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Simone’s OncOpinion

Career development observations and advice for medical professionals from Dr. Joseph V. Simone.

Thursday, December 7, 2017

Editor's Note: Check out Dr. Simone's thoughts on offering advice to the next generation of health care clinicians from this throwback column, first published in the Feb. 10, 2015 issue of Oncology Times.

As physicians and other health care providers age, they often become wiser, but not always. I like to think I am one of those who are self-confident enough to take an honest look at my experience objectively as it developed and evolved over the years.

Like many colleagues I am often asked for advice by those who are in the medical profession or considering joining it about the current status of their careers and/or what steps one might take to advance a career.

Because I have a consulting business, I receive calls from physicians or nurses asking if they could hire me to consult with them on their careers. My answer always is negative; I do not charge any individual for providing career advice or for putting one in contact with an institution or medical group that might be a better fit for his or her career. Providing this advice is a way of paying back the kindness of the many people that offered free advice to me. I believe helping others navigate a career in such a complex profession is part and parcel of our professional responsibility.

Most professionals who have been active for many years in the field are asked for career advice. Unfortunately, some of us should not give career advice because we have serious handicaps. Here are some examples:

  • They have been in the same institution for their entire career including residency and fellowship. Their advice may be OK, but their personal experience is very narrow and they may reflexively recommend that the advisee remain in the same institution, which may not be the best fit for that person.
  • They cannot keep a counseling session in confidence. Too often a professor has a session with the advisee and casually drops bits of information in the cafeteria or elsewhere. "Hey, did you know John Smith is looking for a job at the University of Norwich?" This is a breach of trust, unless the advisee gives permission to spread the word, which is unlikely because it may tee off his immediate superior.
  • They have strong biases in favor of one career direction. A common example: the advisor is an academic and the advisee is talented and it is likely that he/she could make it in academia, so the advisor leans heavily in that direction. What if the advisee has a family to support and is deep in debt for his/her education? What if he/she has a handicapped child that needs special schools? The correct approach is to learn as much as possible about his/her needs, family situation, and what type of career the advisee prefers before narrowing the choices.

A potential advisor should consider his or her self as a confidential counselor, like a good lawyer, whose role it is to help the advisee arrive at the best solution. The counselor asks questions to understand the advisee's circumstances, desires, and talents, and also to raise red flags that the advisee had not considered. Here is where the advisor draws on a long experience and knowledge of institutions and their leaders. There are institutions that are considered "career killers" due to poor leadership, a lack of resources, rapid turnover of staff, or a lack of any extraordinary medical or nursing programs.

An advisor's approach is determined in large part by where the advisee is in career development. He may be asked to advise a professor in the later part of his career; a mid-career faculty member who believes it is time to advance where he is or move on to another institution; a junior faculty member seeking an opportunity to become more independent in his professional progress; a trainee who needs help learning the basics of assessing and getting a faculty or partnership position. Lastly, the advisee may still be in college or medical school, which happened to me recently.

A good friend of mine who lives nearby has a daughter who is in college on track for a bachelor's degree in nursing. She is bright and has done very well in school, so some of her teachers are urging her to apply for medical school. She doesn't have enough experience to know what that means and whether that track would be satisfying. Her father asked me if I would meet with her; I agreed, but suggested that we invite my daughter, who is a physician (she is a big shot at the CDC and my buttons are popping!), to join us to balance our viewpoints.

The four of us, she and her father and my daughter and I, sat around a table and started to chat. She told us about her current course in college and wanted some advice on nursing versus medical school. My daughter and I both described our views of the experience of medical school and the training that comes afterward. She asked a number of questions.

The next step was to ask her what drew her to nursing and what part of nursing she liked best. At first she said public health was attractive because one can influence the health of a large number of people. My daughter then described what type of work nurses do when recruited to the CDC.

