Last month, I attended back-to-back meetings in Washington D.C. Both had a cancer focus, but otherwise it appeared there was little in common. The first was a meeting of the Society for the Immunotherapy of Cancer where the latest scientific and clinical advances in cancer immunotherapy were discussed. The second was a meeting of the National Cancer Policy Forum that included a workshop where we discussed approaches to helping cancer patients navigate the complexities of the health care system.
It is difficult for all of us to identify and address, on our own, those areas where we should and can do a better job. Sometimes dealing with day to day challenges limits our ability to step back and look at the big picture. Sometimes we might see an issue that needs to be addressed but hesitate to do so because of concerns about unintended consequences we know or suspect might result from implementing a solution. Sometimes we might not realize there is a better way. Sometimes we might see a better way, but are simply unable to implement the needed change on our own. This certainly is true for a complex organization such as a comprehensive cancer center where we are working to reduce the burden of cancer across the spectrum of clinical care, research and education – where opportunities and challenges are ever present and ever changing.
Achieving our potential requires we ask ourselves whether we are we doing our best to…
- Identify and support the most promising cancer research.
- Recruit and retain the best faculty, staff, students and volunteers.
- Bring advances from the research lab to where they help patients as quickly as possible.
- Provide state-of-the-art, personalized clinical care and service to every patient.
- Educate the next generation of cancer researchers and caregivers.
- Work within our community and across the state to disseminate advances so they help as many people as possible.
- Collaborate optimally with other units within our own institution (departments, colleges, the hospital, etc).
- Collaborate optimally with outside institutions (referring physicians and medical centers, other cancer centers, the National Cancer Institute, etc).
- Structure our own efforts to be as efficient and effective as possible to facilitate our ability to do all of these things well.
In addition to self-reflection and internal discussion, it helps to ask outsiders to take a fresh look and advise us on how to improve. One of the most forward-thinking aspects of the National Cancer Institute (NCI) Cancer Centers Program is the requirement that every cancer center have a yearly visit from an External Advisory Board (EAB) composed of experts from other cancer centers. Making optimal use of an EAB requires the hosting cancer center be totally open. We do not try to hide or paper over our major challenges when our EAB visits. Instead, we put them front and center. For the EAB to do its job and help us improve, it needs to be highly critical. As Oscar Wilde said “true friends stab you in the front.” Having an EAB say “keep it up, you are doing an excellent job,” just doesn’t cut it. We need the EAB to tell us how we can do better. Our EAB will be visiting next month and our presentations to them will include a discussion of what we are doing with a particular focus on where we feel we can improve. We will put down our armor, show them our soft underbelly, and say “hit me with your best shot.”
I have the privilege of serving on the EABs of nine other NCI-designated cancer centers and chairing five of them. I have no doubt participating on these boards helps me do my job at Holden more effectively. I get to see how other cancer centers handle particularly difficult issues. Sometimes I return home with a new idea of how we can address a gnarly challenge. Just as commonly, I return home after seeing a cancer center’s approach to dealing with a problem, grateful for the team we have at Iowa and the solution we have found to a problem that another center is struggling to address.
Sometimes it feels a bit awkward being on an EAB when I beat up on my colleagues and friends, and am rewarded for doing so by a nice meal and a sincere “thank you.” When our EAB visits next month, I am sure they will return the favor. I will say “hit me with your best shot,” and when they happily (and hopefully ruthlessly) comply, I will feed them and express my deepest appreciation.
Cancer, as in many complex problems, can best be approached by looking at it from every angle, i.e. in three dimensions. We do this literally through reconstructing images such as CT scans, confocal microscope pictures or computerized molecular modeling. We also do this figuratively through the 3Ds of discovery, development and dissemination.
Earlier this week, I was catching up on my computer at home when I received an e-mail notifying us that we had received a couple of important accreditations (more on these below). That got me thinking about writing a blog about the process of obtaining such accreditations. By chance, my eyes landed on an old book on my bookshelf – The Agony and the Ecstasy – a novel by Irving Stone about the life of Michelangelo. The title reflects how the artist’s life was divided into the agony of dealing with the politics and society of the day, and the ecstasy of completing his incredible masterpieces. Once it got into my brain, I just couldn’t shake the silly metaphor of linking the process of obtaining accreditations with painting the Sistine Chapel. So, despite the totally understandable puzzled expressions on the faces of my colleagues when they first heard of my plans for this blog, here we go…
Late last week we received formal notification from the National Cancer Institute (NCI) that our long-standing collaboration with the Mayo Clinic known as the “Iowa-Mayo Lymphoma Specialized Program of Research Excellence” or “SPORE” for short, has been refunded for another 5 years. This program has been funded continuously by the NCI for the past 15 years. We now know we will be funded for years 16 through 20. Like most cancer research grants, funding decisions on SPORE grants are based on a robust peer review process and are highly competitive. Needless to say, we were thrilled to hear that our SPORE was viewed positively by our peers.
