Leonard L. Berry, PhD, MBA; Katie A. Deming, MD; and Tracey S. Danaher, PhD
Nonclinical and clinical-support personnel serve patients on the front lines of care. Their service interactions have a powerful influence on how patients perceive their entire care experience, including the all-important interactions with clinical staff. Ignoring this reality means squandering opportunities to start patients out on the right foot at each care visit. Medical practices can improve the overall care they provide by focusing on nonclinical and clinical-support services in 5 crucial ways: (1) creating strong first impressions at every care visit by prioritizing superb front-desk service; (2) thoroughly vetting prospective hires to ensure that their values and demeanor align with the organization’s; (3) preparing hired staff to deliver excellent service with a commitment to ongoing training and education at all staff levels; (4) minimizing needless delays in service delivery that can overburden patients and their families in profound ways; and (5) prioritizing the services that patients consider to be most important. We show how cancer care illustrates these principles, which are relevant across medical contexts. Without nonclinical and clinical-support staff who set the right tone for care at every service touchpoint, even the best clinical services cannot be truly optimal.
Marin Cancer Care recently celebrated the work anniversaries of several long-term employees. We are proud that we have staff who have worked here for a very long time and we have little turnover. More than half of the employees have been part of the Marin Cancer Care family for five years or more. This is especially important for developing relationships and connections with cancer patients and their families. The following doctors and employees were honored for their longevity with the practice:
Marin Cancer Care of Greenbrae, CA Achieves AAAHC Accreditation
Greenbrae, California – November 15, 2018– Marin Cancer care has achieved accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC). Accreditation distinguishes this medical group from many other outpatient facilities by providing the highest quality of care to its patients as determined by an independent, external process of evaluation.
Status as an accredited organization means [name of your organization] has met nationally recognized standards for the provision of quality health care set by AAAHC. More than 6,000 ambulatory health care organizations across the United States are accredited by AAAHC. Not all ambulatory health care organizations seek accreditation; not all that undergo the rigorous on-site survey process are granted accreditation.
“We believe our patients deserve the best,” stated Harvey D. Bichkoff, CEO of Marin Cancer Care. “When you see our certificate of accreditation, you will know that AAAHC, an independent, not-for-profit organization, has closely examined our facility and procedures. It means we as an organization care enough about our patients to strive for the highest level of care possible.”
Ambulatory health care organizations seeking accreditation by AAAHC undergo an extensive self-assessment and on-site survey by AAAHC expert surveyors – physicians, nurses, and administrators who are actively involved in ambulatory health care. The survey is consultative and educational, presenting best practices to help an organization improve its care and services.
“Going through the process challenged us to find better ways to serve our patients, and it is a constant reminder that our responsibility is to strive to continuously improve the quality of care we provide,” said Bichkoff.
The Accreditation Association for Ambulatory Health Care, founded in 1979, is the leader in ambulatory health care accreditation with more than 6,000 organizations accredited nationwide. AAAHC accredits a variety of organizations including, ambulatory surgery centers, office-based surgery centers, endoscopy centers, student health centers, military health care clinics, and large medical and dental practices. AAAHC serves as an advocate for the provision of high-quality health care through the development of nationally recognized standards and through its survey and accreditation programs. AAAHC accreditation is recognized as a symbol of quality by third-party payers, medical organizations, liability insurance companies, state and federal agencies and the public.
57-year-old Scott Davis grew up as an Air Force brat. His family moved around a lot, but it was during their time in Phoenix that Scott got the sunburns that would eventually catch up with him, decades later, in the form of an aggressive melanoma.
Scott first came to Marin in 1994 when he and his wife moved to Tiburon. They immediately fell in love with Marin and especially, Mt. Tamalpais. A graduate of the Brooks Institute of Photography, Scott has a life-long passion for taking pictures. He makes his living as a location scout and producer for advertising and loves photographing nature.
