• B ULLETI N • Volume 15, Number 1 | Winter 2008 • B ULLETI N • INSIDE THIS ISSUE Count on the Consistency of ACRO’s Efforts during a Year of Change . . . . . . . . . . . . . . . . . . 2 Machine Learning Algorithm Speeds IMRT Planning . . . . . 3 Shortfall in the Number of Medical Oncologists to Reach 34% by 2020 . . . . . . . . . . . . . . 4 ACRO and AMA Conducting Physician Practice Information Survey . . . . . . . . . . . . . . . . . . . 6 Focus on Scientific Inquiry to Contain Cancer-Care Costs . . 7 Views of the Presidential Candidates regarding the Healthcare Crisis. . . . . . . . . 8-10 Once upon a Time I Wrote a Book . . . . . . . . . . . . . . . . . . 11-13 Mark Your Calendar . . . . . . . 14 2008 Advertising Rates . . . . . 15 DO WE SEE P ATIENTS AS ‘CASES’ OR ‘BIOGRAPHIES’? A Sociological View of the Physician-Patient Relationship According to sociologist Carol A. Heimer, formerly of Northwestern University, in the Annual Reviews of Sociology, those who work in systems deal with “cases,” which requires determining protocols that govern the treatment of each case in a stream. However, in a less- structured system, a holistic “biography” is an alternative form of analysis. Physicians, of course, view their patients as cases. We do this because, according to Heimer, healthcare is not only a system but a social form that makes “a virtue of standardization.” She writes: “We gain efficiency by having routines that tell us how to think about and work with similar objects. By working with objects that are standardized and ignoring the features that make them different one from the other, we are able to streamline our work and eliminate the noise from differences that are not central to the tasks we are performing.” Outside the medical field, it may be necessary to view a person as a biography, which characterizes that person as unique. Thus, at separate times in our lives, we are either classified with others or considered one of a kind. Guidelines for medical procedures require that we consider our patients part of a category. Progress in the medical field would be impossible if we considered every patient— and, by extension, every patient’s disease—unique. We work efficiently if we consider each patient a case, but this conflicts with the patient who identifies him- or herself as an active, individual social being. Although Heimer wrote her article six years ago, her ideas still describe conditions in the healthcare field today. Medical institutions create routines that classify patients according to already established categories. For example, forms, organization schemes, and procedures support the notion of the patient as a case. With too little routinization, physicians may have “too few cues about where to direct their attention.” But too much routinization is “mind-numbing.” An analysis of situations at various levels of routinization can reveal what happens when individuals resist categorization. This is most likely to occur, says Heimer, when situations are “so mind-numbingly overinstitutionalized that participants ignore routines, situations are so underinstitutionalized that participants must Machine Learning Algorithm page 3 B ULLETI N WWW. ACRO . ORG • 1 ACRO is Your Organization Help it Thrive! To become a member or to sign up a friend, please contact the ACRO office at (301) 718-6515. continues on page 5 Oncologist Shortage page 4 Headlines page 8
Transcript
•BULLETIN•
Volume 15, Number 1 | Winter 2008
•BULLETIN•
INSIDE THIS ISSUE
Count on the Consistency ofACRO’s Efforts during a Year ofChange . . . . . . . . . . . . . . . . . . 2
Shortfall in the Number ofMedical Oncologists to Reach34% by 2020 . . . . . . . . . . . . . . 4
ACRO and AMA ConductingPhysician Practice InformationSurvey . . . . . . . . . . . . . . . . . . . 6
Focus on Scientific Inquiry toContain Cancer-Care Costs . . 7
Views of the PresidentialCandidates regarding theHealthcare Crisis. . . . . . . . . 8-10
Once upon a Time I Wrote aBook. . . . . . . . . . . . . . . . . . 11-13
Mark Your Calendar . . . . . . . 14
2008 Advertising Rates . . . . . 15
DO WE SEE PATIENTS AS
‘CASES’ OR ‘BIOGRAPHIES’?A Sociological View of thePhysician-Patient Relationship
According to sociologist Carol A.Heimer, formerly of NorthwesternUniversity, in the Annual Reviews ofSociology, those who work in systems dealwith “cases,” which requires determiningprotocols that govern the treatment of eachcase in a stream. However, in a less-structured system, a holistic “biography” isan alternative form of analysis.
Physicians, of course, view theirpatients as cases. We do this because,according to Heimer, healthcare is not onlya system but a social form that makes “avirtue of standardization.” She writes: “Wegain efficiency by having routines that tellus how to think about and work with similarobjects. By working with objects that arestandardized and ignoring the features thatmake them different one from the other, weare able to streamline our work andeliminate the noise from differences thatare not central to the tasks we areperforming.” Outside the medical field, itmay be necessary to view a person as abiography, which characterizes that personas unique. Thus, at separate times in ourlives, we are either classified with others or
considered one of a kind. Guidelines formedical procedures require that weconsider our patients part of a category.Progress in the medical field would beimpossible if we considered every patient—and, by extension, every patient’sdisease—unique. We work efficiently if weconsider each patient a case, but thisconflicts with the patient who identifieshim- or herself as an active, individualsocial being.
