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

Eureka!

As I sat and watched, with awe, Vice President Biden’s summit speech on his vision of the cancer moonshot, I came alive and transformed… I felt empowered and validated. Oh the calamity of thoughts that went through my head. “By golly he’s got it!” Everyone has been there at some point, that delirium that accompanies figuring something out. “Eureka!” I thought. Mine hit all at once, and I have been reeling ever since that day of June 29th but my mind is settling to tell you a story. My friends, I am back, maybe not as often, but I will tell you I never left.

He sat across my stool afraid. He was bright eyed, sharp and thinking through the things I had discussed. “You are going to do what?” he asked, “Inject my sarcoma with a herpes virus?” I remained calm but my passion was bursting out of me because I was excited. This was my idea, an idea that has been brewing in my mind for the last 2 years, an idea that allowed me to use my knowledge to help someone, a clinical trial that I wrote. I don’t know how my patients do it; they find the wisdom, the courage, the generosity and open-mindedness to accept my words. Was it that I danced in front of him telling him about the science? Was it the cancer that inspired him to be creative? Was it his immense trust in me? It did not take him long to contemplate the proposal, to believe as he told me. Enter Subject 001.

Cancer, as VP Biden clearly remarked, is a threat the human race can unite to double the rate at which we make progress in trying to push and propagate the knowledge we have to solve its mysteries. As I reflect on this statement, the one person who comes to mind is subject 001- I get the equivalent feeling that we as humans were able to conquer space to get to the moon and back, I reflect on the day I put my patient on my trial, a trial that was unique in its rights, different and innovative. Subject 001 to me, is the first person on the moon. What a feeling!

Eureka! The day has come for us to find out that I am out of a job, that cancer has been cured, that the world is at peace, that we have overcome our fears and that we have won the war against despair. Yeah sure, we all dream. And maybe that is what makes us achieve our dreams; our hopes, our engagement and our efforts. Perhaps it’s a man standing up and saying, “What’s wrong? Why can’t we do this?” I sometimes recognize how hard it is for a General in the army to will his soldiers to go to battle. This is a war, an urgent need to develop cancer breakthroughs and a strong message for us to do things without submitting to bureaucracy, greed, and negative inertia.

“My patient is interested in joining this clinical trial” the bark of a General that does this daily. The coordinator picks up her task; she is as excited as I am. What drives people to work so hard behind the scenes to actualize a clinical trial still fascinates me. It is this ownership, this dedication that can turn the tables in this fight against this devastating disease… let’s not turn against each other, retard each other’s progress, allow politics and competition to stop us.

Don’t just sit there, do something! Don’t put it off for another day, don’t lean on reasons not to act, but rather seize the moment you are in and become part of the history-changing initiative, become a part of how we revolutionize cancer treatment.

Mo.

“Notes on the Journey: Living with Sarcoma and Hope”

Tonight Mo will be in Rock Island, Illinois signing books with sarcoma patient and new author, Laura Koppenhoefer. Mo wrote the forward for her book “Notes on the Journey: Living with Sarcoma and Hope” and all proceeds go towards his sarcoma research program. Below is a brief summary of the book from Laura herself.

“When I show up at the clinic for appointments and chemotherapy, the day starts with lab work.  Within the hour Dr. Mo will know what is going on “inside me” and make decisions about my care.  This all seems routine to me now.  Three years ago at my diagnosis of sarcoma nothing was routine.  I started writing on Carepages.com to help me sort out this journey with cancer, and communicate that journey with my congregation, family and friends.

Three years later, I am still living with sarcoma and know a lot more about myself than what shows up on lab tests.  I know about courage, hope, my faith, my need for community, the importance of top rate medical care at a sarcoma center, how to “read” what my body needs, and more.  I also know that we don’t know enough about sarcoma.

“Notes on the Journey: Living with Sarcoma & Hope” is a compilation of updates from my Carepages, with a foreword written by Dr. Mo.  All of the proceeds from the sale of this book are going to support sarcoma research at the University of Iowa Hospital and Clinics Holden Comprehensive Cancer Center.  To learn more about this effort, buy a book, link to my Carepage or other sarcoma resources, check out the Foundation’s page at www.LivingInHopeFoundation.org.”

You can also purchase Laura’s book on Amazon.com.

The book signing is from 6:30-8:30pm tonight at St. John’s Lutheran Church, 4501 7^th Avenue in Rock Island. Mo will make a few remarks at 7pm.

