OncoDaily Dialogues #4 – Therese Mulvey / Hosted by Roupen Odabashian

In our series “OncoDaily Dialogues,” we continue to spotlight eminent figures in oncology, sharing their successes, challenges, and pivotal experiences.

Today, we are honored to welcome a prominent oncologist from the Massachusetts General Hospital, Dr. Therese Mulvey.

Dr Mulvey is the director of Breast Oncology at the Massachusetts General Hospital (MGH) North Shore Cancer Center, a community affiliate in Danvers, Massachusetts. She also serves as the director of Quality Safety and Value for the MGH Cancer Center and Network Affiliates. She was previously the physician-in-chief at Southcoast Centers for Cancer Care in New Bedford, Massachusetts. Dr. Mulvey has previously worked as a physician at other community practices in Massachusetts, including East Boston Neighborhood Health Center and Commonwealth Hematology Oncology, where she also served as president and CEO.

Dr. Mulvey is a Fellow of the American Society of Clinical Oncology (FASCO). She served as chair of the ASCO Clinical Practice Committee and on the Editorial Board of the Journal of Oncology Practice. She has served on the Cancer Quality Alliance and as chair of the Oncology Carrier Advisory Committee. Dr. Mulvey recently served on the Board of Directors of ASCO.

She was the President of the Massachusetts Society of Clinical Oncology.

Dr. Mulvey is a recipient of the ASCO Statesman Award, Goodspeed Chair Award and Lecture for Quality Care, Elizabeth Seton Humanitarian Award.

Dr. Mulvey received her medical degree from Tufts University School of Medicine, and completed her internship, residency, and fellowship at Tufts New England Medical Center. She completed a research and clinical fellowship at Massachusetts General Hospital.

Our host is Dr. Roupen Odabashian, hematology/oncology fellow at Karmanos Cancer Institute in Detroit, USA. Beyond his clinical practice, Dr. Odabashian possesses an unwavering passion for delving into the intricacies of healthcare policy, regulations and Oncology. He understands the multifaceted nature of cancer as a medical condition and acknowledges the various stakeholders and regulatory bodies that influence the delivery and administration of cancer treatments. In alignment with this commitment, he has joined OncoDaily, where he plays a pivotal role in conducting interviews with Leaders of the Cancer world.

About OncoDaily

OncoDaily was founded in 2023. It is a US-based oncology media platform, which features the latest news, insights, and patient stories from the world of oncology. Within a short period of time it became one of the leading oncology media platforms globally.

OncoDaily gathers content from various sources, including social media posts from renowned oncologists from all over the world, news from oncology societies and cancer centers, patient and survivor stories, and career-related information for professionals.

The mission of OncoDaily is to empower patients, survivors, and professionals with the knowledge and inspiration they need to fight cancer. The motto of OncoDaily is “Cancer doesn’t take a day off – neither do we”.

Previous series:

OncoDaily Dialogues #1 – Harout Semerjian / Hosted by Roupen Odabashian

OncoDaily Dialogues #2 – Piotr Wysocki / Hosted by Roupen Odabashian

OncoDaily Dialogues #3 – Andrés Wiernik / Hosted by Roupen Odabashian

Follow the transcript below

RO: Thank you so much, Dr. Mulvey, for being here today. I really appreciate it.

TM: My pleasure. Thank you for having me.

RO: Dr. Mulvey, I read a lot about you, but first thing I want to understand: why did you pursue a career in oncology? What motivates you to become an oncologist?

TM: A lot of small things during my medical school and residency. There were several things that interested me in cancer medicine, both hematologic malignancies and solid tumor malignancies. First and foremost was the science. The science was amazing; it was the amalgamation of everything that one learned about cell biology, molecular biology, embryology. It seemed to be changing on a nearly daily basis. It was truly amazing. And the patients, you know, you have these incredible intense relationships with patients at a time in their lives when all of the pretense is stripped away, and you’re actually caring for the human being in front of you, irrespective of their social class or all the other things that we think otherwise are important. Those are probably the two most important reasons why I chose oncology. And I would think, thirdly, it has become less so in my career as I’ve become more specialized in one disease, but to be an oncologist, you needed to be a very good internist because your patients can develop cancer at any part of their body, can affect all organ systems. And so being a really good internist also was appealing to me because I loved internal medicine. So it didn’t happen overnight; it evolved over time. But I’m so glad I did, and I haven’t looked back.

