Happy New Year!

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cancer, epatients, medical education, medicine, mentoring, oncology, participatory medicine, social media, twitter, wellness

As opposed to last New Year, I’m beginning 2012 relatively peacefully.  I’ll take a little laryngitis and bronchitis rather than last year’s open heart surgery anytime.  Early in my recovery I had more time to read, which was a plus since reading is one of my favorite hobbies.  While reading my e-mail a few days ago, I noticed a Medscape review of books recommended for physicians.  Included were two books I read: The Emperor of All Maladies; A Biography of Cancer (1) by Siddhartha Mukherjee and The Immortal Life of Henrietta Lacks (2) by Rebecca Skloot.  I agree with Dr. Bruce Cheson who thought so much of these books he gave copies of each one to his fellows at Georgetown.  They read like historical novels, confirming that truth is sometimes stranger than fiction.

But after the “Must Read” list, one item caught my attention that resonated with me:  “Doctors’ Bucket List:  20 Things to Do Before You ‘Kick the Bucket’ “. The idea is derived from the movie starring Jack Nicholson and Morgan Freeman.   I’ve practiced hematology and medical oncology for 36 ½ years after 2 years of fellowship following 4 years of internship and residency in internal medicine.  That’s 42 ½ years in medicine, almost 2/3 of my life, dealing with everyone one else’s mortality, but devoting only a small amount of energy to mine.

After surgery, my surgeon said he got me 10-15 (or was it 15-20) more years.  The implication was to make the most of it.  Next Friday is my 1 year anniversary from surgery.  So far, the cow aortic valve and the 3 coronary artery grafts are doing well.  It’s hard for me to believe, but in 1 month I will be 70 years old.  So there’s no time like the present.  Citing Caroline Adams Miller, MAPP, a certified professional coach, “The list should consist of things you plan to attempt and want to reach for so that you leave behind the imprint you wanted to have.”  It is advised to set specific goals that move you beyond your comfort zone.

I was encouraged to realize that, without actually writing anything down, I had started the list.  My wife and I are planning a trip to China for both business and pleasure.  She will practice her Tai Chi and hopes to attend a psychology conference.  I am planning to visit hospitals and clinics to educate myself in Traditional Chinese Medicine.  Since we have the beginnings of an Integrated Oncology Program in our practice, future affiliation may be possible.

Speaking of reaching outside my comfort zone, blogging and podcasting were new to me 8 months ago.  I am enjoying this new technology more as I’ve gained experience with time.  Gaining knowledge in new technology certainly is exciting and keeps me young.  Same for research.

It’s now 2012.  I have places to go, things to do and people to see before I kick the bucket.  By the way:  the origin of the phrase “kick the bucket” is unclear.  One theory is that people hanged themselves by tying a noose around their necks, standing on a bucket and kicking the bucket away.

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Surprise!!!

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clinical trials, clinicaltrials, CME, Dr Just, elder wisdom, Just Oncology, legacy, medical education, medicine, mentoring, oncology, Pacific Oncology, participatory medicine, pharma, physician, podcasting, research, San Diego, social media, wellness

As I was browsing through the Harvard Business Review the other day (seriously, this is not my usual reading material), I happened on an interesting article.  Actually, the piece was an interview in the “Idea Watch” section entitled:  “Defend Your Research; The Color Pink Is Bad for Fighting Breast Cancer”, HBR, pp. 30-31, July-August, 2011.  Professor Stefano Puntoni, an associate professor of marketing management at the Rotterdam School of Management, Erasmus University, was asked to explain the counter-intuitive findings of his research.  He stated:  “Our original prediction was boring.  My research partners-Steven Sweldens of Insead and Nader Tavassoli of London Business School-and I thought pink and other gender cues would make campaigns against women’s diseases, such as breast and ovarian cancer, more effective.  But we found the opposite”.

Perplexed, they delayed publishing their results and kept running tests.  After 3 years, the same basic finding was validated 10 times.  Initially, women who wrote an essay about gender were less likely to donate to ovarian cancer research than women writing gender-neutral essays (42% vs. 77%).  Then, breast cancer banner ads were placed on a website but not mentioned to the women viewing them.  When the site was feminine-oriented, 33% recalled the ads; when gender-neutral, 65% remembered.  The color pink turns out to be one of many feminine gender-cues, but prior to the 20^th century it was actually associated with the male gender.

Most importantly, “these findings seem to fly in the face of the marketing principle that you should build a strong brand that emotionally connects with consumers”.  So why is this?   Interestingly, ideas or concepts that are regarded as threatening or difficult to comprehend elicit defensive responses, mainly denial.  The color pink tends to connect women with the thought that they could die of breast cancer.  Another fascinating fact is that not all gender-cues result in defensive responses.  Mascara ads were placed on control websites and 76% of the gender-primed group recalled these non-threatening ads, even more than the control group (65%).  Additionally, gender-cues involving prostate cancer are not as threatening in men.  The author postulates that prostate cancer is more a disease of older men and has a longer natural history, i.e., it is not associated with impending fatality.

