Sunday, August 26, 2012

Survivorship Care Plans (JOP podcast - August 2012)

I host and edit the Journal of Oncology Practice podcast for ASCO, and this month I interviewed Deborah Mayer, who is an advanced practice oncology nurse and clinical researcher at UNC, on the topic of survivorship care plans. Deb's current interests include eHealth and cancer survivorship, and you can read her bio on the UNC website. The podcast is available on the JOP site or it can be downloaded from the iTunes Store here.

The article that we covered in the interview was in the July 2012 issue of JOP and was entitled "Patient and Provider Preferences for Survivorship Care Plans." In the article, the researchers, who were from Duke and UNC, describe how they did focus groups with cancer survivors to elicit their preferences for survivorship care plans, including format and mode of delivery. They also interviewed five primary care physicians to get their perspectives.

You can read the article for a full description of what they found in regards to patient preferences for the different survivorship care plan templates, but in the podcast interview, what I thought was even more interesting and was not covered in as much detail in the article, was what the focus group of cancer survivors had to say about their overall experiences of the diagnosis, treatment, and follow-up phases of their cancer, particularly communication issues. For example, the survivor group pretty consistently said that while the idea of a written survivorship care plan was very nice, it was really too little, too late. What they wanted was not so much to be presented a summary document at the end of therapy, but rather each wanted his or her oncologist to write down all of the details at the beginning of therapy, including drug names and key pathology points. Along those lines, ASCO as been promoting the idea of a chemotherapy treatment plan as a companion to the treatment summary document, although in reality the penetration of both documents is pretty low in most practices. In addition, once treatment ended, the patients were very interested in knowing which symptoms they needed to report to their doctors and which they could ignore. They were interested not so much in the actual percentage risk of recurrence, but rather if they were having a symptom, when should they worry and, even more commonly, whom should they call - med onc, rad onc, surgeon, PCP, etc. I thought this was a particularly good point, one that many oncologists overlook - i.e., how bewildering it can be for many patients as to which doctor to call for which problem. I've always assumed patients knew they should call me for most symptoms, especially when they are in the middle of chemo, but this is not always straightforward from the patient's perspective.

Another key point that was brought out in these focus groups was how patients were keenly aware whenever the different members of their care team weren't communicating with each other. Too often, it seemed up to the patient him- or herself to update the PCP about the status of their cancer treatments, something that most patients weren't too happy about. In the interview, Deb makes a great point about how oncologists should be even more proactive at the start of treatment in including the PCP in the medical decision-making and explicitly dividing up the different treatment and follow-up tasks between oncologist and PCP. This is particularly true in the surveillance phase, and it should be crystal clear which doctor is going to be ordering the follow-up CEA's for example. But I know from my own experience this is much trickier to operationalize than it sounds. When the oncologist and PCP are not on the same EHR, it can be a real nightmare to exchange information and meaningfully coordinate care like that. Not an excuse, just a reality check. Even on the same EHR, it's not always at all clear cut who is going to do what, meaning that the patient is the one who gets caught in the middle if doctors don't talk to each other.

The interviews with the five PCP's were also interesting. The PCP's liked the idea of treatment summaries, but they asked that they be shorter and more to the point. They wanted the Reader's Digest version, and the amount of detail that is in some survivorship care plan documents, while it may be ideal for the patient, is irrelevant to many physicians. They also asked that these summary care plan documents not contain the usual inscrutable treatment abbreviations or onco-speak gobbledygook. I suppose they tire of getting notes from us saying that the patient received AC x 4 then T x 12, with concurrent Herceptin, followed by PMRT and an AI. While that sentence makes perfect sense to me, I totally understand how it may not do much for care coordination.

