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I came across an interesting post on a business blog, challenging managers to create two lists, “arguably the only two you'll need to keep focused at work.”1 How can you pass up this advice? The two lists? “1. Things that keep me up at night. 2. Reasons I get up in the morning.” The blog cites Alan Webber, who states that attention to these two lists help managers and leaders to define who “they are.” Webber argues that leaders must know themselves before they know their businesses.2
Oncologists can answer these questions on two levels. Worries about decisions of patient care clearly interrupt our sleep. Conversely, it is the satisfaction of caring for others that gets us out of bed. But do those answers gloss over the challenge of these questions for a practicing physician? If we look at the growing pressures of practice, with the increasing accountability and oversight to which we are subject, and the concurrent lack of “control” we have in these worlds, insomnia ensues. And, on reflection, “why would anyone want to do this?” slips from our mouths!
I was struck by this dichotomy of answers during a recent debate within a practice group about mission. Is the mission of a physician group practice oriented or patient oriented? This may seem foolish, but as you delve into the question, you begin to get a sense of how the differing emphasis is likely to define the group. When decisions are made in the board room, will they be oriented to determine the well-being of the practice entity or will they be guided by doing what is best for our patients (or both)?
Sir William Osler said, “We are here to add what we can to, not to get what we can from, life.” Yet we know the truth of the conventional wisdom: “no money, no mission.”
Patient navigators epitomize these tensions. In this issue of Journal of Oncology Practice, Mumber et al discuss the use of a patient navigator to bridge the many fractures of cancer care. Doing so may improve the patient experience. However, using another employee to “fix what is broken” will not solve the health care system's ills, and adds another unreimbursed service for practices to absorb. Such are the competing interests that baffle oncologists' lives.
In this issue, there are seven original reports. Three of these manuscripts include additional commentary and several of these reports highlight the challenges we face. With quality measurement comes the ever-increasing reliance on the medical record to define the patient experience and serve as the quality yardstick. Abernethy et al outline the inadequacies of relying on our records. Mike Neuss comments on the challenge and promise of quality oversight. Similar challenges are described by Amin et al, who assess how well we apply guidelines in venous thromboemboli prophylaxis. Gary Lyman puts these data in perspective. The patient's perspective in accessing his or her own medical record is analyzed by Leonard et al. Bob Miller highlights the potential value of this tool, and raises cautions. Buell et al present challenging data on practice access to drug assistance programs, providing more fodder for the conflict of patient versus practice. Shulman et al help define the value of different models of care incorporating nonphysician practitioners, possibly bridging the gulf as these models serve both the patient and the practice.
Mike Neuss is stepping into the role of Clinical Practice Committee Chair this year and begins his JOP journey with two contributions in this issue. Wearing his long-recognized hat as an expert in quality measurement, he provides commentary (as described above), and also ably pens his first column as Chair. Readers will find his perspective on practice well presented.
Lastly, a must-read in this issue is Lowell Schnipper's editorial concerning the work of the Cost of Cancer Care taskforce. Referencing the committee's product that was recently published in Journal of Clinical Oncology,3 Dr Schnipper emphasizes the import of providing patients with information concerning the costs of treatments proposed. In this age, to ignore these discussions is doing a disservice to the patient who is responsible for a growing percentage of the costs, and to the practice that must absorb any unpaid costs. As a profession, we must gain skills to intelligently manage this uncomfortable dichotomy.
As always, we welcome your feedback at gro.ocsa@ksedsrotidepoj.