In 2001, Scott’s wife thought it would be a good idea for him to get his moles checked and made a dermatology appointment for him. The two were contemplating a move to New York and she decided to take a trip to Chicago to visit family while Scott went out to New York to get the lay of the land. While the couple was apart, tragedy struck. Scott’s wife died suddenly from a congenital heart defect.
When Scott returned, he went to the appointment his late wife had made for him – an appointment that likely saved his life. The dermatologist found a melanoma on his back. The doctor removed the growth, which did not appear to have spread, and Scott went through with the planned move to New York.
Scott lived in New York for a year, where he met his current girlfriend. In 2002, the two moved to Los Angeles. Scott was ready for a new beginning, but melanoma was not finished with him. In 2003 he was getting really bad headaches and found himself suddenly losing his peripheral vision. He started bumping into walls and couldn’t keep his signature on the line when he was signing traveler’s checks. An MRI revealed a brain tumor.
Within days of his diagnosis, Scott had emergency brain surgery followed by CyberKnife radiosurgery 2 months later. Although the tumor was successfully destroyed, Scott’s oncologist was not enthusiastic about his prognosis. Sure enough, a year later, follow up scans revealed two more brain tumors. This time, Scott had Gamma Knife® radiosurgery to destroy the tumors. In addition, two lymph nodes under his right arm showed involvement by melanoma.
For a decade, Scott went about his life with no sign of a recurrence. In 2014, his girlfriend was hired by Levi’s in San Francisco, and the couple moved from Los Angeles to Marin. Scott was delighted to be back in Northern California and felt perfectly healthy. However, his girlfriend and his sister, who is an oncology nurse, kept nagging him to get a checkup.
One person whose nudging made quite an impact was Scott’s long-time friend, Dr. Peter Eisenberg, a medical oncologist at Marin Cancer Care and member of Marin General Hospital’s Cancer Institute. “Peter,” Scott points out, “is the kind of guy who won’t take no for an answer.” Together, they decided Scott, who was officially “disease free” and hadn’t seen a doctor for years, should have a PET scan. That’s when Scott learned his cancer was actually back and had spread to his lungs, lymph nodes, intestines, and liver.
There was no question in Scott’s mind as to where to get his treatment. “Staying in Marin became a kind of a no-brainer, because I needed to keep living my life. I needed to keep working. When you get a diagnosis like this, you choose a horse and you ride him. Dr. Eisenberg was the horse I chose, and I was counting on his expertise.”
Dr. Eisenberg immediately went in to high gear. He recommended immunotherapy. “There’s no other treatment that had the potential to be successful,” he explained. As Scott points out, “Peter’s been great about networking and meeting with experts.” Dr. Eisenberg started by consulting with the melanoma specialist who had treated Scott in LA. He also corresponded with the author of the groundbreaking immunotherapy study reported in the New England Journal of Medicine. All agreed that immunotherapy was the right course of action.
Like chemotherapy, immunotherapy is given orally or intravenously but the way the drugs work is very different. In the case of melanoma and certain other cancers, tumors secrete substances that mask the cancer cells, effectively “hiding” the tumor from the patient’s immune system. Immunotherapy disables the cancer’s masking abilities and allows the patient’s immune system to work as it should.
Once he had his port put in at Marin General Hospital, Scott was able to have his immunotherapy treatments at the doctor’s office with Dr. Eisenberg and his colleague, Dr. Barbara Galligan, monitoring his progress. Treatment began with two drugs, given every three weeks over a 12-week period. Then, treatment continued with one of the drugs, given every two weeks to complete a year of treatment.
Throughout his treatments, Scott felt totally supported by his doctors and by Marin General Hospital. He worked with a nutritionist at the hospital’s Center for Integrative Health & Wellness to ensure that he maintained a healthy diet. When Scott developed rheumatoid arthritis in his knee as a side effect of treatment, Dr. Eisenberg tracked down a UCSF rheumatologist who was participating in a Johns Hopkins study on the side effects of immunotherapy. But the main effect far outweighed the side effects: Scott’s most recent PET scans show no signs of the tumors! “It’s mind blowing,” Scott marvels. “It’s like magic.”