Deb was a great person to interview, and the points she brought out were instructive. For me, I realize that even now practicing at Hopkins with a dedicated breast cancer survivorship program, I still can do a much better job in getting patients the information they need in a format they can really use and engage. Once again, the key word is communication. Doctors need to be better at communicating with patients about treatment specifics, long term side effects that affect quality of life, and key issues in the post-treatment survivorship phase. For the minority of us filling out survivorship care plans or any type of treatment summary document, we should stop patting ourselves on the back that we've actually done it in the first place and try to improve the ongoing communication our patients really need from us.

Hope you enjoy the article. Since you have to be a JOP subscriber to read the full text (or wait 4 months and it will be freely available on Pubmed Central), listen to our podcast to get a real flavor of this specific research study and some of the larger issues facing our patients in this transition phase.

Monday, August 20, 2012

Choosing Wisely campaign - what do medicine housestaff think

I'm on a two week rotation as inpatient attending on the Solid Tumor service at Hopkins through the end of August, and this morning before rounds I gave a short lecture to the medicine housestaff and the oncology fellow on service about the ABIM's Choosing Wisely campaign, specifically ASCO's Top Five list, or "opportunities to improve quality and value in cancer care." This is a little bit of an offbeat topic for our morning lectures, as usually we cover some area of inpatient management of a common oncologic condition like febrile neutropenia or a disease-specific talk. Not too surprisingly when I asked them if any of them had heard of Choosing Wisely no one had. We didn't have much time for discussion, so I wasn't able to spend much time seeing their reactions, but they did seem to be paying attention to me (or they daydream well with their eyes open). Perhaps I made a slight impact, since later in the day, in discussing the management of a specific patient, one of the residents reflected out loud whether we really should be ordering a CT on this patient, since they had just had prior imaging that perhaps was sufficient.

Coincidentally, I read a blog post this morning on the very same topic from Vineet Arora, who is an academic hospitalist and the associate program director for the internal medicine residency at University of Chicago. In Teaching Costs of Care: Opening Pandora’s Box she writes about an interesting pilot video vignette being used at her institution to stimulate residents into thinking about the costs of ordering tests. Some of the discussion she captures, about how residents express concerns about malpractice and how to handle patient demands, is pretty interesting.

So I ended my brief talk this morning by reminding the housestaff that, since everyone agrees that the trajectory of the cost of medical care in the U.S. is unsustainable, it was their generation's responsibility as physicians to help come up with solutions and leadership in this area. God knows when and how our tortured reimbursement system in this country is going to change to reward quality and outcomes and not quantity of services. I just know that by the time I am eligible to dip into the Medicare Trust Fund in another 13 years or so, the new generation of physicians better be the ones who have solved this clinical and regulatory mess, since my generation has been spectacularly unsuccessful at making any headway.

Saturday, August 18, 2012

Why I think online access to the biomedical literature is one of the most important advances in science & technology of the past 30 years

It's the 200th year anniversary of the venerable New England Journal of Medicine, and they have been running a series of articles noting seminal advances they have published over the last two centuries, as well as forward-looking prognostications about the future of medicine. It made me think of the most important advances I have witnessed in my 20 years as an oncologist, and I am not restricting it to therapeutics. Examples that immediately come to mind for me, in completely random order, are filgrastim, 5-HT3 receptor antagonists, imatinib, rituximab, PET imaging, cloud computing, and social media. We all tend to be drawn to top ten lists, be it the top articles from 200 years of the NEJM, the top clinical papers of 2012 so far, the most clinically important genomic discoveries affecting patient care, or the top hospitals in the U.S. (a painful subject for us at Hopkins ever since that…ahem…medical center in Boston nabbed the top spot). But IMHO, thinking back over the last 20-30 years, you would be hard pressed to identify a series of advances with greater impact and a more amazing evolution than what has occurred in the area of information retrieval, especially search, as it applies in particular to the biomedical literature. 