Laura Koppenhoefer

 

 

 

Perception

Clinic ended in the usual way. A daughter and her father came to have a closure visit. The Cancer Center was quiet as I made my way to the room where they were waiting. I walked in and we hugged each other deeply remembering the moments we had spent and the many struggles we had been through. My closure visits are usually at the end of my clinic visit, but there was something different about this one.  She looked down as she talked, her voice strained and her mind rattled as she spoke. There were questions this time on what happened, on why it happened and “please explain it to me?” She continued, “where is science to answer these questions, what is pain? And how is it that we don’t know more about what to do?” She sobbed “I saw things I did not want anyone else to see”. She re-iterated “don’t want anyone to see, things that have changed the reality around me”.  Her mother had died, her close friend, her confidant. “When my mother was coming for her chemotherapy, people would say to me I am sorry, and I would look at them and say “sorry? This was a chance to hang out with her, to be with my mom, to lie in the bed and bond as we watch television and shared our stories”.

This was a very young woman who got exposed to death at an early stage in her life. She wanted to talk. Her speech was pressured, she touched my heart. No, she penetrated ripping right through. She vividly described all the stages that she had witnessed as her mother became acutely ill, her voice was shaky, and I could hear her unrelenting grief as she told her story. She had met death, and it had changed her. She told me of how when someone asked her “how she was?” She would just look at them as if they had asked her something that did not make sense. They should rather ask her who she was, because death had left its mark on her, embedded itself in her history and future. Death had become a fact for her, a part of her life now intimate in the details she shared of what it really meant to lose someone dear. She did not search for words, she found them and the courage to share them with me for which I was honored to receive them. In this discussion, many doors opened as we settled and submitted. Her mother was so unique as her cancer was a rare diagnosis with sparse cases and documentation on its treatment. The husband looked at me and asked “did you learn something from this?”

I explained to them both that to me each human that I treated was like a piece of a larger puzzle I was trying to solve. I was trying to connect the jigsaw pieces collaborating with researchers in Iowa and in the nation. How each person gave us clues and a wealth of information that was used to create a network for us to better understand what at this moment I was having a hard time explaining. She asked me why is that? I explained that her mother’s sarcoma diagnosis was rare and that progress in these cancers was slow. I explained that the knowledge would eventually come to explain it but it did not exist now. In Iowa we have built a resource that is proving powerful in bringing researchers together uniting them in a common cause to decipher the cancer code. I have often quoted it as being like a coral reef in an ocean that is formed slowly over time, but allows the development of ecosystems of different living organisms that can thrive and be nourished.

Her questions continued, and I was stunned at the depth of their feelings, their attachment, and their grief. She traversed the mindset that death is something out there to fear, avoid, kick and scream about, the perception of the masses. To her it was present, it was unexplained and it was intimately associated with her recent loss. They were accepting the ambiguity and mystery around the other side. Our human bodies are vulnerable, and our lives are delicate. And death is bigger than life because it is inevitable and certain. She demanded answers.

They thanked me and made their way to leave. At the doorway, she paused; her tears began to flow again. As I sit tonight I ponder that image. How many of us stand at the doorway of death not fully understanding its implications in neither our lives nor the provoking questions that erupt when it happens.

-Mo

 

Bounce.

“It’s a fine line between optimism and pessimism” he said to me, and I looked at him staring blankly. We talked about how it’s so easy to see things with a half empty glass and how the pressures around us sometimes dictate how we view life as it pertains to our practices and the decisions we face.  It could be as Nicholas Taleb would see it, that there really is no glass, but it’s how we in the end decide to see.

It’s been that kind of day.  Bounce.  Like a ball.  I have to have the spring to go from one patient to the other. “Your scans look great” ……….”I am sorry I have some bad news”. Not much more to say when the scans are good; good news brings a few laughs and off they go- anxieties abated until the next scans.  Bad news brings much more discussion, “is there hope? can we beat this?” Like the ball, I am elastic ready for both situations; the good news helping me spring back from the collision of the bad news. I think I am answering the question I am sometimes asked when my patients say “how do you do it?”

I have sat alone in a doctor’s office in silence waiting to be seen. That silence is unbearable. And all I needed that day was an injection into my shoulder. I dislike making patients  wait to hear good news. I yell out loud “yes!” after looking at a scan, springing out of my chair like a kid to get to the person who gets that good news. It’s amazing to watch relief. I have gotten good at reading the faces of my patients.

Bad News. I stare at the scan disbelieving. A meticulous and wise mind takes over, filled with understanding of the greater mysteries of life that the science I know helps me unravel. I sometimes find myself thinking about my own mortality, my heart is heavy, but this when the person waiting really needs me. They do not need me to feel sorry, they need me sharp, ready to navigate and able to get them through this. Like a pilot in a bad storm, as a passenger who knows nothing about flying, I hear myself saying “he better land this plane”.

I want nothing more than to deliver good news to every room I walk into. Reality says differently. I find myself thinking today mostly about the bad news I delivered, not as a sympathetic person but as a physician needing to find the answer to help land the plane, weighing all the odds and stretching my mind to figure this out. Perhaps the answer lies in tomorrow. I have to believe there is an answer out there, that some day while sitting listening to a researcher present his work or explain a phenomenon that there is enough talent in the room to figure this out.

I bounce in and out of rooms, between today and tomorrow, between discovery and a dead end.

Mo