Nowadays, Scott sees Dr. Eisenberg every six weeks and has scans every six months. He feels great and spends a lot of time at his beloved Mount Tamalpais, taking photos. As Scott says, “It allows me to let go of even thinking about the disease and the kind of the journey that I’ve been on, and just puts me in the moment for being right there and appreciating what I’m seeing and where I’m at.”
Listen to Bill Klaproth discuss Immunotherapy with Dr. Barbara Galligan
One of the most promising tools in an oncologist’s toolbox is immunotherapy. This treatment boosts the body’s own immune system so it can effectively destroy cancer cells. Immunotherapy has proven very effective in certain cancers, such as some melanomas and lung tumors. While immunotherapy is still unavailable at many community hospitals, it has been prescribed at Marin General Hospital for several years, with encouraging results.
Learn more as Dr. Barbara Galligan explains immunotherapy and how it works. Topics covered include how the treatment is administered, who is a good candidate, and potential side effects.
Advances in immunotherapy have had a continual impact on how physicians help patients with cancer, bringing a complex mix of challenges and successes, says Barbara Galligan, M.D., an oncologist at Marin Cancer Center.
“Immunotherapy means a lot of different things,” she says. For example, the Food and Drug Administration (FDA) has approved immunotherapy for use on only some cancers, including metastatic melanoma, lung cancers, bladder cancer and others. “These are new, expensive, drugs that are promoted with direct-to-consumer advertising campaigns resulting in patients coming in to their doctors asking for immunotherapy.”
“Immunotherapy doesn’t work on every cancer, says Galligan. “Or, it may not be the right time for immunotherapy. There are times over the course of someone’s treatment where immunotherapy may or may not be useful.” She explains some of the complex conditions behind the miraculous-appearing results portrayed on ads.
“The thing about immunotherapy is that if you have a great response, it looks like a true miracle drug,” says Galligan. For example, there are people whose cancers such as a deadly metastasized melanoma, have disappeared for years after treatment with immunotherapy. “But the flip side is that there are patients who won’t respond,” she adds. Current statistics place the responders (those who show lasting improvement) in the neighborhood of 20 to 30 percent. This means there are a great many for whom the drug, no matter how seemingly miraculous for others, does not work.
Why don't all patients respond? “We’re learning that cancer is not just one disease,” says Galligan. “It’s many diseases. And even within one cancer type (lung cancer, for example), there are many different types.” According to Galligan, it’s important to take a sample of a patient’s tumor to take a closer look at the biology. “If you take a sample and study it, you can see the differences,” she says. “The closer you look at the biology, [you note] there’s a lot of variability.” One patient’s lung cancer may not be the same as another patient’s lung cancer. “That’s what predicts [a patient’s] response to immunotherapy.”
Another complication is that the cancer’s “disguise” can be outsmarted by the immunotherapy drug, but the cancer may mutate and outsmart it back. As a result, says Galligan, you may need to change treatment to select for new mutants that are not going to go away with prior treatments.
Currently, medical science is working to find ways to predict whether cancer patients will respond to immunotherapy. “That’s a nascent field and I hope it gets better every year,” says Galligan. Some patients are set on immunotherapy, and are frustrated when they hear that it might not be the right treatment for them at the time, she adds. When preparing for treatment, she says, the best approach is to find a doctor who will support you. “It’s important to find an open-minded, enthusiastic oncologist and to establish a good doctor-patient relationship, one with communication and trust, because the field is complex, and [immunotherapy] is not one-size-fits all,” she says.
A little over two years ago, the American Society of Clinical Oncology (ASCO) in its annual report, named cancer immunotherapy the clinical cancer advance of the year.
“No recent advance has been more transformative than the rise of immunotherapy” said ASCO President Julie Vose. “These new therapies are not only transforming patient lives, they are also opening intriguing avenues for further research.”
