Communicating Cancer: How to Convey What You Really Mean to Your Patients

Transcription

PROFESSIONAL DEVELOPMENT
Communicating Cancer: How to
Convey What You Really Mean to
Your Patients
CHAIR
Don S. Dizon, MD
Massachusetts General Hospital
Boston, MA
SPEAKERS
Mary C. Politi, PhD
Washington University in St. Louis
St. Louis, MO
Anthony Back, MD
Seattle Cancer Care Alliance
Seattle, WA
DIZON, POLITI, AND BACK, MD
The Power of Words: Discussing Decision Making and Prognosis
Don S. Dizon, MD, Mary C. Politi, PhD, and Anthony L. Back, MD
OVERVIEW
One of the most important skills in medicine is communication. It lies at the heart of the doctor-patient relationship, and is particularly
important when one has been diagnosed with a potentially life-threatening condition. Words are powerful and too often can be
interpreted in ways not intended. In our session at the 2013 ASCO Annual Meeting, we discuss the communication of cancer and ways
we might want to consider discussions regarding treatment options and prognosis. We recognize that all patients are different and that
approaches should be individualized, to reflect each person’s needs (what they want to know) while respecting their limits (how much
they want to know). We discuss the concept of shared decision making, and how it can be used when there is uncertainty in what
treatments may (or may not) accomplish. Finally, we discuss the skills that constitute a toolkit for communication, which we hope can
be tailored to meet the variable needs of those we are caring for and by doing so, can be of help to clinicians in their own practices.
In the era of personalized medicine, treatments may become more complex, and more options may be available. We hope to encourage
providers to welcome patients as active participants in their care by sharing information, requesting their input, and by engaging them
in important processes such as advance care planning—to ensure their needs and wishes are respected in the present and for whatever
may come in the future.
D
r. Dizon*: In my fırst year as an attending, I took care of
Amy (name has been changed), a young patient with
ovarian cancer. She had just relapsed from fırst-line treatment and we were discussing where to go next. “I am hopeful
treatment can help and prevent the cancer from causing you
symptoms,” I explained. “Despite failing fırst-line treatment,
there are many more options for you.” The words had barely
left my mouth when a lesson one of my fellowship attendings
had tried to teach me came back in full force. My patient,
already scared about her recurrence, became teary and
turned away from me. “You make it sound like this was my
fault, like I did something wrong!” she said. “I am sorry I
‘failed’ chemotherapy, if that’s what you think, and I am sorry
I disappointed you.”
I was stunned. It was never my intention to place “blame”
for something so devastating as a cancer recurrence, and I
certainly did not mean to imply that she had failed. I remember using the rest of the visit apologizing, ensuring my patient
she had done nothing wrong and that she did not fail chemotherapy, but rather chemotherapy failed her. Years later, I still
consider this encounter a watershed moment in my career as
an oncologist.
In May 2012, I found myself thinking about what to write
about for an ASCO Connection blog. I had recently reviewed
a manuscript and had noted some of the phrases used; it
stated that women were eligible for the study if they had
“failed upfront therapy” and if “no further salvage treatments
were available. ” As oncologists, we are often guilty of allowing this verbiage to leak into clinical practice, where the connotation of “failure,” “salvage,” and “war” can be devastating.
A patient less articulate than Amy might not have said or reacted to me; instead she might have left my offıce feeling like
she failed—the last thing any oncologist would want.
This paper aims to highlight aspects of communicating
with patients with cancer that influence treatment decision
making and prognosis. The way we communicate the what,
when, and how of the clinical situation may touch our patients and their families long after their visits with us.
We acknowledge that the experience of cancer is a highly
variable one, and that patients will react and respond to scenarios in very different ways. Indeed, not all patients experiencing the same degree of fear, anxiety, or vulnerabilities
(and some may not experience these at all). What we present
here are suggestions in how to think about communication
with our patients. To do so, we draw on experiences each of
us have had with our own patients which we hope illustrate
the components of shared decision making and our toolkit
on communication.
* This blog post was originally published by Don S. Dizon on ASCO Connection (http://connection.asco.org/Commentary/Article/ID/3219/The-Power-of-Words.aspx).
From the Gillette Center for Gynecologic Oncology, Massachusetts General Hospital Cancer Center, and Department of Medicine, Harvard Medical School, Boston, MA; Division of Public Health
Sciences, Department of Surgery, Washington University in St Louis and Siteman Cancer Center, St Louis, MO; and University of Washington, Fred Hutchinson Cancer Research Center, Seattle,
WA.
Author’s disclosures of potential conflicts of interest are found at the end of this article.
Corresponding author: Don S. Dizon, MD, Massachusetts General Hospital Cancer Center, 55 Fruit Street, Yawkey 9E, Boston, MA 02114; email: [email protected].
© 2013 by American Society of Clinical Oncology.
442
2013 ASCO EDUCATIONAL BOOK | asco.org/edbook
DECISION MAKING AND PROGNOSIS
A TOOLKIT FOR BETTER COMMUNICATION
Despite the progress in medicine, the patient– doctor relationship remains at the heart of clinical care, and this may be
especially true in oncology. Situations dealing with diagnosis,
treatments, and prognosis form the basis of routine oncologic care. Each one provides an opportunity and a challenge
in helping some of our patients (if not most of them) understand the information being relayed to them, particularly
when faced with decisions regarding subsequent care.
Shared decision making (SDM) provides a framework for
discussing options around treatment or subsequent care during which clinicians can engage patients in a conversation
about their options. SDM involves discussing options and
their potential outcomes, eliciting patients’ preferences, acknowledging the decision and any associated uncertainty,
and agreeing on a plan to reevaluate the decision in order to
determine whether and how the selected option is working
for the patient.1-3 During each step of the decision process,
patients rely on their clinicians to support them by communicating evidence-based information in a patient-centered
way. Clinicians, in turn, rely on patients to communicate
their experiences and preferences so that together they can
achieve what is often described as “shared mind,” or a mutually agreed-on course of action informed by the input of
patients and their treating clinicians.4,5
In this article, communication skills and SDM are woven
together as they would occur in a clinical case. These toolkit
skills are not innate but learned through modeling, practice,
and feedback.6-9
Jane is a 40-year-old woman with two young children. She
presented with abdominal bloating and pain prompting emergency surgery where she was diagnosed with stage III ovarian
KEY POINTS
䡠 The language of oncology may not necessarily translate
from the professional realm to the clinical realm. Our
words may matter to patients and the consequences of our
words may stay with them long after the clinical visit has
ended.
䡠 Shared decision making is a framework for discussing
decisions that encourages patients to be active
participants in these conversations. It involves
acknowledging the decision, its associated uncertainty,
alternative options, and their potential outcomes. It also
involves patients’ preferences to reach plans for
subsequent care.
䡠 There is a delicate balance between the disclosure of
information and providing too much information that might
impact decision making.
䡠 Not all patients want or understand statistics. For those
who want to know them, clinicians should approach them in
as straightforward a manner as possible.
䡠 Cancer care that is technically perfect can fall short if we
cannot effectively communicate with those we are trying
to help.
cancer. Surgery and adjuvant chemotherapy were administered, and she was in remission for about 1 year. After a second
surgical procedure and then second-line chemotherapy, she
had a remission of only 3 months. Because of recurrent bloating, she is here for a CT, which showed a third recurrence, and
now she is ready to discuss the CT results and treatment
options.
SET A TONE THAT INVITES PARTICIPATION
Oncologists should begin any consultation by helping the patient feel that he or she is a valued partner. For some patients
who were required to get undressed as part of an examination, the simple gesture of allowing the patient to get dressed
before discussion can help alleviate a feeling of vulnerability.
In addition, others may appreciate conversation in a room
separate from the exam. Finally, if family members are present with the patient, it may be important to invite them to
participate in any discussions that are to take place.
A patient once described her feelings about getting a diagnosis of cancer while sitting in the exam room in the following way: “I wish they told me the news in a more comfortable
room. I thought I was going to be told I had a cyst. I was
shocked. I did not have a pen or paper to write things down,
and my feet were dangling off the exam table. I would have at
least preferred to be sitting down near my purse, fully
dressed.”10
ENSURE A SHARED UNDERSTANDING OF THE PAST
Too often there is an assumption (on both sides) that the
other understands the sequence of events that preceded that
particular visit. However, this is not always the case. Clinicians should review past treatment history and outcomes
with the patient to ensure there is a mutual understanding of
what has occurred during the course of the patient’s illness.
This step might sound unnecessary, but patients may not remember complete information about their prior treatments
or may have lingering questions regarding their illness.11-14
Reviewing treatment history can build rapport with some
patients. It might also serve as reminders of the factors that
are influencing the current discussion, and can help ensure
that both the patient and clinician are beginning the discussion from a similar viewpoint about past treatment history.
