Monthly Archives: August 2013

The lows and highs of a difficult job done well

The doctors and nurses are the most visible contributors to the delivery of care to cancer patients at the Holden Comprehensive Cancer Center, but a huge amount of work is done behind the scenes by clerical staff, pharmacists, laboratory technicians, administrators and many other highly dedicated professionals with dozens of different job descriptions. Top quality patient care requires input, coordination and dedication of all these individuals doing jobs that are both visible and jobs that are not.

Many staff members experience the lows and highs of interacting on a daily basis with cancer patients and their families in person or by phone. Even those who do not interact directly with patients are driven to do the best job possible because they recognize the importance of the job they do – making a difference at a critical time for patients and their loved-ones who are dealing with cancer.

Dealing with people in such a time of need is an honor but also adds to the pressure of the job and takes an emotional toll. Not only the doctors and nurses, but all who work in the HCCC know how hard it is when a patient we have come to know and admire does poorly, even when we have done our best  (for a fantastic, heartfelt, and wrenching perspective on how providing cancer care can impact a professional, see Dr. Mo’s blog at http://doctormoiowa.wordpress.com/ ). On the other hand, what keeps the outstanding group of people who work at the HCCC going is the satisfaction that comes from an important and difficult job done well. Continue reading

‘Intelligent Intervention’ in Facing Federal Funding Impasse

If you keep up with current affairs, you know about the ongoing stalemate in setting our federal budget that has led to the “sequester”—across-the-board cuts in federal spending. Biomedical research and cancer research are among many worthwhile efforts supported by the federal government that have been damaged by this sequester.

Last Sunday, George Will wrote an outstanding column about the effect of the sequester on biomedical research titled, “The sequester’s a public health hazard”: http://tinyurl.com/will-nih

Mr. Will is much more eloquent than I am. Briefly, he states “research proposed by extraordinarily talented physicians and scientists cannot proceed because the required funding is prevented by the intentional irrationality by which the sequester is administered.” and “to see the federal government at its best, and sequester-driven spending cuts at their worst, visit the 322 acres where 25,000 people work for the National Institutes of Health.”

Most of the biomedical research supported by the NIH does not take place on those 322 acres, but across the country at research centers such as Holden Comprehensive Cancer Center at the University of Iowa. Our researchers compete for cancer research funding from the NIH (and the National Cancer Institute, which is a branch of the NIH) based on the quality of their research ideas. We have been very successful in getting those grants. Indeed, the cancer research taking place on our campus is another example of support from the federal government at its best. This support has led to unprecedented scientific discoveries that are reducing the burden of cancer in our communities.

We also know we still have a long way to go. Our daily routine involves meetings with extraordinarily talented physicians and scientists to discuss new research directions and opportunities. Sadly, since the federal sequester, we also have meetings to discuss how we are going to deal with the sequester-induced cuts in research grant support from the NIH.  We do what we can to stretch every research dollar, and to find alternative sources of support for the most promising research, but there is no doubt progress is being slowed. As Mr. Will states, it is hard to avoid “dismay about exhilarations postponed.”

In his column, Mr. Will links medicine and policy. In both cases, some things get better by themselves, while others require intelligent intervention. The government’s sequester, and its effect on the NIH budget and biomedical research, will not get better on its own, and requires intelligent intervention. Legislators on both sides of the political aisle understand the importance of the work supported by the NIH. What we need is a greater outcry from the public telling our legislators that “intelligent intervention” is needed to overcome the current impasse, reverse this sequester, and support the NIH.

Thriving in a Matrix

Role models in medicine and biomedical research from the last century included the lone country doctor with a black bag making house calls and the researcher struggling alone to make a scientific discovery in a back-room laboratory. Such individuals had a thorough knowledge of what was then the state of the art in their field. When combined with creativity and passion, this familiarity with a topic allowed them to provide the best possible medical care available at the time, or make breakthrough discoveries, on their own.

Oh my, how times have changed.

Even the most well-educated, brilliant, and hard-working physicians and scientists in our modern world can’t come close to keeping up with the depth and breadth of knowledge and expertise required to succeed as an independent clinician or researcher. State-of-the art clinical care and research are both dependent on interdisciplinary interactions, including interactions with others from very different disciplines. Internists, surgeons and pathologists need each other’s expertise, as well as the expertise of pharmacists, biologists, geneticists, biostatisticians, epidemiologists, informatics experts, and many others. Indeed, a key to success in biomedicine today is the ability to be successful and creative in identifying the best possible collaborators who bring different backgrounds, knowledge bases and perspectives to the bedside and research lab.

A major goal of a successful comprehensive cancer center is to encourage and support such interactions. This effort is not facilitated by a strong top-down, one-dimensional organizational structure with a single boss telling everyone what to do. Success requires that we support quality people and facilitate their ability to develop novel collaborations and interactions with a broad range of colleagues.

Organizationally, the Holden Comprehensive Cancer Center does this through a matrix structure. Our talented faculty, staff and students interact in multiple dimensions.