I remember when I was working in a lab as an undergraduate in college in 1980 and needed to learn something about H2 receptors (we were studying the effects of cimetidine on lymphocyte blastogenesis, of all crazy things), I went to the intimidating medical library at University of Virginia and pulled down these massive copies of the bound Index Medicus, which was a catalogue of all - yes, that's all - of the published scientific literature. So you would find the article you were looking for (sort of, since this was in the era before hyperlinks), and then you went to the stacks, located the bound copy of the journal, and trudged back to the copy center where you paid $0.05/page to copy your reference. And you couldn't be sure your copy was always going to be legible, since the binding was often so tight you had a large vertical blurry patch on the edge of every page where you couldn't totally press the book against the glass. Things were marginally better when I was in medical school and residency in the 80's, since there was a librarian who could run searches for you. For those of you too young to know what I am talking about here's the way it worked. You decided what terms you wanted to search ("breast cancer" AND "thiotepa" NOT "intrathecal"), submitted your request to the medical librarian, who may or may not have been any help in refining it (often not), paid the fee for the search, then…waited and waited. Sometimes it was two weeks before you got the results, which were usually displayed in these huge sheaves of continuous computer paper (the kind with the holes down the sides) printed on a dot matrix printer in faded grayish ink. Half the time - probably 80% of the time - you realized then that the terms you searched weren't right and most of the references were irrelevant, but you were either too broke to pay another fee to run a different search or you didn't have another two weeks to kill waiting for the results.

Then the 90's came and with the growth of the Internet, online searching became a reality. But it was nothing like today where searching is real-time and free of charge. There were several different methods to access the PubMed database, but many were associated with either an annual fee or a per-search fee. So unless you had an unlimited institutional account, you had to be judicious about how much searching you would do. And you often needed to use some type of front end software to access PubMed like Internet Grateful Med, which had its own learning curve and quirks. You still had to go to the library to actually read the full text of the article you retrieved, since full text online was not a reality in the early days. Storing results was another issue, since formats were not standardized and PDF's were just penetrating into biomedicine.

I remember how amazed I was when the PubMed database became totally free to use, having lived through the hassles of the previous eras. The fact that you can now construct and execute an endless series of online searches with instantaneous results using a web browser still amazes me today. Even better, access is not restricted to health professionals. Patients and families now have access to the same literature database as I do, and this dissemination and democratization of knowledge, in my opinion, has done more to improve patient engagement and enable true patient-centered care than almost anything else. It is why I say that the evolution of information retrieval of the biomedical literature is one of the greatest advances affecting medicine over the past 30 years. Of course, there still are some critical barriers to overcome, such as access to full text articles for all, better use of metadata to search, and the all-important semantic deficiencies of the web; i.e., you can search by a given term, but if you really don't know what that term means, the computer often can't help you, since humans are still needed to interpret the information retrieved. (For more on the idea of the semantic web see here.)  Considering how far we've come since I was an undergrad in a lab in 1980 trying to teach myself pharmacology, I am pretty optimistic it won't take another 30 years to achieve this level of data integration and reusability. 

Thursday, August 16, 2012

Crowdsourcing a title for my grand rounds on social media

A few weeks ago I was flattered to be asked by an old friend from Stanford fellowship days, Dr. Ed Nelson, Chief of the Division of Hematology/Oncology, UC Irvine School of Medicine, to give Grand Rounds  for the UCI Department of Medicine in October 2012, on the topic of "Social media in medicine, now and in the future." Since it's a grand rounds, the audience will probably be mostly physicians, and my expectation is that their familiarity with social media tools and comfort with using them in their professional lives and in interacting with patients probably pretty limited. I could be wrong, but I suspect they are similar to the faculty at most other medical schools. I haven't fully decided yet on how I am going to shape the talk, but I expect I will cover such topics as:
  1. General overview of SM tools and applications
  2. Statistics on the tremendous growth of SM in healthcare and medicine
  3. Examples of best practices from prominent institutions like Mayo Clinic, MD Anderson, Hopkins, etc.
  4. Opportunities to use SM to promote enrollment to clinical trials and for other areas of patient engagement
  5. Use of social media for sharing medical information with other healthcare professionals and for continuous professional development, which was some of the research I presented at Medicine 2.0 at Stanford in 2011 with Brian McGowan et al
Since I am a believer in the power and inevitability of social media and social networks in healthcare, while still maintaining a healthy skepticism about its utility in clinical practice, I intend to give a generally positive, enthusiastic, and balanced presentation, particularly highlighting my personal growth in this area.

