Nothing makes a physician feel older (or should) than realizing that he/she just started a discussion with a younger colleague, fellow, resident or student with the sentence “When I was in training … ”
In a recent article in the health section of the New York Times, Gardiner Harris skillfully depicts the culture gap between younger and older generations of physicians. Using a three-generation physician family as an example, he describes what my generation of oncologists (20 to 30 years since fellowship) has been noticing for 5 or 10 years: recently trained oncologists have different expectations and career goals which result in different practice patterns. The pressing question about these changes is how they will affect the care received by patients with cancer treated in the community setting.
My generation of community oncologists arrived on the scene with the expectation of being owners of our practices and working 60-70 hours or more (often many more) per week to develop and maintain referrals, manage business aspects, train and nurture office and hospital staff, stay up-to-date with new advances and provide almost uninterrupted access for our patients. We were products of residency and fellowship training that stressed personal responsibility for the welfare of each of our patients, regardless of hours worked or call schedules. As we matured in practice we learned to share night and weekend call responsibility with our partners but still rarely left the office at night without stopping at the hospital to see one more anxious new patient consult, reassuring the family of a hospitalized patient and checking on the patient admitted earlier in the day. Unfortunately, we sometimes missed our kids’ school plays, ballet recitals and concerts, football, soccer, basketball and baseball games and award assemblies. Our success was often measured by our reputation in the community as well as the size of our practices and the number of colleagues who insisted that their patients with cancer see only us.
Recent graduates of oncology training are certainly more knowledgeable than we were with a broad understanding of signaling pathways and targeted therapies and use of genomics and biologic markers to assess risk and select therapies. They are better trained in management of psychosocial issues and incorporation of palliative care techniques earlier in the course of treatment. However, they arrive in community practice with a preference for reasonable work hours over practice development, valuing balance between work and family over unrestricted patient access. They have trained in a system that emphasizes the value of hospitalists for their specialized technical skills and knowledge about inpatient care while downplaying the lost value during disease crises of the therapeutic relationship between the patient and his long-term primary physician. Few recent grads have a strong interest in the business aspects of their practices and many prefer employee status (within a large practice or a hospital setting) rather than ownership. Success is still related to respect of the community but is no longer linked to the size of their practice or number of new patient referrals.
The key question is if and how these differences in goals and expectations will affect patient care. It is not only a question for oncology patients but for patients of all types in the United States. Has the culture of oncology been changed by training in an environment that emphasizes leaving the hospital on time at the end of your shift over personally assuring that your patients have received all of the tests and treatments you intended? Undoubtedly no one wants to receive care from an exhausted resident or fellow, but have we unintentionally trained young physicians that their care of patients is less important than their scheduled time off? Have we sent the message that giving good care from a technical standpoint is sufficient? Have we deemphasized the value of personal responsibility to the point that the anxious newly diagnosed hospitalized cancer patient and family will have to wait until rounds the next morning to receive the expertise and reassurance of the cancer expert because it isn’t a medical emergency? Or will the better-rested oncologist with the different perspective provided by having a more “normal” life be able to relate better to the stresses faced by patients and families? Has the science of medicine in general and oncology progressed to the point that the skills and tools of our younger colleagues trump the “hustle” and obsessiveness that characterized the most successful physicians of my generation? Only time will tell but I am convinced that we could benefit from more discussion between the older and younger generations of oncologists to be certain that both understand the values that nurtured oncology community practice through its infancy and childhood to reach its current adolescence.
Cancer care has come a long way in the past 30 years. However, until cancer has the same kind of outcome as community-acquired pneumonia and peptic ulcer disease, patients with cancer and their families face a challenge that requires an ally and advocate as well as a medical expert. Frequently the greatest need for the patient and family happens outside normal working hours. Hopefully, recognition of the unique responsibility and opportunity afforded to the oncologist has not been lost among the generational changes in goals and expectations.
Richard Leff is Chief Medical Officer of Conisus.
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