Then we asked the most important question, I believe. We asked if her ultimate goal was to work directly with patients or was it something else, such as an administrative role. She leaned toward working directly with patients. Then my daughter explained that nursing opportunities include nurse practitioners and physician assistants, some of whom specialize in one aspect of medicine and nursing and advanced training was available in all. The downside of medical school is that she would need to take extra classes to qualify for applying and the number of years required after medical school to become a specialist in medicine.

The discussion lasted over an hour and neither she nor we arrived at a decision. That was not the purpose of our meeting; it was to provide her with ideas, information, and vignettes from our own careers, and also to offer a place to go (us) to discuss any of the issues that may come up in the future. She is clear-headed, smart, and realistic without the fanciful pie-in-the-sky ideas that we sometimes hear from people her age.

She left us feeling that she would make her own decision based on what she learns at school and from people like us, and most of all, what she believes is likely to make her happy in her career. That is the way these advisory chats should end.​

Monday, November 13, 2017

Editor's Note: Check out Dr. Simone's thoughts on how to expand your understanding of leadership from this throwback column, first published in the June 25, 2013, issue of Oncology Times.

A few years ago, I wrote several columns on leadership prompted by leadership changes at the NCI and FDA. I cited some well-known writers on this topic, such as Peter Drucker, and offered some guidelines for recognizing good leadership. The topic is endlessly fascinating to me because a leader has such an enormous impact on productivity and job satisfaction. I read those columns again recently and thought they were OK, but I realized that my viewpoint had expanded because of responses to lectures I have given in the past few years on Simone's Maxims, which deals with leadership, institutions, and other issues.

The revelation was that ordinary people in ordinary jobs could assume leadership in those jobs without being given a fancy leadership title. The "light bulb over my head" came from a simple note from two women who attended a program funded by the NCI to teach people how to build supportive care programs for cancer patients in their institutions. I gave two of the lectures in Colorado from two women who worked in the Colorado institution. They have given me permission to reveal their given names and to quote their note. Here it is in its entirety:

Dear Dr. Simone:

Our new mantra: "Institutions Don't Love You Back." We have a renewed sense of leadership.

Thank you,

Susan Barbara

The "mantra" is the first maxim in the book I wrote called, Simone's Maxims. (It is available from Amazon.) At that same meeting, several attendees had approached me and said nice things about the talk, mainly that they gained a better appreciation of their roles and the importance of understanding and adapting to the culture that they worked in. When I got the note, I finally stitched all the comments together in my mind, which turned on the light bulb.

What I believe happened was that my talk planted seeds of empowerment through understanding the "rules of the game" and demystifying institutional culture to some extent. But the more powerful influence on the attendees was being together with over 70 others from across the country who were facing the same issues as the two women. The collegial and informal atmosphere over several days let the seeds sprout in some, I believe.

What each person does with that experience will certainly vary. But now I have the unexpected feeling that I have a continuing obligation to help them, if I can. Therefore, I will offer them and others a few recommendations below for assuming an unofficial, and possibly temporary, leadership role when action is needed, but when no direction is forthcoming from above. One caution: these recommendations are not meant for new employees who have not yet earned a significant level of trust from colleagues. Rookies often would be viewed as "pushy" and "overreaching" if they tried to assume leadership roles, which would defeat their ability to lead.

Know the players.

A person who wants to lead must know as much as possible about the cast of characters and their strengths and weaknesses. Decide who might be allies and who might aggressively oppose your moves. Ask yourself whether there is an existing method of addressing those problems and, if so, who in the organization would be responsible and who might act. If there is not, or if that person is one who never acts, please read on.

Understand the politics and culture.

Every organization has unwritten rules of behavior that are deeply engrained. Some of these "rules" may be established as part of a powerful leader's management style (and may change under his successor). These are land mines that must be identified and avoided.

If the first two recommendations sound military, that is not a coincidence. Sun-tzu was a military theorist who live around 500 B.C. and who is the (reputed) author of The Art of War. His first rule was that you shouldn't fight a war if there is any other means of achieving your goal—in other words, war or confrontation is a last resort for solving only very, very important issues. This also applies to non-military efforts, such as those we are discussing.

