George W. Sledge, MD, FASCO

Sep 27, 2011
During the past year, I became an avid reader of the Journal of Oncology Practice. This was not to the detriment of either the JCO or any of the other scientific browsing I perform. It was, instead, recognition that being a good clinician now requires something more than just knowing the doses of the latest biologic advances or the result of the latest Phase III trial in metastatic breast cancer. Instead, I came to the conclusion that how we practice oncology is as important as what we practice with. And while the JCO is great with the "what" of oncology, the JOP is the great purveyor of "how."

The current issue is a good example of this. First, Thomas Barr and Elaine Towle bring us up to date on oncology practice trends over the past five years. They document what they call "The Squeeze," with the space separating practice revenue and total operating costs continuously diminishing, even as total revenue per full-time equivalent cancer doctor increases. They predict a continuing decline in operating margins, as labor costs rise faster than revenues.

We are also working harder. In 2003, the median number of new patients per year seen was 235; that number has now increased to 345. The authors don't say why this increase occurred, but we can guess. We have more treatment options available in more cancers, and the population is aging.

These trends are not supportable going forward, in either financial or human terms, if the old models hold. One way that practices have dealt with this increasing volume of new patients has been to hire physician extenders in the form of nurse practitioners and physician assistants. Towle and colleagues also explore this phenomenon in an article on collaborative practice arrangements. They identify three practice models: the Incident-to Practice model, where nonphysician practitioners (NPPs) see patients independently, but in close proximity to a physician; the shared practice model, where the NPP sees the patient in conjunction with a physician; and the independent practice model, where the NPP sees patients completely independently.

The Incident-to Practice model is the most common model, partly for billing reasons and partly for reasons of efficiency. What is important is that these collaborative arrangements clearly work, both in terms of patient satisfaction and practice efficiency and productivity. This will likely be the future as the changing demographics of cancer care places increasing pressure on our health care system.

I’ve become convinced that, as a result of the rapid changes in our understanding of cancer biology, we are in the midst of a revolutionary era in oncology. It may be the one that will finally turn the page on most human cancers. But it won’t come easily. The old health care model is broken (and broke), the research and regulatory apparatus is not in sync with the new biologic realities, and there are simply too few of us (us clinicians, us researchers, us nurses, us pharmacists) for what lies in store. What fun we will have figuring this all out!

What is clear, or should be by now, is that we need to think in much more systematic terms, not just about medicine, but also the economic and social and bioinformatic bases of tomorrow’s health care system. And this is where the JOP comes in, as every issue attests.

There are many other wonderful articles, on survivorship plans, global partnerships, and exemplary research attributes, but the above gives you some taste of the JOP. This journal has taken off and spread its wings in recent years under the able leadership of John Cox and his editorial team, and now attracts a great deal of top-notch research. So read it: it's not that throwaway that comes wrapped with the JCO, but a worthy journal in its own right.


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