Judging by the increasing traffic of emails and phone calls I am receiving that seek an opinion, advice, or career help, one may conclude that there is more concern for the future in oncology and medicine in general. This uneasiness seems, to varying degrees, present across the wide spectrum of practices, hospitals, and academic medical centers as well as among trainees, junior, and senior faculty. Uneasiness of this type is often due to potential or actual changes beyond one's control. Here are some of the underlying factors.
The decline in physician reimbursement is a factor well known to oncologists and primary care physicians alike. The Medicare Modernization Act of 2003 cut reimbursement for the sale and administration of chemotherapy by oncologists. This has had a number of major effects. Smaller oncology practices suffered more than larger ones, leading to the dissolution of some and mergers with larger practices.
It has led more oncologists to leave independent practice and become employed by a health system or hospital. Even large practices have joined university systems as paid employees. A related factor is the Affordability Care Act passed by Congress last year. Most doctors think that health care costs will, as a result, be constricted even more so reimbursement will decline further or at least not increase.
These forces have led many larger oncology practices to sustain income by building diagnostic imaging, radiation oncology, and other revenue-rich services within the practice. The risk of a conflict of interest causing overuse in these cases was addressed in one of my previous columns (“The Self-Referral Boom,” in the February 25th issue).
Change in Lifestyle
For years there has been a progressive trend among trainees and new doctors to seek shorter working hours and more family time. This evolution has influenced specialty choices and provides an additional impetus toward institutional employment rather than independent or small group practice.
The physician who is on call 24/7 is fading fast. The reduced work week is growing at a time when health care reform and an increase in those with medical insurance will require more doctors, leading to predictions of a severe shortage of oncologists and primary care doctors, especially the latter since an increasing fraction of medical graduates choose specialty or subspecialty careers. And dual professional careers in a family are more common, putting additional stress on career choices.
Although there are signs the economy is improving, the past three years have been financially challenging for some practices and health care institutions. Some states are making drastic cuts in educational funding and others are reducing unemployment benefits, Medicaid support, and other services. The people most affected are forgoing medical care, dental care, and other essentials.
University-based cancer centers are feeling the squeeze, particularly those in state-supported medical schools, limiting the ability to hire new faculty and develop new technology.
As I write this, Congress and the White House still have not agreed on the budget. Whatever happens, all signs point to major cuts, the only decision being, “How much?” The National Cancer Institute, according to its director, Dr. Harold Varmus, will have less money for grants and programs in the coming year. This will probably affect young scientists most and will negatively impact medical school and cancer center budgets.
This also creates uncertainty, and many scientists and financially weaker departments in medical schools will have fewer degrees of freedom for growth and hiring.
I have listed a few of the issues that make many believe we are witnessing “the worst of times.” However, this is the point where an old semi-retired curmudgeon puffs on his pipe (metaphorically) and says something like this: I have been through three other serious downturns in the economy (admittedly not this bad) with very tight grant funding, but we adapted and eventually things got even better than before the tightening. I have also experienced the cultural evolution of medicine over the past 50 years; some were good changes and some were bad, but the medical community has always been able to adapt and prosper in the past, regardless of the environmental changes.
Furthermore, in many ways we are experiencing “the best of times.” Cancer mortality and incidence are both dropping. The cure rate for children with acute leukemia has continued to improve despite no new front-line agents over the past four decades; it is at or above 80%.
We have better therapy for most adult cancers, though lung cancer, glioblastomas and pancreatic cancer keep us humble. Small molecule targeted therapy is getting its sea legs and, in combination with some conventional agents, will have an increasingly positive impact on results.
We have the technology to prevent some cancers that includes vaccines for cervical cancer (papilloma virus vaccine) and liver cancer (hepatitis vaccine). And colonoscopy, or development of a better non-invasive imaging approach, can prevent colon cancer.
The use of quality improvement methods has caught on and will be promoted even further by health care reform. Smoking rates are down in the US, and the incidence of lung cancer is declining.
So the bottom line is that everyone thinks his difficulties and uncertainties are unique to us today. But that is clearly not the case. In 1859 Charles Dickens published, A Tale of Two Cities, set in the turbulent era before and during The French Revolution. The opening sentence of that novel, probably the most famous opening lines of any work of fiction, tells us that “the best and worst” are simultaneously part of the human condition, with many ups and downs for both. He says it better than I can:
“It was the best of times, it was the worst of times; it was the age of wisdom, it was the age of foolishness; it was the epoch of belief, it was the epoch of incredulity; it was the season of Light, it was the season of Darkness; it was the spring of hope, it was the winter of despair; we had everything before us, we had nothing before us; we were all going directly to Heaven, we were all going the other way.”
I am an optimist; it is difficult for an oncologist to be otherwise.