Joe’s Career Blog
Career development observations and advice for medical professionals from Dr. Joseph V. Simone.
Monday, March 24, 2014
An article in the current issue of The ASCO Post (15 March 14) addresses the NCI’s cooperative group program, and includes some interesting comments by Dr. Richard Schilsky and Dr. Laurence Baker, both former heads of major cooperative groups.
Their comments reflect long-standing problems in the NCI-sponsored clinical trials program. I attended and spoke at the Institute of Medicine hearings that helped prepare for the IOM’s 2010 report to the NCI. During my day there, basically two opinions were expressed: The first was the tweaking, consolidating, and/or "more money” approach -- despite the fact that more money was never a likely prospect because of the economy and NCI’s very tight budget at that time.
The other approach was to step back and hire independent experts (like Rand and some universities) to examine why and how the current model has become so inefficient technically and scientifically. An RFP could then be sent out to develop several new models for the program that could be tested to see if they can overcome at least some of the problems.
I was apparently the only proponent of this approach. I offered that idea because the clinical trials program is a shopworn system with deeply ingrained interests accustomed to the old model, which makes substantive changes extremely difficult. But the cancer research landscape has changed dramatically in the past decade.
Furthermore, as Dr. Schilsky pointed out “…NCI’s creation of the National Clinical Trials Network will revert the power to a small number of individuals on steering committees within the NCI. They will decide what clinical trials will be done. It’s a very different model with a narrower vision, and I’m not confident [in its success].”
I agree. The track record of the NCI making dramatic changes in the cooperative groups has been short of vision and a disregard for unconsidered side effects that damage the system. The failure to harness the research creativity available across the country, in the context of a more efficient model, would be a giant step backward.
Thursday, March 20, 2014
I wrote a post in December focused on the unusually large turnover of cancer center directors and what characteristics I would look for if I were engaged in replacing them. At least one-quarter of the 60 comprehensive and clinical centers experienced this change in the past two years or anticipate a change in the next year or so.
I did not mention the impact of so many changes in the operations of the cancer centers, but it is significant -- particularly in the projected changes in funding under consideration by the NCI.
A change of the CEO of any complex organization can be smooth, rough, or destabilizing -- virtually all will face at least a period of instability or an undercurrent of fear that changes might adversely affect one’s job. Particularly in centers that had the same director for a decade or more, the transition can mean lost jobs at any level, rearrangement of leadership roles, a steep and treacherous learning curve, and the loss of the useful contacts and “connections” of the retiring director.
Bearing the responsibility of preparing a Cancer Center Support Grant for renewal can be daunting, with at least 18 months needed for preparation and working to get all the data and text together for a wide range of clinical and basic scientists, particularly if the new director is new to the institution.
The other problem is NCI funding for cancer centers, which has been largely stuck at the same level for years. Furthermore, based on recommendations of a committee of the National Cancer Advisory Board, there are plans for restructuring the grant support system to compensate for the advantage that large, long-term centers have had over the newer and smaller centers in funding increases. The discussion of this plan was reported in detail in the most recent issue of The Cancer Letter (14 March 2014).
As reported in the article, NCI Director Harold Varmus said he likes the new formula, “because it allows de novo consideration of each of the centers’ budgets, eliminating the advantages of longevity.”
As always, the devil is in the details, and it is not clear that all of these recommendations will be adopted. But this clearly complicates not only how a center prepares for a grant renewal, but what internal changes might need to be made to offer the best chance for receiving a maximum monetary benefit.
One might argue that the new directors will be better prepared to deal with a new grant formula because they didn’t have the old one engrained in their thinking. On the other hand, it is hard enough for a new director to restructure a center; adding another factor in that restructuring will cause some additional headaches, especially as the new NCI approach will likely be at least somewhat different than first offered, with enough uncertainty to raise the gastric acid levels in directors.
History says they will get through this OK since the new directors are talented and hard working. But these changes almost certainly will cause some unease.
Wednesday, February 26, 2014
The issue of physician burnout seems to pop up every few years. Two articles published recently have addressed this topic from very different vantage points:
The first, “Burnout and Career Satisfaction Among US Oncologists,” by Tait D. Shanafelt and colleagues, is in the 1 March 2014 issue of the Journal of Clinical Oncology. The authors contacted 2,998 oncologists; 1,490 returned the surveys, and 1,117 completed full-length surveys. About half were women and slightly more were in private practice compared with those in academic practice. The measures of burnout were based on the standardized Masiac Burnout Inventory. Overall, 45% had at least one symptom of burnout on the emotional exhaustion or depersonalization categories, slightly higher for those in private practice. Hours per week working in direct patient care were positively correlated with increased burnout. On the other hand, overall career satisfaction was high -- about 82%, slightly lower in private practice.
The remedy suggested is fewer work hours, especially in patient care. However, the common use of “productivity” in both private and academic practices incentivizes oncologists to work more hours and see more patients. This creates a classical double bind, especially since oncologists already work more patient care hours than most other physicians.
A more global approach to the issue of burnout is taken in “Medicine’s Search for Meaning,” by David Bornstein, which appeared in the New York Times (18 Sept. 2013). He begins by saying that the health care system is in crisis -- “We are going bankrupt,. There are too many lawsuits. We practice defensive medicine. We restrict access.” But he says doctors face a more serious problem. Almost 50% of practicing physicians report symptoms of burnout, such as emotional exhaustion, low sense of accomplishment, and detachment. He believes medicine is facing a crisis that is not about money, but about meaning.