I need a catchy, non-cliched title for my talk, something that conveys the optimism and promise but doesn't sound like a press release from the latest Web 2.0 start-up. So I decided to crowdsource it! Please make suggestions for a title for my Medicine Grand Rounds, either in the comments below or tweet it to me @rsm2800. Thanks!

Wednesday, August 15, 2012

Aspirin and cancer prevention

Every month there seems to be a new study released about the potential for aspirin to reduce either cancer incidence or mortality. The latest came out this month in the Journal of the National Cancer Institute, authored by Eric Jacobs and colleagues from the American Cancer Society. Here is the full text (subscription or institutional access required, but if you don't have that you can always read the abstract), and even better here is a succinct summary from MedPage Today. The overall effect was relatively modest but seemed to show that daily users of aspirin had an 8% reduction in the risk of dying from cancer. The effect was more pronounced for the risk of dying from a cancer of the GI tract, since individuals using aspirin on a daily basis for 5 years or more had a 59% lower chance of dying of esophageal cancer and a 64% lower chance of dying of stomach cancer than those who did not take it.

The April 2012 issue of The Lancet also had two important papers relevant to this topic. One was an analysis of 51 randomized trials of aspirin use for another endpoint (vascular events), and it demonstrated that there was a 15% reduction in overall cancer deaths in daily aspirin users. The other  suggested that the effects could be seen more long term, since there was a reduction in the incidence of distant metastases, with a 36% reduction overall and even higher benefits seen in adenocarcinoma, particularly adeno's associated with GI primaries, including an amazing 74% reduction in the incidence of metastases from patients presenting with localized colon cancers. And the same may apply to the use of aspirin in women with Stage I-III breast cancer, based on a paper in the Journal of Clinical Oncology from 2010, which showed a protective effect especially in women surviving several years after initial diagnosis.

Speculating on the cause for these associations is beyond the scope of this blog post. Does this mean that we should be taking aspirin daily or at least several times weekly to ward off cancer? To my knowledge, no professional society or guideline is recommending the use of aspirin in this fashion just yet, and it is important to note that not all studies have shown a similar effect. Many of these studies were retrospective, which can lead to all sorts of biases and confounding factors, and can never truly prove cause and effect. And aspirin is not lacking in side effects, as serious bleeding was definitely associated with even a single baby aspirin a day. I am not yet routinely recommending the use of aspirin to my breast cancer patients who have completed treatment, since I am inherently skeptical about many of these things. But…the data are certainly provocative, and I am watching this story closely.

Tuesday, August 14, 2012

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, 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!

Sunday, August 12, 2012

Lessons in empathy

I follow a number of breast cancer survivors and patient advocates on Twitter (see the #bcsm hashtag), which leads me to some interesting blogs that I probably would not have otherwise discovered. One is written by Chemobabe who per her biography is a social scientist and survivor of Stage III, HER2 positive breast cancer. Her most recent post Schooling the Resident is about her experiences at a 3-year follow up visit. Thankfully, she's NED, but she recounts her impatience with the resident who was interviewing her before her regular oncologist entered the room. What was particularly annoying for her was the fact that the resident starting fiddling with his iPhone while the attending was talking to her, which led her to wonder if he was texting his friends or even taking pictures of her. She used the experience to remind her regular oncologist to mentor this resident and try to remind him to be more empathetic. In one of the comments, one person went so far as to say that the resident should be formally reprimanded with a letter in his file.

I had several reactions to the post. I went into Defensive Doctor mode first, thinking of ways to defend the hapless resident.

