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What We Do

Bolwell, Brian J., MD, FACP

doi: 10.1097/01.COT.0000557603.40077.75
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Every now and then, it is important to step back and remember what it is that we do in cancer centers. What our primary purpose is. The tendency for leaders of cancer centers is to get wrapped up in metrics, finances, budget, HCAHPS scores, and RVUs, as well as the number of publications and grants earned. The list goes on and on. All of these metrics are important, but they are not the core purpose for our existence. Our primary purpose is to try to help people who are sick.

Cancer medicine is a bit different than other specialties, and I believe more rewarding, because we develop relationships with our patients and their families over long periods of time. If you step back when you are with a patient, especially one with a relatively new diagnosis of cancer, it is easy to see the fear in their eyes, to see their desire for some form of good news. You can see that they are looking to you for hope. The trust they place in you is tangible. Our days get busy and time is a precious commodity. It's not always easy to stay present, rooted in the moment, but it's necessary to do so.

The best way to remember our primary purpose is being a patient ourselves. Be sick. Experience the enormous and complicated medical industrial complex for yourself as a patient. You don't need to be a cancer patient; any procedure or significant diagnosis will accomplish this change in perspective. I've been a patient more often than I would have wished, but it gives me first-hand experience that informs what I strive for as a doctor and what I try to instill as a leader of a cancer center. The most recent example was in mid-February.

My specific diagnosis is not important. What is important is that I yet again lived the experience of being a patient. In a large institution, you can still be anonymous—treated like everyone else. The nurses who cared for me had no idea who I was or where I worked. Which is fine because it means that I experienced being a patient just like everyone else.

Being a physician who is a patient has certain advantages, and certain drawbacks. One of the drawbacks is that you know too much. You are fully aware of all the complications that can, and have, happened during the procedure you are about to receive. Yes, you have great confidence in your caregiving team, but you are still aware of the risks. Like everyone else, you experience doubt and fear—and trust in your care team.

Patients are scared. But the best way to remedy that, both in the short term and the long term, is human connection. Human connection reduces fear. Human connection lowers anxiety. Human connection is what empathy is. It begins with the front desk where you check in. If the person who is checking your insurance and your date of birth makes eye contact and smiles, it is a big deal.

Then, of course, there are the nurses. Nurses spend the most time, by far, with patients. Nurses are key to the development of human connection. They are vital for the delivery of any sort of medical care or procedure, but they are also absolutely essential for the emotional connection between a frightened patient and the health care team. I had a great nurse on this visit. We both noticed that we were wearing Fitbit watches and started a conversation about steps. That may seem mundane, but it was a connection. Connections are everything when you are a patient.

Additionally, when you're a patient, time is of the essence. If something needs to be done, do it fast. Be efficient. That morning, I had a procedure, and nothing was going to make it fun. Be safe, but be quick. Fortunately, that was my experience.

Perhaps against my own better judgment, I decided to go back to my office and try to get some work done instead of going home and resting. As I returned to my office, checking my calendar, I saw that our monthly budget results would be released. At the beginning of a new year, these results are a big deal to the organization—appropriately so. At the time however, it was not top of mind. My morning's appointment, how I was treated, my pending results, and the importance of making enough human connections in our cancer center was front and center in my thoughts.

I think (and hope) we are making those valuable connections. Little things matter for patients. Be aware that all of your employees in your cancer center are crucial to making a basic human connection with your patients. You, as the leader, should set an example by being social and friendly. Consider saying hello to people you do not know who are waiting to see one of your docs. Spend a bit of time with the people who work at your front desk—thank them for what they do. Talk about the weather, sports, anything. Support your nurses at all times. Be aware of staffing issues and do what you need to do to make sure that they have enough caregivers to not just do the technical parts of their job, but to have the time to make connections and be empathetic to their patients.

Your cancer center needs to be as efficient as possible and, as I mentioned above, time is crucial for patients. Lines waiting for check-in or waiting a long time for chemotherapy to be mixed and delivered are not good. Waiting weeks and weeks to even get an appointment in the first place is not ok. Rightly so, we obsess about Time to Treat (TTT)—the time it takes for a newly diagnosed cancer patient to receive their first treatment.

At major academic cancer centers in the U.S., the average TTT is over 6 weeks. You might think that is a reasonable time for an appointment or to begin treatment, but I promise you that if a relative of yours has a new cancer diagnosis you will want their TTT to be a lot shorter than 6 weeks. If it's not OK for your family member, it's not OK for any patient. TTT can be reduced—we have reduced ours by 33 percent (NEJM Catalyst, Feb. 14, 2019). It's a big deal to patients and families, and it should be a big deal to all of us in the cancer community.

Most importantly, when you are in front of a patient, forge a connection. Ask social questions. Listen to the answers. Let them know that, during the time you are with them, nothing is more important to you than they are. And do whatever you need to do to be able to spend enough time with them for that statement to be true.

Your job as a leader of a cancer center is always to remember what it is that you do and what your cancer center does. You are in the medical business and you need to be superb in the medical business, but you are also in the human connection business—the empathy business. Support your team and remind them, not just with words, but also with action—that this is, and always will be, our primary purpose. We are here to help people who are sick, and we do that by being really good at medicine and really good at relationships. You can't separate the two, and you never should.

BRIAN J. BOLWELL, MD, FACP, is Chairman of the Taussig Cancer Institute and Professor of Medicine at the Cleveland Clinic Lerner School of Medicine.

Straight Talk: Today's Cancer Centers

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