Inner Thoughts

Better incentives, infrastructure key to unlocking collaboration

True collaboration should be embedded in the practice of medicine. It should be baked in, a given, something we don’t need to write columns on. Today, it’s not. In today’s health care environment, fully integrated, cross-disciplinary teams remain a work in progress. We need to move faster to better serve our patients.

Why? As with many things, there are financial reasons. There’s an incentive to be competitive with other caregivers because we get paid for services we perform. If your practice runs a test, that’s one test that my practice is not running and not getting paid for. Of course, we clinicians aren’t sitting around actively thinking that, but the structure of today’s predominant payment model and the way we physicians are trained makes it a natural, almost invisible, contributor.

These misaligned incentives, along with inconsistent infrastructure, put physicians in a tough spot. There’s a saying, “forgetting the face of your father,” meaning someone has lost touch with their roots. I worry we doctors have forgotten the face of our father, Hippocrates. We have built a system of care that is so complex it can at times be emotionally exhausting for all of us–patients and clinical staff.

Our patients come to us seeking advice and help. It shouldn’t be necessary for that advice to be linked to a relative value unit or monetary reward. Doctors want to provide a feeling of comfort and care, yet are losing that spirit because, when we walk out of the room, we often have to deal with redundancies and inconsistency and inefficiency within the system.

Collaboration will return if we can reset and reconnect to our purpose–bringing back the empathy, compassion, and spirit that sits at the heart of medicine. Collaboration happens when we all believe we’re doing it for a bigger purpose, something more than just revenue.

Think about it: the smartest people are scattered across the country. Instead of holding onto information because of the natural tendency towards tribalism, what if we shared it? What if we were able to view data together, at the same time? The problem will be solved–and probably relatively quickly. In this scenario, we see the shared purpose–the philosophical piece–and the tools/standards–the infrastructure.

I’m fortunate to work at University of Iowa Health Care, a place I believe provides an excellent case study in collaboration. People across our organization share information and are receptive to debate and counterargument. We’re unafraid to get around a table and see things through different perspectives. There’s an emphasis on teams, not on individuals trying to make a name for themselves.

Here’s an example: The sarcoma group here at University of Iowa Health Care was participating in a sarcoma clinical trial. For patients to participate, their eligibility had to be agreed upon by a radiation oncologist, a surgeon, a pathologist, and a couple of us oncologists.

A few weeks in, the clinical trial team called us and said, “You’re putting more patients than anyone into this trial. How are you doing it?” What they meant was, “How do you get opinionated, highly-educated leaders in their fields to agree so consistently?” Here’s the simple answer: We look at each patient’s care as a collaborative effort, and we decide as a group.

Our ability to make group decisions was built on a philosophy created long before we’d evaluated a single patient. We all knew the science of the trial, but beyond that, everyone on the board bought into a collaborative approach when they joined. We all agreed that we’d focus on the trial as an important resource for patients, that it represents a better treatment because at the time we didn’t have good answers. In other words, we had an agreement on the basic philosophy. Then, when two of us might argue, we could go back to the core values of mutual trust and respect for each other as professionals and people. That kept us from letting any one person’s opinion take on an outsized importance, which then lets us get to consensus quickly.

Which brings up a final point–relevant both to small teams and to our health care system as a whole. It’s the idea of delegation and specialization. Creating standards and a shared language requires an arbiter. In the oncology world, we have the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and other groups to manage guidelines that help us navigate very difficult decisions.

Using oncology as an example, we need to allow others to be in charge. Today, instead of acknowledging, “Sloan Kettering is the best in sarcoma; let’s all let them guide best practices for the sarcoma world,” some might fight the idea and compete to displace them as number one. This is largely a waste. Delegation allows expertise to shine and specialization to emerge. It also allows for standardization, because only one group is creating the guardrails.

Ultimately, what we need to do as clinicians is create an environment that lets each organization, each department, and each provider operate at the height of their ability. Change the ecosystem, remove distractions. We need good leadership to see opportunities to make changes that remove burdens.

This is not to pass the buck onto a faceless administration or to call out executives (or department heads, or anyone). We all have some form of leadership role, and it is therefore incumbent on each of us to find those opportunities. We are responsible for managing our own ego and not just recognizing but celebrating the fact that others will supersede our abilities. Rather than defending against that reality, we should embrace it.

My hope is that we can bring a moonshot mentality to all of medicine. Not necessarily in terms of the solving-huge-problems (though that’s important), but in terms of collective action. Former Vice President Biden demonstrated this idea when launching the National Cancer Moonshot initiative: the focus was on collaboration as much as it was the scale of the problem being solved. Why not instill the same attitude across medicine, regardless of whether a program is a national initiative backed by prominent names or an intra-institutional research project? Why not spur collective action towards creating an industry-wide culture of collaborative care?

– Mohammed M. Milhem, MBBS


Difficult times.

Cancer patients are fighting two wars, not one anymore. A battle that is personal, and one they fight with us. 

Cancer and COVID-19.

Different times.

I walked into the room looking at her from behind a face-shield and covering my face with a filter. I felt like myself but she was scared. My patient was visibly frightened. I was a policeman in a riot. I was not Mo. She did not recognize me. With visitor restrictions she was alone no husband for support, no mother either. She started to cry. This is not the usual way my patients greet me. 

Your scan is fine I said. That did nothing to relieve her fear. I talked and talked, I engaged, I pulled at every muscle in my brain to find a way to make her feel cared for and loved. I asked her to call her mother. She resisted. She was afraid that calling her mother would elicit a fear that something was wrong. I asked her to still call, reluctantly she did. Immediate relief set into the room once her mother was on the line.