Although Heimer wrote her article sixyears ago, her ideas still describeconditions in the healthcare field today.Medical institutions create routines thatclassify patients according to alreadyestablished categories. For example, forms,organization schemes, and proceduressupport the notion of the patient as a case.With too little routinization, physicians mayhave “too few cues about where to directtheir attention.” But too much routinizationis “mind-numbing.” An analysis ofsituations at various levels of routinizationcan reveal what happens when individualsresist categorization. This is most likely tooccur, says Heimer, when situations are “somind-numbingly overinstitutionalized thatparticipants ignore routines, situations are sounderinstitutionalized that participants must
Machine Learning Algorithm page 3
BU L L E T IN W W W.A C R O.O R G • 1
ACRO is Your OrganizationHelp it
Thrive!To become a member or to sign up a friend, please contact the ACRO office at (301) 718-6515.
continues on page 5
Oncologist Shortage page 4 Headlines page 8
INTERESTING TIMES
2 • W W W.A C R O.O R G BU L L E T IN
ACRO BULLETIN
Advertising Rates 2008
Comprehensive socioeconomic, political,and professional news affecting thedaily practice of radiation oncology
Official Newsletter of theAmerican College of Radiation Oncology
5272 River RoadSuite 630
Bethesda, MD 20816Telephone: (301) 718-6515
Fax: (301) 656-0989
Published: Winter • Spring • Summer • Fall
Payment must accompany order. Makechecks payable to American College ofRadiation Oncology (ACRO), or paymentmay be made by credit card (MasterCard,Visa, or American Express); call for details.Payment should be submitted to “ACROBulletin Advertising” to the addressshown above. Advertisers who cancel adswill not receive refunds.
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Classified Advertisements50 words or less $90; 51-100 words, $135;each word over 100, $1 per word.Box service is $30 additional per insertion.No multiple insertion or agency discounts.
The ACRO Bulletin accepts classified advertising for:
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Ads must be submitted, typed, anddouble-spaced. Initials or abbreviationsequal one word. Telephone numbers witharea code equal one word.
Technical questions regardingadvertisements can be addressed to ACROat (301) 718-6515.
Comprehensive socioeconomic, political, and professional news affecting the daily practice of radiation oncology
Editor A. Robert Kagan, MD
Chairman D. Jeffrey Demanes, MD
President Louis Munoz, MD
Vice-President Michael Kuettel, MD, PhD
Secretary/Treasurer William Rate, MD, PhD
Executive Director Norman Wallis, PhD
Managing Editor Stuart J. Birkby
Published: Winter • Spring • Summer • Fall
The ACRO Bulletin welcomes letters, comments, sug-gestions, and submissions of articles for consideration.The Bulletin reserves the right to edit letters for clarity
and length.
The opinions and views expressed in the Bulletin are not necessarily those of the
American College of Radiation Oncology.
Please send your correspondence to:
A. Robert Kagan, MDEditor, ACRO BulletinAmerican College ofRadiation Oncology
5272 River Road, Suite 630Bethesda, MD 20816
(301) 718-6515 • www.acro.org
•BULLETIN•
COUNT ON THE CONSISTENCY OF ACRO’SEFFORTS DURING AYEAR OF CHANGEby A. Robert Kagan, MD, FACRO
By the time you read this ACROBulletin, the primary-election season willbe in full swing. By the end of thispolitical process in November, we willknow which person will become our newpresident on January 20, 2009. Asradiation oncologists, we will all have thesame question: Will our nation’shealthcare system change drasticallyover the next four years? It is hard forany one of us to predict accurately. Ournation has many issues to deal withinternationally and domestically. Ourhealthcare system is in crisis but ourpoliticians and our new leader will befaced with competing concerns—the warin Iraq, the economy, the increasing priceof oil, the Social Security system, andglobal warming, just to name a few.Whether our new president is a formerpresident’s wife, a big-city mayor, ayoung African-American senator, aMormon, or a television actor, healthcarewill remain a critical issue. Thus, onething needs to be consistent—our unitedvoice under the ACRO umbrella. We need
to keep up the effort to addresshealthcare and continue to prod ourleaders at the federal and state level tomake effective, fair changes forphysicians and patients. Undoubtedly,the next 12 months will bring changes,but ACRO will continue to represent usand work toward the improvement of ourfield. It should be an interesting year. g
Dr Kagan is the Editor of the ACROBulletin and past-president of ACRO.
FROM ONE DAY TO MINUTES
BU L L E T IN W W W.A C R O.O R G • 3
MACHINE LEARNING ALGORITHM
SPEEDS IMRT PLANNING
Radiation oncologists are often frustrated by the largeamount of time it takes to design a precise treatment plan. Yetthis process is necessary to achieve therapy effectiveness and todecrease the potential for adverse side effects. When it comes tospeeding up intensity-modulated radiation therapy (IMRT),however, an electrical engineer at Rensselaer PolytechnicInstitute in Troy, NY, thinks he might have the answer.
Approximately one year ago, Physics in Medicine andBiology published an article describing a machine learningalgorithm that could determine 20 settings pertaining to IMRT.Previously, these settings were determined manually andpainstakingly from a series of computer-tomographic images insuch a way that a tumor, but not the surrounding healthy tissue,would receive radiation. This could take an entire day forcomplicated head-and-neck cancers. Richard Radke, PhD, anassociate professor of electrical, computer, and systems
engineering at Rensselaer Polytechnic Institute, recognized thatIMRT is precise but “difficult mathematically” and that there “isa huge optimization problem to solve in order to follow thedoctor’s treatment plan.”
Ten-Minute Planning for Prostate CancerConsequently, Dr Radke and his assistants attempted to
develop algorithms that let computers “learn” relationships inlarge datasets. Their research revealed that 14 of the 20 therapyparameters had almost no effect on treatment outcome and thatanalysis of a decreased set of sensitive parameters could resultin a workable plan. The resulting machine learning algorithmwas tested with 10 prostate-cancer patients. For each patient,clinically appropriate treatment planning took five to 10 minutes.Dr Radke hopes he can soon expand his research to includethose with head-and-neck cancers
Dr Radke’s project is a part of the Bernard M. Gordon Centerfor Subsurface Sensing and Imaging Systems, which is amultiuniversity program, funded by the National ScienceFoundation, to develop new technologies for finding objectshidden by something opaque. g
Growth.
