There are over 33,000 ASCO members now, and the size and diversity of our membership increases the challenge of keeping the Society in touch with the concerns and opinions that matter the most to our members, the concerns that wake us up in the middle of the night or occupy a good part of our waking hours. The health and future of community practice is at the top of that list for ASCO because the vast majority of patients with cancer receive their care at community practices, and the high quality of that care is threatened by continued cuts in reimbursement. The Institute of Medicine has invited me to speak on the viability of oncology community practice in November. Perhaps federal recognition as an endangered species might be appropriate.
There is little question in my mind that unless community medicine evolves and evolves rapidly, more and more community practices will disappear. Recently I was joined by several ASCO community practice leaders in Town Hall meetings at the Los Angeles and Boston Best of ASCO Meetings. Bob Moss, President of the Medical Oncology Association of Southern California (MOASC), and John Cox, Editor of the Journal of Oncology Practice, joined me in Los Angeles. Terry Mulvey, ASCO Board Member, and Charlie Penley, Chair of the Board of ASCO Conquer Cancer Foundation, came to Boston. John, Terry, and Charlie are all past Chairs of the ASCO Clinical Practice Committee and, as with Bob and myself, all have very active clinical practices.
The remarks of one oncologist who has been in community practice for many years are what prompted this blog. He stood in Boston to comment on the loss of the personal connection between physician and patients that results from the insertion of intermediaries such as nurse practitioners and physician assistants, and loss of the values of physician responsibility for patient care, for which he received a generous, spontaneous round of applause.
There are of course good reasons why quality of care and the patient experience with health care are improved by a team approach. Oncology care has become too complex and requires too many separate skill sets for any one physician to master. An oncology pharmacist understands drug-drug interactions better than I and is more cost efficient than an oncology nurse. Oncology social workers have more knowledge about community resources for patients. The issue at hand is how can ASCO help these members of the oncology team acquire sufficient learning to support optimal cancer care and how can the oncologist be comfortable that this is in fact the case? This question was part of the ASCO Board Strategic Planning Meeting last March and ASCO staff were directed to help the Board address these needs.
A second reason why the delegation and sharing of cancer patient care by a team built on mutual respect is important for oncologists is avoidance of professional burnout. The adage "physician, heal thyself" comes to mind. A recent ASCO survey has shown that while ASCO member satisfaction with their career is among the highest in medicine, the emotional burnout rate ranks at the top as well. ASCO has a responsibility to our members to shine light on this troubling finding and provide solutions that help to keep our members' professional careers vibrant, fresh, and rewarding.
However, coming back to the community oncologist comments in Boston, I now see that the current phrase popular in many circles of patient-centric care, worthy as that concept is in its many interpretations, may be conceptually incomplete. It leaves out and diminishes the role of the physician-patient relationship. A better conceptualization is a physician-patient dyad to establish goals of therapy along with articulation of patient values and preferences from which the work of the entire cancer care team emanates.
Change is difficult and we are speaking about changes in the meaning of what an oncologist’s professional identity is. The more difficult change is perceived, the greater is the likelihood that such change will be deferred until time of crisis. A Chinese proverb states, “Unless the old leaves, the new will not arrive.” Solace for the pain of giving up what we have grown comfortable with in recognition of what can be gained.