OUTLINE TREATMENT OPTIONS
Perhaps one of a clinician’s most important jobs is to outline
options for subsequent treatment. For our patient Jane, this
would entail a brief overview of the current treatment options, which would include chemotherapy (single agent or
combination treatment), endocrine therapy, surgery, clinical
trials, and palliative care. Using plain language is key to communication, and avoiding words that may denote negative
connotations (e.g., “treatment failure” or “second-line chemotherapy”) can assist this process.15
Risks and benefıts should be communicated as explicitly as
possible, which can be accomplished by using frequencies
asco.org/edbook | 2013 ASCO EDUCATIONAL BOOK
443
(X out of 100) or percentages.16 Although many oncologists
think in terms of relative risks, those are much not very
meaningful to individual patients. Frequencies or percentages allow patients to compare risks and benefıts of treatments using the same denominator.
NOTICE AND RESPOND TO THE PATIENT’S
EMOTIONS
As you discuss the comparison of third-line therapy and supportive care, Jane’s eyes fıll with tears, and she looks away. Her
friend notices this and steps in to say, “Now Doctor, Jane did so
well with the chemo before—she took care of her children,
walked daily, and did the chemo too! She could do that again,
could she not?”
From any patient’s perspective, including Jane’s, the information regarding treatment options can be emotionally
charged. Although her emotional reaction appears to come
fırst, it is entirely normal. This is an uncomfortable moment
for most oncologists, and many may feel like they have
caused the sadness, which may lead them to withdraw.
Numerous studies in which patients and oncologists have
been recorded demonstrate that oncologists tend not to comment on emotion.17 Yet for an oncologist to acknowledge the
emotional response and then to respond empathically (“I can
see this is tough stuff to hear.”) accomplishes a number of
things: (1) it validates the patient’s experience, (2) it slows
down the conversation so the patient can process what is
happening, and (3) it enables the patient to prepare him or
herself to take in more information. In one study, the clinician’s responses to a patient’s emotional cues were more
highly associated with patient recall than the clinician’s responses to the patient’s informational cues.18 In such situations, a practical response might include the following: “Jane,
I can see you are upset. It is a tough situation, and I can only
imagine what it is like for you. But I will be here to support
you and provide treatment to help you.”
It is important to note that what the clinician does in this context is different than what a therapist would do. Although a therapist would delve into the emotion, the majority of patients are
not looking to their oncologist for that—when it has been studied, patients report that they simply want to know their physician understands what they are going through.
In addition to responding directly to the patient, this case
illustrates the approach to others who might be involved in
the consult. In many cases, patients who anticipate important
decisions bring a family member or trusted friend. A clinician should underscore the importance of the role of the
other person (or people) in the room (praise is a useful tool)
rather than evaluate the accuracy of the friend’s recall.19 In
Jane’s situation, a statement to acknowledge her friend and
underscore her role can bolster both Jane and her friend:
“Mary, I know how important your support is for Jane. I can
see how concerned you are, and I know that having you here
will help us make a better decision together.”
444
ACKNOWLEDGE UNCERTAINTY
Acknowledging uncertainty about probabilities and outcomes can be crucial, as it is in this case where it is centered
around discussions on treatments for recurrence. Although
clinicians might fear that acknowledging uncertainty can
lead patients to distrust their oncologists, patients value
transparency and honesty about uncertainty when it is handled appropriately.10,20,21 Even though no patient wants to
hear that there are no guarantees that the benefıts of treatment will outweigh risks, they also tend to recognize the reality of a serious cancer diagnosis. For patients who want to
be actively involved in treatment decisions, withholding information or portraying false optimism can undermine the
patient– clinician relationship. However, we recognize that
others may use partial denial as a coping mechanism. For
such patients, stressing the uncertainty of the situation (particularly as it relates to prognosis in the context of recurrent
disease) may be as much honesty as one patient (with or without his or her family’s support) may be able to deal with.
In Jane’s case, there are multiple drugs that can be used to
treat her recurrent ovarian cancer. Faced with the question of
which is the “best” treatment, one might respond with the
following: “There are no data to show which one choice is the
best for you. Because the cancer came back three months after treatment, the likelihood that we can get a response to
treatment is low with any of these treatments. Hopefully we
can stop the cancer from getting worse with treatment by
making some of your symptoms go away or at least more
manageable. The goal is to preserve your quality of life while
treating your cancer. What are your thoughts about the treatment options I presented, given this information?” In this instance, the clinician supported the patient’s involvement in
the decision, discussed probability, and instilled trust while
still disclosing uncertainty.
TITRATE INFORMATION
There is a delicate balance between disclosing information
and providing too much information that might hinder decision making.22 For example, when discussing a breast cancer treatment decision with a patient, a clinician once
described to a patient that her tumor was moderately differentiated and discussed its nuclear grade. The details about
the tumor’s nuclear grade might have been meaningful to the
clinician, but the information wound up hindering the patient’s decision making. She fıxated on that detailed, complex
information instead of attending to information that might
have better helped her make a treatment decision (such as
whether the cancer was confıned to one breast and the size of
the tumor).10 When the clinician noticed that the patient was
fıxating on a detail, he or she could have said, “I am wondering if you are thinking you need to understand all this to
make a good decision? Although I mentioned it, I want to try
to explain a couple of other issues that are even more important. So could we step back for a moment? I will give a overview of the issues that are most important to your decision,
and then if we need to go back to the details, we can do it
DECISION MAKING AND PROGNOSIS
then.” Anxiety often drives patients into details, so acknowledging the worry of trying to master all the medical information can be crucial.
ASK WHAT ROLE THE PATIENT WANTS IN DECISION
MAKING
Clinicians should not assume all patients want full control of
decision making, nor should they assume they can tell beforehand how much involvement a patient wants during
SDM.12,23,24 After providing an overview of options, the oncologist should check in with the patient and question how
much involvement he or she wants in the decision. Does the
patient want to know more about more detailed risk/benefıt
information? Does he or she want to pause and review the
information fırst before moving on? If available, a decision
support intervention could provide the patient with an opportunity to review complex information outside the consultation room so he or she feels more prepared to engage in
shared decision making with the oncologist.25-27 For example, one patient once commented, “I wish I had a brochure
about my diagnosis and options before my appointment so I
knew what she was saying after I heard the news and I could
ask questions.”10 A useful question is, “Would you like to get
all the information and make the decision yourself or make
the decision together with me, or do you want me to make a
recommendation?” This enables the patient to indicate how
he or she would like to proceed.
Jane replied, “I know this decision is ultimately up to me, but
this is the fırst time I’ve dealt with recurrent ovarian cancer,
and you have had lots of experience with other patients.” The
oncologist replied, “Well, how about if we make sure you understand the issues, and I will bring in my experience as
needed. Could we start with what is worrying you now?”
INCORPORATE PATIENT CONCERNS INTO THE
DECISION
During SDM, acknowledgment of the patient’s concerns and
preferences can be as important as determining prior treatment toxicities and her performance status; each should play
a role in the development of a subsequent treatment plan.2,5
In the example above, Jane is stating her desire to be involved
and informed, yet also acknowledging that her oncologist
had clinical experience and expertise. Oncologists should ask
about worries, not simply to uncover them but to see which
ones might have an important role in decision making. As an
example, one might say to a patient who is also a musician, “I
hear you saying that your ability to play the piano is very important, and I mentioned that one of the side effects of the
chemotherapy is neuropathy, which means damage to
nerves. So that means we need to monitor your neuropathy at
every visit and that you should call if you fınd it is really interfering with your music.”
useful time to offer to revisit prognosis. Although many patients wish to know something about the future, not all fınd
statistical information useful. Thus asking the patient about
his or her “need to know” information at this specifıc time is
an essential communication tool: “Jane, would it be helpful
to talk about what to expect in the future? I fınd most patients want to know something about this–some patients
want to know the statistics, others just want to know the
big picture. What would be most useful for you?” The patient’s response can then guide the oncologist’s discussion of
prognosis.28,29
For patients who want to know statistics, the oncologist
should be straightforward. Using a 25th/75th percentile
bracket for “best case ” and “worst case ” scenario can be helpful.30 However, for patients who do not wish to know statistics, a brief exploration of concerns can be used to set the
stage for future conversations. Patients who are not willing or
have great diffıculty discussing prognosis may become more
challenging as time progresses; in these cases, consider an
early palliative care consultation.
MAKE ADVANCE CARE PLANNING A STEPWISE
PRACTICE
Jane said, “I do not really need to discuss the statistics again.
We did that already, and I know this cancer can be really bad.
