Harvard/Stanford trained community practice Heme/Onc - Director of Hematology Research US Oncology - challenging white collar traditions with blue collar moxie
BTK inhibitors have transformed the lives of many patients with Chronic Lymphocytic Leukemia and other lymphomas. These drugs "exploded" onto the scene in 2013-2014 and have fundamentally changed the way we treat the disease. What many people don't know is how it all happened..
1/x True story that highlights the loss of autonomy and agency by physicians - the force that results in more burnout than any other:
A physician colleague of mine in a different practice that was recently acquired by a major financial firm was on back-up call…..
Conclusions: Washington post writing that physicians are overpaid is incredibly oblivious to the reality on the ground - we can’t find enough doctors to hire - and my practice is one of the good ones. Sounds like the market is broken.
Conclusion
#3
: financial investors who are consolidating ownership of medical practices is one of the worst developments in healthcare and will leave irreparable damage. Avoid such jobs!
Conclusion
#6
: a wise friend told me, “if you are not sitting at the table, you are likely on the menu.” Docs need to take back control of the practice of medicine or we will be eaten up by our financial masters.
Conclusion
#2
: autonomy is a value you don’t appreciate until you lose it. Working for an “overlord” that controls your time and effort and doesn’t appreciate your reality is a fast track for burnout
Conclusion
#5
: if you are “managed” by someone with far less education and experience than yourself and lacks a medical background - watch out - I’ve heard many stories over the years that are equally ridiculous.
Conclusion
#4
: physicians have delegated business decisions to others for so long that many are now just small pawns in the large machine: find a job where you are closer to the business decisions and you can affect your fate. You will be happier in the long run
5/x After 36 hours without sleeping- getting all of his work done early - he let his clinic know he was headed home early to get some sleep before his drive.
His “manager” told him he would need to use his allocated “vacation time/pto” if he planned to leave clinic early
You may not intend for us to do this on vacation but the reason the tweet went viral is that most of us have to do it that way. Our lives don’t give us big chunks of time to do this. This is our reality and why we reacted so strongly
#ENDmoc
@IranRevolut2018
Due to ongoing fallout- I don’t want to say publicly what happened - but you highlight the consequences appropriately. Physicians are viewed as “replaceable widgets” by corporate medicine. They believe the work will get done and frankly are ok with “cost reduction”
4/x he therefore adjusted his afternoon clinic. He had afternoon patients come in early and worked through lunch in order to finish early. Only two patients had visits cancelled.
By working efficiently and through lunch he was able to be done 2.5 hr early
He was in a surgical discipline and got called to help in a challenging case that kept him in the or from midnight until 5am. The medical emergency resulted in major trauma to young woman but saved her life
Since clinic started only a few hours later he stayed at the hospital and then began seeing patients at 8am as though it was a regular day.
He was planning on driving to Portland after work for a family event but was concerned about sleep deprivation and a long drive
Now accepting nominations for “dad of year award” T-Swift in Nashville (props to my wife Anne for making it happen) - thinking of using the shirt during next ASH conference presentation
Conclusion
#7
: physician income has been squeezed for decades. blaming docs for cost of healthcare is a fundamental misdiagnosis. If Washington and the profiteers keep extracting concessions from md’s - insurance will not be the barrier to care but provider supply will be
Phase 3 study results leading to fda approval of
#acalabrutinib
for untreated cll. Good evidence of safety and efficacy. Grateful for the team that brought this to fruition
Re:
#COVID19
/
#Hydroxychloroquine
- single arm phase 2 data is the scientific equivalent of a hypothesis - don’t confuse larger number of uncontrolled patients as evidence - it is only the volume with which you are yelling. Proof requires randomized studies
@VPrasadMDMPH
3rd year oncology fellows: We're hiring for our Eugene practice. Join a top 10% MGMA practice with incredible clinical research and sub-specialization opportunities. 4d clinic schedule with pretty light hospital responsibilities. Group includes rad onc / Gyn onc and 25 docs!
Like many in the book - I never made a penny off of the original idea, but I am very proud that an idea I brought forward has resulted in so much good for so many patients
Genuine question to spark discussion on behalf of hematology-oncology fellows:
What are the benefits of staying in an academic institution versus community practice?
Thoughtful replies only please
For hematology-oncology fellows wondering how to continue clinical research in their careers, the newly combined US Oncology / Sarah Cannon Research Institute is the biggest platform in the world. 20% US patients treated in our network.
@VPrasadMDMPH
Lots of graduating Heme-onc fellows prioritize geography over job characteristics because they don’t know what is out there.
Important “personal finance question” to ask yourself - “what does my geographic preference cost in the long term?”
Trying to hire a medical oncologist for Florence Oregon (Beautiful Oregon coast) position. Incredible work/life balance position. 2-3d work week, no hospital coverage, competitive pay / negotiable. DM me
@AaronGoodman33
This is professionally indefensible. In an era where physician shortages are already limiting access to care, and burnout threatens to drive many others from the field - "hey, why don't you just work through your vacation" seems uniquely tone deaf.
#MOCery
At our hospital 4% of patients admitted for COVID were fully vaccinated. The remaining 96% were either unvaccinated or partially vaccinated. I am having trouble getting some procedures scheduled for my cancer patients who need care. Please be kind to your neighbors - vaccinate
A lot of implications from this MCL late breaking abstract!
1) Ibrutinib approval previously withdrawn in MCL? Time to revisit?
2) Does this combo data impact choice of BTK in r/r MCL?
3) New SOC in eligible patients?
4) Are age related toxicities the same in CLL/MCL?
I've been working on this molecule for a decade. A long journey but finally across the finish line. Huge props to Calvin Lee, Jamie Hirata and Wayne Chu, who carried it a long way
FDA Approves Polatuzumab Vedotin Plus R-CHP for Treatment-Naïve DLBCL ()
Attn: 3rd Yr Onc fellows: Do you know what a "puppy mill" job is? Watch out for private practice jobs where there is no chance you will ever make partner! Ask about every doc in practice that has left and why. Don't get "used" for 3-5 years then leave unhappy!
3rd year onc fellows: the “highly desirable” urban locations to work are often the most expensive - but also associated with lowest earning potential. This is due to contracting strength and independence from dominant health systems
@HemOncFellows
I was in a high school jazz band with
#taylorhawkins
who went on to become iconic rock drummer with
#FooFighter
. Sad to learn of his death. He was a lot of fun to be around although he gave our conductor heartburn.
Recent questions on "specialization" in community practice. I call it "regionalization." This week I see:
CLL =28 pts
Indolent NHL = 8
Aggressive lymphoma = 5
Myeloma = 8
Myeloid / benign heme = 10
Solid Tumor = 11
4d work week about 70 pts. I love the mix / diversity
It took a year for the first cohort to enroll which is a disaster for a small biotech so Pharmacyclics reached out to my new group to see if we could assist enrolling patients into the study.
Shortly thereafter I treated the first CLL patients in the world with ibrutinib
@DGlaucomflecken
This provides an obvious satirical glimpse into the reality of modern healthcare - but the satire and the reality are far too close for comfort. This direction will be the end of quality in medicine (what is left of it)
I love being a doctor and I would never trade that experience for the fortune I may have made had I followed the idea into industry... a choice that would have fundamentally re-routed the course of my life
In 2004 I became convinced that turning off B-cell receptor signaling would cause cancerous b-cells to stop growing. This theory came into focus based upon an understanding of epstein barr virus protein LMP2A, EBV relationship to Hodgkin lymphoma, and other breadcrumbs
@chadinabhan
@ilanayurkiewicz
Physician work force is collapsing. Efficiency of employed docs is 30% less that physician owned practices (and more expensive). Add in impact of baby boomer retirement, decreased work intensity in rising generations….
As the physician scientist who first proposed inhibiting bcr signaling and a bit character in the book - I wish I had taken this “crash course” before becoming a clinical trialist
#imbruvica
#calquence
So much progress in CML and CLL - saw two patients in clinic today who together had combined WBC count of 1400 (two separate patients with WBC > 700K) within the last month. Both doing remarkably well!
#physiology
Excited for the next installment in the history of BTK inhibitors - this time from the perspective of a drug developer. Coming out this summer - preorder now!
@nathanvardi
To any doctor practicing medicine:
This video gives us a 45 second call to action with concrete step to take. It is a moral imperative to do so.
Lose this battle and we sacrifice our dignity and our profession
@adamcifu
When will we stop criticizing hypothesis generating studies because they don't meet the "randomized placebo controlled phase 3 trial" standard.
These are important studies because they are building blocks in our understanding. They are not proof, but they are a start.
When you build a hospital on top of a hill and have worst roads for access anywhere... one cool solution is a spectacular tram ride with views of the cascades
I decided the best way to turn off the receptor would be to use drugs which shut off the signaling pathways emanating from the B cell receptor - notably SYK.
Fortunately Ron Levy M.D. of Stanford was willing to let me test the hypothesis in the laboratory
MAJIC: a phase III trial of acalabrutinib + venetoclax versus venetoclax + obinutuzumab in previously untreated chronic lymphocytic leukemia or small lymphocytic lymphoma | Future Oncology
The role of CD20 in addition to BTK inhibitors is not a closed story. We previously published obinutuzumab benefit with acalabrutinib ().
Now we show, Ublituximab to Ibrutinib has benefit in 17P
#TGTherapeutics
@anthonymatomd
Median age of frontline fcr in cll from landmark md Anderson study = 57 years. In the rest of world that cannot travel / afford mda - average age =74 at 1st rx. Many died from therapy because data didn’t export to “real world” well
We manage 95% of US adult cancer pts based on data generated from the 5% that are treated on clinical trials;& trial pts R younger, less co-morbidities, able 2 travel 2 trial sites, more caucasians, & have better psychosocial support. That’s the “real-world” I keep talking about.
He had PCI-32765, a molecule that inhibited the next enzyme in the BCR signaling pathway - BTK.
Based upon our experience with fostamatinib, we set up a consulting agreement and I helped design a study to test ibrutinib in patients with NHL/CLL
I think they are not expecting anyone to challenge their “evidence” but it is circumstantial at best and insulting when you get to
#5
. They clearly don’t regard this effort seriously - labeling them “myths”
#ENDmoc
ABIM is sending out these talking points. Look at
#1
You have to have a concussion to think these absolutely TRASH papers prove MOC has value. ABIM needs CME in evidence appraisal.
For 20 million a year, I offer to teach them
@doctorwes
@AaronGoodman33
I love watching as “big evil corporations” and “greedy pharmaceutical companies” scramble to save our asses while the government inept dawdling flounders. Yet some would have us believe more government is the solution???
#COVID19
I acquired
#fostamatinib
from
#RigelTherapeutics
and set to work - quickly learning that I didn't belong in the lab at all (not my skill set)
Fortunately, others came to the similar idea and shortly thereafter we began testing the compound in patients with lymphoma
At the time
#pharmacyclics
was a zombie company almost left for dead but Richard Miller MD was at the helm and saw my patients with me at Stanford receiving fostamatinib.
I explained to him the hypothesis of BCR signaling inhibition which turned into a critical moment
I urge our professional societies including
@ASH_hematology
@ASCO
to advocate for us on ABIM MOC.
We support our societies with our dues and participation. By 99:1 membership opposes ABIM MOC. We need your advocacy.
#MedTwitter
@TheRealDoctorT
The difference is profound and yet easy to understand. Private practice is incentivized to do good work to build a business. In academia, working harder doesn't necessarily yield material benefit. It accrues to the institution - so the motivation is to do the least necessary.
I'm going to keep adding pictures of Florence periodically until we get someone interested joining our group with elite MGMA performance, incredible research opportunities. This is perfect job for anyone wanting to balance quality of life and favorable work!
Sad to me that most people's opinion about mask is informed more by politics than by science. Thought this summary article was fascinating about volume of cough cloud with and without different masks
@calliecoombsmd
Enormously important study for the field. Thank goodness for German CLL research! They school us in large CLL studies. Now we need data for optimal doublet BTK/Ven vs CD20/Ven - MAJIC anyone?
Post 1d of
#ash18
#cll
meetings I believe:
1) ibrutinib beats chemo immunotherapy 2) cit contraindicated in 17p and unmutated frontline CLL 3) in r/r disease targeted regimens are superior to chemo
@AaronGoodman33
@msf33178
There are three values you get to chose from in a career in medicine:
Geography (city/family/school/etc)
Ratio of compensation to effort (are you paid well for your effort)
Existential (job has meaning, autonomy)
2/3 is pretty good job
1/3 is common
@Gabby_Brauner27
Can’t find a primary care doc because….????
A: most can’t afford to go into primary care due to accumulated debt relative to income expectations
@toddstarnes
4/20,000 patients treated with the vaccine. Thanks- happy to take my chances with the vaccine over my chances with the virus any day. Hospitalization and death are not the only measures of harm caused by covid.