RO: Yeah, I agree with you. I think the patient-physician relationship was like, for me also, was a the most driving factor. You still have great physician-patient relationships in all fields of medicine, but I think in oncology specifically, you are in touch with patients in their most critical time in their life, and that relationship grows throughout the years, especially now with breast cancer, it’s becoming more like a chronic condition rather than a deadly disease.

TM: I can tell you I have learned more from my patients, not just about cancer medicine but about life and negotiating some of the more difficult parts of life. I’m inspired by their courage, their grace, their humility. These are lessons that have helped shape and enrich my life. So selfishly, I feel that in that relationship, I’ve come out the winner sometimes.

RO: I agree. You also have extensive background both in community and in academic practice. Can you share with me how your experience has varied between these both two settings and how this shaped how you approach patient care?

TM: Sure. So first up, I think the first question is, why did I jump between academics at the beginning of my career, community medicine in the middle of my career, and now academics in the last third of my career? I trained at a time when there were less than a third of your medical school class were women, and although there were, I was in a 50/50 residency program with men and women, fewer women chose sub-specialties, and oncology was a very low subspecialty. I have three children, now grown women, all married, all with children of their own. My youngest is a physician. I tried very hard to balance an academic career with having children, and what I learned very quickly is that there were structural reasons why that was difficult, and there were, you know, I think there’s a perception that women have this, have pregnancy and time off after their pregnancy, and after that, they’re on equal footing as men. But in fact, children at three months old don’t raise themselves, and they require a lot of curation and effort. I had an amazing mentor who at the time gave me the advice, sat me down and said, “Look, you have really some options here. You can have an incredible academic career. I had just secured my first grant. I was doing well.” And she said, “Or you can have children and grandchildren at your feet when you retire who adore you.” She said, “But the way things are structured right now in the 1980s, that’s not going to be… you can’t have both.” And so when put in stark contrast like that, it wasn’t a decision; it wasn’t a choice. I mean, of course, I was going to choose my family and my children. And so I left academics to have a career that was incredibly meaningful and offered me tremendous opportunity for growth and personal development and that would never have come to me in academics so that I could work a four-day work week and have one day to be home with my children. And I worked with a group of men because they were all men that I worked with who supported me to be able to balance being a mom and also the best clinical physician I could be.

I honestly don’t see a huge difference between community oncology and academic oncology insofar as patient care. Everyone goes to work to do the same job, which is to alleviate the suffering of cancer, both in community practice and academic oncology. I think there’s a lot of discussion about, “Oh, people in academics don’t have to worry about the finances, and therefore they’re more pure and can approach their patients without having to worry about their salary.” And there is some truth to that when you think about the traditional physician-owned private practice. But that distinction is now so blurred by so many people in what we call community practice are working in large healthcare organizations, are employed, working… you know, the days of physician-owned fee-for-service practice and academics and nothing in between is long gone.

I also think that people in academics are… there is something we don’t talk about very much, that is, you know, you hear it from the administrators in the hospital, “No money, no mission.” So, reimbursement and financial constraints are absolutely present in academics. They’re different than in private practice. You don’t worry that the Mass General is going to close their doors because their reimbursement is what they wanted it to be. They have multiple streams of income and philanthropy and an endowment, which a private practice might not have. But I do think that the distinction of clinical practice, reimbursement, practice models is far more blurred than we actually give credit to.