I want to put my energy into this next treatment, and I want to
live my life.” The oncologist said, “That sounds good. We’ve
talked about a lot today, so thank you for hanging in there with
me. There is one last thing I’d like to ask about. With this kind
of cancer, once in a while there can be a situation where someone gets sick quite suddenly. I am not expecting this, but I want
us to be prepared. If you became so ill that you had trouble
making decisions, who do you want us to turn to?” Jane said,
“Well, Mary of course—she really knows me.”
In advance care planning, the most important fırst step is to
have the patient identify a health care proxy (or surrogate
decision maker). It is important to understand that the patient may choose someone other than a spouse, child, or
other relative. In one study of women undergoing treatment
at an academic cancer center, more than 30% of respondents
in relationships did not name their spouse or partner.31
A strategy for care at the end of life should also be
addressed; however, these do not have to be done simultaneously.
The oncologist says: “That is very helpful for me to know.
Next time you come in I have one other issue we should discuss—it is about the kind of care you would want if the cancer
had gotten much worse. Could I schedule time for you to sit
down with both me and the social worker next time?” Jane says, “I
do not want to think about that, but I guess I should.” The oncologist smiles at her, “You know, you are doing a great job.”
OFFER TO DISCUSS PROGNOSITC INFORMATION
CONCLUSION
Although prognosis may well have been covered as an element in decision making, new treatment decisions are a
Cancer care that is technically perfect can still fall short because the words clinicians use have power. Communication
445
and shared decision making are clinical skills that must be
intertwined to enable patients to understand what they are
facing, cope with the challenges of cancer, and make medical
decisions that match their values.
Disclosures of Potential Conflicts of Interest
Relationships are considered self-held and compensated unless otherwise noted. Relationships marked “L” indicate leadership positions. Relationships marked “I” are those held by an immediate
family member; those marked “B” are held by the author and an immediate family member. Relationships marked “U” are uncompensated.
Employment or Leadership Position: Don S. Dizon, UpToDate. Consultant or Advisory Role: Don S. Dizon, Amgen. Mary C. Politi, Merck. Stock Ownership:
None. Honoraria: None. Research Funding: None. Expert Testimony: None. Other Remuneration: None.
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Optimizing the Role of
Advanced Practice Professionals
in Oncology Practice
CHAIR
Dean F. Bajorin, MD
Memorial Sloan-Kettering Cancer Center
New York, NY
SPEAKERS
Maura Polansky, MS, PA-C
The University of Texas MD Anderson Cancer Center
Houston, TX
Lawrence N. Shulman, MD
Dana-Farber Cancer Center
Boston, MA
ADVANCED PRACTICE PROFESSIONALS AND PHYSICIANS
The Advanced Practice Professionals’ Perspective: Keys to a
Good Working Relationship between Advanced Practice
Professions and Physicians
Maura Polansky, MS, MHPE, PA-C
OVERVIEW
A strong working relationship between advanced practice professionals (APPs) and supervising oncologists is essential for reducing
medical errors, retaining employees, and improving work environments. Although there is rather limited data on the unique relationship
of the APP and physician, fundamental communication skills—including open communication, mutual respect, establishing expectations,
and working with mutual purpose—should be the foundation of these relationships. This paper addresses various aspects of relationship
building between APPs and physicians with suggestions for establishing successful working relationships.
D
evelopment of strong, successful relationships is essential for APPs (physician assistants [PAs] and nurse
practitioners) and physicians. Literature on practices employing APPs indicates that oncologists are usually very satisfıed with APPs in their group, which leads to enhanced
quality patient care, increased physician job satisfaction, and
additional physician time for research and other academic
activities.1 Although APPs’ job satisfaction is usually quite
positive, their satisfaction is strongly impacted by their relationships with practice physicians. Patient interactions and
autonomy and independence are also important factors.2 A
study of PAs found that physicians note that entry-levels PAs
are usually competent to “work effectively with physicians
and other health care professionals to provide patientcentered care.”3 PAs in oncology typically report that they are
skillful in “negotiating their clinical role with physicians” and
that this is not particularly diffıcult to accomplish.4 It is likely
that nurse practitioners share similar preparation and competencies in communicating with physicians regarding their
roles. Primary phrases related to APP-physician relationships as reported in the literature include respect for clinical
decision making, trust of the physician, physician appreciation, physician respect for the APPs’ roles and trust of their
decisions, and the physician treating the APP as an equal and
being supportive.2 Successful working relationships between
APPs and physicians may require attention to ensure these
characteristics are developed and nurtured.
Common concerns discussed informally among APPs
relate to the challenges faced when their roles are not well defıned within the practice setting, when supervising physicians
have different practice styles, which is most challenging for
APPs new to clinical practice, and when physicians provide
medical care inconsistent with standard of care guidelines.
Although most all relationships require shared trust,
appreciate, and respect, APPs practicing in oncology may
face unique stressors that may be relieved or aggravated by
their relationships with supervising physicians. APPs have
reported that telling a patient about a diagnosis or recurrence, transitioning patients into palliative care, managing
unrealistic expectations, and intervening with patients who
KEY POINTS
䡠 Core values of patient-centered care, trust, mutual respect,
inclusiveness, and professional development should be the
framework on advanced practice professionals
(APPs)/physician teams.
䡠 Clinical roles and responsibilities for APPs should be
established before recruitment so employers can establish
an appropriate fit with APP candidates and practice.
䡠 APPs should be introduced to practice staff (including
attending physicians, physicians in training, other health
care professions, and administrative staff) to ensure the
APP’s training, experience, and clinical responsibilities are
understood by those in the practice environment.
䡠 Systems that encourage regular communication between
APPs and physicians should be established, including
dedicating time to discuss routine patient care, urgent
patient issues, and practice improvement.
From The University of Texas MD Anderson Cancer Center, Houston, TX.
Corresponding author: Maura Polansky, MS, MHPE, PA-C, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; email: [email protected].
e375
POLANSKY
are angry or in denial are usually diffıcult conversations to
have, although APPs also report being skillful in doing so.4,6
These are areas that likely require professional development
and mentorship as well as support from a practice oncologist.
Professionals and trainees may benefıt from interdisciplinary
training in effective communication and it may also lead to
improvement in patient care and patient safety.5,7
Physicians and APPs who seek to develop strong, supportive relationships may consider some of the following recommendations:
• Learn about and display respect for each other’s education, training, experience, and professional identifıes.
• Develop a team approach to patient care allowing APPs
and physicians to contribute to patient care decision
making.
• Establish clear roles and responsibilities for each
team member (physician and APPs) and ensure other
members of the practice understand these roles. Readdress responsibilities as APPs develop professionally,
and develop additional clinical competencies over
time.
• Ensure APPs receive proper orientation and practice related training.
• Schedule regular times to discuss routine patient care
(will vary depending on practice model)
• Have a clear mechanism to communicate on urgent or
other time-sensitive patient issues.
• Show respect each other’s time.
• Seek opportunities for interdisciplinary educational opportunities, particularly related to patient communication.
The author(s) indicated no potential conflicts of interest.
References
1. AAMC Center for Workforce Studies. “Forecasting the supply of and
demand for oncologists: a report to the American Society of Clinical
Oncology from the AAMC Center for Workforce Studies.” http://www.
asco.org/ASCO/Downloads/Cancer%20Research/
Oncology%20Workforce%20Report%20FINAL.pdf.
2. Towle EL, Barr TR, Hanley A, et al. Results of the ASCO study on collaborative practice arrangements. J Oncol Pract. 2011;7:278-282.
3. Marincic PZ, Ludwig DB. Physician assistant self-assessment of entrylevel competency: a comparison with observations of supervising physicians. J Physician Assist Educ. 2011;22:23-33.
4. Parker PA, Ross AC, Polansky MN, et al. Communicating with cancer
e376
patients: what areas do physician assistants fınd most challenging?
J Canc Educ. 2010;25:524-529.
5. Brock D, Abu-Rish E, Chiu Chia-Ru, et al. Interprofessional education
in team communication: working together to improve patient safety.
BMJ Qual Saf. Epub 2013 Jan 3.
6. Ross AC, Polansky MN, Parker PA, et al. Understanding the role of physician assistants in oncology. J Oncol Pract. 2010;6:26-30.
7. Baile WF, Epner DE. Teaching Interprofessional Communication
Skills. Training Program Directors Session at ASCO Annual Meeting;
June 5, 2011; Chicago, IL.