Oral OncologyPharmacy.
Evidence-BasedMedicine.
Clinical Research.
Stay at the leading edge of cancer care. We’ll help.US Oncology, headquartered in Houston, TX, supports one of the nation’s largest cancer treatment and research networks. US Oncology provides extensive services and support to more than 1,100 affiliated community-based oncologists nationwide to help them:
n Expand their offering of the most advanced treatments and technologies,
n Build integrated community-based cancer care centers,
n Improve their therapeutic drug management programs,
n Create and share operational and clinical best practices with their physician peers,
n Obtain their infusable, injectable and oral oncology and supportive care drugs through a secure distribution system featuring leading e-pedigree technology,
n Participate in Phase I – Phase IV cancer-related clinical research studies,
n And much more.
US Oncology-affiliated physicians provide care to more than 550,000 patients annually in more than 443 locations, including 91 cancer centers and radiation oncology facilities in 39 states.
The demand for medical oncologists will rise by 48%, butthe supply will only rise 14%, creating a 34% shortfall in thenumber of medical oncologists needed in the workforce by 2020.These conclusions come from a study performed by theAmerican Association of Medical Colleges and reported recentlyin the Journal of Clinical Oncology Practice.
The 2020 forecast was performed using data from the 2005American Medical Association master file to establish thenumber of medical oncologists needed in the United States. Thenumber of patients projected in the year 2020 was forecasted byNational Cancer Institute cancer incidence and prevalenceprojections. The number of patient visits was determined fromthe National Cancer Institute analysis of Surveillance,Epidemiology, and End Results database. There was noadjustment for the ever lengthening regimens of palliative oradjuvant chemotherapy, nor was there any adjustment forpatients with metastatic cancers who may live longer as theresult of palliative treatment, thus requiring increased patientvisits in the future.
In the Journal of Clinical Oncology Practice article, authorErikson Salsberg, MD, proposed increased use of nursepractitioners, physician assistants, and delays in retirement for
current medical oncologists. He also proposed increased use ofprimary-care physicians to monitor patients during and afterchemotherapy.
A Role for Radiation OncologistsACRO leaders wonder if it would not be a good time for
radiation oncologists to develop a more comprehensive role inthe management of cancer patients. Radiation oncologists arefully trained and capable of providing informed guidance forvirtually all solid-tumor oncology and could easily direct themedical care for cancer patients during all aspects of theirdisease. Given the need, there is every reason for radiationoncologists to see cancer patients in consultation and design aprogram for work-up and management of their malignancy evenif it did not initially include delivery of radiation therapy.
A long-time leader in radiation oncology, Luther Brady, MD,teaches residents that radiation oncologists are, first andforemost, cancer physicians who use radiation to treat cancerand that radiation treatment just happens to be one effectiveform of cancer therapy. As with other oncology disciplines, thereis no reason radiation oncologists cannot oversee the oncologypatient-care plan and give proper guidance to the cancer patientfor surgery, chemotherapy, immunotherapy, and palliative care.
Radiation oncologists must step up and provide moreconsultative services, more direct patient care, and more cancerpatient-care general oversight than ever before. This new andimportant role may be one of the most important challenges forradiation oncology and, when realized, could benefit countlesscancer patients by 2020. g
Dr Schilling practices at the Community Cancer of NorthFlorida in Gainesville.
ACRO WELCOMES NEW MEMBERS!ACRO is pleased to welcome the following individuals who became new members in 2007:John Vito Antonucci, MD, Royal Oak, MIEbrahim Ashayeri, MD, Washington, DCAlan Baker, Cherry Hill, NJRandy Blackburn, Warner Robins, GAThomas P Boike, MD, Dallas, TXMark Bonnen, Lake Jackson, TXMichael Burke, MD, Scranton, PAMichael D. Chan, MD, Boston, MASea Chen, MD, PhD, Chicago, IL Eric E. Chung, MD, Lake City, FLJohn Copeland, Mobile, ALWilliam A. Dezarn, Cary. NCPaul Goetowski, MD, Myrtle Beach, SCVictor J. Gonzalez, MD, Salt Lake City, UTVivian D. Griffin, MD, Chicago, ILDaniel Hamstra, Ann Arbor, MIJuan Herrada, MD, El Paso, TXShane Hopkins, MD, Buffalo, NY
Saad M. Ibrahim, MD, Chicago, ILShruti Jolly, MD, Royal Oak, MIBrian Lawenda, San Diego, CAAlbert Lee, Du Bois, PAJames L. Leenstra, MD, Rochester. MNStella Ling, MD, Wilmington, OHGina Mansy, MD, San Diego, CAKilian S. May, MD, Buffalo, NYEdward F. Miles, MD, Durham, NC Layth Y Mula Hussain, MD, Amman,
JordanKevin Murphy, MD, La Jolla, CATodd Pawlicki, PhD, LaJolla, CABushra Rana, Fredericksburg, VAMaria-Amelia M. Rodrigues, Coconut
Grove, FLGregory A. Russo, MD, Philadelphia, PAArif Y. Shaikh, MD, Chicago, IL
Michael K. Shehata, MD, Lexington, KYReza Shirazi, San Diego, CAWilliam Sigmon, Jr, MD, Hickory, NCJonathan B. Strauss, MD, Chicago, ILChester T. Szerlag, MBA, Chicago, ILBernard Taylor, MD, Longview, TXMark Thompson, DO, Corpus Christi, TXAnthony Tran, MD, Texarkana, TXJonathan D. Tward, MD, PhD, Salt Lake
City, UTAntonio Vigliotti, MD, Davenport, IAKent Wallner, MD, Seattle, WAShih J. Wei, MD, Indianapolis, INHarvey B. Wolkov, Sacramento, CABrian K Yeh, MD, PhD, Los Angeles, CA g
'CASES' OR 'BIOGRAPHIES'?
