The next step

Go to the edge of the cliff and jump off. Build your wings on the way down.

--Ray Bradbury

D.A. Freccia: You're a pretty smart fella.

Joe Moore: Ah, not that smart.

D.A. Freccia: [If] you're not that smart, how'd you figure it out?

Joe Moore: I tried to imagine a fella smarter than myself. Then I tried to think, "What would he do?"

--Gene Hackman, Heist (2001)

It’s smarter to be lucky than it’s lucky to be smart.

--Charlemagne “War is a Science” Pippin (1972)

I don’t think I’m jumping off a cliff – and I know I don’t have any wings, at least not yet – but I am taking a leap into something new, different, and exciting, and I want to share the news with all of you today. Beginning December 3, 2014, I will be leaving my current position in the breast cancer program at the Kimmel Cancer Center at Johns Hopkins and beginning a new full-time position as Medical Director of the Institute for Quality of the American Society of Clinical Oncology (ASCO) in Alexandria, VA. I will help lead and support a number of key programs that make up ASCO’s quality portfolio, including the Quality Oncology Practice Initiative (QOPI), the QOPI Certification Program, and the revolutionary and ambitious CancerLinQ project, among other ASCO quality initiatives. The ASCO Board of Directors and CEO Dr. Allen Lichter recently made the decision to bring on board to the ASCO staff a physician to provide medical oversight for this key area. I am deeply honored to be the inaugural person selected for this position.

ASCO’s vision for the future of oncology, well articulated in the 2012 document “Shaping the Future of Oncology: Envisioning Cancer Care in 2030” is one that really resonates with me. ASCO believes that all patients with cancer should have access to high quality care and that the information learned from every patient should accelerate the progress against cancer. ASCO has identified health information technology, particularly the ability to collect and analyze vast amounts of big data, as a key driver to achieve this vision. I couldn’t agree more. For the past 23 years that I have practiced clinical oncology, patients and families have come to me for my expertise in what is often the most overwhelming crisis of their lives. They may be full of fear and anxiety, but they are all hopeful for cure, while expecting compassion and respect. As a clinician, I know that the only thing that really matters is the needs of that patient in the exam room across from me, and my primary responsibility is to help them navigate the shortcomings of our byzantine and often-insensitive healthcare system, to deliver to them the right diagnosis and the right treatment, based on the best possible evidence and shaped by their own preferences and values. To do that, I need access to data, information, and knowledge of a complexity and quantity that was unthinkable when I graduated from medical school in the 1980s. To get this access, oncologists need tools that can’t be discerned in the Google searches and social media streams of today, as critical as the Internet is to medicine – let alone the medical libraries and Index Medicus of the last century! ASCO’s rich portfolio of quality programs, which started with QOPI, an oncologist-led, practice-based quality assessment and improvement program that launched in 2002, through today’s eQOPI and the growing library of practice guidelines, to tomorrow’s CancerLinQ rapid learning system, will continue to be foundational in providing oncologists with some of these needed resources.

I’m joining ASCO now as a full time employee because I’m passionate and optimistic about the future of our field, and I want to devote the rest of my career to enabling this change. I’ve not been blessed with unique or extraordinary vision, but I think I can see what it is going to take. We need to create a world where medical practice consistently reflects unfettered access to meaningful data; where clinical care and discovery co-exist and enrich each other; where oncologists discover new knowledge not only from the 3% of patients who bravely enroll on clinical trials but from the routine care experiences of all; where the documentation of such care experiences is freed from proprietary electronic systems – currently shoehorned into the rough and inflexible mandates of the meaningful use requirements (as necessary a first step as they were) –  and shared freely by all; where delivery is not constantly undermined by the specter of the perverse incentives of quantity-based reimbursement particularly “buy and bill;” where the amazing advances in panomics are allowed to flourish and inform today’s care processes and not exist only as vague promises of “precision medicine;” and where patient-centered care is something we all are proud to deliver, not just to satisfy next month’s Press-Ganey surveys, but because it represents the fundamental passion and dedication of our profession as physicians.

Will I be able to do all of these things as an ASCO Medical Director? Lordy, I’m going to need a lot of help! I’ve experienced oncology in both private practice and academics, so I know all too well the challenges of transformation and how disappointment oft rules. But I think I’m smart enough to associate myself with some very smart people, and I’ve been lucky enough in my career – blessed in fact – that I’ve been able to enjoy a wonderful, fulfilling practice environment and the collegiality and camaraderie of superb colleagues everywhere I have been. So I think this “leap” – from the familiarity of a single institution to a visionary, mission-driven organization like ASCO and this work blending quality, clinical medicine, and information science – is not just the next step for my professional development but something that feels positive, natural, and just right. I’ll build the wings later.

My Three Words for 2014

It’s fashionable for anyone with a blog to post their New Years’ resolutions, but I have never been very original or consistent. (Looks like my last attempt was in 2011 - that's lame.) So instead, I will follow the lead of Chris Brogan and Bryan Vartabedian and choose three words that I hope will be my guideposts for 2014:

Focus. I will try to be less distractible and multi-task less this year. I will try to start every week by creating a short, realistic list of what I want to accomplish. Certain things will always pull me away from tasks, with patient care being the most important. But in my other jobs - EHR design/implementation at Hopkins, Cancer.Net editorship, JOP podcasts, social media research and evangelism - I will focus more on the task at hand, even if it’s only 20 minutes of uninterrupted thinking. And speaking of 20 minutes, I will try to spend 20 minutes every single day in the month of January writing (here's the source of that one). Not sure if that means that my blog will be any more successful, but a 20 minute goal is manageable.

Innovate. I’ve never thought of myself as visionary or creative, since I’m more the slow, steady, and thorough type, but I will try to devote energy and personal resources to creating innovative ideas for the things that are important to me, including patient-centered care, consumer-health informatics and patient-reported outcomes, and the intersection of digital health and cancer care. I would like to look back at the end of 2014 and say these are the 5, 10, 20, whatever truly original ideas I came up with and what I did with them.

Recharge. I will try to spend a fixed amount of time every week unplugging from what I have to do and do what I want to do (notice I didn’t specify the amount of time - I’m still trying to figure that out). I will recharge by exercise, listening to music, and reading for pure pleasure.

Wish me luck…

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.

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!