C'mon, it's hard to imagine he was using the phone to take pictures of you he was tweeting somewhere.

Be realistic. I can't imagine he was texting his friends. Maybe he had to answer a page, or look something up to help another patient.

Or maybe he was using his phone to research something about YOUR condition.

It's 2012 for God's sake, we all have pay way too much attention to our digital devices when we shouldn't be. It's not a cause for reprimand.

And don't be so hard on the guy when he was talking about how your arm pain might have been caused by neuropathy or lymphedema. Yes, that's obvious to you and your regular oncologist, but the resident has never met you before, and maybe he is just trying to be certain you do have an understanding of your diagnosis. It's very hard to assess a patient's understanding by reading another physician's documentation in the chart.

But on further reflection, this is wrong, wrong, wrong. I think Chemobabe really nails it here. The visit IS about her, and even if at the point the regular oncologist was taking charge of the interview from the resident, the guy should not be focusing on his phone, at least not longer than a second or two to see if it's a page that requires immediate attention (and by saying "excuse me" or something). It's just rude, and it misses the point of why he is in the room in the first place. And maybe he could have saved himself some grief by spending the first minute or two trying to develop rapport with the patient and asking her what she knows about her symptoms, and more importantly, what he can do to help her that day.

I haven't at all forgotten what it's like to be a trainee, even though it's been 20 years for me. It is intimidating when you are in a patient encounter where your fund of knowledge is minimal, your experience is nil, and everyone knows that. But the biggest regret of my days of residency and fellowship is not that I didn't know the answer to the attending's question or I made a mistake that someone else had to fix. It's that I missed too many opportunities to be empathetic and listen, right at the moment that the patient across from me needed it the most.

Wednesday, August 8, 2012


Don't let the perfect be the enemy of the good.

If I sit through another meeting (usually something related to EHR implementation) and hear that quote, I think I'm going to…well I don't know what I am going to do, since everyone seems to be saying it and acting like they thought it up themselves. But that quote, supposedly paraphrased from Voltaire, partially explains why I have finally decided to put aside all of my reservations and actually go ahead and start a blog. A physician blog is hardly unique or interesting any more, but for me, with my increasing involvement with social media (and some level of visibility), the time is right to do this. To be more accurate, I have already been contributing to a blog on ASCO Connection for a few years now, and even prior to that to one of ASCO's first forays into social media, which was an EHR-focused blog on the Ning platform, which ASCO later migrated to ASCO Connection. I have contributed to ASCO Connection a few times a year, although I definitely feel far eclipsed by Don Dizon, Mike Fisch, George Sledge, and others, who are writing great blog pieces that have helped propel the ASCO Connection site to greater prominence, including a recent national award, a 2012 Apex Award for publication excellence. In other words, even though I was one of the first, these guys do such a great job, they should continue to carry the freight, and I'll probably just continue as a part-timer.

And let me say a word for and give a shout out to George Sledge in particular. I got to know George a little bit when we were both on the ASCO Board of Directors, and it's not an exaggeration to say he is the real deal - interesting and articulate guy, extremely well read with a broad range of interests, a brilliant scientist and clinical investigator, and as far as I can tell from the outside, a truly compassionate physician. But not only that, he is a great writer and really elevated the content and quality on the ASCO Connection blog pages. (Hey George, I'm not slurping you for any hidden reason, just to make this point.) I frankly don't know how he has the time to create these long and nuanced blog posts for ASCO and for Oncology Times, but they are always a great read. So…I knew I couldn't keep up, particularly with the length. Which is one of the reasons I realized it would be best for me to write my own blog - so here it is. Don't worry, Amy Fries and ASCO staff, I'll still post to Connection, although I will probably post it to this blog first and share.

