Last week, I had the pleasure of giving a talk on cancer at the University of Iowa Carver College of Medicine Mini-Medical School, a series of presentations provided to the lay public to introduce them to a topic in medicine. Every time I give a talk to a lay audience, I think back to a wonderful woman I had as a patient when I was doing my oncology training in the 1980s. She was a retired English teacher who took pleasure in gently ribbing me about the words I selected when I spoke with her (once a teacher, always a teacher). I recall one time when I suggested we consider putting her “on trial.” Her response – “Put me on trial? What a strange phrase. I certainly wish getting cancer was against the law! Why do you want to put me on trial?” That lead to an animated conversation about not only that phrase, but how doctors use expressions when talking to each other that are interpreted differently by patients. While I don’t recall which additional specific phrases we discussed back then, that conversation had a long lasting effect on me, and the phrases I use when I speak to patients, families and the public.
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.
We each have the right, indeed the obligation, to speak up as private citizens for what we believe should be of high priority for our government. An example is advocating for biomedical research grants. It is important to point out that advocating to government should be done as a private citizen. Any advocacy done as a governmental employee or in the name of an institution – in my case the University of Iowa – should be done in coordination with the institution as a whole.
Recently, I had an opinion piece published in “Oncology Times” that describes my personal perspective on the importance of having researchers and clinicians advocate for biomedical research. In other words, I was advocating for advocating. Instead of writing a new blog this week, I am providing a link to this article entitled “Advocating for Biomedical Research – Debunking the Top 5 Excuses for Not Getting Involved” which can be found at http://journals.lww.com/oncology-times/Fulltext/2014/05100/VOICES__Advocating_for_Biomedical.24.aspx .
Every day, we each make choices. Some choices are pretty obvious and require little discussion or thought; for others, individual preference plays a major role with different people making different choices based on different perspectives.
A personal example involves a trip my wife and I plan to take to a warm, seaside location in January. One choice is whether we will use sunscreen. This is a “no-brainer.” Another choice is whether we should go scuba diving. I love scuba diving and jump at every chance I get to spend time swimming with the colorful fish of the underwater world. My wife makes a very different calculation. Factors that impact on her decision include being in cold water, breathing through a small rubber tube, and the thought of being in the water with potentially nasty creatures. When it comes to sunscreen – the choice is obvious. When it comes to scuba diving, we each made our own calculation based on our own perspective. Continue reading
In the classic Japanese film “Rashomon,” various characters tell very different stories based on their observations of the same incident. The term “Rashomon Effect” is now used to refer to contradictory interpretations of the same events by different persons. After watching this movie, I realized one person can experience an internal “Rashomon Effect” and have very different interpretations of events depending on the perspective from where they sit. I have experienced this myself in my various roles.
As an administrator, I think a lot about accountability. I know that there is great value in being held accountable by others. This applies to me and to those who work with me in the Cancer Center. I also know that administrative systems designed to assure accountability sometimes rely on imperfect or rigid measures of success that can get in the way of being responsive to necessary change. In those cases, being held accountable can feel like oppressive micromanagement. So … “accountability” from one point of view can look like “oppressive micromanagement” from another – it depends on where one sits. Continue reading
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.