Lying in the pre-op room before open heart surgery in January, the last thought on my mind was the ‘state of the health’ of community based oncology. Making it through this procedure was of paramount interest to me. Surprisingly I was quite relaxed.
Never thought of dying. Didn’t see my life pass before my eyes. Perhaps it was my wife’s hypnosis? Perhaps Versed?
Post-op I concentrated on my recovery. This was my first real “vacation” from clinical practice of hematology and medical oncology for 36 years. All of my energy was devoted to caring for patients and their families and raising a family myself. Never had much time to pursue other interests. Now I had to address my health, but also there was an opportunity to consider what the last 36 years were all about.
I thought back to when I was a second year medical student in the mid-sixties. That’s when Watson and Crick were awarded the Nobel Prize for elucidating the double helix structure of DNA. Prior to that time, we studied Mendelian genetics. Now we’re talking molecular oncology and personalized cancer care. In 1969 I treated a patient with advanced Hodgkin ’s disease with the newly published MOPP regimen. Unfortunately my patient died of an overwhelming infection. I vowed never to subject another patient to such a toxic regimen. When I returned from military service two years later, MOPP was accepted as first line treatment and was being administered on an outpatient basis! This was the first demonstration that combination chemotherapy could result in cure of an advanced malignancy. Of the original patients who were treated with MOPP, 81% went into complete remission and 69% remained in their first complete remission after 10 years. Thus, a previously ‘incurable disease’ could be ‘cured’ with combination chemotherapy, an event that resulted in rapid growth of medical oncology as a specialty. I started my practice in 1975 and passed the boards the second time they were offered.
Fast forward to the present era of biologics. The practice of oncology has become increasingly complex, expensive and demanding. Healthcare in general has changed dramatically with transition from traditional indemnity or private payment plans to managed care to HMO’s and their current reincarnation as ACO’s. Community based oncologists are expected to operate as businesses to remain financially viable, to be more efficient and to control our overhead, to practice evidence based oncology, and fund an Electronic Medical [or Health] Record (EMR/EHR) so we can determine outcomes of these treatments. We have essentially become dispensing pharmacies for chemotherapeutics, biologics and all the supporting drugs necessary for safe administration. Stress and burnout are becoming more common issues. As each day presented more challenges, I would jokingly say: “If this continues, I’m going to clot off my left anterior descending”. Then I did (watch what you ‘pray’ for or otherwise invite into your life).
Two months after surgery, I had recovered sufficiently to return to work on a part time basis. Within two weeks, my wife pointed out that I was coming home with a furrowed brow, and once again I was talking to myself in the shower. Since my surgeon said he had given me 15-20 years of life, I really didn’t want to return to the same environment that resulted in so much stress. I thought of retirement, but didn’t want to be completely removed from what I do best, i.e., interact with, and care for people with cancer. I realized that my experiences were of value to help preserve community based oncology and in mentoring the new generation of oncologists as this is their future. Thus the birth of JustOncology.com.
As alluded to above, I have been fortunate to have lived through the logarithmic growth phase in the knowledge base of oncology. But with progress there can be unintended consequences:
- How do we disseminate and manage this information? Classically, journals and conferences were the major instruments for this purpose. Subscriptions to journals resulted in unwieldy collections of bound or loose journals that required a lot of storage space or clipped articles that needed to be filed in metal cabinets. I remember binding all the New England Journal of Medicine articles from 1965-2001. I donated some to a local School of Nursing. The rest no one wanted and I had no place to store them. Attending conferences usually meant long distance travel with time away from the office which in turn had adverse financial ramifications. ASCO meetings were mostly opportunities for fellows to present their research data in 15 minute segments. The lights went out and an endless number of slides ensued. I didn’t last long at these sessions and learned very little except in the rare review sessions that concentrated on one topic. Gratefully, ASCO has done a great job renovating its educational process, aided by the advent of innovative methods of communication, including social media. Using these technologies, we can communicate over large distances in a cost effective manner. Additionally, these modalities frequently provide for instant feedback, promoting dialogue. JustOncology.com intends to host and engage others in the conversation via this emerging suite of technologies.
