Winners and losers in Las Vegas
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Those of you who read last month’s editorial by Derek Raghavan, MD, PhD, are aware that he and I will be stepping down from our roles as Chief Medical Editors of HemOnc Today at the end of this month.
We have enjoyed 6 years in these roles and, like Derek, I have allowed myself some time to reflect on those years and the changes they have brought. Doing so has made me realize how much the editorial work has helped me in my role at the cancer center — not only in keeping informed about developments in oncology outside my own immediate area of interest, but also in staying informed about broader issues of cancer care, which are so important to the way we design our services.
I look upon my experience at HemOnc Today as a progression on a learning curve that I began to climb many years ago, and which reached an inflection point about a year and a half before I became an editor — specifically, the time I spent at the UC San Diego Nevada Cancer Institute in Las Vegas.
In retrospect, my time in Las Vegas turned out to be the “sabbatical” that I never had. Until that point, my experience had been fairly typical for a clinician/clinical investigator — something that changed dramatically with the move. Although events there were sometimes challenging, the lessons I learned proved invaluable in subsequent years.
The detailed history of the institute is complicated and not the subject of this editorial but, for brief context, the Nevada Cancer Institute was established in 2002, opened its doors to patients in 2005 and closed in late 2012. I was there during the closing and my perspectives are based on observations from that time, some of which may seem obvious to you as readers, but which I have referred back to frequently in my subsequent positions. I should add that I greatly valued the support and friendship I received from the Nevada Cancer Institute and UCSD leadership under difficult circumstances and my comments below are not intended to imply any criticism or disrespect of their great work.
‘Part of the ecosystem’
As academic oncology centers, our purpose is to serve the communities within our catchment areas and beyond through research, education and excellent clinical care.
As such, we hope to fill an unmet need for specialized services, a clinical and trial portfolio that is differentiated from community colleagues, and outreach and education efforts.
We therefore need to see ourselves as part of the ecosystem of oncology care in our respective environments, rather than as reproducing what already exists. Developing a competitive rather than a collaborative stance risks shutting down potential pathways to referral, resulting in narrowed options for our patients. Recognizing that some level of competition is inevitable and beneficial in our communities — the population benefits from choice between strong health care providers — this should not be an obstacle to allowing patients access to all options that might benefit them.
Our patients expect and deserve fully integrated multidisciplinary care, which is difficult to deliver in isolation from an associated hospital facility with an appropriate range of subspecialties. Although this seems obvious at the end of 2020, it is still essential to keep this in mind as cancer centers develop wider networks with an increasing base in the community. Ensuring that patients in these venues have full access to the range of services provided on the central campus is critical.
The generosity of our local and more distant communities is remarkable and represents a vital source of funds to support the mission of our cancer centers. Reliance on philanthropic funds for operational support is, of course, a high-risk strategy. Similarly, providing salary support for staff through such funds, although often an excellent way of priming a new position or service, is generally not a sustainable long-term model and can be disruptive for patients and affected employees.
Coping with challenging circumstances
The most impactful observations for me during the closing of the center were the varied reactions of its staff and employees as the closing was announced and the decommissioning and wind down of operations took place over many weeks.
The responses to the announcement varied from anger and frustration to resigned acceptance, deep concern for the future of patients under our care, and mutual support for colleagues affected by the closing.
Navigating this range of emotions and some of the actions prompted by staff members was challenging and, in many respects, inspiring. For me, the inspiration came from the many staff members whose dedication to our patients led them to stay the course up to the last day, even though they could have moved to other centers to follow other opportunities. I hope that I learned to be nonjudgmental, to try to make calm, objective decisions and to keep the well-being of our patients and staff as my priorities. Others would have to judge whether I succeeded.
As a byproduct of this process, I also gained a more in-depth understanding of cancer center operations by watching the process of deconstructing these over a period of weeks and months. I’m certainly not recommending this as a way to learn operations, but it provided me with a crash course that I might not have received otherwise.
In the end, all our patients were referred to other oncologists and continued to receive excellent care, and our staff relocated to other employment and mostly had soft landings. Personally, as I moved on to my new position, I felt far better equipped to take on the new role as a result of the experience in Las Vegas.
Reflecting on my experience, as I guess is always true in Las Vegas, there were winners and losers. The story of the institute is full of inspiration and disappointment. Patients with cancer in the community lost an option for their care and the workforce at the institute lost employment.
For my small part in it, I regard myself as a winner — my experience there well-equipped me for my subsequent roles, and I am grateful to have had the opportunity. The many articles I have reviewed for HemOnc Today and the research I have done for editorials has helped me to build on those experiences.
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