Be prepared.

The Boy Scouts got one thing right: their excellent motto, "Be prepared." The one who walks into a meeting best informed about an issue and best prepared to address potential solutions is likely to be recognized as interested, intelligent, and sensitive enough to lead the task of fixing the problem. She may become the leader of the effort by acclamation.

Whining is counterproductive.

If you don't like the way things are, don't constantly whine about it; that tends to erode morale. And even those that agree with your assessment may not be willing to support you because of your negativity and bad-mouthing. The appropriate old saying is, "move ahead or get out of the way [i.e., leave]," and I would add, "and don't discourage those who are trying to improve things." So whining like a child while offering no solutions is a losing proposition for you and your organization.


Anyone who has a good idea for improving a bad situation should also be willing to volunteer to lead or be a part of the (usually) hard work needed for fixing it. Most staff members in medical facilities work hard and are reluctant to take on more responsibility. That is understandable, but if you can't or won't contribute in some way to fixing the problem, then you are saying that you have good ideas and valid complaints but someone else needs to do the work. This is not a good way to get things done expeditiously or convince colleagues that you are capable of leading any effort of the group.

Seasoned veterans in medicine, nursing, and other specialties often know the organization and its members very well. They are often very loyal to the institution and dedicated to the well-being of their patients. The accumulated talent and wisdom that they have is too often wasted because they are given no opportunity to grow. Leading small but important projects is one way to foster professional growth and job satisfaction. Not all are suited to leadership roles, but those who are should be given the opportunity in any organization.

Tuesday, October 10, 2017

Editor's Note: Check out Dr. Simone's thoughts on lessons and advice he's received over the years from this throwback column, first published in the March 10, 2013, issue of Oncology Times.

It is not unusual during one of my walks in the park for some aspects of my life to pop into my head for no discernable reason. I find myself reminded of a success or failure, a bit of wisdom or foolishness, a productive or embarrassing act. In fact, my embarrassments and poor judgments pop into my head unbidden more often than any other aspect of my musings.

It seems the negatives left deeper impressions on my psyche than the positives. My favorite in this category occurred when I entered the first grade at Ryerson School. Miss Peterson asked some of us students when our next birthday was due. When she asked me I said, "I don't know what it is this year, but last year it was September 19." My classmates' roared in laughter immediately. That is the only thing I remember from that class.

Fortunately, it is also not uncommon for me to think of how lucky I have been in life. And that thought always reminds me of those that helped make that "luck" happen, including family members, teachers, mentors, colleagues, and authors. We all receive lots of advice and learn important lessons during our lives; most of it is evanescent, like a fleeting fog that leaves no permanent impression. The advice and lessons I remember are those that I acted on and benefited from: what follows is a selection.

The first professional advice that stuck with me was offered during my residency in internal medicine at what was then Presbyterian-St. Luke's Hospital in Chicago. It was my first in-depth exposure to careers in academic medicine. It began to appeal to me so I told Dr. Ted Schwartz, an endocrinologist that the house staff held in great regard, of my interest and what advice he might offer me. He said, "You need to learn to do two things: write well and speak well." He said these were essential basic tools and that the science and medical direction would come later.

I then asked him how one develops these skills. He said you must write and speak. That was pretty thin gruel for me so I began reading about how these skills are developed and found written advice. To write well, you must read excellent literature so that a good style and vocabulary become embedded in your thinking. I also bought The Elements of Style by William Strunk and E.B. White. The fourth edition, a slim paperback of less than 100 pages, sits on my desk. It is the most concise and accessible primer on writing well. I also read that good writing comes from reading poetry. A poem's concision, clarity, and economy of words often leave a strong impression; this was something to emulate in prose or scientific writing. Very good advice.