ASCO recognized advancements in immunotherapy again in 2017 and in 2018, with the expansion of adoptive cell therapy. This recognition has driven a lot of research and development within the field of immunotherapy, with some projecting that the global immunotherapy market, valued at $60 Billion in 2016, will grow to $120 Billion by 2021.
The excitement over these treatments stems from the fact that immunotherapy can get dramatic, durable results in cancers that are difficult to treat. But the story behind immunotherapy is not simple.
Immunotherapy encompasses many different types of treatments both old and new including vaccines, antibodies, and the newer checkpoint modulators and adoptive cell therapies. What these treatments have in common is that they all harness the body’s own immune system to fight cancer.
But ramping up the body’s immune system can cause serious side effects including fatigue, pain, autoimmune diseases and organ damage. Patients undergoing immunotherapy must be monitored carefully for such side effects with regular physical exams, blood work, and scans.
Another limitation to immunotherapy is that it is not always effective. Even in best cases scenarios, only about 20% - 30% of patients receiving immunotherapy respond to treatment. That is why immunotherapy is not as widely used as radiation therapy, chemotherapy or surgery, and the Food and Drug Administration (FDA) has only approved immunotherapy for certain types of cancer.
Doctors cannot yet predict if an individual cancer patient will respond to immunotherapy because cancer is a complex set of diseases and individuals have their own unique response profiles. It can be confusing for patients when direct-to-consumer advertising campaigns for immunotherapy portray results as miraculous without discussing side effects or the chances that the treatment will not work.
For cancer patients navigating the field of immunotherapy it’s especially important to have a good relationship with an oncologist. When discussing immunotherapy with an oncologist, start by asking if the type and stage of the cancer make it eligible for treatment with immunotherapy. Ask if the goal of treatment is to eliminate the cancer, or to slow it down so that it does not spread. It’s also good to know if immunotherapy will be combined with other cancer treatments and how often treatments are given.
No treatments are without side effects, so asking about short term as well as long term side effects is important. The cost of treatment and insurance coverage are also important to consider. A frank conversation with an oncologist can help set expectations and develop the best treatment plan for the patient including monitoring for side effects and checking to see if the cancer is responding to treatment.
The field of immunotherapy is complex and, like all aspects of cancer care, there is no one-size-fits-all approach. Patients in Marin interested in discussing immunotherapy as a possible cancer treatment can find it right here in the community because together, Marin Cancer Care and Marin General Hospital offer immunotherapy as well as clinical trials in immunotherapy. When deciding if these treatments are appropriate, it is important to have a good relationship with an oncologist who can help explain the many new treatments now available to cancer patients.
Developing good communication and trust with a doctor can help patients navigate the path between older cancer therapies and newer treatments such as immunotherapy and personalized medicine. No new treatment can ever replace the healing that happens when a doctor cares for a patient as a unique individual with distinct personal characteristics, goals and plans.
Drs. Lucas and Eisenberg were delighted to learn they were both featured in an excerpt from author and Marin County native, Glasgow Phillips’ novel, The Royal Nonesuch, where the author describes his first meetings with Peter and Jen. We are all incredibly proud of their “literary cameo”, and invite you to read part of it below!
“…It was dusk, and we were back in the car to leave when we saw her oncologist walking across the parking lot. This was the doctor who had sent her marrow down to Stanford, and I had missed him on the first day. She told me I was going to love him and rolled down the window to call out. He smiled and came over to the car, greeting her warmly and shaking my hand. His name was Dr. Peter Eisenberg.
Dr. Eisenberg was a portly but vital man, maybe in his early fifties, with the red-bridged nose of a runner and a salt and pepper beard. In the past seventy-two hours, Dr. Eisenberg, without his knowledge, had been comprehensively vetted by my aunt Tawnie—technically my ex-step aunt, but we were as close with her family as with any of our blood kin. Dr. Eisenberg was supposed to be the best, and Tawnie was in a position to know. Her research on physicians, dentists, educators, realtors, babysitters, and any other persons who might provide support services to the job of keeping your families’ lives in order and on track was so rigorous that she could have started her own credentialing service. Not that those were her only areas of interest—she was also knowledgeable in the areas of architecture, contemporary art, and global politics—but without a doctorate in fluid dynamics, you would have small hope of becoming her pool guy.