MODELS OF COLLABORATIVE CARE WITH ADVANCED PRACTICE PROFESSIONALS
Efficient and Effective Models for Integrating Advanced
Practice Professionals into Oncology Practice
Lawrence N. Shulman, MD
OVERVIEW
Advanced practice professionals (APP), primarily nurse practitioners and physician assistants, are increasingly being integrated into
oncology practices. The reasons are numerous, and models of care options are numerous as well. Models of care have developed
without much forethought and are often the result of the relative interests of the physician, the APP, and the mutual “comfort” of
practice style. The increasing complexity of oncology care, the pressures of the health care crisis and health care reform mean that
it is necessary that we examine models of collaborative care in terms of both quality of care and productivity.
A
s the workload for medical oncologists increases and oncology care becomes more complex, advanced practice
professionals (APPs), primarily nurse practitioners (NP) and
physician assistants (PA), are more common in oncology
practice. There is great variability in how APPs function in a
practice, and ideal models are not clear. Regulation governing the practice scope for APPs varies from state to state. We
will attempt to elucidate some of the issues related to collaborative practice between oncologists and APPs.
APPs function in both out-patient and in-patient venues.
This manuscript focuses on out-patient practice where the
majority of cancer care now occurs. The roles of APPs in inpatient care can be extensive and critical, but they are beyond
the scope of this review.
NURSE PRACTITIONERS VERSUS PHYSICIAN
ASSISTANTS
practices, with 73% of those physician-owned private practices. Fifty-eight percent of the practices included APPs.
Among the remaining 42%, the reasons for not using APPs
included disinterest, unsuccessful use of APPs in the past, or
not enough patient volume to support inclusion of APPs in
the practice.
GOALS OF APP/PHYSICIAN PARTNERSHIPS IN
AMBULATORY ONCOLOGY CARE
There are many potential advantages to an APP/physician
partnership in ambulatory oncology care, but it is important
to be clear about practice goals. APPs add considerable expense to a practice and the value of including them must be
clear (Table 1).
Improved Patient Care
NPs and PAs undergo different educational experiences and
career paths, but both can be very skilled in the care of patients with cancer. Traditionally, NPs worked primarily in
medical specialties and PAs in surgical practices. In recent
years this trend has disappeared, and both can work in each
venue. Although licensing laws vary from state to state and
even though their training and career paths differ, skilled
NPs and PAs can function in essentially identical manner,
working in both independent and collaborative models. In
this manuscript we will not distinguish between NPs and PAs
but will refer to them collectively as APPs.
First and foremost, APPs can signifıcantly contribute to the
quality of patient care. It is certainly possible for physicians to
perform all functions an APP may perform, but physicians
frequently concentrate on diagnostics and therapy whereas
APPs focus more on teaching about chemotherapy and
symptom control, including nausea/vomiting and pain, and
arranging successful home care/hospice care. All of these
tasks take both skill and time, and APPs can play a signifıcant
role in improving quality of life for patients and their families
with these efforts. APPs may also be more available to patients and families who call with problems associated with
symptom management or home care support.
USE OF APPs IN ONCOLOGY PRACTICE
Increased Clinical Productivity
In 2011 ASCO published the results of a study on collaborative practice arrangements.1 The study surveyed over 200
Physicians and practices are continually faced with the need
to increase productivity, and APPs can add to overall practice
From the Dana-Farber Cancer Institute, Boston, MA.
Corresponding author: Lawrence N. Shulman, MD, Division of General Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215; email: [email protected].
e377
LAWRENCE N SHULMAN
TABLE 1. Goals of Physician–APP Practice
Partnerships
1. Improved patient care
2. Increased clinical productivity
3. Improved access for new patients
4. Urgent care patient management
5. Care of the long-term cancer survivor
6. Coverage for the academic physician
clinical volume. They can do this in several ways, which will
be detailed later in this manuscript.
dissatisfaction because of wait times, ineffıciencies in care,
and care by providers unfamiliar with the patient’s set of
problems. In addition, use of the ED generates health care
cost and is sometimes a measure of quality of care and cost of
care. Management of patients requiring urgent (not emergent) problems within the practice is a goal of many practices
and when done well can result in better care, improved patient satisfaction, and lower cost. Some practices have established separate urgent care clinics staffed primarily by APPs,
and others see the urgent care patients within their main
practice. In either case, the APP can play an integral role in
the model, doing initial assessments, triage, and treatment.
This frees the physician to continue his schedule with fewer
interruptions, and it also provides coverage when the physician is not in clinic.
Improved Access for New Patients
As the oncology market becomes increasingly competitive,
new patient access times have become a focus of process improvement. Rapid access for new patients is viewed, appropriately, as an important factor for patient and referring
physician satisfaction, and many practices have used this as a
marketing strategy. New patients essentially always require
signifıcant physician time, and scheduling constraints based
on number of on-treatment and follow-up patients scheduled can be a practical issue. Follow-up patients often have
their appointments scheduled months in advance, when the
physician schedule is relatively open, and treatment patients
require appointments at frequencies dictated by their treatment regimen. Both of these categories of patients can
quickly fıll a physician’s schedule, leaving little time for
new patients. Having the APP see follow-up patients and stable patients on treatment can free up signifıcant time on a
physician’s schedule for new patient slots. This requires planning in advance, proactively scheduling patients needing
follow-up and treatment the APP.
Urgent Care
The nature of oncology practice dictates that patients with
urgent problems will frequently need to be seen, evaluated,
and treated. Traditionally, many of these patients have been
sent from home to the emergency department (ED) of the
affıliated hospital. Use of the ED is often a source of patient
KEY POINTS
䡠 APPs are valuable members of oncology practices.
䡠 APPs and physicians can work in a number of different
models.
䡠 APPs-physician models will progressively need to be
determined by specific clinical needs and need to optimize
efficiency and productivity.
䡠 APPs can perform specific roles in clinical practices and
these should be determined proactively.
䡠 Respective roles of APPs and physicians will evolve with
time as the health care environment evolves.
e378
Care of the Long-Term Cancer Survivor
As our treatments improve and survival rates go up, there are
an increasing number of cancer survivors requiring oncology
follow-up care. Although some say these patients should be
transitioned to primary care physicians (PCPs), that often
does not happen, and oncology expertise continues to be required. For some diseases such as breast cancer, in which 80%
of patients are long-term survivors, these patients rapidly accumulate in a practice. These patients also have special needs
related to late cardiac effects, bone health, fertility, cognitive
capacity, and many other issues that may not always be addressed in a follow-up physician visit. APPs can be trained to
meet these needs. Having dedicated APPs see these patients
can open up a physician’s schedule for new patient slots, etc.
Coverage for the Academic Physician
Physicians based in academic cancer centers have a plethora
of responsibilities outside of their clinic, including in-patient
attending time, teaching sessions, research, and travel. An
APP can be a critical part of the practice by providing ongoing care for patients during the physician’s absence. The APP
will know the patient well, whereas covering physicians often
do not, and can provide both excellent care and continuity of
care with the support and back-up of covering physicians.
Towle and colleagues found in the ASCO survey that APPs
provided the following services, in decreasing order1:
1. Assisting patients during treatment visits
2. Pain and symptom management
3. Follow-up care for patients in remission (survivorship
care)
4. Patient education and counseling
5. Urgent care
6. End-of-life care
7. Ordering chemotherapy
BASIC MODELS OF CARE
Even though most APP/physician teams practice in hybrid
models of shared and independent care, there is frequently
MODELS OF COLLABORATIVE CARE WITH ADVANCED PRACTICE PROFESSIONALS
TABLE 2. Models of Care
1. Shared Care Model
MD and APP see patients together
2. Independent Care Model
together at the same time and can “flex” patients between
them as the patient needs dictate (the incident-to practice
model or ITPM), or whether they are in clinic at separate
times, practicing completely independently (the independent practice model).1
Incident-to-Practice Model: APP and MD see patients independently
Independent Model: APP sees patients independently when MD is not in
clinic
3. Mixed Model
APP works both in the shared care model and the independent model
at different times
one dominant model that the team fınds comfortable
(Table 2).
Shared Model of Care
In the pure shared model of care, the physician and APP see
all patients together. They may divide up the tasks around
each patient, but each patient is seen by both practitioners.
The physician may make a clinical assessment, including status of the disease, treatment recommendations such as continuing current chemotherapy or changing to a new regimen,
and the APP may manage symptoms such as nausea or pain,
or work on home care and social support. Typically in this
model the physician will complete the visit note and bill for
the services rendered.
Independent Model of Care
In this model, the physician and APP see patients independently. Patients may be assigned to one or the other depending on the needs of the patient or the phase of disease. The
physician may see a new patient in consultation, whereas the
APP may see a patient returning for routine chemotherapy
or long-term follow-up. Two subcategories of the model are
determined by whether the physician and APP are in clinic
Mixed Model of Care
Often APPs function in a mixed model of care, working
within the shared model some portion of the week and within
the independent model at other times during the week.