My time in community practice afforded me the opportunity to do leadership development training, to get involved with the American Society of Clinical Oncology in a deep and meaningful way, to learn from those experiences and to bring those experiences along with me in my career. So I am very grateful for that time that I had to spend more time with my family, have a more flexible schedule, and also do a lot of personal growth during those time periods.

RO: And you touch on very deep points. And like you mentioned in the past, it was hard for women to become academic at the same time have a family. Do you think that this is changing or changed now, or do you feel that the barrier is still there?

TM: I think there are some barriers that remain. However, it is a significantly different landscape than it was for me, you know, in the late 1980s, early 1990s. And I say this really from firsthand knowledge, observing my youngest daughter, who has gone through medical school and her residency, and moving into her first employment, contemplating fellowship, who had a baby during her junior residency year. It was not easy. It’s never easy to balance a career and children and a family. But I think that the roles of men and women in a relationship are different. I think that there are built-in… you know, there was no maternity leave when I had my oldest daughter as a third-year resident. I came back to work 72 hours after she was born to do a 24-hour shift in the emergency room. My daughter had a structured maternity leave. She knew what it was before she became pregnant. I think that it is a different world. I also think that there, that the medical student and the millennial doctor have very different expectations about work-life balance than I did. You know, I, we were always… we always said yes. Everyone did, men and women. There was, you know, there were no work-hour restrictions, there were no time off restrictions. So I think it was a different world, and the world has changed, and I think it’s changed for the better.

Sustainability in the medical workforce is something I worry about a little bit. This is a hard job, regardless of how much support one has. I’ll tell you a story about a colleague of mine who tells this story all the time, and he has a Google executive shadow him periodically. And, you know, he goes in, and he tells a patient about the findings on a scan and the diagnosis, and the Google executive says, “I’ve got AI that can do that.” And, you know, he goes into the next person who’s doing really well, and everything is great, and he says, “I’ll see you in six months,” and he said, “Google could take care of that.” And then he goes to see a new patient who’s a 24-year-old with a terminal illness, and he spends time with the patient and the family, and he explains that, you know, they’ve exhausted the options and that there are no more therapy options available. The patient is crying, the family is crying, and now the Google executive is crying. And he walks out, and he said, “And that’s why I’ll never be a doctor.” So I think no matter how much augmentation we will have in the future, no matter how much science grows to alleviate suffering, we will always be humans caring for other humans, and making that a sustainable career is important.

RO: Oh, wow, yeah, that’s very deep, especially in these times where almost everything is being replaced by a machine and AI.

TM: Mhm.

RO: And we touched base on breast cancer, and it’s becoming more like a chronic disease. What are the changes or advancements in the field that excite you the most?

TM: Oh my gosh, there are so many things that are amazing. First off, breast cancer isn’t one disease; it’s multiple different diseases. And on every front, there have been breakthroughs. I think we were stuck for a while about the role of immune therapy in breast cancer. The San Antonio breast meetings are going on as we speak, and we’re seeing the benefit of drugs like pisab and talab in combination and in ways that are now making a difference for patients. I think the antibody-drug conjugates offer a completely new path for patients. The understanding of inherited cancers and the targeted therapies for inherited cancers is simply an amazing thing. I think using AI to detect cancers on mammograms, in concert with a radiologist, is tremendous for early detection. I think that early detection with ctDNA and finding cancer before it’s visible on a mammogram is going to revolutionize how we approach women at risk for cancer. I think large language models and machine learning will change how we actually practice medicine. And to go back to Google again, I listened to the CMO of Google, and she said, “AI will not replace an oncologist, but an oncologist who doesn’t use AI will be obsolete.” And I think that’s really true. So I think there are tremendous changes happening right in front of us. I’m waiting for CAR T therapy to continue to be expanded from the solid tumors that they’ve started with into breast cancer. I think the HER2-positive patients and the triple-negative patients are most likely to benefit from this, but who knows? The sky is the limit.