I saw many things in this moment. I saw a frightened patient, frightened by me; and frightened for her mother. I saw love and isolation; courage and surrender; I saw bonds that are covalent and connections that are elusive, when broken they destroy the person facing the cancer war. We must go above the barriers that have been placed before us to deliver the intimate care we now don’t have.

 I am sitting at home now. 

 We did not stop. Cancer providers of all kinds, the front line to helping the patients through the visit, the many precautions now being implemented to make sure they stay safe. The many different layers of vigilance we have to be aware of.  It’s an amazing group that is filled with resolve, bravery, and kindness. 

 It’s that kindness, that still does not feel complete for that patient fighting this battle alone. That lonely patient sitting in a room filled with fear, that is the dread we all feel now. That we will die alone. That feeling is permeating all of us.

Death has never been such a communal affair. As a community, we stand with you. Our collective patience, compassion, and tolerance of this will get us through these very uncertain times.




I would be lying if I claimed I did not think about this daily. When I walk into my clinic, my pace is slow, deliberate and meditative.

I remember once walking at my usual pace, preparing for my clinic in my mind, sinking with each step into the depth of the struggles that I will face on my road that day. I remember seeing a colleague from a different discipline of medicine pass me, racing to get to the road that crossed into the hospital. He called hello and asked what I’m doing. I said “looking at the birds.” I got to the light before the crossing and there he was in his haste to get to the same spot I was. He looked at me and smiled “I should have just looked at the birds too.”


We don’t talk about it. We remove ourselves from any sort of discussion about it. It’s as real as the sun. Tell me, when could you hold your stare at the sun? It’s brief, often blinding and hard to maintain. You turn away because it’s just too much to bear. Is that why we don’t sit in circles, lecture rooms, or theatres to understand the meaning of death? Is it why we don’t talk about it, teach it to the young, and educate them about its vitality and its supremacy? I ask not about the meaning of life, for that is permissible, well-described and easily talked about. I ask about the nature of death; that paralyzing moment none of us want to face, share or discuss openly.


Are you a hole? Are you a spring, a waterfall, an avalanche, a bursting star, the string theory, gravity, or the sum of all of our acts in life?

Every living thing dies. What a mystery. What a powerful way to really see the world. To slow your pace, to “smell the roses,” to “see the birds,” to walk with deliberation, to reach your inevitable destination. While we cannot stare into the sun, can we acknowledge its singular beauty? We should find ways to stop denying this fact about humanity that all of us must die. Death might be beautiful.

Today, I saw several of my patients who circled death but continued to live. One witnessed the birth of a granddaughter and another returned back to life without even realizing that they were even in danger. I did not sit with them and reflect on the near-death experience. I just marveled at what they had accomplished by not dying the moment they could have.


You wonder why I preface each paragraph with one word? That word. I’ll tell you why. Death dictates the cadence of my walk. It’s a deliberate attempt to make you see each moment of life that passes you by, unique to each individual, your own experience with the one mystery that none of us know anything about. Would you share your experience? Would that bring you closer to the truth of our existence?

That sun never waivers, always there, always looking, always giving. Is that Death? The giver of life?


The ultimate paradox.


There is a button on everyone’s remote control that can at any time mute any electrical device that makes a sound. It’s there and we can use it. We don’t always mute things. We have all grown accustomed to the noises around us. Being around a device emitting any sound keeps us distracted, engaged, and connected.

Death is an irreversible mute button. It leaves behind a bewilderment of emotions, a tearing separation of souls, a loss of interactions that once were, a silence that is deafening. Once pushed, a person is blocked from life. We cannot engage with them. I have questions that are left unanswered, events that I cannot explain to the family of a lost one, to my coworkers and to myself. Unsaid things can never be shared, and unfulfilled connections can never be restored. I have to go deep inside me to find a reason behind what just happened, how they felt, what they last shared before they got silenced. I have to work my emotions through the grief of loss, balance my mind to help someone else and continue to live on through the perils that life still has for me.

I try to imagine a life after the loss of a loved one, where only the living participate, and life must produce from its sole ingredients the answers to those who are no more; answers that even challenge the scientific mind and the soul.

“Why go on?”

Every human life lost to cancer has its toll. To me I struggle with the question, “how to get up and do this again?” I don’t mute my feelings, or block my emotions.  They travel with me, and sadness does overcome me many times over.

Together with those who have felt a loss, I get up.



Death does not put an end to everything. It inspires feelings, questions, and gives perspective. People ask me how I feel when I lose patients. Do I feel sad, angry and defeated? I have walked with my patients down this path and returned alone. It does not end there. Death does not end things. Death is not the last thing.

From each patient I keep something with me. Patients help me gather knowledge that flows stronger than a river and wisdom that propels others who have to walk that path. The path remains uncertain but the journey of those we lost refines and paves the way. There is a certain enlightenment that comes from this that I hope to make you all perceive. What started small in the beginning, with the trust of a few, has become an organic tangible construction of the science needed to move us forward. 

 “A bend in the road, is not the end of the road, unless you refuse to take the turn”. Families always take the turn. What’s the alternative? To go on grieving what could have been? Do we live in our memories? When you meet the loved ones of a lost patient, trudging their way through the rest of life, do you wonder what drives them? I am always touched and humbled by what they say amidst their sadness and fear, their feelings of loss and grief. They say prayers for other cancer patients, and a shout out to me, “You go get this, Mo”, “You figure this out”, and “You find out why?” These words push me on, make me get up, make me see what still needs to be done. 

Memories ebb and flow rubbing into our wounds and heightening our suffering. At times they gather together, like a swarm of locusts they invade, leaving nothing behind: a loss of meaning and loss of purpose, a desolate place. Out of it emerges a new beginning, a new start, that puts the bounce back into our feet and we are alive again. Understand, that is how we make our memories live within us without their crippling effect, and those we have lost can show the way for all of us to succeed.