I then started keeping a journal to write observations and thoughts about my professional work, family, public events, books I read, movies I had seen, etc., anything that interested me just to get in the habit of writing. I started the journal in August 1962, about 55 years ago, and have made entries continuously since then.

What about speaking? The first opportunities I had to speak publicly were at the elaborate grand rounds run by Dr. James Campbell, the Chair of Medicine at that time. He was old school. Grand rounds was held in an auditorium, started precisely at noon and ended precisely at 1 p.m. If you arrived late, Campbell would stop the proceedings and verbally tear a long strip of hide off the offender. You also could not eat or drink anything in the auditorium. If he saw someone with a lunch bag, he would say, "Did you bring enough for everybody?" And the offender was asked to leave.

He did this because in those days we often brought the patient under discussion to the grand rounds to hear directly from him or her about symptoms and signs of the disease under consideration. Campbell said it was discourteous and disrespectful to eat or drink when the patient was there. The ban was enforced even when we didn't have a patient in the room because one could not predict whether or not a patient would be present. We residents had to present the history, physical findings, imaging studies, and all laboratory results in a coherent, concise manner followed by our own diagnosis. This was followed by questions from Campbell and others that were often tough questions to see if the speaker covered all possibilities. The lessons imbued in us were: know your material cold, be prepared for questions, make the presentation clear so anyone in the audience can grasp it. Campbell, by his example, also taught us that respect and courtesy were an essential part of approaching a patient, no matter the setting. This imprint went deep and stayed with me.

Dr. Donald Pinkel offered the next bit of advice that stuck. He was the first Director of St. Jude Children's Research Hospital and the man who gave me my first job after I completed my training in 1967. When I was appointed Director of St. Jude in 1983, he called to congratulate me. I thanked him and asked if he had any advice for me. What he said surprised me, "Take time to think; make it part of your schedule." He knew well the pressures on one's time when heading an entire institution.

So I took his advice and scheduled 2 hours every Tuesday and Friday afternoon to think. My secretary blocked out the time and could not schedule anything in my "think time" without asking me first. Very soon I saw the wisdom of his advice. Sometimes I pondered professional problems, or read an article that I hadn't gotten to, or walked the halls of the building to get a sense of cleanliness, orderliness, and the like.

The time could not always be protected because of an urgent meeting or a visitor so I would skip a day. But the meeting with myself stayed on my calendar for a long time. It was invaluable to me. Many times, the extra thought and investigation helped me choose a better direction. Mary Kledzik, my secretary at the time, understood the principle involved in such an approach. When I would write a blistering note in anger for her to type (no e-mail then, thank God), she would bring it into my office and say, "Dr. Simone, you should put this in your desk drawer for a day or so." More excellent advice.

The final example of good advice I received occurred when I was about 9 years old (1944). My dad loved movies and a big treat for me was when he took me downtown to see a movie at the Chicago Theater. One Saturday, we went to see an early movie (each movie ran continuously in those days), we then had lunch and went to see another movie. Heaven! After the second movie, we walked up Michigan Avenue to the Tribune Tower where an American fighter airplane was on display in the courtyard. It was a P-47 Thunderbolt (I knew all the planes). It was a thrill to be that close.

I can see the scene even today: as we walked away, I commented to my dad that I hated the Japanese, a common and vocal sentiment in those days. He stopped walking and looked me in the eye and said, "You should never hate anyone; you should hate what they do." He said it kindly, without anger, and it reflected how he lived his life. I will never forget that advice, the best of them all.​

Thursday, September 7, 2017

Editor's Note: Revisit Dr. Simone's thoughts on leadership from this throwback column, first published in the July 25, 2015, issue of Oncology Times.

I never thought I would ever see, much less report on, a speech by a pope on leadership. So imagine my surprise when I saw an article in the Harvard Business Review (April 2015) in which Gary Hamel reports on a speech by Pope Francis to the Roman Curia; the Curia consists of the cardinals and bishops who manage the large array of administrative bodies of the Catholic Church. Hamel then "spent a couple of hours translating the Pope's address into something a little closer to corporate-speak."