BU L L E T IN W W W.A C R O.O R G • 5
act without much guidance, or situations in .. . conflict . . . require participants to decidewhich rules and routines are mostappropriate . . . .”
Patient as 'Case' or 'Biography'Given Heimer’s sociological
perspective, a cancer patient goesthrough alternating, dual identifications.Physicians identify patients thoughmedical records and colleaguediscussions. The patient’s family, incontrast, sees the patient as a creaturewith “interpersonal competences . . . apersonality.” A biography, then, is “anentity that has a future, and so has possiblelives outside its present category . . . .”
Physicians, however, must maintainsome distance from their patients,recognizing that they cannot apply alltheir efforts toward one individual. Thepatient's family may subsequently view
physicians as individuals who identifytheir patients as "numbers." Yet, when thecancer patient returns to the comparativelyless routinized home, the family may findit difficult to remember when and howmuch medications are given, whentherapy should be administered, andwhen supplies must be repurchased atthe corner drug store. Thus, routine in thehealthcare setting ensures timely,appropriate care, although it can alsocreate a reluctance to apply newtechnology or lead to confusion whensomething unanticipated occurs.
This case–biography dichotomy hasits roots in Marxist existentialist thought,which holds that routinization (and theclassification of a patient as a case) leadsto an understanding of history; lessroutine (and the classification of a patientas a biography) leads to an understandingof individuals. Heimer suggests that thetwo concepts cannot be applied
simultaneously, thus the patient–physicianrelationship remains a potential source ofmisunderstanding. g
Editor’s note: A more detaileddescription of this concept, and itsapplication to neonatal care and tosettings outside medicine, can be found inHeimer’s article, “Case and Biographies:An Essay on Routinization and the Natureof Comparison” in the Annual Reviews inSociology 2001; 27: 47-76.
continued from page 1
70 MEDICAL SPECIALTIES WORKING TOGETHER
6 • W W W.A C R O.O R G BU L L E T IN
ACRO AND AMACONDUCTING
PHYSICIAN
PRACTICE
INFORMATION
SURVEY
For the first time in nearly a decade,ACRO, the American Medical Association(AMA), and more than 70 other medicalspecialty societies have worked togetherto coordinate a comprehensive multi-specialty survey of America’s physicianpractices. The purpose of the survey is tocollect up-to-date information onphysician practice characteristics topositively influence national decisionmakers. Thousands of practices will besurveyed in 2007 and 2008 from virtuallyall physician specialties to ensureaccurate and fair representation for allphysicians and their patients.
This is unique because it exploresboth the clinical and business side ofmedical practice. This information isimportant for the nation’s policymakers tolearn what is truly involved in running apractice that provides expert patient care,while operating a business that issustainable. A complete understanding ofthe landscape and the requirements fortoday’s care is critical. These data willallow physicians to articulate practiceconcerns to national policymakers thatwill lead to policy initiatives in the shortterm and will allow future generations ofdoctors to continue providing superiorcare to their patients.
There is a small section in this studypertaining to practice expenses and theamounts that are attributable to you.Please encourage your staff to make thesenumbers available. The Centers forMedicare and Medicaid Services recentlyannounced that the results of this studyare considered critical to update physicianpayment. This is a vital part of theresearch, and we need to have accurateand complete data. This informationremains confidential. The survey firm will
not identify any individuals or entitiesparticipating in this research to any of theparticipating organizations.
Dmrkynetec has been retained toconduct the survey among arepresentative random sample ofpractices in each of the participatingspecialties. The survey is an important andnecessary vehicle for positive change.Please watch for this survey and do yourpart in completing it in a thorough andaccurate manner if selected to representour specialty. g
SM
Þwww.acro.org
Check Out Our Web Site
Advancing Communication ...
Realizing Opportunities ...
RSNA ANNUAL ORATION IN RADIATION ONCOLOGY
BU L L E T IN W W W.A C R O.O R G • 7
FOCUS ON
SCIENTIFIC INQUIRY
TO CONTAIN
CANCER-CARE
COSTS, SAYS
DR LICHTER
Although primarily an organization ofdiagnostic radiologists, the RadiologicalSociety of North America (RSNA) hasalways included radiation oncologists aspart of its “radiology family.” Consequently,during its annual meeting, theorganization has always featured anAnnual Oration in Radiation Oncology. Atthe most recent scientific assembly, heldthis past November at Chicago’sMcCormick Place, the RSNA invited AllenS. Lichter, MD, from the University ofMichigan, to talk about the economics ofcancer care.
With cancer costing the United Statesapproximately $263 billion, Dr Lichter saidpolicymakers were focusing on “value-based purchasing,” noting that cancer-treatment advances frequently trumpetedin the popular media on further analysisreveal only the adding of a few weeks or
months to the life of cancer patients. Hesuggested that physicians involved incancer treatment often become toofocused on reimbursement problems andcould better use their time and energy tocontribute by “supporting andparticipating in research for bettertreatments, focusing on evidence-basedpractices, delivering high-quality care,communicating effectively with patients,and not shying away from hard socialquestions.”
Specifically, Dr Lichter believesquantitative scientific inquiry is the bestway to identify not only the most effectivecancer treatments but also thoseindividuals most likely to benefit from thetreatments. “Recommendations based on
solid scientific evidence promote high-quality care and decrease the potential forwasteful, ineffective, and possiblyharmful treatments,” he said. “We need toexpand efforts to develop guidelines andenhance their implementation in practice.The paradigms for treatment and fororganizing delivery of care are shifting.We should lead the way.”