  • They interact as members of a Department and College within the University. This is the traditional academic organizational structure, and is still incredibly valuable. Members of the Department often share a similar educational background, yet focus their efforts in different ways on patient care, research and education.
  • They interact as members of a Research Program within the Cancer Center. Research programs are composed of physicians and scientists with different backgrounds from different departments who share an interest in a particular scientific field related to cancer such as Cancer Genetics, Immunology, Therapeutics, Imaging, Epidemiology, or Free Radical Biology.
  • They interact as members of the Cancer Center’s Multidisciplinary Teams (also known as Multidisciplinary Oncology Groups or “MOGs”) centered on specific cancer types such as breast cancer, lung cancer, etc. Members of these Groups come from multiple Departments and multiple Programs, and include medical, pediatric, surgical and radiation oncologists as well as pharmacists, nurses, geneticists, laboratory researchers and epidemiologists among others.

Let’s look at where I stand (as an example of more than190 members of our Cancer Center) in this three-dimensional matrix of Departments, Programs, and Groups.

  • I am on the faculty in the Department of Internal Medicine and Division of Hematology, Oncology and Blood & Marrow Transplantation. My Departmental home allows me to take care of patients and teach in collaboration with outstanding Medical Oncology colleagues and students at various levels of training.
  • I am a member of the Cancer Immunology and Immunotherapy Research Program. My Programmatic home allows me to have collaborators with varied educational backgrounds (MDs, PhD, etc) who are interested in research extending from basic laboratory research to clinical trials exploring use of the immune system to treat cancer such as with monoclonal antibodies and cancer vaccines.
  • I am part of the Lymphoma Multidisciplinary Group. My Multidisciplinary Group home allows me to interact and collaborate with clinicians with different backgrounds who participate in the care of lymphoma patients, such as pathologists, radiation oncologists, nurses, and pharmacists so we can determine what therapy is best for a given patient. It also supports my interactions with basic laboratory, clinical and population researchers doing lymphoma research and working to discover new ways to improve outcomes in lymphoma.

Each of these interactions helps me collaborate with outstanding individuals who bring skill sets and a perspective I lack. Together, we come up with ideas none of us could have reached alone. This leads to better cancer care and faster progress in cancer research.

Maintaining a three-dimensional matrix is complex, and sometimes messy. We have to identify and empower the right people in the right positions. Recruiting a single outstanding individual who fits our needs in all three dimensions at the same time can be difficult (if you know of someone at another institution who might be interested in moving to Iowa and is an outstanding medical oncologist with expertise in the genetics of colorectal cancer, let me know!).

Finding the resources to support efforts in all three dimensions is a challenge as well, and we rely on a combination of support generated from patient care, grants obtained by our faculty, and donations from members of the public who share our passion for what we do.
Despite these challenges, engineers know that a three dimensional matrix provides strength and stability that cannot be found in simpler structures. The same is true for our cancer center.

Our goal is to continue to thrive in the matrix, and strengthen the matrix structure so we can increase collaborative interactions between outstanding faculty, staff and students in multiple dimensions which, in this day and age, is vital for top-notch patient care and cutting-edge research.

–George Weiner, MD, Holden Comprehensive Cancer Center Director

In Praise of Patient Advocates

Over the past several years there has been an effort to increase involvement of patient advocates when decisions are being made related to how to support cancer research and care. Is this really helpful? After all, those of us involved professionally in cancer research and cancer care also consider ourselves patient advocates. We have all been touched by cancer personally. I lost both of my parents to cancer—my mother when I was still in high school. I have absolutely no doubt that my colleagues and I have the patient’s best interest at heart.

What I have learned is that there is great value in having seats at the table reserved for individuals who are focused on nothing but advocating for the patient.
Advocates bring life experiences and a perspective that is different from those of us who have spent years in biomedical research and patient care.

Even if the advocates say little, their presence reminds the clinicians and scientists around the table of why we are all there.

In Hans Christian Andersen’s story “The Emperor’s New Clothes,” it takes an individual with no preconceived notion (in his story, a child) to point out the truth that the emperor is wearing nothing at all. Good patient advocates don’t hesitate to speak up if they believe there is something important the professionals around the table are hesitant to raise, or that has not been noted for some other reason.

I don’t use this story to suggest those of us making decisions related to cancer are metaphorically buck naked or otherwise self-delusional, only that it helps to have input from someone who is perceptive and is willing to speak up when something important needs to be said.

Here is a brief description of some of the contributions from advocates whom I admire.

  • Lorraine Dorfman (Iowa Advocate for the Iowa/Mayo Lymphoma Specialized Program of Research Excellence) helped us at a research meeting as we struggled with the ethics of using patient samples for research that might result in a discovery that might be of financial value to a research partner.
  • Ben Haines (Mayo Advocate for the Iowa/Mayo Lymphoma Specialized Program of Research Excellence) has taken on crowd fundraising for our lymphoma research program with incredible energy and passion.
  • Nancy Roach (Advocate from Fight Colorectal Cancer) spoke out at a national advisory committee meeting about the importance of investing federal research dollars in research that is most likely to have the greatest positive impact on patients.

I look forward to continuing to work with patient advocates in a broad range of activities at the Holden Comprehensive Cancer Center and at the national level. Seeking their input before stepping out with a plan or a decision gives me an additional level of confidence that the important matters have been covered appropriately.

George Weiner, MD
Holden Comprehensive Cancer Center Director