Although Pope Francis was speaking to leaders of the Church, Hamel thought his approach was refreshingly direct with an understanding of "human proclivities" (read: weaknesses) and that, nonetheless, the Pope said "leaders should be held to a high standard, since their scope of influence makes their ailments particularly infectious. "It seems that Pope Francis continues to surprise us, whether we are Catholic or not. My parents were Italian-Catholic immigrants, so I am a "cradle Catholic."

It is interesting that the Pope chose to use the term "diseases" for the shortcomings of bishops and priests, and he added, "They are diseases and temptations which can dangerously weaken the effectiveness of any organization." I shall list the diseases (some are shortened) and include some of the Pope's comments in Hamel's translation in quotation marks; For some of the "diseases," I will add some of my own comments, particularly when there are parallels in academia, medicine, and other organizations that we belong to. Some of the "diseases" may surprise you.

1. Thinking we are immortal, immune, or indispensable.

"Neglecting regular checkups. A leadership team, which is not self-critical, which does not keep up with things, which does not seek to be more fit, is a sick body."

We have all seen examples of this, particularly a belief that they are indispensable. No one is indispensable and good leaders know this and always prepare for a smooth succession should he/she be disabled. I worked under two leaders in my career who had an advanced case of this disease. One failed to see that things were not going well and began to blame others for the decline—he, of course, was immune to blame. Another was so enthralled by the stature and income he enjoyed as CEO that he was afraid to make or allow any changes—a deadly situation.

2. Excessive Busyness

"This is found in those who immerse themselves in work and inevitably neglect to rest awhile, which leads to stress and agitation. A time of rest, for those who have completed their work is necessary, obligatory, and should be taken seriously by taking more time with one's family and respecting holidays as moments for recharging."

Many of us, including me, have had this disease at one time or another, particularly in the first few years after training and after each promotion. This disease can sap one's energy excessively and distance oneself from family.

3. Mental & Emotional "Petrification"

"It is found in leaders who have hearts of stone, the 'stiff-necked;' in those who eventually lose their interior serenity, alertness and daring, and hide under a pile of papers, turning into paper pushers and not men and women of compassion. It is dangerous to lose the human sensitivity that enables us to weep and to rejoice with those who rejoice. Being a humane leader means having the sentiments of humility and unselfishness, of detachment and generosity."

I have known and pitied some with this disease. A lack of humility is especially damaging to a leader; the ability to laugh at oneself provides a partial cure, and if one adds generosity, one may cure himself of this disease.

4. Excessive Planning & Functionalism

"When a leader plans everything down to the last detail and believes that with perfect planning things will fall into place, he/she becomes an accountant or an office manager. Things need to be prepared well, but without ever falling into the temptation of trying to eliminate spontaneity and serendipity. We get this disease because it is easy and comfortable to settle into our own sedentary and unchanging ways."

Anyone who has developed a strategic plan or written a clinical trial protocol is in danger of thinking that all the thinking has been done. Leaving some breathing room for unexpected events, such as financial disappointments or a change in staff, is one way of avoiding this disease.

5. Poor Coordination

"Once leaders lose a sense of community among themselves, the body loses its harmonious functioning and its equilibrium; it then becomes an orchestra that produces noise; its members do not work together and lose the spirit of camaraderie and teamwork. When the foot says to the arm: 'I don't need you,' or the hand says to the head, 'I'm in charge,' they create discomfort and parochialism."

I have seen a bad case of this disease in one institution I worked in and in many others as part of my consulting work. Like kids in a sand pile the leaders competed, froze out colleagues, or in some other way eroded the space for good will and partnership. See the diseases below for other examples.

