Every March, the ASCO Board of Directors meets for its Strategic Planning Retreat. Although we always have a well-thought-out agenda to work on, we begin the annual event with an open discussion during which each board member is given a few minutes to present the most important emerging threat or neglected issue that, in his or her opinion, the ASCO Board and senior staff should hear about.
The Board is elected by ASCO members, and through the categories of designated Board seats—international and domestic, academic and community, pediatric, surgical, and radiation oncology—it represents the diversity of ASCO membership. These varying perspectives shape program and staff development and the budget as we work throughout the year. As I reviewed this year's Board discussion, several themes emerged that I would like to share with you.
Time and monetary pressures
For some time now, it has become apparent to me that the character of a professional career in community-based oncology practice and academic-based practice has drawn closer together. The differences are now far fewer and less crisp. Both community and academic U.S. oncologists are under increasing pressure to generate more revenue based on volume of care.
Academic patient loads often equal those of community practices, and with fewer allowable work hours for residents and fellows, faculty are spending a greater proportion of their time in direct patient care. This comes at the expense of protected time, which means less productivity in terms of research, publications, and meeting attendance—the heart of an academic career.
Community oncologists, in turn, are increasing their patient loads, which translates into less face-to-face time with patients, a less-rewarding professional experience, and greater risk of burnout. And all of us are struggling with decreased productivity associated with the current generation of electronic health records.
Lessening of professional autonomy
Both community-based and academic-based oncologists are experiencing loss of professional autonomy. Traditionally, one of the great attractions of community-based practice has been the perceived ability to practice medicine as one felt best, accountable first and foremost to oneself and to the patient.
Instead, practitioners are now more and more accountable to both public and private payers, and this will only increase with time. Public reporting of payer-mandated performance measures have begun. On the academic side, the diminished funding of the National Cancer Institute (NCI) extramural programs have meant that NCI-sponsored clinical trials have been reduced in half, to be replaced by industry trials where investigators have far less autonomy regarding the scientific lines of inquiry to be pursued in the study.
Accompanying this stress is a sense that physicians, in general, are being reduced to assembly-line workers, leading to less inquisitiveness and learning, and diminished pursuit of professional interests that do not translate into income. Guidelines and pathways—if implemented without recognition and allowance for the individuality of every patient’s cancer, health status, and value system—will harm patients. For the millennial generation, this may be compounded by learning habits that favor quick answers rather than in-depth analysis, as previously noted by participants in our Leadership Development Program.
The promise and challenge of new therapies
At the Strategic Planning Retreat four years ago, the ASCO Board identified precision medicine as one of the three drivers of oncology’s future (along with value-based medicine and health information technology). This has indeed been the case with a multitude of targeted agents being rapidly approved, in part, because of the breakthrough status they are afforded while raising new challenges, albeit good ones.
Practitioners must now be aware of an overwhelming array of new therapies, many with unfamiliar novel and complex side effects, and each agent is being rapidly tested in a range of cancer subpopulations expressing genetic mutations for which a targeted agent approved for another disease exists. At the same time, the high cost of targeted agents raises concern whether the gap in care experienced by health care disparity populations will widen, worsening social equity. We must also remember that the answers to cancer do not entirely lie in the genome or the immune system, but are also within the patient.
Solutions continue to require broad engagement
The problems are complex and enormous; the solutions are unclear and will lead to redefinition of both our profession and our professional Society. The challenges are certainly not limited to the United States, and engagement of our international members will benefit us all. Indeed, the international oncology community has been experiencing some of these pressures far longer than American oncologists. I will explore this intriguing thought as I visit ASCO members in South America and India in the upcoming months. Together, we must rebalance the center and invigorate our profession.
Fortunately, ASCO has many of the right people in place to tackle these challenges. Our volunteer committees and staff departments are comprehensive and include Health Care Disparities, Clinical Practice, Cancer Research, International Affairs, Education, and Quality of Care.
Important programs with the power to transform, such as CancerLinQ™, have been initiated, and a new Clinical Affairs Department that will develop pragmatic programs to support the practice of oncology is being launched. Alternative payment models to replace the fee-for-service treadmill that we are on will be tested. We will expand our constituency as needed to fashion effective solutions even as we aim to serve our core constituency better.
The Society exists to serve its members; to accomplish that necessitates listening to the individual concerns of ASCO’s constituencies and seeking out the common threads that lead to effective solutions and not patches. The ASCO Board is where the different sides of our organization come together in an atmosphere of mutual respect and a sincere desire to understand the needs of all ASCO members who pursue the collective mission to advance the field of oncology through research, education, and the promotion of the highest patient care.
I thank the Board for its leadership and vision, a vision of a world where cancer is prevented or cured, and every survivor is restored to health.