Joe’s Career Blog
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Tuesday, July 29, 2014
How do we know that one cancer center is “better” than any other? If we had a cancer diagnosis, should an institution’s ranking in U.S. News & World Report be our standard? U.S. News has virtually taken over the evaluation of cancer programs and centers, as well as universities and hospitals. The ranking is highly publicized and institutions publicize their own ranks, if at a high level. In my opinion, though, such rankings depend too much on the opinion of deans and other academic types, most of whom have no first-hand knowledge of what makes a cancer center good or bad today (i.e., not 10 years ago), or they focus only on scientific eminence, personal relationships, or a long-standing reputation.
The result is basically the same old lineup, with small changes back and forth each year. There are centers that are ranked near the top that would never be there if they were they evaluated by a seasoned, knowledgeable group of cancer center leaders. And there are centers that are lower in the ranking that I would gladly choose if I or a loved one got cancer.
But the most important failing of such competitive lists is the fact that the evaluations do not measure the quality, efficiency, and value of cancer care, which the public (and most doctors) care about far more than academic reputation. The public and the medical community are often impressed and deceived by terms such as “NCI-designated” or “comprehensive,” which have nothing to do with the quality and efficiency of the care of cancer patients.
So what should be done? I believe the cancer center community should take control of the conversation on this issue. The cancer center community should take on the task of developing a realistic, broad-based set of standards for measuring cancer center performance in patient care, efficiency of care, clinical outcomes, and the relative cost of care. This is not an easy task, but it is a critical factor in understanding how good a cancer center is in practice, not in theory.
The cancer research of NCI-designated cancer centers (currently 60 that do research and also care for cancer patients) is evaluated by the NCI after they have passed the test of being included in that elite group. The NCI funds such centers to assure a strong research infrastructure that includes an assessment of the cancer research effort of an institution based on stringent guidelines and a peer review process. The NCI reviews each center every five years to ensure the consistency of research excellence. It also grades centers on how well they bring research findings to their cancer patients in the clinic.
So one may take the success of an institution’s NCI review process, which regularly grades each center’s research program, as ample evidence of the high quality of research. As good as it is, however, this process does not measure the quality, efficiency, and value of cancer care.
Complex and Difficult for Several Reasons
Measuring the quality of cancer care is complex and difficult for several reasons. Patients with the same diagnosis vary a great deal. Cancers have many subtypes, and the physical and psychological constitution of patients also varies. Even the culture that the patient lives in can determine how soon he or she seeks medical help, a critical factor in outcome, and patients’ socioeconomic group may have a major impact on the outcome of treatment.
Also, doctors vary in skills and knowledge, and in the face of evidence of better therapy, some are slow to change to the better therapy and continue therapy they have given for a long time and are thus comfortable with. There are many other confounding factors that must be accounted for, but that is a bit less of a problem today as medical information is increasingly digitized and thus more accessible and manageable.
The Association of American Cancer Institutes, with member from many cancer centers would be a good candidate for leading such a project. It has access to all the cancer centers and their expertise and they are a well-established organization in the cancer community.
Experts would develop the model and measures with complete transparency of how measures were chosen and applied. Public information can be gathered independent of any one organization -- e.g., the number of cancer research grants, Cancer Center Support Grant scores, Joint Commission ratings, and hospital evaluations by independent entities. Some measures would need to be developed – for example, clinical outcomes, quality measures, patient satisfaction measured in such a way as to get better data (not Press-Ganey which I believe is flawed because every single hospital I have visited over decades claims a 90+% approval rating). Instead of a ranking of 1, 2, 3, I would have three or four categories like “outstanding,” “excellent,” “very good, and “needs improvement.” Ultimately, the group that collects and analyzes the measures could offer a service to guide a low scoring center to improvement.
The data and results from such an effort would belong to the participating cancer centers. Each cancer center would receive a report of how well it performed compared with the other (anonymous) centers.
There would certainly be some cost involved, but volunteers could do a lot of the initial spadework -- e.g., health services research faculty. Done right, this could be a source of revenue to help cover the costs of the program. For example, a cancer center that wished to be evaluated would pay a fee to cover the cost of site visits, data collection, etc.
