When this column recently passed its 10th anniversary with Oncology Times, I wondered what had changed and what had not in the past decade. A look back at a sampling of past columns has yielded both expected and unexpected results:
The first category is pediatric oncology (full disclosure, I am a pediatric oncologist, retired). My very first column, in the Sept. 25, 2003 issue (http://bit.ly/1bValka), had the pretentious title “Pediatric Oncology: Quo Vadis?” Pediatric oncology as a whole had been quite successful in developing curative therapies. But there were problems. We were victims of that success because it became much more difficult to test radical new therapies. The merger of the two pediatric oncology study groups was in serious trouble and clinical trial productivity declined. Worse, the opportunities for young oncologists to lead studies had been cut in half after the merger. A few months later, my 10th column (6/25/04 issue—http://bit.ly/1fSknp6) expressed concern that pharmaceutical companies largely felt that developing drugs for pediatric tumors was not a financially viable option, so pediatric tumors were viewed as orphan diseases.
Last year I wrote another column on the overall topic: “The Future of Pediatric Oncology” (7/10/13 issue—http://bit.ly/1bn8mbx). One of the key points was the shortage of laboratory-trained pediatric oncologists; pediatric oncologists with strong academic credentials capable of leading a research-oriented program were in short supply. This problem existed to a lesser degree in 2003, but it has been made worse by the lack of substantial support for pediatric departments, particularly those based in medicals schools without an independent and financially strong children's hospital. Such pediatric departments are almost always money losers that must compete for university and philanthropic funds.
So my concern for pediatric oncology—arguably the most successful cancer subspecialty from a patient's viewpoint—has not only not diminished but also grown.
Quality of Cancer Care
My third and fourth columns (“Better Get a Surfboard—Huge Quality Waves Coming” and “Surfing the Quality Wave“—12/10/03 and 12/25/03 issues:http://bit.ly/1fBdVVlandhttp://bit.ly/1nIy1AB) dealt with the new movement in the quality of cancer care. Release of influential studies by the Institute of Medicine: “Ensuring Quality Cancer Care” (1999), “Enhancing Data Systems for Improving the Quality of Cancer Care” (2000) and “Crossing the Quality Chasm” (2001) all pointed out the major shortcomings in the quality of care in general, and the first two focused on cancer care in particular. The cost effectiveness of care became a part of this movement.
These columns made a prediction that came to pass. We can call it health care reform or Obamacare or the unsustainable costs of care, but the big waves are still lapping our shores.
Soon after those reports ASCO began supporting the development of the Quality Oncology Practice Initiative (QOPI) and other quality efforts. ASCO's response to this opportunity was important to me (and ASCO, I believe) at a time when it seemed that financial reimbursement of oncologists was the only issue that concerned the organization. I have written about this welcome change and the amazing progress that ASCO has made in its focus on patients first, oncologists second.
Conflicts of Interest
In the first couple of years of the column, I also wrote about conflicts of interest in medical practice, including self-referral—often by ownership of a service such as radiation oncology (4/25/04http://bit.ly/1bVA4sVand5/10/04http://bit.ly/1bk3nW4issues). Most of these transactions were legal, but clearly raised a conflict of interest. Studies showed that referral to such services rose dramatically after the oncologists or other medical specialists owned them. This has continued to be a problem today, but the changing medical landscape has mitigated some of it.
I did not foresee the impact of two factors that indirectly addressed these issues. Ten years ago the revenue of oncology practices was largely made from the resale and administration of chemotherapy in their outpatient offices. The Medicare Modernization Act ultimately constrained what a practitioner could charge for the resale of chemotherapy. This modification of the law was not done to reduce the costs of care, but to save the money in order to fund medications for seniors through Medicare Part D.
The second impact occurred when the Accountable Care Act was passed, which has mechanisms improving quality and for reducing the cost of care. This happened just after the Great Recession began, which affected cash flow in government and communities everywhere. But, in a column published in the Jan. 10, 2011 issue (http://bit.ly/gHoBNx), I remained somewhat skeptical that major changes were coming.
A major impact of these events has been the stampede of oncologists and other physicians to leave private practice and become employed by a hospital system or university or some other health provider. So the movement toward quality and financial efficiency continued, though with many obstacles remaining.
But there are some things that don't seem to change at all because they are mainly an integral part of human nature. A sample follows:
Aging, Death and Dying, Leadership
Over the past decade, I have written six columns on aging and adapting to it (1/10/08, 4/25/08, 12/10/09, 3/10/11, 1/25/12, and 1/10/14 issues). Of course, these columns are at least partly autobiographical. In my most recent column on the topic (1/10/14 issue, http://bit.ly/1j6Soai), I described the changes in my professional life that were brought on by one or another aspect of aging.
I have written six columns (or more) on death and dying (2/10/04, 1/10/05, 1/25/07, 6/25/07, 9/10/09, and 2/25/13 issues). The most emotional for me were the two columns describing my mother's death and how, at 92 years old, she took control of the whole process (10/10/06http://bit.ly/1iedYGhand11/10/06http://bit.ly/1nISq8Pissues).
I am sure she had planned how she would like the end to be long before. On a routine examination, an ultrasound examination discovered a tumor in the head of the pancreas. She was still feeling quite well and had no jaundice. She declined surgery or even a biopsy; I supported all of her decisions. She wanted to go back to her apartment and make preparations. She died a few weeks later in her own bed after she had completed organizing her affairs. I don't think the tumor killed her; I believe she was ready to go once her affairs were taken care of, and she went to sleep and never awakened.
Finally, I have written many columns on leadership and managing people. It is a favorite topic of mine and the issues never seem to change because this is another example of the expression of human nature. The key points of the early columns I wrote on the topic remain valid 10 years later.
In summary, change occurs with and without our permission. Most changes are in the social aspects of life, but there is little basic change in human nature. That is why Alexander Pope's Essay on Man (really a poem, published in 1734) still rings true. Here is the first stanza:
“Know then thyself, presume not God to scan The proper study of Mankind is Man. Placed on this isthmus of a middle state, A Being darkly wise, and rudely great: With too much knowledge for the Sceptic side, With too much weakness for the Stoic's pride, He hangs between; in doubt to act, or rest; In doubt to deem himself a God, or Beast; In doubt his mind or body to prefer; Born but to die, and reas'ning but to err; Alike in ignorance, his reason such, Whether he thinks too little, or too much; Chaos of Thought and Passion, all confus'd; Still by himself, abus'd or disabus'd; Created half to rise and half to fall; O Great Lord of all things, yet a prey to all, Sole judge of truth, in endless error hurl'd; The glory, jest and riddle of the world.”
‘Joe's Career Blog’
Check out Joe Simone'sOTblog on career development for medical professionals:http://bit.ly/OT-JoesCareerBlog
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