RO: Yeah, I agree with you. I think the CAR T therapy is very exciting for sure. We have a couple of patients in my center who have breast cancer and recruited for this type of treatment. And I think it’s not only oncologists who don’t use… I think any job right now, if you don’t know how to use AI, it’s just going to be very hard to sustain that job because people who use AI are just going to be far more advanced in their career.

TM: Completely agree with that. I do think there’s a risk, and I think we have to be clear and methodical about how we use AI, however, because the large data sets that many of the large language model platforms use have so much bias because the people who’ve been enrolled in clinical trials are generally healthy white patients, and that may not be reflective of older patients, people with comorbidity, and people of other races. So I think we have to be very careful when we’re using it in diagnostic settings.

RO: Yeah, that’s a very good point. I agree with that. The training… I was just in a different meeting about how to… I have an interest in AI, and one of the things is like the training data that you give AI is going to really affect the results that it will be generated by CHPT or other large language models. So it’s very important to pay attention to what you feed, what you feed your brain or what you feed the JBT because it’s going to affect the answers provided.

TM: Absolutely. And, you know, if you’re working in Detroit, as you are, and you’ve got a very heterogeneous population of people, as opposed to someplace else where everyone that’s being seen is white and of a certain socioeconomic class, and those folks are on clinical trials and the people who live in a much more racially diverse area are not, and we know the data around that, we know the disparities that are there, and then you use those data sets to inform your decision-making, you can introduce bias in ways that would be very difficult to tease out as the end-user. So I think you have to be very, very careful about that.

RO: Yeah, I agree. Going back to quality improvement and safety, in your role as the Director of Quality, Safety, and Value at MGH, what are the primary goals that you have, and what are the challenges that you face in this role?

TM: Sure. I like to use a slide in every introductory talk I give about quality and safety that I lifted wholesale from my colleague Joe Jacobson at the Dana Farber. So I count Joe as a friend and a mentor, but he has a great slide that is a traditional pie-shaped slide, and in each section of the pie are the suffering associated with cancer. So the first slice is the suffering associated with the disease itself. The second is the suffering associated with the treatments: surgery, radiation, chemotherapy, immunotherapy, bone marrow transplant. But the third slice is the suffering that we introduce because of inadequate care delivery models. So in my role as the quality and safety and value director, it is really my job to alleviate the suffering associated with cancer because of inadequate care delivery.

So what do I mean by that? A patient comes in, gets a consult, starts on therapy, leaves, and the scheduler says, “I’ll call you to make your appointment,” and the appointment gets missed. And so we know for many diseases, it’s not just the right drug, but it’s the right schedule. And now the schedule is full; there are no room in the infusion chair, so we delay that person by a week or maybe even two weeks. And now, you know, what does that do to their chances of cure or prolonged disease-free survival because a missed appointment was caused by an inadequate care delivery system?

Or a patient is admitted to the hospital on an oral chemotherapy agent, and the hematologist oncologist comes by. The patient comes in because they broke their leg, hematologist oncologist comes by and says, “Hold the oral chemotherapy during this time period because it might interfere with the fracture healing, and we’ll see the patient when they’re discharged. Thanks so much. I’m going to sign off now. Please contact me if any questions.” The patient was anticipated to be discharged in two or three days; the follow-up appointment was made a week later. The patient develops an aspiration pneumonia during their hospitalization, has a protracted hospitalization, and is discharged to rehab. Our electronic health system, any medications that are held during the ambition if it’s not discontinued, shows up on the active med list. The patient gets to the rehab, now debilitated, doesn’t remember three weeks ago the hematologist said to hold your venetoclax. The patient then goes to the rehab facility, starts back on the venetoclax, even though all the notes say don’t take it. It’s on the after-visit summary; it’s on the med list; it’s copied onto the patient’s medical MAR when they get to the nursing home. And a month later, someone realizes that this patient is lost to follow-up, they contact the patient, find out she’s in rehab, order a CBC, and the patient is pancytopenic. Those are the kind of errors that are Swiss cheese. It’s the human-computer interaction we call that human factors engineering issues. It’s working beyond the scope of practice, people not recognizing that they don’t have the qualifications to order chemotherapy. It’s the missed opportunity because you signed off thinking people would call you if there was a problem. Well, they had a problem, but the people didn’t recognize that the problem also affected their cancer. So there’s sort of that anchor bias. These kinds of issues happen all the time because we have fragmented our healthcare in a way that is operationally efficient but does not provide the best care delivery. So 99% of my job is around process improvement. Once we’ve developed, once we’ve identified what the safety issues are, and then improving the value of the care that patients receive.