The program, run by representatives of cancer centers and other experts, would eventually end up being the arbiter of what a program of excellent cancer care, research, and training should look like. Also, some community hospital systems may wish to be evaluated; they could have their own category (no lab research), and pay for the process.
There are potential problems, of course:
· Many in our profession often reject anything new out of hand;
· Conflicts of interest would need to be assiduously avoided; and
· Accepting support from commercial entities like pharmaceutical companies risks a loss of credibility by academic and other institutions.
Nonetheless, I believe this approach should be considered with oncologists leading the pack to develop a system that can honestly advise patients and referring doctors of the quality of cancer care at a cancer center.
Saturday, July 19, 2014
The degree of success and satisfaction in one’s job is the result of a complex interplay of environment, colleagues, opportunity, institutional culture and one’s work ethic and other personal characteristics. Some people have a super intellect that carries them ahead, while others have a fierce worth ethic and make up for a lesser intellect by very hard work.
But there is one factor that is accessible to virtually everyone. Success often depends on recognizing and adapting to the changing dominant cultural and financial features of one’s era. The evolution of academic medicine is a good example of the effect of the shifting economic and professional sands on the structure of an industry.
A failure to keep up with changes that affect one’s job is like an ostrich with his head in the sand. The cycle of ups and downs in NIH grant support is never-ending. I am old enough to have been through at least four and maybe five such cycles. The changes are sometimes caused by a lack of political support for academia or a global economic problem like the Great Recession of the past six years. In any case, those that continue to thrive usually recognize the problem and find alternative sources or write many more grants.
At the professional level, top-level scientists do not wait for the next new thing to appear in publications. They attend elite symposia where they learn what other good scientists are doing. They accept speaking engagements to academic centers and pump all the scientists for the latest information or equipment. They collaborate with investigators around the world, not just in the U.S., to learn of new, efficient twists in studies.
Academic physicians sometimes do the same thing, but, alas, a large number scans the current literature and attends a national professional meeting or two each year. Nothing wrong with that, but by the time they learn of something new, they are already behind. Cooperative groups move very slowly and are seldom making breakthroughs. In other words, one must have colleagues who appear to be doing good work that is a step or two ahead of the game and take advantage of exchanging ideas.
The art of staying ahead of the game or at least being in the game is necessary to both job success and satisfaction. One can choose to wait for publications or meetings and be quite happy and successful at one’s everyday work. But long term satisfaction is more likely with the hard work of trying to stay in the game or ahead of it.
Friday, June 13, 2014
We often admire those who have long tenures in jobs. Some continue to do good work and enjoy job satisfaction for 20 or 30 years. These people often have a niche that is valuable to the organization, so they may be content with the same job for an extended period of time.
But longevity can be a sign of danger. One may have security, but longevity is not a good measure of success, accomplishment, or happiness.
Job satisfaction is never perfect in any job. For some, comfort and predictability rather than professional development are the sources of satisfaction. But for many of us who work in the academic and community medical arena, longevity can be a sign of professional inertia, ego-driven self-satisfaction, or enjoyment of being a big fish in a very small pond, where the competition is weak and the pressure for productivity is low.
In some cases, a person may work at a single institution for two or three decades but have a series of varied jobs during that time, each providing new learning experiences and challenges. Often this results in increasing leadership responsibility and professional growth. Others may find a better career path by leaving the home institution for a job that is a step up in another one.
So how does one know when it is a good idea to move on? Here are a few signs, but they will be of no use unless one is willing to be honest with oneself; sometimes it is better to have a discussion about it with a trusted senior colleague or friend. Here are some signs that a change should at least be considered:
1. Boredom: This is a no-brainer. If you are bored out of your mind with the job, then looking for another one, whether within your current institution or elsewhere, is a good idea.
2. A sense that there is no chance for advancement or serious professional development: That may be because there are no openings or one believes that gender or racial bias are part of the problem.
