Dinosaurs and Podcasts

Dinosaurs and Podcasts

Robert S. Miller, MD, FACP, FASCO

Oct 22, 2010
I would not normally use my ASCO blog to promote something I have done, but since this is an ASCO-related product, and it is a story that I think is very valuable to share, I hope I can get a pass this one time. I was recently asked by John Cox, editor-in-chief of ASCO's Journal of Oncology Practice, to create an audio podcast interview series for articles published in the JOP. I was very pleased that Dr. Jack Keech agreed to be my guest last week for an interview about his first-person article in the September 2010 issue of JOP entitled The Dinosaur Is Extinct: The Demise of Solo Medical Oncology Practice in the United States. The audio file of the interview, as well as links to the other podcasts in the series, can be found here (soon we'll be on iTunes). I hope you have a chance to read his article and listen to his interview. He tells his very personal story of how his successful and cutting-edge solo medical oncology practice in the small Northern California city of Chico was not able to survive the combined effects of the Medicare Modernization Act (MMA) of 2003, a changing medical culture, and the recession of 2008-9. These factors forced him and his wife, who was his business manager, to make what must have been an extraordinarily difficult choice - either stay in his local community practice situation and face the real possibility of personal bankruptcy - or close shop and start all over somewhere else. If you read the article, you know that he chose the latter, and he is now busy at work in an integrated community cancer clinic in the Puget Sound area of Washington. And they call Steve Jobs "The Greatest Second Act in the History of Business!"

It was great doing the interview with Jack, not just because he and I were friends and colleagues in our Northern California days on the ANCO Board, but because he honestly and effectively conveys a larger message about the changes in our specialty. Hearing his story makes me realize that if someone like Jack Keech, who was past chair of the ASCO Clinical Practice Committee and obviously a very business-savvy physician, couldn't succeed at solo practice in this era, then no one can. Of course, the solo and small group practice of medicine has long been an endangered species in the U.S., and that is particularly true for medical oncology, where the combination of upfront financial risk and the clinical demands of the specialty make this mode of practice so very difficult to sustain. Medical practice in the U.S. has often been criticized as being too much of a cottage industry, and some see the rugged individualism of a solo practitioner as contributing to our fragmented, non-interconnected, non-IT savvy, and frequently non-evidence based delivery system. But my reaction is to say, not so fast. I think we all really do lose something when this particular dinosaur - the small to medium-sized physician owned and operated practice - becomes extinct. We lose the pride of a generation of physicians who were deeply invested in the success of their businesses, primarily for the betterment of the lives of the patients, who were able to deliver a level of personalized care in their local communities that was often high-quality, evidence-based, service-focused, and deeply satisfying on a personal level. I am not trying to defend the insanity of the AWP-based reimbursement system of those days, nor am I suggesting that the inevitable trend toward consolidation and integrated delivery systems, and a greater emphasis on physician quality of life and personal/professional boundaries, is somehow undesirable or inferior to the (not so) good old days. For myself, having transitioned in 2009 from a medium-sized private practice in a highly competitive, managed care-heavy area to an academic medical center on the opposite coast, I certainly don't miss the stress and constant worry over whether the business would survive or my values compromised. But the new world is, well, different. Solo medical oncology practice may never again rise from the ashes, but before we are too far down the road on this path toward the larger and more integrated model, with all of the extra baggage that entails, we need to figure out a way to keep at least a few of the values and best practices that the dinosaurs just got right.

I wasn't intending for this blog post to be this long (that's why I love Twitter, 140 characters and a hard stop, point made or not), so I will stop rambling and remember to point out that you should also read another great first person account of medical oncology solo practice in the same Jurassic-themed JOP issue, entitled A Paleontology Primer for Oncologists, by Anthony Provenzano from New York City. And if you do have any comments or suggestions about these JOP podcasts, it would be great to hear from you. Please email them to jopeditorsdesk@asco.org.


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