I recently spent an evening with a group of medical oncology fellows as part of a small panel discussing career alternatives. There were doctors who worked for pharma, academic medical centers, hospitals and a couple of us representing private practice. The questions and comments taught me more than I could contribute. I was surprised to learn not just about jobs and personal futures, but about something basic: the difficulty in defining what is a quality physician.

To set the stage, let me remind readers how an oncologist is trained. After college, the trainee must complete four years of medical school, then three years of an internal medicine residency, at the end of which they must pass the board exam. At this point, if they wish, they can hang out a shingle and practice general internal medicine. However, if they want to practice oncology, and most will also practice hematology, they must take at least three more years of formal training as a fellow. After taking the hematology and oncology boards, they can treat patients with cancer and blood disorders.

When you complete this competitive, rigorous, 100-hours-a-week-for-10-years path, then you apply for work at age 32 — actually getting and keeping a job is of vital importance. Therefore, the desire to succeed lay at the base of the question asked by the fellows of the panel. The question was, “What is the most common reason a fully-trained, board-certified oncologist and hematologist, loses their job?”

After a moment of quiet, the members of the panel answered:

• The doctor who was there to talk about jobs for oncologists in the pharmaceutical industry, to develop and manufacture new cures said, “The company decides that the drug, chemical or ‘molecule’ on which the doctor is working will not be financially successful, at least for that company, and shuts down the project.”
• The doctor who was there to talk about jobs for an oncologist in the academic environment to teach and do scientific research said, “The doctor is not publishing enough or is not able to see enough patients in clinics to support his position.”
• The doctor who was there to talk about jobs for an oncologist working for a hospital said, “The hospital has a shift in corporate planning or the doctor does not have enough patient volume.”
• And finally, as the doctor who was there to talk about jobs for oncologists in private practice, I said, ”The doctor does not get along with his or her colleagues and/or is not willing to work hard.

Look again at those honest, real-world answers. No one said the most common cause or even a reason at all, to lose your job was that “the doctor does not practice quality medicine.” Can we assume that each of the answers that were given is a quality surrogate? Do we believe that if the drug company doc’s project does not have financial value, it is a problem of quality? Is publishing key to developing quality medicine so that when one’s job perishes from lack of writing it is deserved? If a doctor is giving quality care in the hospital clinic, will patients automatically flock? Will the hospital always be happy? Do doctors get on well with other doctors because physicians only like high-quality caregivers? I think we can agree that such conclusions stretch things more than a little.

My point is, many of these “keys to success” do not automatically mean the doctor produces quality medical care. I am sure most of us can think of an example of failed quality. Maybe we know a successful doctor whose mediocre care proves that survival does guarantee good outcomes. This flaw in how we judge and select physicians emphasizes the need to press for more accurate quality measures outside of simply holding onto one’s job.

I believe organized medicine, as a whole, understands these lessons but has been slow to implement answers. We depend on a system of boards and tests, as well as requirements for basic continued training, to assure excellence. True quality, the best possible results, with the least errors, given to the largest number of people, at the least cost, cannot be assumed by these passive and disconnected measures if we are going to continue the maturation of medical care.

Quality requires continuous monitoring and feedback, implementing expert physician and scientist-developed standards, fully integrated by robust real-time top-to-bottom information systems, available in every exam room and at every bedside for every patient. It is hard, complex work and for many physicians and patients a threatening revolution. Nonetheless, it is a vital and exciting tomorrow, which begins now and is only a short time away.

James C. Salwitz is an oncologist who blogs at Sunrise Rounds.

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