Dr. Eisenberg may have passed her vetting process with flying colors, but he struck me as being far too happy to be a highly respected oncologist. Cancer was, after all, the pinnacle of seriousness—thus the saying, “serious as cancer” –and this grinning man was wearing a Mr. Potato Head tie. I could not help noticing, as my eye bounced up and down between Dr. Eisenberg’s face and Mr. Potato Head’s, how very closely Dr. Eisenberg, with his tanned forehead, bushy eyebrows, close-set eyes, and different-colored nose, resembled Mr. Potato Head. If Dr. Eisenberg was as smart as he was reputed to be, he was aware that he resembled Mr. Potato Head, and therefore it followed that he knew that each solemn conversation he had over the course of his day as a highly respected oncologist was punctuated by a goofy sight gag.
My mother asked Dr. Eisenberg if he knew yet whether she had lymphoma. Since she had no obvious tumors, and lymphoma was often detected first through abnormalities in the blood, it already had come up as a strong possibility. Dr. Eisenberg said he didn’t know yet. The results would be in tomorrow. But we should keep our fingers crossed in the hopes she did have lymphoma. “Wait,” said my mom. “I thought lymphoma was bad.” “It’s terrible!” he responded gleefully. “But if you have a lymphoma, then you get Dr. Lucas! And she’s the best!”
We bid good evening to this madman and went home. The next day we went to our appointment at Dr. Eisenberg’s practice, located in a strip of seventies-era office buildings adjacent to Marin General. There we learned that she did indeed have lymphoma: an indolent Stage 4, non-Hodgkin’s B-cell lymphoma, complicated by hemolytic anemia. Lymphoma was a cancer of the white blood cells—that I knew—and the rest was explained by Dr. Lucas, the hematologist of whom Dr. Eisenberg had spoken so grandly the prior evening.
Her first name was Jennifer—Jen. Like me, Jen Lucas had gone to high school in Marin County, a few towns north. She was one year older than I was. In elegant flats, she was about my height, though by contrast she was attractive, clear-eyed, and serious. While I had been making an ass of myself navel gazing, p***s twisting, and branding scams, Jen Lucas had been going to college on a basketball scholarship, matriculating to Georgetown Medical School, advancing hematology research at Stanford, and being recruited as the youngest partner by twenty years at the best private oncology practice in northern California, where her job was saving people’s lives.”
To read more of Mr. Phillips’ novel, visit Amazon.com or your local bookstore.
Gaining access to the experience of oncology practices across the country motivated early participation in CancerLinQ, according to physicians at the vanguard practices.
“If I can benefit from best practices around the country, it will directly benefit my patients,” said Peter Eisenberg, MD, of Marin Cancer Care in California, one of the first vanguard practices to upload its patient records data to CancerLinQ. “What I have to learn by participating is whether we are doing it right and taking care of our patients appropriately. Are we using standard regimens? Are our patients doing as well as we might expect? Are we missing something?”
Dr. Eisenberg noted that randomized clinical trials include a relatively small number of patients, have very specific inclusion and exclusion criteria, and “may or may not reflect the patients we see in our practice.” With CancerLinQ, his practice will be able to track, for example, the thousands of patients with lung cancer who are treated in a year and understand the trajectory of their care, he said.
Uploading data to CancerLinQ from Marin Cancer Care’s electronic medical records (EMR) system was challenging and “cost us something in terms of our practice manager’s time and our [information technology] guy’s time, but the potential for learning far outweighs the expenditures that we have made.”