Dr Lichter was the director of theRadiation Therapy Section of the NationalCancer Institute Radiation Therapy Branchbefore moving to the University ofMichigan. Approximately three years ago,he received the American Society forTherapeutic Radiology and OncologyGold Medal. g
For Information on the ACROPractice AccreditationProgram Please Contact: Medical University of Ohio
3000 Arlington Ave.Toledo, OH 43614
Program Administrator Jeanne Carroll (419) 383-4462
McCormick Place Chicago, IL.Photo Courtesy of Chicago Convention & Tourism Bureau
8 • W W W.AC RO.O R G BU L L E T IN
HEADLINES 2008
Hillary ClintonNearly every physician remembers the
former First Lady’s failed attempt to establisha universal healthcare system approximatelyone decade ago. Now, as a presidentialcandidate and Democratic senator from NewYork, Clinton has a new, less drastic plan. Sheproposes the use of tax credits based onhealth-insurance premiums to ensure that working familiesnever have to pay more than a limited percentage of theirincome for healthcare. Small businesses will also be given taxcredits to provide healthcare benefits to their employees. Healthinsurance will be portable and not end if an individual loses hisor her job. Additionally, the insurance companies will not be ableto deny coverage; they will be legally obligated to provide healthinsurance to anyone who applies, even for those individuals withpre-existing conditions.
Mike HuckabeeThe former Republican governor of
Arkansas does not favor a universalhealthcare system but nevertheless proposes“a complete overhaul.” He has explained thathe favors a move from employer-based toconsumer-based healthcare, with anemphasis on preventive care since,according to his data, the money spent to treat preventablechronic disease takes 80% of the total healthcare costs. He sayshealthcare can be made more affordable by reforming medicalliability, adopting electronic recordkeeping, making healthinsurance portable from job to job, making health savingsaccounts available to everyone, and establishing health-insurance tax deductions for individuals, families, and smallbusinesses. Low-income families would receive money ratherthan deductions. Huckabee does not believe the governmentshould totally control healthcare.
John McCainThe Republican senator from Arizona
believes insurance reforms should increasethe variety and affordability of insurancecoverage available to American families byfostering competition and innovation. Heproposes changing the tax code to provideall individuals with a $2,500 tax credit toincrease incentives for insurance coverage. Families would beable to purchase nationwide systems offered in more than onestate. This, he believes, would heighten competition among thehealth-insurance companies, which would lead to elimination ofexcess overhead and a decrease in administrative costs. Statesreceiving Medicaid would be required to develop a financial “riskadjustment” bonus to high-cost and low-income families tosupplement tax credits and the Medicaid funds. Finally,Americans would be able to get health insurance from anyorganization or association that offers it, including churches andprofessional associations. All health plans would have to meetrigorous standards.
Barack ObamaOn May 27, 2007, in Iowa City, the
Democratic senator from Illinois said: “I . . .believe that every American has the right toaffordable healthcare. I believe that themillions of Americans who can’t take theirchildren to a doctor when they get sick havethat right . . . . We now face an opportunity,and an obligation, to turn the page on the failed politics ofyesterday’s healthcare debates. It’s time to bring togetherbusinesses, the medical community, and members of bothparties around a comprehensive solution to this crisis, and it’stime to let the drug and insurance industries know that whilethey’ll get a seat at the table, they don’t get to buy every chair.”Senator Obama says his plan would save each American family$2,700 a year by providing affordable, comprehensive andportable health coverage for every American. This would occurprimarily though modernizing of the healthcare system and thepromotion of preventive care to contain spiraling costs.
VIEWS OF THE PRESIDENTIAL CANDIDATES REGARDING THE
HEALTHCARE CRISIS IN AMERICA
Editor’s Note: The presidential election season is upon us, and many of us probably think it has gone ontoo long already. In 2007, candidates were traveling across the nation in an attempt to get their party’snomination this summer. Therefore, to start 2008, the ACRO Bulletin has replaced its regular “Headlines”feature of news for the radiation oncologist with a brief overview of the positions on healthcare of thecandidates who are still running for president. Much of this information was gleaned from the officialwebsites of each candidate. While the race has tightened considerably since December, and many haveleft the race, we felt it worthwhile to present all candidates' views on this important manner.
The Contenders (as of February 1, 2008)
BU L L E T IN W W W.AC RO.O R G • 9
HEADLINES 2008
Ron PaulThe Republican congressman from
Texas, and the only physician among thepresidential candidates, wants to “take back”the healthcare system from the federalgovernment, which “decided long ago that itknew how to manage your healthcare betterthan you and replaced personalresponsibility and accountability with a system that putscorporate interests first.” The federal government, he believes, isan inefficient manager of healthcare and would not suddenlybecome efficient if universal healthcare was instituted. Hesupports tax deductions for medical expenses, eliminating offederal regulations that discourage small businesses fromproviding health coverage, allowing physicians to collectivelynegotiate with insurance companies to drive down costs, makingevery American eligible to set up a health savings account, andreforming licensure requirements so pharmacists and nursescan perform some basic healthcare duties.
continues on page 10
Mitt RomneyThe former Republican governor of
Massachusetts believes the nation'shealthcare system should be overhauled.First, he would deregulate the state marketsand make healthcare expenses taxdeductible, thus eliminating the specialtreatment now given to employer-providedhealth plans. States would be given the flexibility to spend theirMedicaid dollars in any way they see fit. Second, he wouldreallocate money now being spent to give the uninsured freeemergency care to buy private insurance for the needy. This issimilar to a plan Romney helped establish in Massachusetts.Additionally, Romney would institute federal-mandated caps onnon-economic and punitive damage awards to eliminatefrivolous lawsuits.
