights instead 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. I have written a bit in the past about the writing skills of these authors relevant to medicine.
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, especially 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 the Patient
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.
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. 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.
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 sometime 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.
A Story of Medicine
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, MPH, 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 May 26, 2010, in The New Yorker. 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 that 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 his article as well as Tolstoy's novella.
Friday, July 8, 2016
I began writing this column when I was approaching my 80th birthday and finished it when approaching 81. It is a time of recollection, assessment, and reverie. Getting to one's 80s means one has lived through a lot of history. And I now can no longer say only that I am aging, though that is true, but more honestly that I am actually old. "You don't look a day over 76," the guy at the gym cracked. Others try to be kinder and say, "You don't look that old." But I am, which is underscored when I recall the notable events—societal, medical, and personal—that I have lived through in over three-quarters of a century. Describing some of these events and changes may make my lifespan more tangible, since we all are influenced by the environment, events, and culture we have livedin.
- I was born in Chicago in the middle of the Great Depression, which had an indelible effect on my family and me; our values concerning the unreliability of financial security and material things never left us.
- My father was an uneducated immigrant who drove a taxi and earned $15-$20 a week. I never realized we were on the poor side of the social spectrum (with many, many others), but we had enough to eat and a loving home.
- I was married in May and graduated from medical school in June; I was 24.
- I started a rotating internship at Presbyterian-St. Luke's Hospital (PSLH) in Chicago (now Rush) a few years before that training category disappeared, to the detriment of subsequent post-graduate clinical experience.
- We did simple lab tests in the inpatient unit (urinalysis, stool guaiac, stomach acid, and hematocrit) at night and during the day when a quick answer was needed.
- The first contraceptive pill went on the market.
- John F. Kennedy was elected president.
- I was in the midst of a residency in internal medicine at PSLH and was on call every other night, the same as during my internship.
- I started writing a journal, which I have continued to this day, because a faculty member said that would help me learn how to write; it turned out to be an excellent way to think about problems, patients, work, life, and family and occasionally a way to vent my spleen (The journal is now well over a million words).
- James Meredith, the first black student, registered at the University of Mississippi escorted by federal marshals.
- St. Jude Children's Research Hospital opened its doors and accepted its first patient, a boy with acute lymphoblastic leukemia (ALL).
- I and most of the house staff at PSLH were drafted into the military due to the Cuban missile crisis; many of the drafts were rescinded (mine included) after hospitals around the country complained that they would be forced to shut down. Many of us then joined the military reserves staffing a virtual military hospital.
- After 4 years as a pediatric hematology-oncology fellow at the University of Illinois Department of Pediatrics, Dr. Donald Pinkel recruited me to St. Jude in Memphis. My wife and I had never lived outside of Chicago and we had three daughters 6 years old and under.
- We bought a four-bedroom house for $27,500 with an FHA loan and a $2,200 down payment that included closing costs. We had only $200 to our name (credit cards didn't exist). We drove all night in our 1963 VW Beetle with the girls sleeping in the back. After a week at work I asked Dr. Pinkel when we would get paid.
- I passed the written and oral certification exams for pediatrics and internal medicine. Oral exams were later abolished.
- This was a historic and tumultuous year for the whole country and beyond. The Vietnam war was at its peak, causing President Johnson to decline to run for a second term.
- In February, my father died.
- Robert Kennedy was assassinated.
- Civil rights and student protests popped up everywhere, and not just in America. The air was filled with tension, polarization, demonstrations, rioting, civil disobedience, and a deep sense of unease and anger. In this medium, acts of violence and lawlessness were selectively condemned or justified depending on one's viewpoint.
- Dr. Martin Luther King, Jr. came to Memphis to support the striking city sanitation workers, who were all black. On March 28 three St. Jude colleagues and I decided to march with him because of the injustice of the city's leaders. In the middle of the march, windows were shattered and riots broke out and everyone scattered. The four of us started to run back to the hospital, but I reflexively picked up two of the posters that the sanitation workers had carried and dropped when the chaos started. The posters hanged in my office until recently when I passed them to my daughter.