RO: Oh, wow, it’s job security. I like to joke it’s job security. It’s very… because I see that happening almost every month, every week, everywhere.

TM: That’s right. And if you’re not tracking it, you’re not trending it, you’re not doing process improvement, how can you improve? It doesn’t matter that we’ve made the right diagnosis and decided on the right treatment if it doesn’t get to the patient in a way that they can take it. Or it gets to them inappropriately, all of the good care that we consider to be the most important part of care, the decision-making, the treatment, it’s for not. And so there’s a misunderstanding and a gap in many provider’s sense of healthcare that they alone are making the decisions and they alone are deciding what the patient is going to get for treatment when, in fact, there’s an entire matrix: pharmacists, the nurses, the nurse practitioners, all of these people provide the care delivery system. The nursing homes, the home care systems, unless we’re all speaking the same language and we all are working off of the same playbook, it becomes incredibly difficult to guarantee that what you said should happen actually does happen.

RO: I agree. And increasingly, we’re shifting care out of the clinic and out of the hospital to more home-based settings. And with that, we are introducing all kinds of variables that we haven’t planned for.

TM: Yeah, yeah, yeah, the… it will be a very interesting era to see how change… how care is going to change and with more shifting toward home. I hope technology is going to be there to… or the system improves because I think whenever there’s an error, you have to improve the system and not punish people.

TM: I think one of the hardest things in quality and safety is that people do things because they have to. And the reason they have to is because they’re reimbursed for it. So you can do a pilot that doesn’t reimburse people, virtual visits on the inpatient side, virtual visits at home. But unless there is a structure to reimburse people for doing these… first, you have to prove it works, but unless there’s a structure to reimburse people to do it, the system doesn’t require you to do it. So unless people are required to do things in their care delivery, it falls to the individual to do things. And that is not a process that is independent of the operator because think about flying planes. The process is independent of who sits in the cockpit, but in medicine, we haven’t made that leap that the process is independent of the physician or the AP providing care.

RO: Yeah. Shifting from quality and safety toward teaching and mentoring, throughout your career, you’ve been involved in teaching and mentoring. What’s your philosophy when it comes to education, the next generation of oncologists?

TM: Yeah, I don’t know that I… I mean, that’s sort of pedagogy beyond my skill set. I think teaching… teaching residents and fellows and medical students is really one of the most fun parts of the job. You know, you’re imparting knowledge and not just about the science and the medicine, but also about how to care for patients. And that’s handson, and it’s very iterative and interactive, and that’s wonderful.

I think mentoring is a much different thing. And so as a mentor, I try to approach the mentee with curiosity and humility because often these mentees are phenomenally accomplished and have true goals about where they want to be in their life. So for some of these folks, I’ve mentored them over a period of years and serve as a guide but also as a sounding board for various sticking points in their career because they have a clear trajectory. For others, I function more as a short-term coach. Here’s a situation I’m in; here’s a problem I’m trying to… how do I get from point A to B? And then I function as a coach, which is asking open-ended questions and not giving the answers but allowing the individual who I’m speaking with to really frame the answers in a way that it informs their own decisions. So these are skills that you can learn through direct programs; these are skills that you can learn through reading a variety of books about mentoring and coaching. But this doesn’t… unlike teaching medical students where you have this body of knowledge you’re trying to impart to someone who doesn’t have that body of knowledge, mentoring and coaching really is a very different skill set. So I take that very seriously. I try to improve my leadership, mentoring, and coaching skills through various classes, programs, reading all the time. It’s less fun and interactive sometimes than teaching the medical students and the Fells because there’s only upside to that, not much downside. With mentoring and coaching, you’re really invested in that other individual, and you sometimes feel the highs and lows of the person that you’re working with. And sometimes it doesn’t turn out the way they expected it, and you may know that at the beginning that what they’re aspiring to is not feasible, but you can’t tell people that. They have to figure that out on their own.