The Also-Rans (as of February 1, 2008)
John EdwardsThe former Democratic senator from
North Carolina supports universal healthcarecoverage. He plans to establish universalcoverage by requiring employers to eithercover their employees or help pay for theirhealth insurance. He would make healthinsurance affordable by creating new taxcredits and expanding Medicaid. He envisions regional“healthcare markets,” which would be designed to giveAmericans shared bargaining power to purchase an affordable,high-quality plan among an increased number of choices.Ultimately, all Americans would be required to have healthcareinsurance.
Rudy GiulianiBest known for being the Republican
mayor of New York when that city was struckby terrorist attacks on September 11, 2001,Giuliani proposes a Health Insurance Creditto low-income Americans that would becoupled with other revenue sources such asMedicaid and employer contributions tomake coverage more affordable to millions of the uninsured. Heclaims that the universal healthcare plans championed by theDemocratic candidates are just forms of “socialized medicine.”Tax deductions for citizens are a part of the former mayor’s plan.
Joe BidenThe Democratic senator from Delaware
says healthcare, along with the war in Iraq,would be his top priorities if he becomes thenext president. He has stated that he wouldconvene a national gathering of healthcarestakeholders from labor, business, themedical field, and all levels of governmentwithin the first 90 days of his administration. His CARE plancomprises four goals: coverage for all children, universal accessfor all adults, reinsurance for catastrophic cases, andencouragement of preventive care and modernizing of themedical field. Unlike other Democratic candidates, he does notcall for universal health coverage.
Chris DoddDodd, the current Democratic senator
from Connecticut, would create a Health CareGeneral Fund (HCGF) and require employersto either cover their employees or contributeto the fund. According to his plan, individualsnot covered by employers would be requiredto purchase insurance from the HCGF at aprice based on his or her fixed percentage above poverty.Overall, healthcareinsurance premiums would be madeaffordable by spreading risk more evenly, reducingadministrative costs, and establishing incentives for greater useof information technology. Health insurance would be portable,and insurance-company discrimination based on medicalcondition would be illegal.
HEADLINES 2008
10 • W W W.A C R O.O R G BU L L E T IN
continued from page 9
Mike GravelAs of this writing, Alaska Republican
Senator Mike Gravel is not even on the ballotin all the state primaries. Nevertheless, hesoldiers on in his bid to become the nextpresident. He claims that, under hisadministration, Americans would paynothing for healthcare. Instead, thegovernment would issue vouchers to every American each year.The vouchers would cover a modest co-pay and deductible.Individuals could pay for more coverage if they so choose. Thevoucher system would be supported by a retail sales tax.
Duncan HunterThe Republican congressman from
California favors bringing “the consumerback into the healthcare equation.” He plansto do this by letting citizens purchase healthinsurance across state lines and allowingcitizens to make informed health-insurancechoices by requiring hospitals and insurancecompanies to post their fee schedules online. Additionally, hewould designate four test hospitals that would be deregulatedand allowed to implement system-side protocol improvements,thus bringing innovation rapidly and safely to the healthcaresystem.
Dennis KucinichThe Democratic congressman from Ohio
claims to be the only candidate for presidentwith a plan for a universal, singlepayer, not-for-profit healthcare system. He maintainsthat the for-profit, private insurers wastebillions of dollars on administrative costs, aswell as providing exorbitant amounts ofcompensation for insurance company CEOs. According to hisdata, the administration of the healthcare system takes nearlyone-third of all money spent for healthcare. By eliminating thiswaste, every American could have comprehensive coveragewithout paying any increased amount for healthcare.
Bill RichardsonThe Democratic governor of New
Mexico, considered by many to be the mostqualified, based on previous experience inthe government, to be the next president,believes working families and smallbusinesses should be able to purchase healthinsurance through the same plan used by
members of Congress today. Americans more than 55 years oldwould be able to purchase Medicare coverage. The quality ofhealthcare for veterans would be improved. Eventually, allAmericans would be required to have health insurance, and allemployers would pay their fair share of employee healthcarecosts. He has also stated that he would prohibit banks andcredit-card companies from charging outrageously high interestfor medical-care debt. He would streamline healthcareadministration and support healthier lifestyles and encourageinvestment in preventative care. Prescription-drug costs wouldbe negotiated by the federal government through Medicare. Thebudgets of the National Institutes of Health and the NationalCancer Institute would be increased.
Tom TancredoThe Republican congressman from
Colorado believes that the immigrationproblem and the healthcare crisis are related.He believes immigration enforcement wouldsave money in the healthcare system anddrive down costs by lowering the number ofuninsured. He claims that illegal immigrantshave indirectly forced 84 hospitals in California to close. Forcitizens and legal residents who can not afford health insurance,Tancredo supports association health plans that would unitesmall businesses and give them the leverage to obtain lowercostinsurance. The state governments, with the help of federalsubsidies, would be primarily responsible for managing thehealthcare of their unemployed citizens.
Fred ThompsonThe former Republican senator from
Tennessee and, more recently, character actorin movies and on television, believes allAmericans should be able to get healthinsurance that is affordable, portable, andfully accessible. He rejects a “one-size-fits-all,Washington-controlled program” that would“ignore the cost, inefficiency, and inadequate care that such asystem offers.” He believes a healthcare system must providemore opportunities for Americans to choose an insurance optionthat best meets their needs. Also, it can be made cost effectivethrough an emphasis on preventive medicine, chronic-caremanagement, personal responsibility, streamlined regulations, andthe widespread use of medical information technology. He alsorecognizes the importance of investing in medical research. g
PERSONAL VIGNETTE
BU L L E T IN W W W.A C R O.O R G • 11
cancer, it is a good cancer.”
Then came the question, “How evilmust a man be to make a cancer good?”