- A week later, April 4, Dr. King was assassinated.
- Dr. Pinkel appointed me to Head of Hematology-Oncology at St. Jude.
- Neil Armstrong landed on the moon.
- Gasoline cost 35 cents a gallon.
- Woodstock attracted more than 350,000 fans.
- The St. Jude group published the first paper projecting the possibility for the cure of ALL. I received nasty phone calls (e-mail did not exist) from colleagues criticizing me for giving patients and families false hope. I responded that if they didn't believe a cure was even a remote possibility, maybe they should send their patients to us (I did have some chutzpah).
- Terrorists at the Munich Olympic Games murdered 11 Israeli athletes.
- G. Gordon Liddy, general counsel of the committee for re-election of President Nixon proposed burglarizing and wiretapping the headquarters of the Democratic National Committee in the Watergate complex in Washington, D.C. A few months later a security guard called the police, which started the Watergate affair.
- The Senate passed the Equal Rights Amendment to the Constitution giving equal legal rights to men and women.
- The St. Jude group published a seminal paper demonstrating long-term survival for half of patients with ALL in Total Therapy Study V, even after cessation of therapy.
- President Nixon was inaugurated in January, but was forced to resign later in the year due to the Watergate scandal.
- The U.S. Supreme Court voted 7-2 in Roe v. Wade making abortion a right based on their interpretation of the Constitution concerning personal privacy and rights.
- Leisure suits became the fashion. I have photos of me wearing one and I assure you they will never see the light of day.
- I was appointed to succeed Dr. Alvin Mauer as Director of St. Jude.
- President Reagan signed legislation making the third Monday in January a national holiday honoring Dr. Martin Luther King, Jr.
- Motorola introduced the first mobile phones to the public.
- ARPANET, founded in 1969 by the U.S. Department of Defense to test models for electronic communication, officially changed the structure to the Internet Protocol, thus creating the Internet.
- Leaders of Washington University asked St. Jude leaders to consider moving the institution to St. Louis; after months of discussion and deliberation, St. Jude stayed in Memphis.
- The AIDS virus was identified and within a year the disease became widespread.
- After 24 years I left St. Jude to become Physician-in-Chief at Memorial Sloan-Kettering Cancer Center.
- Four years later, I was recruited to Utah to help further develop the Huntsman Cancer Institute. I retired from academia 5 years later, in 2001.
- On Sept. 11, 2001, my wife and I moved to Atlanta to be near our two grandchildren and did not hear of the morning attack on the World Trade Center until late afternoon. Our youngest daughter was only blocks away from the attack and we could not communicate with her until late in the day; she was OK physically, but not OK emotionally.
When pulled together, my experiences (and that of many others my age or older) describe a long arc, making my age more tangible in the midst of so many events. And I know how it ends because Shakespeare has told us with the "Seven Ages of Man" speech in "As You Like It" that ends thus:
The sixth age shifts
Into the lean and slipper'd pantaloon,
With spectacles on nose, and pouch on side,
His youthful hose well sav'd, a world too wide,
For his shrunk shank, and his big manly voice,
Turning again towards childish treble, pipes
And whistles in his sound. Last scene of all,
That ends this strange eventful history,
Is second childishness and mere oblivion,
Sans teeth, sans eyes, sans taste, sans everything.
Although Shakespeare was right, in general, I am blessed with good health, a fairly good intellect (short-term memory not as sharp, but OK), financial security, and a wonderful family with all members also in good health and happily bonded to each other.
What a blessing to have lived in an exciting age when: good health is more common; medicine is more effective; and opportunities to do good are more readily available. I can say that 80 is just a number and mean it, and I will enjoy whatever time I have left with gusto.
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:
- 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.
- 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
- 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;
- 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
- 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.
- Affiliation with academic cancer centers;
- 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
- 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.
- 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 firstname.lastname@example.org.