6. Leadership's 'Alzheimer's Disease'

"This consists in losing the memory of those who nurtured, mentored, and supported us in our own journeys. We see this in those who have lost the memory of their encounters with great leaders who inspired them; in those who are completely caught up in the present moment, in their passions, whims, and obsessions; in those who built walls and routines around themselves, and thus become more and more the slaves of idols carved by their own hands."

I am willing to bet my car that 90 percent of readers know of leaders like this—egocentrism taken to a pitiful extent. And the next disease is similar.

7. Existential Schizophrenia

"This is a disease of those who live a double life, the fruit of hypocrisy typical of the mediocre and of progressive emotional emptiness which no title or accomplishment can fill. This disease often strikes those who are no longer directly in touch with patients and 'ordinary' employees, and restrict themselves to bureaucratic matters, thus losing contact with reality, with concrete people."

8. Rivalry & Vainglory

"When appearances, our perks, and our titles become the primary object in life, we forget our fundamental duty as leaders—'to do nothing from selfishness or conceit but in humility count others better than ourselves.' As leaders we must look to the interests of others."

This is probably the simplest and most important disease; what is a leader for but to lead and help those under his/her leadership?

9. Gossiping, Grumbling, & Backbiting

"This is a grave illness which begins simply, perhaps even in small talk, and takes over a person, making him a 'sower of weeds' and in many cases, a cold-blooded killer of the good name of colleagues. It is a disease of cowardly persons who lack the courage to speak out directly. Let us be on guard against the terrorism of gossip."

10. Idolizing Superiors

"This is a disease of those who court their superiors in the hope of gaining favor. They are victims of careerism and opportunism. They honor persons rather than the larger mission of the organization. This disease can affect superiors themselves when they try to obtain the submission, loyalty, and psychological dependency of their subordinates, but the end result is unhealthy complicity."

I would add that overdependence on superiors can be equally damaging and can lead to a career catastrophe.

I shall simply list the remaining diseases since some overlap with the above and I will record only a brief comment by the Pope or me, if any.

11. Indifference to Others

This is ably covered above and speaks for itself.

12. Closed Circles

This is also covered above, particularly in "gossiping" and "idolizing," though the closed circles of cliques that exclude many colleagues is a very specific and destructive disease.

13/14. Extravagance & Self-Exhibition/Hoarding

These two are covered tangentially in "closed circles" and "indifference to others." But Francis makes explicit points about the turning of one's service role into a vehicle for storing power. As a Catholic, I see it as a rebuke of cardinals and bishops who focus on rising up the hierarchical ladder, and do it with extravagance in their own lives. However, academia has no shortage of this disease. It is no coincidence that Francis chose not to reside in the Vatican with its upscale and elaborate quarters, but rather in a simple apartment nearby; and he has chosen to wear simple vestments when he travels. He is a leader by example.

15. The Disease of a Downcast Face

"You see this disease in those glum and dour persons who think that to be serious you have to put on a face of melancholy and severity, and treat others—especially those they believe are their inferiors—With rigor, brusqueness, and arrogance. In fact, a show of severity and sterile pessimism are frequently symptoms of fear and insecurity."

In my career, this last sentence rings very true, and I could name a dozen who fit the description; they are unhappy people who make those around them unhappy.

"A leader must make an effort to be courteous, serene, enthusiastic, and joyful, a person who transmits joy everywhere he goes. A happy heart radiates an infectious joy: it is immediately evident! So a leader should never lose that joyful, humorous, and even self-deprecating spirit which makes people amiable even in difficult situations."

I must say that this is my favorite of all the diseases, especially the curative prescription offered by Francis.

Monday, July 10, 2017

About a decade ago, I learned that many oncologists (and interventional cardiologists, orthopedists, and others, as well) earn very large incomes, seven figures and more. Studies of practices then described the evolution of medical specialists from acting as "single agents" (for the patient), to "double agents" (for patient and payer), and now to "free agents" (for themselves). I called the free agents "econo-docs," for whom economics comes first and the doc part last. And now I ask: Are we oncologists like the interventional cardiologists and orthopedists cited in the articles?

