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 (Oncology Times 9/10/2004 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, etc.;
- 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 email@example.com.