RO: Yeah. You also touched base on leadership. I think you had many previous leadership roles in the past, and you served as a CEO of Commonwealth, a hematology and oncology practice, and also as the service line chief in the South Coast Health. What lessons did you learn from your leadership experience with those groups?

TM: Sure. I think people have a proclivity to leadership from a young age. You know, you were the captain of your soccer team, or you know, you ran the PTO, or you… you know, I think people aspire to that. But true leadership is a learned skill. And having a leadership coach at one point in my career that was an iterative one-on-one process with readings and discussion and… that took a whole year was probably one of the most transformative things in my entire career.

And I learned that first, you have to understand yourself and lead yourself. And you have to understand what your leadership style is and what skills you naturally possess and which skills you need to develop. And then over time, you are then able to lead others. Now it sounds easy, but you’re building the plane while you’re flying it most times when you’re in a leadership position. We think about leadership as having a vision and managing conflict, but it’s having a vision, understanding how to implement a vision, it’s communication, there’s mentorship and coaching that goes along with it, there’s managing conflict for sure. But a true leader can really help cut through a lot of the noise and be able to inspire people, encourage people, and also drive towards the goals that either you or your organization has set because at the end of the day, it’s not enough to rah-rah and do good. You actually have a job to do, and you need to be able to bring folks along in a team and get from point A to point B and accomplish what needs to be done. And like I said, those are skills that can be learned. I’ve been fortunate to have fabulous mentors and coaches who have been able to help me develop those skills. And for someone who’s considering leadership in an organization, I would seek out whatever resources are available to learn about true leadership skills and leadership styles and leading yourself prior to leading others.

RO: Do you think that during residency or fellowship or medical school, we at least get told what are the resources or, or no? Or is it something that we should teach the future residents or doctors?

TM: Because like now you are telling me it’s something that no matter what, you’re going to learn it on the go.

You know, I think it’s like saying, do we… should we teach positions about business? And, you know, we have colleagues who get their MD and their MPH or their MBA or a PhD, or they take courses in leadership development. I think it’s something that all universities have as part of their curricula. Who takes advantage of those alternative paths, I think, is up to the individual. I don’t… I don’t think everyone who goes… you know, everyone who goes to medical school is going to learn about malpractice, about billing, rudimentary things about leadership and, you know, appropriate and inappropriate behavior and, you know, DEI initiatives. So you’re given a taste of a whole bunch of things: population health. I mean, I could go on and on and on. But it doesn’t mean that you do a deep dive into any of it. But knowing where those resources are in your university, whether it’s in your medical school university or if you train in an academic program, I think then taking advantage of those resources… like, I’m never going to go back and get an MBA or a JD. I’m interested in those things, but that just isn’t what drives me. But will I continue to take leadership development courses, and will I participate in formal courses as a mentor? Absolutely. Because those… that is where my interest lies. So I think everyone… there’s so much to medicine, and medicine is so multifaceted. You know, I think… I think it… you know, how many people do you know that stopped along the way and got an MPH or an MBA or a JD, right? So it’s knowing where those resources are and understanding that learning about quality and safety is… can learn… it may be something you were tangentially exposed to in medical school, but you can dive deeper, you know, in your residency. There are formal fellowships in quality and safety. Same thing with leadership. Most academic hospitals or medical schools offer programs of leadership training.

