Practice

Figure 1.

Michael N. Neuss, MD

It is the practice of medicine, and practice is nothing but learning from repetition. At the highest levels of performance, the rote memory and automated behavior allowed by practice leave room for inspiration, adjustment, and improvement to a higher level of achievement.

We talk to patients all day as we practice. We learn what to say and what never to mention. And because we are oncologists, we say things that are unthinkable in any other circumstance. “You have cancer.” “You will not get over it.” “The cancer is progressing.” “You will probably die within a few months.”

The intimacy is astounding. “I have not given up hope.” “I will take care of you the best I can.” “I will not lie to you.”

And yet, as physicians engaged in a common endeavor, we are finding it difficult to talk openly about how the practice of oncology needs to adjust to “… the changes in cancer care delivery that have occurred and are looming on the horizon . . . [in a manner] . . . in which health care professionals can lead satisfying and rewarding careers, and cancer patients can continue to receive the high-quality care they need and deserve.”¹

Public payers will clearly provide the largest source of funding for health care by 2018, and public and private payments will be nearly equivalent by 2013.² One cannot build a long-term strategy of breaking even on Medicare and sustain a practice. We cannot pretend that the Centers for Medicare Services will not be setting the standards for care in the near future.

Though US per capita health care expenditures are about twice those seen in similarly industrialized countries, patient satisfaction and apparent health care outcomes are no better. Though we brag that access to procedures and care is rapid, because of delays consequent to a lack of insurance, overall time from symptoms to intervention is similar here and abroad.³ Given what we spend, we should be doing better.

Mulvey⁴ points out that “no one feels comfortable when circumstances are out of control. In fact, as physicians and health care providers we seek to maintain control over our lives and those of our patients. It is a core function of our daily lives to know the facts, assimilate the data, and make decisions.”

Things are changing, and I believe that ASCO members and staff have worked to prepare all of us to adapt as we make what are, it is hoped, well-informed decisions. They have actually done so much that it is almost impossible to absorb everything that is available. I can only scratch the surface as I mention a few. The Annual Meeting, regional Best of ASCO updates, clinical practice guidelines, and provisional clinical opinions provide access to current information regarding what the best care of today and tomorrow really is. A variety of curricula outline tools for the nuts and bolts of running a practice and help practitioners define and develop their careers, while task forces address issues of the cost of care and the availability of oncologists. The Quality Oncology Practice Initiative has worked to define process-based measures of high-quality care and is working to develop registries that incorporate valid risk and comorbidity assessments into outcomes reporting to serve as the one place where practices can submit data subject to audit that will, it is hoped, satisfy the accountability demands of patients and payers while helping practices identify areas for improvement. A variety of state society and ASCO representatives talk to local and national legislators and listen to patient advocates to help craft policy consistent with the goals and hopes of our patients and peers.

We are accustomed to talking bluntly. I believe what we share is much greater than where we disagree. We are, whether we are in multispecialty practices, academic surroundings, community hospitals, or large or single-doctor practices, all closing the door and listening to our patients, examining them, and collating information from various sources with various degrees of reliability to formulate plans. And as our patients' advocates, we really and truly only want the best possible outcome for them. We know that they need access to care and all reasonable treatments. We believe their autonomy is important enough to allow refusal of transfusions or choice of treatments with small but real benefits. We want to pay attention to our patients and not unreasonable paperwork. We want to sleep at night and have time to think and listen during clinic. We do not mind being accountable for what we do, but we expect the people setting standards to be our peers, and we want the process streamlined as much as possible. We cannot be afraid to talk openly about the money—we cannot simply break even on our practice expenses, as that is no more sustainable than asking our patients to bankrupt their families simply because they want reasonable care. The money is not, however, why we do it: A patient who does not pay does not keep us awake at night the way it does when a patient unnecessarily suffers. We cannot expect nor do we want that things will stay the same, because good enough is not good enough when better is possible.

In closing, I would be remiss if I did not mention what I hope is obvious. I have quoted my two predecessors as chair of the Clinical Practice Committee in this article because I have learned and continue to absorb much from them. Although we often do not agree, we work hard to listen to each other, just like I'll be listening to anyone who cares to join the discussion of how we should work to improve our practices of clinical oncology.

As always we welcome your feedback and suggestions for future columns. Please send your comments to mnneuss@gmail.com.

Author's Disclosures of Potential Conflicts of Interest

The author indicated no potential conflicts of interest.