Inflection points

I've been blessed with many opportunities in life, and while I can't say if I had the chance to replay my career in medicine I would do it exactly the same way each time, I am very satisfied with the path I have chosen (or has been chosen for me). I thought I would explain some of the interesting phases and changes of my career as an oncologist by focusing on a few key inflection points. I realize now, 27 years after med school graduation (geez, that number makes me sound incredibly ancient), how different my career and my family's life experiences would have been if a few of these points had turned in another direction.

The first was when I opened the envelope on Match Day in March 1985 and learned that I would be doing residency in Internal Medicine at UC San Francisco, my first choice. (Trivia question, how many of you remember your rankings for your residency choices in the match? I believe my top 5 in order were UCSF, Yale, MGH, University of Washington, and Case-Western.) While I was very honored albeit very surprised to be accepted into such a prestigious program, at the time I seem to recall my greatest source of happiness was the fact that a good friend and housemate would also be doing his residency in the Bay Area, at the naval base. At that point, I had lived my entire life in Virginia, including college at UVA (where my sister, dad, and grandfather were all alums) and med school at MCV in Richmond (now called VCU). So moving to the West coast as a single person at age 26 and starting the scariest and most intense training of my life was a huge change. How different life would have been if I had matched in a program in the East or elsewhere, considering I then went on to live in California for the next 24 years, met and married my wife there, and raised all three of my kids in Sacramento.

Going to Stanford for oncology fellowship in 1989 was another important inflection point for obvious reasons. Ironically, my first choice was actually Johns Hopkins…except they didn't offer me a slot. Let's see now - Baltimore vs. Palo Alto, hmmm. Guess I landed on my feet. (I love telling this story to Hopkins fellows and residents these days.) Although I went into fellowship assuming I was going to have a career as an academician and clinical researcher, for a number of reasons, mostly personal and family-related, I chose to go into private practice in Sacramento in 1991, where I stayed for the next 17 years. And I might have continued to have a very unexceptional but rewarding career as a community oncologist if it weren't for a few other inflection points. I didn't realize it at the time, but one was in 1995 when I was nominated to be a board member for the Association of Northern California Oncologists (ANCO), the ASCO state affiliate for northern California. I can't even remember if there was an election or not, but serving on the ANCO Board, eventually becoming VP then state society president, afforded me numerous opportunities to understand some of the regulatory and reimbursement issues facing my colleagues and work toward improving our professional lives and indirectly the welfare of our patients. I have no recollection of how I was even nominated, but if that hadn't happened, I am doubtful that I ever would have gotten involved in "medical politics" or anything much outside of my own medical practice in Sacramento.

This may sound strange, but another inflection point was when U.S. Robotics introduced the first PalmPilot in 1996 (then called "Pilot"). I was always a gadget freak and had enough knowledge about personal computers to be truly misinformed, but when I saw the first prototypes of these PDA's, I knew I had to have one and use it in my daily routine as an oncologist. One thing led to another, and eventually I became recognized as an expert of sorts, mostly through reviews and columns I wrote for PDAMD.com, ASCO Online, and other websites. So that led to another turning point, in about 2004, when ASCO President-Elect Dr. Sandra Horning, one of my mentors when I was a fellow at Stanford, asked me to chair the ASCO IT Committee. At the time, there were quite a few older, more tech-savvy, and experienced oncologists whom she could have chosen - I've worked with most of them over the past 10 years in ASCO-related IT endeavors - but I am still deeply appreciative of the trust she placed in me. And it is probably true that my experience as an ASCO Committee Chair and my prior position as a state society president contributed to my nomination and eventual election in 2006 to the ASCO Board of Directors.

One of the stranger inflection points was how I became involved in social media. I've shared this in my talks before, but in approximately 2007 ASCO was experimenting with blogs and social networks, and at the time, as Board liaison to the ASCO IT Committee, I was charged with trying to legitimize this and make it more palatable to the ASCO Board. Historically the Board had been hesitant to officially bless something as potentially wild as social media with the ASCO name. Personally, I had a high level of skepticism when this was starting out. And that's how I began experimenting with Twitter, since I knew I had to take one for the team and make it work for myself, if ASCO was going to endorse it.   The rest is history - along with most other professional societies and non-profit institutions, including most academic medical centers, ASCO is widely recognized for its social media presence including its Facebook page, Twitter feed, and the award-winning blog and social networking site, ASCO Connection.  And for me, oddly enough, I find myself doing research and giving talks on social media and medicine, including upcoming Medicine Grand Rounds at UC Irvine in October 2012. If you had told me in 2006 that my last three papers accepted to peer-reviewed journals would be about Twitter and social media, I would have questioned your sanity.

Finally, my current position at Johns Hopkins which I assumed in 2009 obviously was another inflection point, due to a fortuitous combination of timing and having just the right contacts. At the time, I was becoming increasingly unhappy dealing with the business pressures of being a self-employed physician in private group practice, which was squeezing the joy out of medicine and requiring increasing vigilance to counteract some of the local pressures my group was facing. I was thinking I might look at a job with an EHR vendor or perhaps a chief medical information officer position with a hospital system. But I wasn't quite ready to give up clinical medicine yet. Then, in December 2008, I saw an ad in JCO that Johns Hopkins was looking for a clinician in the breast cancer program. Although I wasn't confident I had the credentials they were seeking, I approached Dr. Nancy Davidson, with whom I was serving on the ASCO Board at the time, to learn that, unbeknownst to me, the position was opening up because she was leaving Hopkins to go to Pittsburgh, and they needed an oncologist to take over the load of seeing new breast cancer patients. But even better was when I learned during the interviews that they also wanted someone to assist with the implementation of their electronic health record…and well here I am.

Here's what I learned from these experiences. It's easy to identify the big changes - matching at UCSF in 1985 and being offered the position at Hopkins in 2009 are obvious examples if for no other reason than the sheer geographic upheaval (subject for another blog post perhaps). But many of the inflection points were much more subtle, and I couldn't possibly have anticipated the downstream implications. If some kind soul hadn't offered up my name as an ANCO Board nominee in the mid-1990's, I'm not sure I would have necessarily gone in that direction. If Sandy Horning hadn't asked me to become an ASCO Committee Chair, I'm not sure I would have taken on progressively greater leadership responsibilities in a professional society like ASCO, as I was quite content at the time seeing patients in the community practice setting. And considering I am not a member of the stereotypical Facebook generation, if I hadn't delved into Twitter for the sole purpose of experimenting with it on behalf of ASCO, perhaps today I would be regarding social media as just another cultural phenomenon that does not particularly affect me. It would have been completely normal, expected, and unremarkable for any one of these events to have gone totally in another direction, and my career and family life could have been so very different.

I have been blessed with these wonderful opportunities, for which I am eternally grateful. Part of the excitement of what I do every day is wondering if the next seemingly unremarkable event, collaboration, engagement, or new technology, is going to turn me in some other unexpected direction. Never boring!