Incredible advances in cancer genetics have revolutionized how we think about cancer. These advances are now being applied to patient care. A brief response to the question “how is our growing knowledge of cancer genetics impacting on cancer research and cancer medicine?” is to say “it’s complicated – and exciting!” That is not a very helpful answer. Here, I will summarize the big picture with the understanding that this brief summary will not even touch on some of the rapidly evolving, nuanced, yet very exciting concepts in cancer genetics.
Let’s start out with a review and discussion of why the genetics revolution in cancer is so important.
Once each year, I take a week off at the end of July and, with 10,000 other crazies, ride my bike across Iowa as part of RAGBRAI. For those of you who are not familiar with this Iowa tradition, RAGBRAI is the “Register’s Annual Great Bicycle Ride Across Iowa”. RAGBRAI follows a different route across the state each year. It starts on the western edge of the state and finishes on the east with the ceremonial dipping of the front bicycle tire in the Mississippi. RAGBRAI is a rolling folk festival with riders in costumes, bands in many towns, church ladies selling pie, and everything that makes Iowa a great place to live (including a growing number of beer gardens selling Iowa craft beer).
Webster’s dictionary defines the word retreat as “an act or process of withdrawing especially from what is difficult, dangerous, or disagreeable.” That definition only partially fits a current use of the word where a group withdraws from day-to-day activities to focus on broader strategic directions and goals. Indeed, my colleague, friend and partner on the Iowa/Mayo Lymphoma Specialized Program of Research Excellence (SPORE), Dr. Tom Witzig, refuses to use the word “retreat” to describe such gatherings. The intent of the effort is to speed progress, so he prefers the word “advance”.
Last week, more than 200 faculty, staff and students gathered off site to participate in the Holden Comprehensive Cancer Center Research Retreat. Using Tom’s affirmative-thinking nomenclature, our Cancer Center Research Advance was a great success, and an inspiring day for a number of reasons.
Those of us who work at academic cancer centers often talk about our three overlapping missions:
- Research – Successful cancer centers conduct cutting-edge cancer research that helps advance cancer medicine so we can do more to help our patients in the future. To assess research productivity we count major research grants, important publications, and research advances that lead to better patient care.
- Education – Successful cancer centers educate and train the next generation of cancer researchers and care givers, as well as the public about cancer. To assess education, we look at how competitive we are at attracting the best and brightest students to our education programs, as well as the accomplishments of our former trainees.
- Clinical care – Successful cancer centers provide quality, state-of-the-art interdisciplinary care including cancer prevention, early detection and therapy. To assess clinical care, we track how well our patients do after they receive therapy from us by looking at survival and quality of life. We also track cancer incidence to evaluate the success of our cancer prevention efforts.
There is an additional component to clinical care that is more difficult to measure – delivery of quality service to our patients. Successful cancer centers work to provide a top-notch patient experience. Cancer centers are very different from settings such as retail where service excellence is a priority. Our patients never want to have to seek our services. They are scared and in unfamiliar surroundings, and they have great anxiety about the future. They should be treated not only for their life-threatening medical condition, but also based on their needs as a person.
How do we measure patient satisfaction and the patient experience in a consistent way? We ask patients about their experience through anonymous surveys distributed by an outside group (the company we work with is called Press Ganey). The results of these patient surveys are shared with us, including both ratings and comments from patients. This allows us to understand and track how well we are doing from the patient’s point of view, and what we can do better.
The surveys have been asking the same questions for a number of years which allows us to track patient satisfaction over time. Patients are asked to rank each question about our service on a simple scale of “very poor”, “poor”, “fair”, “good” and “very good”.
Here are the data on the percent of patients that ranked us at the top level (“very good”) over the past 3 years on three key questions.
It is wonderful to see this steady increase in patient satisfaction over the past three years (essentially all of the patients who did not give us a “very good” gave us a “good”). This is the result of incredible hard work and dedication by our cancer clinic leadership group (Mo Milhem, Hisakazu Hoshi, Zach Pollock, Tina Devery, Geri Quinn, Garen Carpenter and many others) as well as the entire cancer clinic team. They looked carefully at patient comments and suggestions, and used this information to improve the patient experience.
We want our patients to be satisfied with our service, yet we can never be fully satisfied with the service we provide. We recognize there is always room for improvement. We will continue to ask our patients about the areas they feel could be improved further. In recent surveys, these include “information about delays” and “wait time in clinic”. Our team is hard at work on these issues as we strive to provide ever improving service to our patients.
Yes, we must continue to focus on progress in cancer research, education, and cancer care. However, we can’t be satisfied solely with data demonstrating our success in these areas. We must also address the needs the patients themselves identify as important. Only then can we be satisfied that we are doing everything possible to reduce the burden of cancer for those we serve.
Last week, three disparate events came together for me in a remarkable way.