RO: Goa… and you’ve been through a lot. Like, we talked about leadership; we talked about mentoring; we talked about research; we talk about administrative roles. You’ve been through a lot. And on top of that, you told me you have a family and three kids. Like, what’s the secret? How were you able to… I’m just like, because like I’m thinking about that, like throughout the questions, we touched upon like many, many things, and like, she did it all. What’s the secret? How were you able to combine all this?

TM: You need to have a really good partner, which I have throughout my life.

RO: Can I ask you, is your partner in medicine, or no? Does that help, or…

TM: So my late husband was an attorney, and we were married for 31 years when he died. And I remarried eight years after he died, and my second husband is in medicine. I don’t know that being in medicine matters. I think having someone in your life who you can trust and run things by, who is an active listener and an active participant, is really important. So I think having a good partner matters a lot. I think also having a sense of humor really matters because and being… allowing yourself to be humble because you don’t do anything well at some points in your life. Like, you just miss a lot. I know there were plenty of days when I wasn’t quite clear that what the kids were putting on was truly clean or I had folded and just put down on the pile. But everybody was fed, and everybody… when my youngest graduated from high school, we had this giant calendar on the back of the pantry door, and everybody wrote in where they needed to be. And I looked at my late husband, and I said, “We won.” And he said, “What do you mean?” I said, “We never forgot a kid.” And my youngest daughter said it to me the other day. She said, “Mom, I don’t know how you did it.” She said, “You fed us every day and kept us alive. Like, how is this possible?” And she is a… now finishing up her residency. She’s like, “This is really hard work.” And the bottom line is you don’t do it all at once. You do what you need to do with what’s right in front of you. And I didn’t sleep a lot for many years. It’s… you know, I think… and you pick and choose what’s important at the time. You know, I was not monastically dedicated to my research career, and that’s why that part of my career is lacking. But I was dedicated to care delivery; I was dedicated to my family; I was dedicated to safe and quality care. And at the end of my career, I can look back and say, “I’m proud of what I’ve been able to accomplish.” But it doesn’t happen alone. I’ve had colleagues who have supported me, friends who have supported me, mentors who have been amazing. Nobody does this alone.

RO: Very inspiring. Okay, now, shifting gears toward the US and the healthcare system in the US in general, in your experience, what are the most significant challenges that oncologists in the US face today? Of course, there are many, but what are the most important, and how do you think we can overcome those challenges?

TM: I mean, that’s a big question. And if I had to start at the 20,000-foot view, I’d say an inadequate reimbursement system. We are not reimbursed for providing high-quality, safe care. We are reimbursed for widgets. The way oncologists are paid is still subsidized by the margin on drugs rather than the true cognitive work and the care coordination that is required to provide excellent care. If you think about the number of hours that you spend procuring drugs or doing peer-to-peer to make sure that people get appropriate imaging performed or biopsies performed, and the number of times you have to call all your… you know, if you’re a hepatobiliary oncologist, you’re in contact with IR and interventional GI and the physician who’s managing the immune toxicity, the cardiologist, the endocrinologist, the dermatologist that you’re managing. The amount of work that goes into caring for a patient with a complex and high-acuity disease should not be supported, the payment should not be supported, by the cost of the drug. It should be supported by the care that we deliver. And so our care delivery system is based on an outdated payment model. And I think that’s the biggest challenge because we know that we need to build in things like navigation and better social work and better wearables and home-based tools, but our reimbursement system is really on widgets. How many RVUs did you build? Did you give the drug? What was the cost of the tubing? What was the cost of… you know, all the things that are done as a physician are essentially based on a technical and a professional charge. How about what the nurse does? The amount of time that they spend with a patient, some of these complex infusions, some of the skill that’s required to be able to have clinical judgment and understand the processes of what’s going on, and that for that patient who’s receiving combination chemo-immunotherapy and potentially other biologics, it is completely unreimbursed. First, patients want the latest and greatest equipment and technology and place to sit and, you know, a beautiful space to be in and the ability to contact their providers 24/7. It’s all on the back of a professional and a technical and a drug charge that worked when we had 15 or 20 drugs. The care was complex, but the complexity of care… no patient these days with advanced cancer receives less and, you know, X number of lines of therapy, multiple interventional GI, pulmonary, and the, you know, procedures, and urologic stents, and I mean, all of this is complex. And the payment system just doesn’t recognize that. I think that’s the biggest challenge because we know what good care should look like, and yet we can’t get from here to there. And the burden is payment.