3. An unhappy or toxic atmosphere in one’s unit: There may be grudges or difficult personnel making work difficult or unpleasant.
4. The problem may actually be you: One may be trapped in a job that is a bad fit for one’s talents or desires, or the job, in retrospect, was a poor choice. Be careful with this one. Blaming yourself requires courage and truth; a trusted colleague is essential in this circumstance.
What if you want to move, but cannot due to family, geographic, or financial reasons? For this situation, a heart to heart with the leader of your group or the department chair is in order. You must ask for help and advice about how to make your situation more satisfactory. But keep in mind that this may require a change in your behavior.
I repeat: This process requires courage and facing the truth head on. But that will help you choose the best solution.
Sunday, May 25, 2014
Out of the 200 OT columns I have written so far, the one published in the 6/25/06 issue, “The Stonemason on the Integrity & Sanctity of Work,” remains one of my three all-time favorites. Here are the first three paragraphs:
I rarely read works of literature cover to cover a second time; the great majority I read through once and only portions thereafter. But a few I read cover to cover repeatedly, as if for nourishment or direction, assurance or inspiration. It is for these reasons that I re-read “The Stonemason,” a short play by Cormack McCarthy, who is best known for his novels, such as “All the Pretty Horses” and “Suttree.”
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 that 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.
It is the way Papaw views his work that strikes me every time I read the book. And I wish his approach were more commonly applied in medicine, and, in fact, all professions.
Here are excerpts from the play itself. 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. 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 that 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. It is time for me to read The Stonemason again… and I strongly recommend that you do so too.
Tuesday, April 29, 2014
Recruiting is one of the more important exercises in any organization. Too often we are so anxious to fill a slot that we don’t look deeply into the qualifications and fit of candidates. We look at CVs and have a round of interviews and make a decision. But in far too many cases, little attention is paid to whether the candidate is a good fit for the culture, purpose, and needs of the institution. Personality, personal attitude, and team compatibility are grossly underrated in the process. No matter how successful the person is as a caregiver or scientist, if he or she is likely to find it difficult to adapt to the culture, the recruitment is headed for trouble.
Conversely, a small but distressing number of academic programs and other institutions have a stifling air of distrust and scientific secrecy leading to competing factions and an enormous waste of energy and a degradation of good will. The recruit may have a difficult time of adapting to such an environment.
Both the institution and the recruit must realize that each brings a work attitude and culture to the table. Both must recognize that it will take time for a new recruit to fit into a new organization; this often takes up to 18 months.
Judging personality and fitness for a job, both professionally and personally, is not a science. That does not mean one shouldn’t spend considerable time on this important issue. One test I use to help in this process is to imagine each of the following scenarios:
Desert Island: How would I feel if the candidate and I were shipwrecked on a desert island, just the two of us? Could I depend on that person to pull his or her share of the workload? How would we get along under stressful circumstances?
Daily Interdependent Colleague: This less rigorous test imagines how it would be like to deal with the recruit on a daily basis and be dependent on his or her actions and behavior.
Project Collaborator: This is even less stringent because the interaction is limited to a specific project that takes a portion of time but not all of it. Would the person be likely to serve as a good colleague?
Nice Guy…But: This means that the recruit is amiable, a “good guy,” but a bad fit professionally for the position, a painfully slow worker, not aggressive enough for the job, or may not function well as a team player.
‘South End of a Horse’: The SEH may be bright, ambitious, and highly productive, but is considered a complete jerk who annoys and frustrates everyone around him, often reducing their productivity. Propriety, graciousness, candor, and kindness are not part of his personality. He is socially toxic.
If the candidate fits the descriptions in either of the latter two scenarios, I don’t need to tell you that you should not offer the job. If the person fits one of the first three, he or she is likely (but never a certainty -- this is not a science) to do well on some level.
You won’t always have enough information from previous colleagues or former bosses, but the exercise still can be helpful. It is not fair to you or the candidate to recruit someone who is not likely to fit in or thrive in your environment, so spending a little extra time trying to gauge these issues is well worth the effort.