Reflections on a Career in Oncology Care

by Alan S. Weinstein, MD, FACP, former ACCC Board of Trustees Member, senior physician advisor, Virtua Fox Chase Cancer Program, Marlton, N.J.

What a difference three decades make.

When I became a board-certified medical oncologist in 1978, there were less than 1,200 medical oncologists in the entire United States. Now there are more than 10,000, according to ASCO! Very few oncologists practiced in community settings then. Most practiced in single- or two-men groups in the suburbs and carried a clinical academic link to an academic center. Note that I stated “men” not “persons,” because I remember only a few dozen women medical oncologists then, and almost all held academic positions.

When I first entered practice in 1979, I joined another established hematologist/medical oncologist as only the third medical oncologist in our entire county. Our team consisted of a RN cancer registrar, a single radiation oncologist running a “cobalt” unit, and two surgeons who cared for most if not all the cancer patients in our 225-bed hospital. We had one RN in the hospital who “specialized” in caring for our patients and two nurses who gave chemotherapy in our office practice. Patients who could not afford to be seen in our office were treated in the hospital Tumor Clinic where they were seen by the surgeon, radiation, and medical oncologists together with the “cancer” nurse and the registrar. The registrar kept the notes as she needed them to complete her registry entries. I remember thinking then that it was an efficient way to see new patients! The communications were so much better than at my academic training center where notes from other docs often showed up two months later and were carbon copies or illegible scrawl.

More than 30 years later, I marvel how we take for granted the almost instantaneous sharing of our records and reports. I smile at the frequent grumbling when access to information is delayed just a few hours or days. I also marvel at our Cancer Committee meetings, where 20-30 representatives of the key parts of our multidisciplinary team often meet to share operational reports, outcomes, and strategic planning of our program.

Most changes have ultimately led to improvements in practice and patterns of care and better outcomes. Some changes, however, have created difficulties and impediments that make daily care and operations more difficult and less rewarding, even if they are necessary. More complex and sophisticated record keeping and patient care do not always translate into better. I cringe over some of the practice patterns I frequently see: a 15-minute office visit becomes 13 minutes of keying in information on a template or check list and 2 minutes in discussion, leaving no time for listening to the patient, let alone a careful examination!

Coordination of cancer programs has become so complex that the parts demand their own priorities and agendas without regard to the whole. We now argue over what is the best way to maximize return on investment, leave support programs and social programs unfunded as they cannot be supported with the dollars available, and cannot see our less fortunate patients because we cannot afford to care for them. Clinics are a thing of the past because hospitals cannot fund them and clinicians cannot donate their time!

That said, I still have hope for the future.

The number of targeted therapies available is growing rapidly, making individualized cancer care based on the genetic signature of a cancer— not whether it came from breast or lung—a real possibility in my lifetime. With genomic research expanding rapidly, I am confident of success.

Eventually our abilities to communicate electronically will bear fruit as well. I am hopeful that systems will be able to communicate better with each other and that patterns of care will become more standardized, leading to better quality and efficiencies of care.

Lastly, I am hopeful that our programs will become better integrated, so our “parts” will become one. Multidisciplinary programs are a necessity in our very complex specialty, and coordination of care means efficient care. As our hospitals and health systems learn that coordinated, quality care is the best return on investment, outcomes will improve.

As a recently retired practicing community medical oncologist and a retired medical director of a very successful community cancer center, I’ve seen many changes since the late 1970s. Overall, my career has been exciting and rewarding. I’ve been privileged to witness the growth and sophistication of community oncology as it has evolved to serve many communities–urban and suburban, rural and minority, affluent and disenfranchised.

We still have a long way to go, but we have made great strides our ability to deliver excellent community oncology care to all our citizens. Although I might be on the sidelines, I look forward to even greater changes and improvements in the next several decades.