Such interchanges never made it intothe book, but they left me smiling, and Istill marvel at their insights. Their wordswould come back to me later in mycareer.
Chapter Lost in AccidentIn Chicago, I rode to and from the
hospital each day on an elevated train.One evening, on my way home, I wasstanding in the train car, clinging to ametal pole for support. My chapterdealing with cancer of the cervix was in amanila folder tucked under my arm.Suddenly, a terrible crash! My train hadcollided with the rear of another trainstopped at a station. With the crash, I flewforward and landed on a pile of people.The manila folder with the loose pages ofmy precious chapter went flying all overthe car. In the confusion and panic thatfollowed, I, like everyone else, rushedfrom the train. Then I remembered thechapter and rushed back into the train.The lights were out, and, in the dark, I gotdown on my hands and knees to retrievemy precious pages.
Just then an emergency medicaltechnician came in with a flashlight. Hesaw me on my hands and knees andasked me if I was OK. I said, “Yes, I’mtrying to collect the cervix chapter.”Immediately, he called for a stretcher. Hethought I had suffered a blow to my head.He made me leave the train and wouldnot allow me to re-enter the car. I rewrotethe chapter, but it was never as good as ithad been.
Thank goodness I had married aformer speech therapist with an excellentknowledge of grammar. My wife, Rose,proofread every sentence to correct mypoor grammar and spelling to assure thatmy writing was clear and simple.
After four years of blood, sweat, andtears, all of the typing, proofreading,photos, tables, and drawings were
ONCE UPON A TIME
I WROTE A BOOK
by William T. Moss, MD
Editor’s note: According to LutherBrady, MD, one of the founders ofACRO, in “Radiation Oncology:Contributions of the UnitedStates in the Last Years of the20th Century” (Radiology 2001;219:1–5), William T. Moss, MD,Juan del Regato, MD, Gilbert H.Fletcher, MD, and Henry Kaplan,MD, laid the “basic foundations inclinical radiation oncology.”TheACRO Bulletin is pleased to pub-lish a series of vignettes writtenby Dr Moss describing, from hispersonal perspective, his life as aradiation oncologist.Thesevignettes take on the form ofextended diary entries describingwhat seems to be a simpler timefor those in the field of radiationmedicine.This is the final of threeinstallments. Here Dr Moss recallshis thoughts and perspectives ashe looks back on his career as aradiation oncologist. Especiallyintriguing to him was the conceptthat there are “good” cancers.(The first installment, “Missouri,then Manchester,” was printed inthe Summer 2007 issue of thisnewsletter, followed by “FromParis to Chicago,” printed in theFall 2007 issue.)
While I was a trainee at theFoundation Curie in Paris, I came across amarvelous small book that beautifullydescribed the effects of radiation ontissues, written in simple, easy-to-understand French. I decided it should bemade available to American trainees whocould not read French. I started totranslate it.
This turned out to be a much hardertask than I had supposed. A year later, Ihad produced what I thought was a goodtranslation and mailed it to a publisher. Itwas rejected with no explanation. And soit went with four other publishers, threeof whom never looked at the translation.Then I discovered translations are notpublished unless large sales are assuredsince the publisher of a translationusually has to share earnings with theoriginal publisher. That experience mighthave soured a less hardheaded personagainst trying to write a book. But severalyears later, I was back at it.
This time the book was to be myown, designed for physicians in radiationoncology. It was to be a gathering of factsand ideas, some of my own and somefrom others, molded into an easilyunderstood format emphasizing thereasons for certain aspects of patient care.
I just started writing. I cannot beginto tell you how many false starts I hadbefore I began to like what I saw. I told noone but my family because I fearedfailure. I might run out of steam, thepublisher might not like the way I wrote,or a good book on the same subjectmight be published just before mine wasfinished. Despite my fears, the book soonbecame an all-consuming obsession,filling virtually every minute of my free time.
Every night I would collect myinformation (reprints and scribblednotes). I would spread them out on thekitchen table and try to put it all together.My constant concern was that I was notwriting well enough. I wrote and rewrotetime and time again. I feared I wouldnever make it good enough. My childrensensed my concern and joined me at thekitchen table to do their homework.
One evening, one of my childrengreeted me with, “Dad, did you see anygood cancers today?”
After a moment’s reflection, I replied,“There are no good cancers.”
Then the other child piped up, “Yes,there are. If an evil man is killed by a continues on page 12
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12 • W W W.A C R O.O R G BU L L E T IN
completed, but I was so attached to themanuscript that I did not want to releaseit. Finally, one of my sons hand carriedthe precious package to the publishinghouse in St Louis. The employees at theentrance to the publishers were hesitantto believe that anyone would deliver amanuscript this way. Once they openedthe box and recognized the contents, theytreated him to a cup of coffee and adoughnut and saw that he got back to theairport.
Still, I could not relax. What if thepublishers refused to publish it? Abouttwo months later, they notified me thatthey would be delighted to publish it andstated it was one of the best writtenmanuscripts they had seen.
About 12 months later after manycorrections and proofreadings, the editorof the company, traveling throughChicago on business, scheduled a lunchwith me and handed me the first copy ofmy book. That evening, my wife and I hadchampagne at dinner. Then she remindedme that unfavorable reviews might yettrash my book. Would the suspense neverend?
The Good Cancer and the Evil ManLater in my career, my children’s
words about “good” cancers strikingdown evil men came back to me. I was atmy office desk catching up on the day’sbusy schedule when a surgeon I hardlyknew called. He had a “special” patient hewanted to refer for treatment. Hedescribed the patient as a man in his 60swho had lung cancer.