Buswell and colleagues looked at provider and patient satisfaction and productivity in an academic cancer center,
comparing the shared vs. independent model of practice.
They found high levels of both patient and provider satisfaction with each model and relatively equal productivity.2 In
the ASCO survey, APPs who worked with multiple physicians had the highest productivity, possibly related to design
of practice models in that circumstance.1
CONCLUSION
APPs are frequently used in medical oncology practices,
working within various practice models and performing a variety of clinical tasks. Oncology care is becoming more complex, with the rapid introduction of new treatment modalities
associated with unique characteristics and toxicities, and
there is increasing pressure in the current health care environment for high productivity and cost control. Because of
these factors, the roles of APPs and models of care should be
evaluated for quality of care delivered, patient and provider
satisfaction, productivity, and cost. Allowing practice models
between individual physicians and APPs to evolve based on
previous experience and “comfort” levels will probably not
lead to the best results in any of these areas other than
provider satisfaction. Bajorin and Hanley review these
issues well.3
The author(s) indicated no potential conflicts of interest.
References
1. Towle E, Barr T, Hanley A, et al. State of Oncology Practice. Results of
the ASCO Study of Collaborative Practice Arrangements. J Onc Practice.
2011;7:278-282.
2. Buswell L, Reid Ponte P, Shulman L. Provider practice models in
ambulatory oncology practice: Analysis of productivity, revenue, and provider and patient satisfaction. J Onc Practice. 2009;5:
188-92.
3. Bajorin D, Hanley A. The study of collaborative practice arrangements:
where do we go from here? J Clin Oncol. 2011;29:3599-3600.
4. Coniglio D, Pickard T, Wei S. Commentary: Physician assistant perspective on the results of the ASCO Study of Collaborative Practice Arrangements. J Onc Practice. 2011;7:283-284.
5. Brown C. Commentary: New fındings substantiate the successful use of
nurse practitioners and physician assistants in collaborative practice
models. J Onc Practice. 2011;7:285-286.
6. Moote M, Nelson R, Veltkamp R, et al. Productivity assessment of physician assistants and nurse practitioners in oncology in an academic
medical center. J Onc Practice. 2012;8:167-172.
e379
Women in Oncology: Challenges
and Keys to Success
CHAIR
Elizabeth M. Jaffee, MD
The Johns Hopkins University School of Medicine
Baltimore, MD
SPEAKERS
Enriqueta Felip, MD
Vall d’Hebron Institute of Oncology
Barcelona, Spain
Katherine Elizabeth Reeder-Hayes, MD, MBA
The University of North Carolina at Chapel Hill
Chapel Hill, NC
Debra A. Patt, MD, MPH
Texas Oncology
Austin, TX
REEDER-HAYES
Women in Oncology: Progress, Challenges, and Keys to Success
Katherine Reeder-Hayes, MD, MBA, Enriqueta Felip, MD, PhD, Debra Patt, MD, MPH, and Elizabeth Jaffee, MD
OVERVIEW
Women have an increasingly significant presence in the oncology physician workforce but remain underrepresented in leadership
positions and at the senior levels of academic medicine. Initiatives to close these gaps are underway both in the United States and
Europe. However, many areas for improvement remain on an organizational level and in the trenches of career development and
mentorship for individual female oncologists in both community and academic settings. Solutions to advance women in the oncology
workforce will involve policy initiatives by professional and funding organizations, individual initiatives by universities and practices to
recognize and develop female leaders, an increased focus on teamwork and novel practice arrangements, and high-quality mentorship
of young women entering the oncology field.
T
he presence and role of women in oncology is an issue of
great practical importance in providing a large and vital
physician workforce to meet the ever-growing need for oncology providers. It is also an issue of immense personal importance to women entering the ranks of oncologists, those
who have served in those ranks for decades, and the men who
have worked alongside them. In this manuscript the authors
present the professional and personal insights of four female
oncologists who span the range of career stages, practice settings, and research interests, discussing strategies to successfully bridge the gap between the current state of women in
oncology and the future to which we aspire.
ELIZABETH JAFFEE: AN OVERVIEW OF WOMEN IN
ONCOLOGY, PAST AND FUTURE
Women are now a substantial group within the medical profession, thanks to pioneering predecessors and the male physicians who supported them. It was only a generation ago that
few women enrolled in medical school, and those that succeeded in becoming physicians had fewer opportunities in
the job market and at a reduced salary than their male counterparts. Women now comprise about 31.2% of all physicians
(2011) and are represented in most subspecialties, even
those that were dominated by men in the past. In oncologic
fıelds (hematologic, medical, surgical, pediatric, gynecologic,
and radiation oncology) the number of physicians has continued to increase in the past 9 years by approximately 3%
per year, mostly in pediatric and surgical oncologic specialties. The number of female oncologists has also increased
from 22.4% (2004) to 28.4% (2011) of the total number of
U.S. oncologists. Women in oncology pipeline programs
make up approximately 46% of physicians (44.7% in internal
medicine, 81.4% in obstetrics/gynecology, and 72.7% in pediatrics), and this is about the same for women currently
training in oncologic specialties.1 Salaries have also equalized
for women, although more women than men choose parttime positions, which sometimes skews the published data.
Although major barriers have been overcome and glass
ceilings have been cracked, women in oncology still identify a
number of challenges that are unique to women as well as one
important challenge that is shared with their male colleagues.
First, although women in medicine and oncology have
made major strides over the past generation, they continue to
be under-represented in areas of leadership. Women often
receive fewer invitations to speak at, organize, or chair national meetings and compete less often for major leadership
positions including division/department chairs, cancer center directors, leaders of national committees, and president of
national societies, when compared with men at similar stages
in their careers. This is a complex issue and the outright inequality issues of the last generation do not apply here. Instead, the inequality is subtle, with male meeting planners
forgetting to make a conscious effort to think of women who
are as accomplished as their male counterparts to deliver a
seminar at a national meeting or serve as an organizer of the
meeting. In the case of leadership positions, women often are
encouraged to apply for leadership positions but decline because the opportunities arise at inconvenient times, when
their work life is competing with raising their family.
The key to succeeding at being invited to national speaking
engagements is simple: women need to work towards being
From the Johns Hopkins University School of Medicine, Baltimore, MD; Oncology Department, Vall d’Hebron University Hospital, Barcelona, Spain; Texas Oncology, US Oncology Network, Dallas,
TX; Division of Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill, NC.
Authors’ disclosures of potential conflicts of interest are found at the end of this article.
Corresponding author: Katherine Reeder-Hayes, MD, MBA, 170 Manning Dr., Campus Box 3705, Chapel Hill, NC 27599; email: [email protected].
448
WOMEN IN ONCOLOGY
more visible on the national stage. A woman who is interested in talking at a particular national meeting needs to contact the organizer directly and share her work; even if the
agenda for the meeting has been set, she will now be on the
radar for future meetings. For example, when I recently organized a national meeting, fıve men emailed me with summaries of their latest work and requested an opportunity to
share their work by giving a talk. Not one woman did the
same. A few pro-offered short talk slots were still available,
and three of the soliciting investigators were given the opportunity because their work fıt into the program well.
The key to leadership success is more complicated. In medicine in general, fewer women than men pursue academic careers after fellowship. Studies conducted by the National
Institutes of Health (NIH) as well a report in EMBO Reports
have shown that the number of women who are in tenuretrack positions in science has remained unchanged in the
past 10 years. Although women make up approximately 45%
of biomedical science fellows in training programs, they represent only 29% of tenure-track investigators, and less than
20% of senior investigators at academic institutions.2 Therefore the pool of women available for leadership positions is
much smaller than for men. Furthermore, fewer women than
men want to take on this diffıcult task because they value the
little time they have at home. In addition, there are too few
women currently in leadership positions to serve as role
models and mentors. Women often feel less equipped with
the skills to take on these higher-level leadership positions,
and there has been very little mentorship in this area for
women. The key to success on this issue requires a larger
effort. We need to provide more incentives to senior women
to apply for these leadership positions. More local and national efforts to provide leadership training to women seeking these top jobs would provide additional training and
mentorship to women thinking about these positions and
would give women more confıdence that they can take
on these positions successfully. In addition, access to more
KEY POINTS
䡠 Women are well represented in oncology training pipelines
in the United States and Europe but continue to be underrepresented in academic and leadership positions.
䡠 Policy initiatives that incentivize women to remain in
academic positions and that develop leadership skills
among women can further reduce gender inequities in
oncology.
䡠 Interventions to promote work-life balance may help
women find sustainable ways to advance professionally and
make maximal contributions to their fields.
