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J Oncol Pract. 2008 May; 4(3): 137–138.
PMCID: PMC2794004

Sink or Swim

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Therese M. Mulvey, MD

It seems impossible that this is the final Voice of ASCO that I will write as Chair of the Clinical Practice Committee (CPC). Over the past year, this column has covered diverse topics such as volunteerism, electronic health records, clinical trials, the role of nonphysician practitioners, and quality of care. Each of these broad topics are discussed regularly at the Steering Committee meetings and general meetings of the CPC. As chair over the past year, I have had the opportunity to participate in a variety of American Society of Clinical Oncology (ASCO) meetings and society task forces, many of which other state society leaders and CPC members have also attended. Ours is a complicated world, a tsunami of ever changing science on the molecular and clinical level burgeoning regulations by payers and increased scrutiny by the consumers of our care—patients, survivors, and their families. The big tent of ASCO grapples with these seemingly diverse issues because they belong to all of us who call ourselves oncologists.

So, why the angst between our varied sites of service? Are we not aware that there are too few oncology providers to care for the growing number of patients? The Workforce Study was very clear. By 2020, we'll be 30% short of the number of oncologists needed to meet expected demand. And that doesn't begin to consider the dire straits confronting our nursing colleagues. Why then the “gap” as John Cox, MD, a past CPC Chair, so aptly called the perceived divide between the community solo practitioners, the large group practices, the hospital based practices and the National Cancer Institute/NCCN–designated centers? As former President George H.W. Bush learned, “it's the economy, stupid.” We as oncologists are competing against one another, against systems that support our infrastructure and against our colleagues in varied sites of service to increase our grant funding, our productivity, our publication lists, and our contracting rates. I use the word ‘against’ because the system is backwards. The payment and profit of cancer medicine pit one against another at a time when we as providers should be circling the wagons and cooperating even more. Meanwhile, as we compete for the last eligible patient, the better-insured newly diagnosed person, and the larger market share, we all drive up the cost of care with duplication and fragmentation of care. Again, there are already too many patients who need care, too few of us as providers, and a shrinking budget to care for these patients. Nancy Davidson, MD, the current ASCO president, states it best, “We are all one boat, and we will sink or swim together.”

Being cognizant of the skills each of us bring to the discussion allows everyone to grow, learn, and develop mutual respect. As a community-based practicing generalist, I benefit from the discussions with my bench-based friends about seemingly esoteric topics such as the sonic hedgehog pathway. Although of no apparent relevance to me today, the drugs that will be developed from their research will be in my office sooner than one might think. My colleagues who chose academic clinical research positions call me now, as they are under increasing pressure to meet production numbers and look to those of us who have been in those trenches to point to best practice models. Understanding and addressing these diverse challenges in oncology practice was the genesis of the Journal of Oncology Practice. The journal did not begin simply because ASCO wanted another blue-covered journal; it fits a need that spans many providers and their staffs who give care in many different practice sites.

The CPC has similarly expanded to include researchers, oncologists who drive policy decisions, and survivors. Liaisons from ASH, SGO, and pediatric hematology/oncology participate in meetings and members of the CPC participate in other major committees within the organization. They also serve as representatives in other organizations such as the American Medical Association and ACP. As a committee, we recognize that we all provide care for the patient with cancer and that practicing oncology care looks very different from each of our perspectives. Therein lies the strength of the CPC and the strength of ASCO as an organization. Although a general oncologist may feel overwhelmed at the track-based annual meeting, there is someone on the Cancer Education Committee, often a CPC member, trying to make sure that the practice-changing breast cancer presentation is not held simultaneously with the critical lung cancer presentation. The length of one's sprint between these lecture halls is also considered, but, I personally will never again wear new shoes to the annual meeting; a sure sign that I am a domestic member.

Policy and payment decisions are often out of hands of the individual oncologist, but may be positively influenced when oncologists participate in organizations like ASCO. As a start, the organization can provide tools and tips to negotiate the waters. The CPC and the leadership of ASCO have gone further and attempted to address this issue in a proactive way. Meeting with payers and establishing and maintaining contact is but a first and important step. There is much work that will need to be done.

This year, my middle daughter will graduate from high school. I bring this up to highlight an example of how things can go right. In high school there are cliques of girls, groups of jocks, and, of course, future oncologists—the nerds. Her school decided to embrace the movie Sparta and took on the moniker of the movie, “Tonight we fight as one.” They made a conscious effort to make their final year in high school a cooperative year. They will proudly tell you that they have won more games, performed better plays, and enjoyed the freedom that inclusivity provides, allowing conversely more individualism and diversity. The effort has been infectious throughout the school. As oncology providers, perhaps we can learn from these sage adolescents. It is naïve to believe that where success is so varied in our sites of service—monetary, paradigm-shifting clinical research, or genome-based discovery—that we can embrace this motto blindly. But, by visiting diverse practice sites and centers and meeting oncology providers at state society meetings and on committees, it is clear we are all proud of what we do. And, we are all proud with good reason—the goals are the same: caring for and curing the patient with cancer. The ultimate goal is congruent whether we are genotyping tyrosine kinase mutations, developing quality measures, or providing palliation. And, of course, we also must consider our important alliances with our colleagues in radiation oncology, surgery, and pathology, as well as the other key members of the multidisciplinary care team like our nurses and social workers. We have a common enemy, and many will try to divide us with promises of rewards. As long as we remember why we come to work each day, the gaps between us narrow, and the respect for each of our work can be recognized. We can sink alone or we can choose to swim together. We can fight as one.

Articles from Journal of Oncology Practice are provided here courtesy of American Society of Clinical Oncology