As the surgeon told me the patient’sstory, it became clear he was hesitant toreveal the patient’s name. I hadexperienced such reluctance before onlyto find the doctor was describing his ownillness and wanted to know myrecommendations before consenting totreatment. So I asked, “Are you thepatient?”
He chuckled and said, “No.” Thepatient was a well-known executive, a“Mr Jones,” who did not want it knownthat he had cancer. This was a sort ofgame some patients often play, and Iusually went along with it.
An appointment was made for “MrJones” to see me. The next day, he andhis associate arrived with radiographsand medical records. I reviewed the
information, then examined and talkedwith the patient. He was a well-groomed,gray-haired, nicely tanned gentleman. Hisyoung, hefty associate was always at hisside.
I spoke quite frankly to “Mr Jones”about his cancer and the palliative valueof radiation treatments, then asked him ifhe had any questions. He asked how longI judged he had to live. I told him I had noidea, but six months or so would be myguess. He then added, “All I want is to liveto see my daughter graduate from collegein about three months.”
I replied, “We will do what we can.” Ischeduled him for irradiation the nextday.
As I left the room, the associate of“Mr Jones” came with me. He whisperedto me, “Do you know who he is?”
I said, “No.”
He then told me “Mr Jones” was theboss of the Chicago Mafia and that hewas the bodyguard. As we parted, heflipped his jacket back, revealing hispistol. I caught my breath then assuredhim that all would go smoothly.
A CALL FOR ‘CLINICAL PEARLS’Good research can be descriptive, but a bias has developed in the healthcarecommunity leading to the exclusion of such work by many peer-reviewed journals infavor of experimental studies with randomization, which many assume to be the onlyvalid design for obtaining new medical knowledge.
Consequently, the ACRO Bulletin is calling for submissions of “Clinical Pearls,” a250–500-word description of a special clinical case you believe is unique buthas not become part of the medical literature due to its exclusion from
experimental research.
Unusual case reports not only provide interesting reading but complementquantitative work through a process research methodologists refer to as “triangulation.”
Here is your chance to enhance medical knowledge by sharing a clinical case report withothers in radiation oncology.
Please send your submissions to: A Robert Kagan, MD; Editor, ACRO BulletinDepartment of Radiation Oncology; Kaiser Permanente Medical Group4950 Sunset Blvd; Los Angeles, CA 90027(323) 783-3865
PERSONAL VIGNETTE
BU L L E T IN W W W.A C R O.O R G • 13
I knew, as a physician, I could notconsider a patient’s moral character whendeciding the quality of care. But “MrJones” was a beast who had destroyednon-cooperating businesses, brutalizedpeople and even ordered them killed. Toprolong his life meant he could continuehis crimes. I felt I would be a party to hiscrimes by treating him. Even so, I had nochoice. I had to give him the best careavailable. So his therapy started.
Before his first radiation treatment,the bodyguard entered the treatmentroom first to verify that the room wasclear; then he beckoned his boss to enter.This was repeated each day. And each daythe guard waited to join “Mr Jones” as heleft for home.
The Mysterious PackageA week after the start of his
treatment, my wife answered our doorbellin response to a young man who said hewas told “to deliver a package to DrMoss’s home.”
When my wife started to questionhim, he set the large cardboard box onthe porch, said, “I was just told to deliverit,” and quickly left. She pried open thebox and found a card that said: “Inappreciation for your care,” signed “MrJones.” That evening, as we looked at thegift, she told me what had happened.What should I do with this gift of 12bottles of the finest scotch? Was “MrJones” really appreciative? Was he
making me indebted to him? Was hetrying to buy a longer or better life? Iimagined it was a bit of all of these. I mostcertainly was not going to anger the bossof the Chicago Mafia by returning his gift.The next day, I thanked him. He smiledand said, “I appreciate all you’ve done.” Itall appeared quite proper, but I could nothelp thinking otherwise.
The last day of treatment came threeweeks later. He had done well and wasalready breathing easier. I gave him aone-month return date and said, “Call meif you have trouble before then.” At thatinstant, I realized I should have qualifiedthat as “any medical troubles,” but it wastoo late to change it.
One month later, he returned right onschedule. A chest radiograph showedsubstantial improvement. He had gaineda few pounds and was feeling muchbetter. Again, he mentioned hisdaughter’s graduation.
I said, “I think you’ll make it.”
He was smiling as I gave him a three-month return date.
By three months, he had gained a bitmore weight. His energy level was nearlynormal. His daughter’s graduation hadbeen joyous. As he left with anotherthree-month return date, he stated, “Nowhelp me live to see my daughter’smarriage in four months.” This type ofbargaining by patients with cancer hasbeen described by Kubler-Ross as
common. It may even be beneficial sincepatients have hope, generally a goodattitude, sometimes eat better, and somethink they live longer. He left in goodspirits.
Three months later, he had lost a fewpounds and complained of low-back pain.Radiographs revealed that his cancer hadspread to his lumbar spine. Irradiation ofthis new spread was started. I believe heknew the end was just ahead, but hedesperately wanted to see his daughtermarried. The treatment diminished but didnot completely control his back pain, soarrangements were made for his long-time family physician to prescribe painmedication as needed. Though nothingwas said, I knew and he knew that it wasunlikely we would ever meet again. Hedid not live to see his daughter married.
I do not know how much I prolongedhis life nor what crimes he may havecommitted because of any prolongation.But a sense of chronic guilt stuck with mefor months as I wondered about mydecision to care for him. g
William T. Moss, MD, is currentlychairman emeritus of the Oregon Healthand Science University Department ofRadiation Medicine in Portland.
continued from page 12
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World Conference on Interventional OncologyJune 22–25, 2008Hyatt Regency Century PlazaLos Angeles, CA
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ACRO 2009Key Issues for Practicing Radiation Oncologists:
