Spotlight: Learning from Different Oncology Practice Settings

How does the day-to-day management of oncology vary across the different types of practice settings and what does it mean for the average medical oncologist? We asked oncologists from a general hospital, an academic centre and private practice what they considered to be the main challenges and advantages of their particular workplace environment and what the different settings could learn from each other.

  • Date: 27 Mar 2018

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Thoughts of a private practice oncologist

burkhard-meier-ulrike

Ulrike Burkhard-Meier Moenchengladbach, Germany; ESMO Examination & Accreditation Working Group Committee Member

The main challenge of private practice is that you are very much a generalist, treating many different cancers, and this means that you need to have a good understanding of all cancer types and also to keep up with current knowledge across the board. This is particularly important now, at a time of increased rates of progress in the understanding of cancer development and the generation of new treatment approaches. Added to this is the fact that the private practitioner’s responsibility extends beyond the medical arena into the business side of the practice. This involves being able to manage a diverse range of issues—including IT, personnel and medical equipment—being aware and up-to-date with medical policy, and keeping the business competitive. You can see that there is a lot for the private practitioner to do that would be managed by several departments in a hospital setting.

We can address some of these problems in several ways. In terms of business and political issues, there are a number of professional organisations in Germany that are involved with government and policy and which support and promote the views of private practitioners. When it comes to medical matters, ESMO is a great resource for information and is incredibly useful for providing the latest information and practical guidelines in areas in which private practitioners have comparatively less experience than a specialist.

I think that a real advantage of the hospital setting over private practice is the ability to work in teams and to be able to call on multidisciplinary input. This is not always possible in private practice. In Germany, tumour boards are mandatory for many cases, particularly those being managed by multiple disciplines. As a privately practising medical oncologist, I am able to present patient cases to a tumour board at a designated hospital and to base management decisions on the consensus. This is a useful alternative to having an in-house team and can help to determine optimum treatment approaches. However, I’m not aware if this is the situation in all countries.

For me, the greatest benefit private practice has over the hospital setting is flexibility.

It is easier to respond more quickly to changes to standard treatment approaches and policy in private practice than it is in hospital. It can also provide faster access to certain drugs, particularly novel compounds. These advantages are largely due to the lower burden of administration in private practice compared with large hospital settings. Another important lesson for larger organisations is to try to ensure continuity of care. In private practice, the same doctor will look after the same patient throughout the course of their disease and its treatment. In hospitals, the patient may fall under the care of several different doctors along their management pathway and this can result in a lack of joined-up care. I think that patients really benefit from the personal doctor-patient relationship that can be built more easily in private practice.

Thoughts of a general hospital oncologist

Gábor Lakatos

Gábor Lakatos Egyesített Szent István és Szent László Hospital, Budapest, Hungary; ESMO Practising Oncologists Working Group Member

I should say first that here in Hungary, cancer patients are treated either in high-volume academic institutions or in the oncology department of a general hospital; we don’t have a community-based private practice setting. My experience is as an oncologist working in a large general hospital, which, I would say, lies somewhere between an academic and a non-academic centre.

In my opinion, one of the biggest challenges of the general hospital setting is the fact that the doctors are not specialists but are instead working across the whole spectrum of tumour types. For many doctors, cancer treatment is only one aspect of their job. In general hospitals, doctors don’t see as many cancer patients with a particular tumour type as in academic centres and so don’t gain the extent of specialised experience. General hospitals also have fewer doctors and so are unable to create the teams of tumour type-specific specialists available in academic institutes. They also struggle with multidisciplinary boards. Compared with the specialised boards available in academic centres—for instance, the National Institute of Oncology in Budapest, Hungary’s largest academic institution, has separate tumour boards for different types of malignancy, with multidisciplinary team (MDT) members coming from a variety of specialist disciplines — in a general hospital you will often find the same doctors making decisions across a range of tumour types. And it’s not unusual to find only a surgeon and a clinical oncologist being present during the decision-making process because other members of the tumour board don’t have time to attend.

Education is another problem area. For doctors in a general hospital, staying abreast of the current literature in all tumour types is virtually impossible, whereas doctors in academic settings have more opportunity—and in fact an obligation, because of teaching responsibilities—to keep up with the latest data and clinical trial results in their specific area.

Doctors in general hospitals, at least here in Hungary, also do not have access to the types of resources available in many academic institutions, including: on-site access to most laboratory and imaging facilities; being able to offer patients experimental treatment because of on-site availability of more clinical trials; a higher degree of accuracy in the conduct of clinical trials due to the greater numbers of study nurses and coordinators available; on-site access to radiotherapy, which is only rarely available in general hospitals; better access to support services, such as physiotherapy, psycho-oncology, rehabilitation; and a greater number of research opportunities.

The challenges of working in a general hospital are really an inevitable consequence of the environment and the resources available. However, despite the disadvantages I have outlined, I believe that general hospitals perform well in the treatment of commonly occurring tumours.

General hospitals offer patients some important advantages over academic institutions, especially from a quality-of-life perspective.

Probably the greatest benefit for patients is that they don’t need to travel long distances to get their care. This is particularly important for those patients receiving extended courses of chemotherapy with significant side effects. Being able to receive treatment closer to home is more convenient for the patient and for their friends and family. I also think there is a friendlier atmosphere in smaller hospitals, with people knowing each other better.

Thoughts of an academic centre oncologist

osterlund-pia

Pia Österlund Tampere University Hospital and University of Tampere, Finland; ESMO Global Curriculum Working Group Member; ESMO Nominating Committee Member

Working in an academic setting does have some drawbacks. The volume of cases a practitioner sees influences their general clinical expertise. Hospital doctors will often see a good deal more patients during the course of their work than those in academic centres, and, as a consequence, many are splendid clinicians. Also, specialisation is crucial to the effective treatment of individual tumour types, but it is not without its challenges; while you have an in-depth understanding of a particular tumour type, your knowledge across different cancers may be more limited than, say, that of a general hospital doctor.

In an academic setting, it may also be easier to lose sight of the fact that, at the end of the day, we are there for the patients. This is something we can learn from general hospital oncologists and, possibly even more so, from private practitioners. When I work in private practice, we are able to spend around twice the amount of time with patients than we do in the academic setting. This gives you the opportunity to help the patient understand more about his or her disease and its treatment. The high degree of patient satisfaction this creates is also very motivating for the clinician.

But there are many benefits of working in an academic centre. You have specialists there and, in the MDT setting, they are all working together, supporting each other. Aspects of a case that you, as an individual, may miss often come to light during MDT meetings. In a smaller, general hospital, MDTs may not always be feasible, due to a lack of relevant specialists or limited time. Patient contact may be more difficult to maintain in academia, particularly as you ascend the hierarchy, but this is largely a personal choice. I’ve elected to stay in a position that allows me to keep in touch with patients because this is an aspect of work I particularly enjoy.

One of the main benefits for me of working in the academic setting is the access it allows to clinical trials.

Investigating ways to improve treatment and reduce toxicity is one of my main interests and the scale and scope of the trials conducted would not be possible in most general hospital settings. It almost goes without saying that education in the academic centre setting is excellent. I teach a lot of medical students and am responsible for the education of those in training. And I am learning all the time from my more experienced colleagues. I think that continuing medical education is very important for oncologists, especially at this time, when what we learn this year may be old next year. We need to find ways to share this knowledge, this advantage of the academic setting, with oncologists in other settings. ESMO really helps in this way, providing general and tumour-specific education across the spectrum of cancer care.

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