䡠 Team patient care and team science arrangements
maximize contributions from women in oncology while
promoting sustainability.
䡠 High-quality mentoring is a key tool to equip junior female
oncologists for career advancement.
convenient child-care may help increase the pool of younger
female investigators interested in pursuing academic careers.
Second, women still need to be more assertive in the workplace to have their input heard and to ask for what they need.
This is often linked to lack of self-confıdence. Although there
is no easy way to explore the prevalence and consequences of
this issue in the workplace, many women report that a lack of
confıdence can hinder them from asking for what they need
from their leaders to facilitate their work objectives. Many
women in oncology that I work with or have spoken to about
this topic are afraid to ask for what they need and are often
more hesitant to negotiate for what is important to them. The
most successful women are willing to talk about their own
strengths and contributions to make sure their value is appreciated, facilitated, and compensated. The key to success is
to become less concerned with what others think, to believe
in oneself, and to “wear” self-confıdence for others to see.
Third, women need to learn to deal with adversity and criticism. Oncology is a competitive fıeld that is changing rapidly. As technologies advance and information systems move
more and more quickly, female oncologists need to embrace
learning and realize that they cannot possibly master everything. They must learn to accept input even when it may seem
negative. Many women tell me they feel threatened by many
forms of criticism, especially when provided by male colleagues. Many women take this criticism personally. The key
to successfully overcoming adversity and criticism is to accept it as part of daily business and to learn from it. And,
when in the position of having to give feedback that may be
viewed as critical, always be honest, give it to others with a
positive spin as part of the learning process, and show respect
for colleagues’ input. When one of my female faculty members is feeling frustrated about what she perceives to be negative feedback from a colleague, I always say, “Watch The
Godfather. ” No one says it better than Tom Hagen when he
tells Sonny about his father’s being shot: “It is business, not
personal.”
Finally, the biggest challenge is one faced by both men and
women in oncology—learning how to balance work and a
home life. There is a growing interest in understanding worklife balance among many Americans who struggle to maintain high-pressured jobs while raising a family, caring for
aging parents, spending time with friends and partners/
spouses, cultivating hobbies, and maintaining personal
health. This issue is even more complicated for oncologists
whose job it is to care for individuals who are in critical life
situations and/or participate in high-pressured research
aimed at understanding cancers and fınding new treatments
and preventions.
Achieving a satisfactory work-life balance is necessary to
achieve happiness, well-being, and contentment in life and
should lead to a healthier attitude and enhanced productivity
at home and at work. The pressures to work harder and longer hours in all areas of oncology are increasing as reimbursements for medical services decline, costs of running private
and academic practices increase, regulatory oversights of research continue to demand more time of the researcher, and
449
REEDER-HAYES
funding for research continues to decline. In addition, people
are more connected than ever through multimedia devices
that lead to addictive behavior and inhibit the ability to periodically “disconnect” from work. However, there are solutions that can solve this challenge as well.
As individuals we must prioritize. Some women are considering restructuring their jobs– either through part-time
work or job sharing– or arranging for a more flexible work
schedule. Other women have chosen either team-based patient care, working with other nonphysician providers in private practices, or team-based science, working with other
investigators and researchers. Although technology has increased connections to work, members of the fıeld of oncology need to make better use of technologic advances to speed
up work tasks, allow for faster and more effıcient communications between physicians and patients or between researchers, and to save time for more important work-related
and home-life issues.
Some agencies and employers are implementing policies to
facilitate a better balance. In academics, in particular, the
NIH has had innovative grant opportunities for women who
became part-time employees during early child-bearing
years, and some institutions provide modest research funding for junior faculty in need of flexible hours or job sharing
opportunities. More employers are realizing the benefıts of
facilitating work-life balance, including less burn-out and increased health and productivity. Yet institutions can facilitate
more. In particular, academic institutions can loosen criteria
for moving rapidly through the tenure track, and clinical
practice environments can be improved to facilitate patient
care. However, most importantly, individuals need to step
back and consider their priorities. Success will depend on
choosing the right job fıt, identifying mentors and role models, letting go of the type-A personality requiring perfection
at everything, overcoming guilt, setting limits on time and
use of technology, and fınding the right life partner. Achieving work-life balance is an active process that requires active
participation by the individual seeking this balance.
In conclusion, women have made great progress in pursuing careers in oncology and medicine. The big barriers inhibiting entry into M.D. and Ph.D. training programs no longer
exist. However, less apparent challenges still exist but are diffıcult to quantify as a result of the lack of studies that are ongoing to identify and monitor these challenges. Although
many women are succeeding at overcoming these remaining
obstacles, continued research and proactive initiatives are
needed to ensure that women fully succeed in their goals. Finally, we need to increase the pool of qualifıed female mentors who can serve as role models to attract and continue to
increase the pool of women choosing a career in oncology.
These role models are the key to success for women who need
to learn how to work productively with others, become more
inclusive in research, show generosity in acknowledgments,
authorship, and on grants, and to become the future role
models for the next generation of women pursuing a career in
oncology.
450
ENRIQUETA FELIP: AN INTERNATIONAL
PERSPECTIVE ON WOMEN IN ACADEMIC ONCOLOGY
Academic medicine is a process of continuous learning that
has to serve three outstanding tasks: teaching, research, and
patient care.4 The fıeld of oncology offers opportunities for
tremendous career satisfaction. Academic medicine in oncology encompasses the mission of educating the future generations of medical oncologists, discovering causes of cancer
and establishing appropriate treatment approaches, and advancing knowledge of cancer care while caring for patients.
Although the majority of medical graduates are now
women, available data indicate that women in academic
medicine are not reaching the same levels of career advancement, leadership responsibility, and fınancial compensation
as their male counterparts. An American study analyzed
whether women who graduated from medical school from
1979 through 1993 are more or less likely than their male
counterparts to pursue full-time careers in academic medicine and advance to the senior ranks of medical school faculties.5 In this study women were shown to be more likely than
men to pursue an academic career and to become faculty
members. However the proportion of women who advanced
to the senior ranks of academic medicine was lower than that
of their male colleagues.
A number of issues may influence the low proportion of
women in academic leadership positions: potential gender
discrimination with differential access to career-promoting
experiences, lack of serious attention to female candidates in
search processes, inability to acknowledge the contribution
women make, lack of effective and willing mentors, and the
impact of family and domestic responsibilities. Furthermore,
during their career, women have to make conscious efforts to
transcend gender prejudice (incompatibility of academic demands with family commitments, replication of traditional
roles in the assignments earmarked for women, constraints
on career-related choices) when negotiating their terms of
employment.
It is unclear whether women themselves have different career expectations and professional skills when compared
with men. The results of one survey of academic medical professionals showed that the intellectual challenge of academic
medicine is as important to women as it is to men, but that
achieving recognition as a physician or being viewed as a
leader seems to be less important to women than it is to men.6
Effective collaboration, networking, and being a team player
are essential in academic medicine. Carr and colleagues7 addressed how faculty experienced collaboration in regard to
gender. They interviewed 96 medical faculty members at different stages in their careers and in diverse specialties. They
found that female faculty expressed enthusiasm about the
potential and process of collaboration; male faculty were
more likely to focus on outcomes.
In Europe, in the latter part of the 20th century, the number of women going to university rose constantly and is, at
present, higher than the number of male students in many
European countries. In Spain, women comprise 54.4% of
WOMEN IN ONCOLOGY
university students and 61% of students who complete their
studies. Nowadays over 60% of medical school graduates in
Europe are women. In Spain, in the academic course 2010 –
11, 69% of medical students were women. Despite the clear
increase in the number of women entering the medical profession, women continue to be underrepresented in the
higher levels of European academic medicine.
Currently in Spain 954 of the 1,721 (55.4%) medical oncologists who are members of the Spanish Society of Medical
Oncology (SEOM, www.seom.org) are women; there are 82
medical oncologist residents, of which 57 are women
(69.5%). However, only 17 of the 91 (18%) heads of medical
oncology departments are women. All 17 presidents of the
Spanish Society of Medical Oncology, who are elected every 2
years, have so far been men. However, this precedent may be
changing, as the present president elect, Pilar Garrido, MD,
PhD, is a woman, and she will be the next SEOM president as
of October 2013.
At present, the European Society of Medical Oncology
(ESMO, www.esmo.org) has a female President, Martine J
Piccart, MD, PhD, an exceptional academic medical oncologist, who has held numerous international posts. It is worth
mentioning here that the ESMO executive board is composed of 11 members, only three of whom are women (including the President). An ESMO working group, the ESMO
Young Oncology Group has 15 board members and, encouragingly, nine of them are women.