- How do we study and validate this new knowledge? Unfortunately, the clinical trial process is not keeping pace with demands. Community oncologists are responsible for 80% of patients that are placed in clinical trials. That’s the good news. Unfortunately, only 3-5% of all cancer patients that might be eligible for a trial actually are entered. Social media is being tried in a preliminary way to improve accrual. It costs Pharma about $1 billion and 10 years to bring a new molecule to market. This is outrageous.
The regulatory burden in the U.S. has been blamed for this, and has spawned another unintended consequence with the export of clinical trials to foreign countries. As chairman of our local Investigational Review Committee (IRC) for the past 22 years, I can attest this growing mountain of paperwork. But Pharma has to clean up its act too. You can only take the argument that the cost of drugs to U.S. patients is so high because they have to recoup their R&D costs so far. This argument has been utilized so often that it has lost its credibility.
A major effort by Pharma will be necessary to restore trust in that industry. In addition, study designs of biologic agents differ from trials involving chemotherapy in that endpoints are different. Many of the targets for biologics are still being studied so it is difficult to know when the agent is effective. Certainly this is a topic we have a lot to talk about.
- How do we ensure evidence-based practice and document outcomes of our interventions? The Electronic Medical Record is advanced as the answer to all our problems. I agree that these are necessary to address the cited problems. But there is a learning curve with all these systems which is longer for older physicians who did not grow up with computers. Like me. My experience with my groups’ EMR has not been good. And the cost of maintaining and upgrading a client-server system has been enormous. So instead of saving money and headaches by investing in the least expensive (at the time) EMR we consumed a great deal of resources and still haven’t achieved our goals. But in our defense, I don’t know of anyone who is totally happy with their purchases and several oncologists haven’t purchased any system for fear of bankruptcy. Yet health plans and government are mandating that we purchase an EMR. The latter has promised rebates if we satisfy certain requirements which seem to be flexible. The end result is a fast growing Information Technology consulting business skimming much of the vital (for survival) funds needed to pay for this equipment.
Which leads me to…
- How do we pay for all this? Having been a patient recently reinforced my practice experience with patients who are struggling to pay for their treatments. As oncologists we are experiencing decreased reimbursements for almost all drugs at the same time health plans and government are unloading more of this cost on patients. As stated above, the current rage is the trend to ACO’s, still not clearly defined. What is clear is that this movement is being spearheaded by our community hospitals primarily aimed at primary care physicians. Also clear is that many oncologists are approaching or being approached by hospitals to join their foundation models. For me, this is déjà vu all over again. As soon as I had established my practice, it was obvious to all of our physicians on staff at our local hospitals that patients were leaving our communities and obtaining their health care elsewhere. To counteract this we formed an IPA. I was the first president of this organization and obtained my baptism to managed health care and attempts to organize physicians into collaborative groups under fire. No sooner had we formed our organization than our hospitals, which stood to gain from our efforts, formed a competing group and raided our membership, thus undermining the entire effort. In order to preserve community oncology as a viable alternative to ACO’S, it is imperative that we merge together, utilize a common EMR to measure outcomes, develop clinical pathways that are evidence based and use our size to leverage a more favorable relationship with Pharma. In my career, I started in solo practice and then grew it into a small group. I then went back into solo practice and finally merged with two other multi-member groups to form a corporation consisting of 7 oncologists, 4 treatment sites and a business office. It is difficult for me to envision how a solo oncologist can survive in the community in this hostile environment. But I see one glimmer of hope. Our previous attempts to organize into a large cohesive organization failed because we practiced in a culture that fostered competition between us. This culture has now changed into one of collaboration. There is hope.
So it’s the best of times, and the worst of times. But the cause is a worthwhile one: the preservation of community based oncology as the most patient and family friendly method of delivering increasingly complex cancer care. We should capitalize on this current spirit of collaboration which has been born out of necessity. The bad news is I had to go through major surgery to realize that my career experiences have value. The good news is I now have the time and opportunity to speak and write about it. Join me in this conversation!