Bornstein points out that, “Great doctors don’t just diagnose diseases, prescribe medications and treat patients; they bring the full spectrum of their human capabilities to the compassionate care of others. That is why doctors, upon entering the medical profession, speak noble words like the Oath of Maimonides: ‘May I see in all who suffer only the fellow human being.’”
Nice words, but he says that almost half of medical students suffer from some form of burnout before they even enter residency training. There is convincing evidence that this problem has a negative effect on the quality of care. Dr. Bornstein then introduces the reader to Dr. Rachel Naomi Remen, who is at UCSF. She gives a course called The Healer’s Art, which is now taught in 71 schools in the U.S. and in 7 other countries. The course is very popular because it addresses the difficult issues of gaining the confidence of patients and recognizing the dignity and nobility that should be a part of medical care. It also helps students keep their spirits alive as they go through training.
Burnout can be addressed in practice, but in the current reimbursement environment, only with the prospect of lowering one’s income, and it may be worth every penny lost for longevity and inner peace. But it seems that starting earlier is an even better idea, and action at both opportunities would be a prudent mechanism for avoiding burnout.
Wednesday, February 12, 2014
I’ve had a newspaper clipping on my desk for several months that continues to resonate with me. In that article, in the business section of the Atlanta Journal Constitution (19 May 2013), Henry Unger reported an interview he had with a local banker, Joe Evans. It was unusual because most of such interviews are vapid vanilla regurgitated from some business book, but this one impressed me.
Evans grew up on a dairy farm in rural Georgia and his parents saw to it that he got a good education. His specialty became acquiring a group of failing small banks and turning them around. He has been very successful and sold two groups of banks at a premium, and is currently in the process of developing a third group.
His father had 50 cows and decided to build the herd up to 400. But after a time his father soon calculated that he could make more profit with less work with a herd of 200, so he scaled back the herd. The lesson was that it is not the top line (total revenue) that counts, but the bottom line (profit in the pocket). He said the same was true in banking. Past a certain point in growth, one needs a different, more complex management structure to effectively deal with the larger size, but the growth and income must be able to justify that step. They had a saying on his farm, “You don’t name your cows” -- meaning don’t become wedded to an idea or direction, and be willing to admit a mistake.
This lesson is applicable in many organizations. Leaders of hospitals and academic medical centers also make what turn out to be bad, and often expensive, decisions. Some behave like Evans’s father, but others keep pumping money and time into a program that just isn’t profitable financially or because of a lost opportunity. Growth beyond the point of financial and administrative efficiency is not rare in the health care world. No one bats 1,000 in baseball or health care administration. But good players and administrators learn from the unfortunate decisions and move on.
Evans also taught me something about recruiting: “In job interviews,” he said, “I typically ask people to share with me something that they really botched. It’s not what people tell me, but the ease with which people tell me, that makes an impression on me. You want self-reflection, but you don’t want someone saying it with a cavalier attitude. I look for somebody who can comfortably learn from their experiences and grow from them.”
I get the sense that Mr. Evans is a rock-solid individual with high standards and values. It is clear he has learned many lessons along the way, taken them to heart, and I am delighted he was willing to share them.
Wednesday, January 22, 2014
If you are in a leadership position, you will undoubtedly face the unpleasant issue of whether to fire an employee. If the employee has been coached and several chances have been given, they may be incompetent or, worse, troublemakers. What you must not do is transfer them to another area because they most likely will continue to be incompetent or troublemakers. They force others to pick up the slack or repair their mistakes, reducing everyone’s efficiency.
If this continues for long, those that are consistently unproductive may become the majority because the competent learn that the institution sees no virtue in hard work and collaboration. As difficult as it may be, the best solution for all parties is to fire the individual. This is true even though one often must deal with unrealistically positive evaluations of the past, complicated and unpleasant grievance procedures, bureaucratic barriers, and the unpleasantness of confrontation.
I have been burned several times on this issue and have developed some safeguards. For non-faculty, at the hiring interview I usually tell them that the job may not work out because of them, because of me, or just because of bad chemistry. Therefore if I must terminate them, it is a bit easier for both of us. If possible, it is best to do this in the probationary period. With faculty it is more complicated. There may be contracts or understandings and a person’s whole career to consider along with all the other issues noted above. One can begin with the same approach described above -- i.e. coaching and second and third chances.
There is another important possibility to consider when deciding about letting someone go. Are they simply a bad fit for the job they were hired to do? I didn’t realize this until an underperforming lab technician, a recent college graduate, came to my office one day saying she knew she wasn’t doing well and she felt she wasn’t suited for the job. I realized that explanation might account for many underperformers. In that case, both the institution and the employee are responsible for the situation. She resigned and her record indicated she was a very hard worker, but the job and she were just not suited for one another.
This also happens with faculty. The job may have fit well at the beginning, but despite the person’s hard work and perseverance, the requirements for continued productivity grew but the person was unable to compete at that higher level. In that case, the person and the institution are better off if he/she moves on.
My experience with several cases like this is that the faculty member usually gets a better job at higher pay because the new job is a better fit for their current skills. Those individuals did not return to thank us for firing them, of course, even though they were much better off in their careers. That is the best outcome!