The present disparity between the proportion of female
medical oncologists and the proportion of women in key academic oncology positions may discourage women from
pursuing academic careers, thus having a negative effect on
the hope of changing the situation in the foreseeable future. It
is, therefore, essential to encourage women to pursue wellplanned careers with the objective of achieving medical leadership. To reach such an objective, there is a need to ensure
equal opportunities for women in accessing academic appointments and attaining promotions. Essential to this is the
role of the mentor, which is crucial for career development.
Unfortunately, outside of the U.S., the fıgure of the mentor is
not always formally established, and junior doctors are often
without the necessary support to project their careers. Young
female medical oncologists should be encouraged to seek
mentors who can empathize with their specifıc challenges,
and women in key positions in academia should be aware of
their responsibility to act as mentors. Oncologic medical associations also have a prominent role to play in ensuring
equal opportunities in academic medicine for men and
women. Data on the gender of association members should
be gathered, and women should be encouraged to be candidates for key positions in the association.
A recent European initiative, the project “gender in science” (genSET), funded by the Science in Society Programme
of the European Commission’s Seventh Framework, creates a
forum of sustainable dialogue between European science
leaders, science stakeholder institutions, gender experts, and
science strategy decision-makers to agree on the gender dimension in science in order to produce practical guidelines
for implementing gender action plans within existing institutional mechanisms. The goal is to develop practical ways in
which gender knowledge and gender mainstreaming expertise can be incorporated within European science institutions
to improve individual and collective capacity for action to
increase women’s participation in science. genSET focuses
on fıve key areas in which gender inequalities and biases negatively affect women’s participation in science: science
knowledge-making, research process, recruitment and retention, assessment of women’s work, and science excellence
value system. The group gives several recommendations, and
the report can be found at www.genderinscience.org.
In summary, in recent years, the presence of women in academic oncology has been slowly but steadily increasing and,
at present, there are an encouraging number of women in key
positions in academic oncology. These female leaders can act,
not only as mentors to young women who want to build a
career in academic oncology, but also as visible role models
for women oncologists. However, we have a long way to go,
and more should be done to improve career prospects for
young female oncologists. Key actions should include,
among others, ensuring that conditions for promotion are
clear and explicit, making women’s professional contributions more visible, increasing women’s awareness of salary
negotiation tactics, encouraging women to apply for clinical
excellence awards, and supporting women who are considering leadership in academia as a career option.
DEBRA PATT: WOMEN BUILDING BRIDGES THROUGH
TEAMWORK IN COMMUNITY ONCOLOGY
A great challenge within community oncology is learning
how to foster collaboration between different groups to work
as a team toward shared objectives. Although the strategy of
teams delivering care and working toward common goals is
not unique to community oncology, the ability to align interests and work in collaboration is of heightened importance.
Community oncologists must work with the resources they
have, as there is often an absence of larger institutions that
can support their strategic initiatives to improve the quality
of care and patient experience. Improvements are achieved
on common ground shared between hospitals, practices,
community support organizations, support services, political
leaders, religious organizations, family, and friends. In this
way the ability to build bridges and foster collaboration has
greater direct impact on the ability to provide care to the
community and the patients who live within it. As a woman
and a mother, this idea of collaborative synergies has been
instrumental to my personal and professional growth.
Building Teams
I manage my life by building bridges and teams to serve my
various communities. Like most of my female colleagues, I
lead or serve on many different teams: patient care teams,
research teams, program development teams, policy teams,
community teams, and, most importantly, my home team,
451
REEDER-HAYES
which I codirect to manage the development of three very
charming social experiments: ages 10, 7, and 4 years old. The
function of these teams working toward our strategic objectives lies in management within each team and integration
between them.
Managing Teams
The successful management of these teams depends on
group motivation, investment, and coordination. Motivation
for shared vision is best achieved when a leader appeals to the
personal, social, or structural motivations of the team so the
team’s goals are held internally by each team member. In
medicine, many practitioners share common motivations
that draw them to the path of patient care: the need to serve
and improve the lives of others, integrity, and views on justice
are commonalities among health care providers. Understanding and appealing to these motivations of team members will help them internalize the team’s strategic goals with
an innate drive toward a common purpose.
Personal investment develops and nurtures strong teams.
Leaders invest in the professional development of their team
members. This involves both mentorship and opportunity,
and even the opportunity to fail. By building bridges with
others and strengthening each pier and beam, the collaborative effort is stronger and more enduring.
Fostering Team Dynamics
In my novice oncology career path I am both a mentor and
mentee, and I have benefıted and continue to benefıt greatly
from exposure to strong leaders who continue to shape the
way I interact with the world around me. Based on my experience in leading and participating in team development
there are behaviors that foster benefıcial team dynamics: set
expectations for and meet expectations of others, be candid
(with praise and, particularly, with criticism), listen and foster environments that allow open communication of ideas,
learn from others, and encourage diversity and independence, as they breed innovation.
Why Teambuilding Is Important for Women
Experience, too, is a great mentor. Unlike my mother before
me, I was reared in a household in which I was taught that my
opportunities were endless. We have seen the proverbial
glass ceiling rise, crack, and often break in this era of professional development, offering women unprecedented opportunities in medicine. What I learned only after the birth of my
fırst child is that endless opportunity still exists in a system of
limited resources, and that my most scarce resource is time.
We do not have the ability to do everything on our own.
What I learned with my second child is that we should not try
to do everything on our own, and with my third (through
experience and exhaustion), I learned that although our independent resources are limited, our collective team resources are rich. Reaching across and grabbing the hands of
my partners is the only way to continue to move forward—in
collaboration. My ability to manage my competing opportunities and priorities is only realized by managing time well,
452
building teams with common goals, and integrating teams
that can act together in synergy.
Team Integration
In addition to healthy team management, as a woman with a
family, my teams must be integrated. My professional partners are often guests in my home and understand that my
family is the cornerstone of balance in my life. My children,
by design, come to my offıce and do their homework about
twice a month. They see (from a short distance) that I care for
people who are sick. They understand well what I do when I
am away from them and why I value it so highly. Their presence and integration in my professional life gives them insight and understanding that when I cannot be there with
them it is only because I am giving a service to others that is
also really important. My informatics and clinical content
teams within my network are removed from direct patient
care but have traveled to my offıce, in which they can see systems of patient care delivery in action. As opposed to being
value-neutral, this integrative function actually strengthens
each team. Resulting from this, these teams have developed
clinical insight that fosters understanding of what they do
from different perspectives and share in the motivation to
improve patient care as they develop tangible insight toward
that common goal. Similarly, bridging between local support
organizations and our local hospitals for cancer resources
improves the value of each organization and clearly improves
care delivery within the community. Usually with integration
of these disparate parts, synergies arise that add value to each
independent system and tremendous value to the collective
effort.
Defining Balance and Presence
I have the great pleasure of learning from and having close
friendships with many strong women who are bright, leading
in their communities, and share the need to strike balance
between their work and family. It has been my experience
that successful balance has a different structure for each
woman and tends to evolve over time as their teams grow and
mature. I also believe that our ability to balance is in part our
personal choice, and in part our capabilities that are largely
defıned by the ability to rely on others. In comparison to my
friends and colleagues, I have always had an easier time with
balance because my husband (also a physician) is an equal
partner in parenting our children. Although our home is far
from perfection, I am certain that my family always knows
they are loved and cared for.
In addition to learning balance, it is vital to be 100% present
in each moment. Let teams know that when they are given
attention it is enthusiastic, complete, and without distraction. This will make the time that can be given to each team
exponentially more valuable.
I think understanding this balance of competing priorities
makes women natural collaborators, and each community can
benefıt from women’s contributions to leadership within them.
Ultimately, each person can make a difference as an individual, but greater change will occur only when dissimilar
WOMEN IN ONCOLOGY
stakeholders come together to collaborate, compromise, and
form strategic synergies that innovate cancer care for the
global community. Facilitating meaningful change within
collective communities requires leaders to stand at the intersection between sometimes disparate stakeholders (pharmaceutical companies, payers, physicians, policy makers, large
corporate partners, academia, private practice, professional
organizations, etc.) and build bridges to conquer cancer.
KATHERINE REEDER-HAYES: BUILDING MENTORING
BRIDGES FOR WOMEN IN ONCOLOGY
Not infrequently, I look around my workplace and wonder
what I did to accumulate such talented mentors. Luck is part
of the equation, certainly, but assembling an all-star mentoring team also requires thoughtful and diligent work on the
part of the mentee. Persistence and self-advocacy in reaching
out to mentors will almost certainly yield a large professional
and personal payoff down the road, and there is widespread
agreement that such a payoff is particularly critical for advancement among women in early career stages. There are a
number of “mentor myths” and conversely “mentor truths” that
should be identifıed when searching for good mentorship.