Finally, since pink is synonymous with breast cancer, “is there any way to preserve it but overcome the negative effect”?  Women found pink ads about breast cancer harder to read than more gender-neutral peach ads.  But, men found pink ads slightly easier to read.  One suggestion that results from this is “that seeing more men wearing pink as part of breast cancer awareness may start to break down the color’s effect as a gender cue”.  Another thought is that pink may empower men to donate more.  Obviously,  work in this field is very preliminary.

As a result of the above article, I tried to think of research where the opposite of the anticipated result was found.  Tamoxifen was approved for clinical use shortly after I started my practice in 1975.  It was marketed as an anti-estrogenic alternative to surgical oophorectomy.  Therefore, the concern was that it could lead to osteoporosis.  To test this hypothesis, studies were initiated in 1980 and completed 10 years later.  If anything, Tamoxifen resulted in slight reduction in the incidence of bone fractures.  But: surprise, surprise!!  Increases in endometrial cancer and deep venous thrombosis, occasionally leading to lethal pulmonary emboli, were found.  These complications led to the realization that the drug had estrogenic properties and was in fact a partial, not total, Selective Estrogen Receptor Modulator (SERM).

Quoting Don Miguel Ruiz from The Four Agreements:

“The Third Agreement Is Don’t Make Assumptions.  We have the tendency to make assumptions about everything.  The problem with making assumptions is that we believe they are the truth.  We could swear they are real.”

This is why we do research.

Mentoring

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cancer, CME, coaching, Dr Just, elder wisdom, Just Oncology, legacy, medical education, medicine, mentoring, oncology, Pacific Oncology, physician, San Diego, twitter

When my son was asked if he wanted to become a doctor just like his dad, he responded that his dad was hardly ever home and that wasn’t the type of life he wanted.  He’s now 40 years old and a graduate of law school.  In spite of his business requiring a lot of travel, he does devote as much time as possible to his family.

Interestingly, I started a solo practice in oncology in the same communities twice.  Initially, I interviewed with solo physicians (and there were only two) nearing retirement who were looking for someone fresh out of fellowship to take all weekday and weekend call as well as cover the practice during office hours.  For that privilege, my annual salary would be $24,000.00!!  There were only two multispecialty medical groups at the time, but the offers were similar.  So I decided to do it myself (that was possible then).  My wife and I took out a loan at a local bank which we paid off in seven years, celebrating the event by cremating the note, and we bought a home in the community.  We raised our children in that home and still live there 36 years later.

Managed care and computers weren’t a requirement then.  My practice grew to the point where 24/7 was becoming onerous.  So I started a group which provided coverage, but times had changed.  Managed care, PPO’s, EPO’s and those dreaded HMO’s with capitated payments based on per member per month calculations made for a lot of anxiety .  I spearheaded the effort to form a multispecialty IPA to meet these challenges.  This effort was scuttled by our hospitals that formed a rival IPA.  My former partners and I tried to piece together a single specialty IPA in oncology with plans to be a county-wide organization.  But lack of a collaborative culture ruined that attempt and my partnership dissolved.

Solo again.  The new challenge was the burgeoning cost of managing the business of oncology.  Managed care plans have replaced private insurance to a large extent, thus lowering reimbusements.  Several chemotherapy agents are no longer feasible for us to provide and patients to buy.  Computers are required and now mandated.  Obviously survival of solo oncologists is questionable.  My solution was to merge with two other established practices to form a larger group better positioned to deal with the era of ACO’s. So, as the senior member of the group, how do I advise young oncologists in this much more complex environment than I faced?

1. Firstly, we cannot survive practicing in our own silos.  We need to leverage large numbers to increase our purchasing and contracting power.
2. Next, we have to truly collaborate.  Government and health plans are justified in wanting to know what they’re getting for their money.  This requires diagnostic and treatment pathways which we agree on.
3. We have to listen to our patients who constantly provide us with constructive criticism.  New technologies such as social media can give us tools for listening and promoting dialogue.  The current (and first) issue of OncLive (formerly Oncology Net Guide); Vol 12, No 3; 3.11 contains an article called “Socializing Medicine; Oncology Joins Facebook Era” describes the proliferation of these technologies and why it is important for us to become familiar with them.
4. I furnish copies of Michael Gerber’s “E-Myth Physician”, a short but excellent book has been very useful to oncologists embarking on the road to private practice.  Although somewhat dated, he describes a new physician who is bitten by the entrepreneurial bug, which ultimately leads to his destruction.  While this didn’t happen to me, I made plenty of mistakes in my career.  I learned from my mistakes and hopefully others can too.
5. The titles of the chapters in Gerbers book are revealing about what he considers important:  “Money”, “Growth”, and so on.  Basic financial knowledge and awareness of the economics of health care are also quite valuable.

There are three options for new oncologists:

1. Stay in academics.
2. Join a multi-specialty group
3. Join a single specialty group, like mine.

Under the third choice, this last year has seen an exodus of oncologists joining with their local community hospitals usually under a Foundation Model.  I must admit this is appealing to me as it may be to new oncologists facing this brave new world.  Management and financing of the practice would no  longer be my worry.  I would take home a salary and work as much or as little as I want until retirement.  But a young oncologist would have to start over as I did on two occasions,  Neither was easy; today it would be almost impossible.