It is impossible to deny there are some of us in oncology who behave as if the patient serves principally as a source of revenue and whose practices are focused inordinately, and sometimes obscenely, on the business of medicine. I have spoken with numerous oncologists who can provide examples of (other) oncologists who fit the profile of the "econo-docs."

Econo-docs often engage in behavior that is unprofessional at best and mired in unethical conflicts of interest at worst. A few examples (all of which I have observed) of such behavior follow:

  • prescribing chemotherapy that is clearly futile ("churning");
  • prescribing chemotherapy the oncologist sells to the patient at an exorbitant markup;
  • ordering outpatients to receive costly IV hydration that is not indicated;
  • using software programs to choose among drugs not by relative efficacy and safety, but by highest profit margin; and
  • preferentially referring patients to other specialty services in which they personally hold equity positions that are hidden from the patient and public, e.g., radiation oncology or diagnostic imaging facilities.

Other examples include responding to the pending decline in chemotherapy reimbursement by sending to their patients frightening letters that threaten the use of inferior or more toxic therapy, or indicating to their Medicare patients they may no longer be cared for (featured in the New York Times articles and editorials in March 2004). An informal survey of community medical oncology practices revealed top incomes in a practice often exceed $1,000,000, particularly in large practices in smaller metropolitan areas.

To be sure, HMOs, Medicare, and medical insurance companies have created a perverse system of reimbursement. The system values an appendectomy more than spending hours diagnosing a cancer patient and describing the prognosis, laying out the treatment options, talking to the family, and repeating information the often stunned and distraught patient cannot remember from one visit to the next.

The system has also rewarded oncologists far more handsomely for the purchase and resale of chemotherapy than for face-to-face care of the patient. Yes, the system's incentives are terribly warped. But with few exceptions, the outcry of the oncology community at the unjust reimbursement schedule came only after the lucrative chemotherapy business was threatened.

Should we respond that these econo-docs make up a minority of cancer caregivers and, therefore, should not concern us? Should we ignore them as minor aberrations that one is likely to find in any profession? Or tolerate them as overzealous business types who occasionally step over the line of ethical propriety? Well, let me test the reader's response with related questions.

Is the reader outraged at rapacious business leaders' theft of billions of dollars from ordinary people, while lying and cheating to hide their crimes? That CEO/chairmen vote themselves almost unimaginably rich compensation packages as their companies consistently lose value? That cozy complicity in these shenanigans is practiced by certified public accountants? I am and I hope the reader is. One might argue these professionals committed more serious breaches than the econo-docs and some were engaged in criminal activity.

But the concern here is not for legality, but the much higher standard of professional ethics. As professionals who are entrusted with the care of the sick and who take an oath of ethical behavior, we are held to much higher standards because we care for people at very vulnerable and often dangerous periods of their lives. The behavior of econo-docs has exposed major cracks in professional ethical norms that include actual or potential conflicts of interest.

Most of all, by taking advantage of vulnerable patients, econo-docs betray the public trust; that is what should concern us most of all.

It is true there are some scoundrels in every profession. But the bigger worry is that our silent tolerance, and sometimes admiration, of the econo-docs' entrepreneurial activities may insidiously encourage some of the large majority to cross the line and engage in practices devised primarily for economic gain. The irony is that econo-docs most likely will find a way to prosper even when the rules change; it is the non-entrepreneurial docs who are likely to suffer most and even be forced out of business.

While an ethical profession may be embarrassed by the transgressions of the few, the quiet acquiescence, approval, and participation of the many ordinary, basically decent docs eventually destroys its professional fabric.

Just because our patients like us and trust us does not necessarily mean we give high-quality care that is free of economic conflicts of interest. It is the professional responsibility of each of us and our leaders to be vigilant and take steps to assure ourselves that both, in fact, are so.​