Mentor Myths
Your mentor should be the most approachable person in your
department. During my internal medicine residency I sent an
email to the oncology faculty seeking a project for a monthlong research elective. Only one faculty member responded,
and she was not the woman I wanted to hear from. This senior researcher was only slightly known to me from the clinical wards, and she was intimidating. It only took a brief
encounter for one to realize that she was formidably intelligent, had an impressive fund of knowledge, and set high standards for everyone on the team from the medical students up.
My knees were quaking a bit as I said “yes ” to her invitation,
but I could not have made a better decision. Those same qualities that made her intimidating on fırst meeting have served
me well over a long mentoring relationship: high expectations, an acquaintance with a wide variety of research methods, and the ability to give direct and constructive feedback.
Overcoming natural hesitation to collaborate with an accomplished mentor can make their strengths your own.
Your mentor should be the twin of your future self. We naturally seek out as mentors those whose example we would
like to follow, and often this strategy is appropriate. However,
particularly in the current environment of multidisciplinary
and translational research, many people outside of one’s own
immediate fıeld of research interest can be excellent mentors,
provided that there is at least some overlap between interests.
In fact, working with a mentor whose interests only partially
overlap with one’s own can foster the chance to become the
“expert” in a particular area rather than being constantly in
the mentor’s shadow. As my career has developed from resident to fellow to early-career health services researcher, I
have received wonderful career guidance from lab scientists,
social scientists, health policy researchers, and physician researchers in other clinical specialties.
Mentorship should be a monogamous, longtime partnership.
What is true of marriage may not be true for mentorship.
Over time, an oncologist’s career path is likely to change signifıcantly as a result of shifts in research interests, the need to
learn new methods, or a move from one institution to another. A mentor who is well-positioned to give guidance at
one stage may not have the right expertise, time, or proximity
to play a central role later on. Mentoring relationships tend to
follow a natural progression of the “getting-to-know-you”
phase, a period of maximal productivity, and then an “emeritus” stage, in which the relationship is hopefully still cordial
and collaborative, but requires much less time and commitment by both parties. It is helpful to recognize these stages
and seek new mentors as one’sneeds evolve.
Mentorship is the responsibility of the mentor. Nothing kills
a mentoring relationship like a passive mentee. Mentors in
academia are usually busy mid- or late-career investigators
who may be pulled in many directions even if they are truly
dedicated to the person they are mentoring. Thus, time with
a mentor will be dramatically more productive if the mentee
has a defıned idea of what he or she needs from the mentor at
each encounter. I highly recommend regular, structured
meetings with key mentors that show respect for the mentor’s other time commitments and give the mentee the access
that is needed to receive thoughtful feedback. Individuals
with a true passion for mentoring are energized by someone
who appears in their offıce with specifıc needs, questions, and
plans around which to center feedback. Some of my mentor
meetings are as simple as a stroll down the hall, but even for
these casual meetings I try to have a simple “agenda” with a list
of topics for us to talk about. Of course, we often wander offtopic, but the agenda reflects what I most want feedback about
and helps me clarify how I am progressing.
The best mentor for a woman is a woman. I strongly believe in
the importance of senior female role models for women in
academic medicine, particularly with respect to issues of creative career structuring during childbearing, if desired, and
balancing traditionally female family roles such as caregiving for elderly parents. I have personally benefıtted from
the examples of such role models. However, wisdom regarding work-life balance and other important issues facing female junior faculty is not exclusive to women. Many
important “ah-ha moments” in pacing my career and prioritizing commitments have been delivered by male mentors.
In particular, I have found that male mentors have encouraged me to say “no” to inappropriate commitments and deliver critical feedback in a direct but professional way. These
two interpersonal aspects of professional life are uncomfortable for many female junior faculty, and good examples can
come from mentors of both genders.
453
REEDER-HAYES
Mentoring Truths
Choose the mentor who has the time and career capital to
invest in you. The most important characteristic of a mentor
may be altruism–the willingness to give of her own resources,
whether it be time, expertise, lab space, or funding, to advance your career development. You should feel sure that
your mentor is secure enough in her own career trajectory to
be able to donate these resources. It is both unfair and unproductive to ask for mentorship from a colleague who is not
suffıciently senior or well-supported to be altruistic toward
you. There are many ways to repay your mentor’s investment
in you, but ultimately mentoring is somewhat of a “pay-itforward” enterprise.
Choose the mentor who has the skills you would like to develop. Although you do not want to be the professional clone
of your mentor, it is particularly important for women in oncology to identify mentors, whether male or female, who exemplify the workplace and personal values they would like to
emulate. Does a senior colleague seem to have a talent for
leadership? Does she share your priorities regarding work
and personal commitments? Does she demonstrate assertiveness in faculty meetings or possess unusual ability in public speaking? Mentors can teach these skills in addition to
research or clinical skills, and the best mentoring relationships model these vital competencies in both professional
and personal life. My mentors’ willingness to open their
homes and personal lives, allowing me a peek at their children, pets, cooking skills (or lack thereof) and more, have
been invaluable in helping me defıne the professional woman
I want to be.
Choose the mentor who helps you “guard the plate”. Of all the
skills a mentor can teach, this may be my favorite. The
“plates” of female junior faculty, whose professional trajectories often compete for limited resources with intimate
partner relationships, childbearing, and rearing young children, can seem to be constantly overflowing, yet saying “no”
is diffıcult. I am eternally grateful to mentors who encourage
me to ask the following questions: (1) How will I benefıt from
saying “yes ” to this activity?; and (2) What will I have to give
up to meet this commitment? These questions have stopped
many a promising addition to my to-do list by reminding me
of a poor fıt with my overall desired career direction, short
term, or long-term priorities. If the answers clearly reflect
that the activity is not a good addition to one’s plate, a good
mentor will also be there to back their mentee up if the “no”
or “not yet” must be delivered to someone with seniority or
other influence in the workplace.
Choose the mentor who supports you as a whole person. Over
the course of my career from medical student to faculty
member, I have also given birth to four children. That means
36 months of prenatal appointments, four maternity leaves,
48 months of “breastfeeding brain,” and all the rest. My mentors truly deserve some sort of award for navigating these
stages with me! They struck the perfect balance between
avoiding false assumptions (“she has a baby, so she will not
take on any new projects this year”) and reminding me to
develop my professional path at my own pace and in a sustainable fashion. By giving me both the space to say “no” and
the opportunity to say “yes,” they enabled me to fınd my own
formula for mixing my personal and professional obligations. This is a diffıcult balance in mentorship, as in life, and
it is an immensely valuable asset in a mentor.
Conclusion
The mentor-mentee relationship can be an immensely satisfying brand of collaboration for both parties. Women bring
special competencies to the table on both sides of the mentoring equation through their skills in team building, integrating input from diverse sources, and building social
networks. A successful mentoring relationship is key to career development for women in oncology, so begin building
those mentoring bridges today.
Relationships are considered self-held and compensated unless otherwise noted. Relationships marked “L” indicate leadership positions. Relationships marked “I” are those held by an immediate
family member; those marked “B” are held by the author and an immediate family member. Relationships marked “U” are uncompensated.
Employment or Leadership Position: None. Consultant or Advisory Role: None. Stock Ownership: None. Honoraria: None. Research Funding: None.
Expert Testimony: None. Other Remuneration: Elizabeth M. Jaffee, Aduro Biotech; BiSante.
References
1. Key Trends in Tracking Supply of and Demand for Oncologists. A
report to the American Society of Clinical Oncology (ASCO) from
the AAMC Center for Workforce Studies (Association of American
Medical Colleges, Washington, DC), 2012. Available at http://www.
asco.org/sites/default/fıles/workforce_information_system_12.17.12.pdf.
Accessed March 22,2013.
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2. Martinez ED, Botos J, Dohoney KM, et al. Falling off the Academic
Bandwagen. EMBO reports vol. 2007;8(11):977-981.
3. Francis, Lanie. A Post-Modern View of Women in Hematology: A
Focus on Work/Life Balance. American Society of Hemotology.
http://www.hematology.org/Publications/Hematologist/2012/
8566.aspx.Accessed 2012.
WOMEN IN ONCOLOGY
4. Kanter SL. What is academic medicine?. Academic Medicine. 2008;83:
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5. Nonnemaker L. Women physicians in academic medicine. N Engl
J Med. 2000;342:399-405.
6. Brown AJ, Swinyard W, Ogle J. Women in academic medicine: A report
of focus groups and questionnaires with conjoint analysis. Journal of
Women’s Health. 2003;12:999-1008.
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Communicating Cancer: How to Convey What You Really Mean to Your Patients

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