Now that his practice has worked through the technical challenges with the help of the ASCO CancerLinQ team, Dr. Eisenberg and his partners will soon be taking a look at the rich data from their own practice. They anticipate that later this year they will be able to compare their data with practices across the country. “If somebody is getting better results in Kansas City or elsewhere, I want to know what they are doing,” he said.
“I think it was very bold of ASCO leadership to put such an effort together. It is a huge project but one that has terrific implications for the care of our patients. I applaud the team that has spearheaded this effort,” he said.
Montgomery Cancer Center
Keith Thompson, MD, at Montgomery Cancer Center in Alabama said that having access to the “combined wisdom of so many patients treated in centers all over the country will be a tremendous advance in our understanding of cancer and cancer care. The opportunity to understand what is happening with so many patients is a big deal.”
CancerLinQ, he said, will give physicians the ability to “measure their quality and look at what they are doing. Physicians around the country really embrace the idea of being able to look themselves in the mirror and see whether they are doing a good job and whether there are things they can do better.”
A team from CancerLinQ was instrumental in helping Montgomery Cancer Center upload its data. “They came in and analyzed the way we interact with our own EMR, asked questions about how data are stored, and then they analyzed our data before drawing it into the system.” That process, he said, took several months and a lot of hard work, “but they made it easy for us.”
Dr. Thompson’s center has recently started looking at a subset of the data, “taking it for a test drive” to understand how this information can be used to improve patient care.
Robin Zon, MD, at Michiana Hematology-Oncology in northwest Indiana, said her practice “couldn’t say yes fast enough” when given the opportunity to be among the first participants in CancerLinQ.
“The whole concept of using big data to better enhance our overall learning has been long in the making. This is a fabulous initiative that ASCO is doing, with the goal of improving quality and patient care.”
The Michiana practice holds about 120 tumor boards each year, she said. “There is something to be said about experience, which is above and beyond what you would get from a guideline. We would often say that it would be great if we could share our collective wisdom. We have all this experience in these file cabinets and now in EMRs.” With CancerLinQ, that depth of experience can now be shared with other practices across the country, she said.
Dr. Zon, a member of ASCO’s Data Governance Oversight Committee, said that she and her colleagues rely on ASCO as a trusted and honest broker. ASCO is “our go-to in terms of education, understanding new information, new interventions, new technology. It makes sense that ASCO’s CancerLinQ would be our go-to for rapid learning to enhance patient care.”
SUMMARY: The first participants in CancerLinQ say that gaining access to the experiences of other oncology practices will enhance patient care. Peter Eisenberg, MD, of Marin Cancer Care in California, says that CancerLinQ provides his practice the opportunity to learn “whether we are doing it right and taking care of our patients appropriately.”
TWEET: CancerLinQ vanguard practices say they will have the ability to measure their quality and share their collective wisdom.
Dear Friends, We are training as “Two Caring and Daring Docs” for an 11 day sacred trek in Nepal in September to raise funds for the Breast Cancer Fund. We will be trekking up to 9 hours a day at 12,00 – 14,000 feet in the Mustang region of Nepal, a hidden kingdom that was completely closed to foreigners until 1991.
As medical oncologists, we take care of women with breast cancer. Every day. many are cured – – some are not. But whether they are cured or not, they all have to endure the fear and anxiety that accompanies the diagnosis. They all have to keep dozens of doctor visits. Some have to complete long chemotherapy regimens. Most have to take pills for years. They all have family and friends who worry about them. Many have small children. Work is disrupted. Life is disrupted. All wonder why they got breast cancer. And all wonder if it will ever “come back.”
The key to unlock the secret of the causes and cures of breast cancer hasn’t been found yet, but great strides are being made. The Breast Cancer Fund is examining the scientific evidence linking exposures to environmental chemicals and radiation with breast cancer. To this goal, we are raising money with the help of your generous support.
EVERY PENNY YOU DONATE GOES TO THE BREAST CANCER FUND. We pay for all the expenses of our trip. If you donate $100 or more, we will carry a prayer flag with the name of whom you wish to remember or honor.