RO: All right, I completely agree. I think one of the things I read about the current payment system is like back in the days, surgeons sat down with insurance companies, and then they decided who gets paid what. And based on that, it’s like if you do procedural things, you get paid more. If you don’t do procedure, think you do cognitive medicine, you get paid less. Was that the case?

TM: So the payment system is based on the Medicare RUC, the Relative Value Unit Group. And Medicare has X number of dollars, say they have $100. They can divvy up that $100 however they want. And there is a… the AMA provides, and other groups, American Heart Association, American Society of Clinical Oncology, American College of Surgeons, has representatives to the Medicare RUC. And they have that amount of money to spend, and then they fight amongst themselves how they divvy it up. And so that is how the federal payment system works. And they work… the people who volunteer to do this job work incredibly hard, and they’re incredibly skilled at what they do, but it is a negotiation about who gets paid well. And then the private and private payers, who do fee for service, essentially follow that model. The amount of money is different, and some small things are different, but it’s basically that model.

I think the global payment models that have been evolving, OCM, which is now completed, and the EOM, the Enhanced Oncology Model, and some of the other models that are out there for oncology that are oncology-specific, are beginning to show what unfunded mandates we are all doing and why we can’t improve on the care delivery that we’re given. Some of the most important data was presented two years ago at the ASCO Quality Symposium, where folks from various places, but probably the best presentation came out of Yale, looking at the amount of unfunded mandates that oncologists are required to do. And that if you’re spending your time making sure that you’re doing prior authorizations and peer-to-peers and paperwork to make sure that stuff happens for patients, that’s time you’re not spending doing something else that patients think is of high quality. So I think this is a problem, and one that a lot of people are thinking about. Far be it from me to think I have the answers. I don’t. I have more questions every time I get involved in this. But improving care delivery is going to require fundamental changes in the payment system that we currently have.

RO: Good job. All right, I think we’re almost at time. Thank you very much for sharing all this with us today. Are there any last words or anything you would tell your younger self if you have to do this all over again? What would you do?

TM: Other than not going to medicine? No, I would do it again in a… and I think the most fun conversations I have a week, and don’t tell my other children this, are with my youngest daughter as she’s driving home from work. It is so amazing to hear the excitement and the wonder of, you know, “Mom, did you know?” and she begins to explain about a case or something, and I listen, and she’s like, “Did you know this?” I’m like, “Well, it sort of is the day job.” But it’s infectious. And, you know, there’s no greater privilege than to be able to understand how humans work and to be able to alleviate suffering for another human being. I mean, it is a privilege every day and one that all of us should remind ourselves of and not take lightly. And I have to say, having sat in the waiting room with my late husband when he was diagnosed with cancer and when he was finally told that we had reached the end of the road, I was so grateful for the kindness, the simple human kindness that was expressed. It wasn’t the science; it wasn’t those things that were so important at various points in our care trajectory, but the human kindness is something that AI will never, ever be able to replicate. And so it’s a privilege to do this job, and I would do it again in a heartbeat.

RO: Great. Thank you so much. It was very inspiring. And thank you so much for all this. I think I… and underestimate the privilege of helping people. And no matter how much you appreciate it, it’s not appreciated enough because, like in one point or another, it would be 10 or 15 minutes in your day, but for someone else, it’s a life-changing appointment.

TM: That’s right. That’s right. So it’s a great gig if you can get it.

RO: Sweet. Thank you so much.

TM: Thank you for being here today.

RO: Terrific. Thank you so much for asking.