So here is what I would like to do with this blog and a little more of my motivation for creating this. One of my main purposes is to allow me more space to share ideas than I get in 140-character Twitter posts. People who know about my social media activity of the past few years know that I am active on Twitter, and much to my surprise but also satisfaction, have 2000+ followers and growing (and some aren't spambots). But Twitter is all about quick bursts of information and instantaneous sharing, and not about thoughtful content creation. This blog will allow me to share articles, news stories, and other items I find online, that I am currently sharing on Twitter, but on a blog, you just have more "room." Sentences, not just phrases - what a luxury! And you can write in English, not in SMS-speak (Gr8 articl 2 read abt lng ca - blah blah blah).

Another reason to blog is to engage more with followers, more than what you can do with Twitter replies. I intend to enable comments on the blog and when I feel up to it, respond and engage in dialogue, although I don't have the time for a lot of argumentative back and forth, which is not my style anyway. Social media is always primarily about community and connection; a blog will help facilitate that. And I think it will also help people who read me to understand more of the life and experiences of an oncologist and informaticist (there's that word), particularly someone who has been doing this for 20+ years. Not that I think anyone is particularly interested in me as an individual, but sharing on social media is also about sharing who you are and what values you hold. In another post I will talk a little bit about my career and what led me from the East coast to the West coast and back again, and from private practice to academics. Again, not because I think it is particularly interesting to many people, but it helps define my current perspectives.

[Addendum 3/27/13: Re blog comments, I've learned after 6 months of having a blog that unfortunately a lot of comments are spam. There is a way to filter out a lot of them which I am doing. However, even if you get by the spam filters, I don't intend to publish comments where the primary purpose is advertising a specific service unless it has general applicability. That is true even if you have a legitimate medical practice or service. My blog is not free advertising for you. Sorry.]

Another reason I want to blog is purely selfish. I need to learn to write more quickly. I was an English major in college in a different century, and for all of my career, even in private practice, I have been doing a lot of writing and editing. And I think I am fairly talented in this area, I will say in all modesty. But I am definitely not fast, and the hardest thing I ever have to do is to start a manuscript. I sit and dawdle and waste time on the Internet and a million other things. A blog won't cure me of my procrastination tendencies, but if I am really going to make this work, I have to post regularly, and I don't have hours of extra time to do that. So another example of not letting the perfect become the enemy of the good.

A few other thoughts about what I want this blog to be. I expect I will blog about what I cover on Twitter right now, mostly my professional interests. These, of course, include medical oncology, particularly breast cancer, biomedical informatics and health IT, patient-centered care especially as enabled by consumer health informatics, and healthcare-related social media. I may share experiences about clinical practice, but will never give specific medical advice (that is why you have your own oncologist or PCP, and it ain't me), and I will never blog about a specific patient, at least not in any way that could lead to the identification of an individual. Patient privacy is a sacred trust, and not just because of HIPAA, but because it's what our patients absolutely expect of us. So if I talk about clinical practice, it won't be about what happened that day, but it might be about something long ago, where details have faded, or it might also be a composite of several patients or situations, so that no links to real patients can reasonably inferred.

I am going to try very hard to post a few times a week. I expect that many of my posts might be fairly short, since one of my main purposes will be to share articles or other items that my readers can explore themselves. I think that shorter, more frequent posts will be more effective for what I hope to achieve here, and that practice will certainly be a better discipline than slaving over a 1500 word blog post that takes 3 weeks to write. Again, I'm not going to let the perfect be the enemy of the good, or at least the adequate.

Finally, this isn't going to be pretty, at least not to start. Don't look for clever polls, beautiful graphics, or lots of widgets. I am just starting to play with the Blogger tools, and one of the reasons I chose Blogger over Wordpress was that Blogger is much simpler to configure. It's the words that matter. Sorry, if you want fancy, you will have to read a professional.

So here goes. I can safely say that no one will read this post the day it goes up, since I decided not to promote the existence of this blog until I can convince myself it will happen. But perhaps over time, just like it happened for me with Twitter, a community will develop and maybe I can accomplish something unexpected.