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Resignation
Along with resigning as chairman of the department of hematology and medical oncology at the Cleveland Clinic (Reunion), I am also resigning as editor in chief of Hematology News. In contrast to the drawn out process of choosing the next department chairman, however, I was in the enviable position of being able to hand pick my successor as editor in chief. I am proud to announce that Ifeyinwa (Ify) Osunkwo, MD, MPH, will be the new editor in chief of Hematology News. Dr. Osunkwo’s new perspective and energy will guide the further development of Hematology News for the benefit of our readers.
As editor in chief, I have had the opportunity to write essays for Hematology News that reflect my experience as a leader in an academic medical department. By doing so, I was trying to summarize some of what I learned along my career path. In my final essay, I want to direct some of these nuggets of wisdom directly to aspiring leaders who are closer to the beginning of their career journey than I am.
My junior colleagues are very interested in developing their careers to maximize opportunities in leadership, and I have coached many to try to understand that the path to leadership is not always straight, may be difficult, and does not always end comfortably. While the goal may seem to be in one direction, the path may lead to another. That is what has happened to me.
I did not seek to be Chairman. The opportunity came to me while I was busy doing other things. As I expressed in an earlier editorial (Seeking the chair), those who are diligent about their work without actively trying to rise through the leadership hierarchy are the ones who seem to rise more often.
Ambition is overrated. The ambitious find it harder to accept failure, and some degree of failure is likely. In his book “Falling Upward: A Spirituality for the Two Halves of Life,” Father Richard Rohr suggests that failure is required in order to mature from someone whose life centers on self to someone whose self centers on life.
Junior faculty tend to focus on self. They try to excel at whatever they attempt as they always have. Whether that is teaching, performing research, or treating patients, they try to be the absolute best teacher, researcher, or practitioner they can be. Many try to do all three well. Rare are those who can perfectly balance all three endeavors. Tension results, both at work and at home. Here is where failure often happens. The student disappoints, the paper is rejected, the grant isn’t funded, the patient relapses, and the family wishes you were home more. This confluence of difficulties challenges our concept of self. Maybe we aren’t perfect after all. Perhaps for the first time, failure looms.
In my experience, the usual solution to the possibility of failure is a desire to reduce patient care responsibilities. Academic faculty cherish their protected time and usually look for ways to increase it rather than to balance it (Professional time). Academic careers require thick CVs, not satisfied patients. A talk on leukemia at a major conference is more valued than talking to a patient about their leukemia. The cognitive dissonance between what we think is important and what is actually important challenges our personal sense of identity. The resulting burnout represents the necessary failure required to then mature spiritually and reprioritize our ambitions.
On some level, then, the path most of us are on is the time-honored – but painful – journey that must be traveled in order to attain peace.
I also recommend planning a career path with quality work, not a future title, as the goal. Quality work implies measurable objectives. For teachers, work could be measured by teaching scores and student accomplishments. For researchers, work could be measured by published papers, grants received, and invited lectures. For practitioners, work could be measured by outcomes, particularly patient-reported outcomes. Once work is measured, continuous improvements can be made and tracked. Highly reliable teachers, researchers, and practitioners who value quality work will be rewarded both personally and professionally (Defining high reliability).
There is a difference, however, between trying to be the best and trying to improve. The former implies competition with someone else, while the latter involves only one person. Competition can be motivating, but can also undermine interpersonal relationships while causing unhealthy behaviors like overworking and sleep deprivation. If the position sought requires selfish and destructive behaviors, it is not a position worth seeking (Rat race).
By doing quality work – not just more work – leadership positions will inevitably follow. Once a position is obtained, the work increases because a leader is now responsible for others. There are some easy-to-learn tools that can help with that responsibility. I find them very useful for helping colleagues work through interpersonal struggles and resource issues (Leadership hacks: The drama triangle; Leadership hacks: Structural tension).
Success as a leader is harder to measure, but many institutions employ engagement surveys similar to job satisfaction surveys. Leadership scores are generally accurate reflections of leader effectiveness, as are 360-degree surveys of those who work with you. Of course, being a leader also means holding those in your charge accountable for their behaviors (The white wall; Full disclosure). Leadership is no place for someone unwilling to hold crucial and difficult conversations with colleagues.
Success, of course, begets success and additional leadership roles are offered to successful leaders. Meanwhile, the work you started in order to get to the leadership position will probably need to be scaled back as excellence in teaching, research, patient care, and leadership is daunting, difficult to manage, and threatens work-life balance. The ability to say “no” is a valuable skill to learn as leadership roles increase.
Even though none of us work alone, academic medicine generally rewards only the individual. Yet, the camaraderie developed over time working together helps balance work and life roles. To advance as a leader, learning to work in a team is a critical ability. There is a science behind teamwork and aspiring leaders should acquaint themselves with it (Successful teams). While you may be rewarded as an individual, your success will be dependent on your ability to work on a team.
Finally, at least for clinicians, our obligation to our patients largely supersedes all our other commitments. Knowing the most, or being the most technically gifted, is not what patients value. They value empathy and relationships. We need to develop care designed for them, not us (Timed perfectly). We need to communicate with them on their terms, not ours (Pathologic superstition). We must walk with patients on their path, not ours. A patient-centered approach to care and career can take you far. Good luck on your journey.
Dr. Kalaycio is the outgoing editor in chief of Hematology News. He is a hematologist-oncologist at the Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Along with resigning as chairman of the department of hematology and medical oncology at the Cleveland Clinic (Reunion), I am also resigning as editor in chief of Hematology News. In contrast to the drawn out process of choosing the next department chairman, however, I was in the enviable position of being able to hand pick my successor as editor in chief. I am proud to announce that Ifeyinwa (Ify) Osunkwo, MD, MPH, will be the new editor in chief of Hematology News. Dr. Osunkwo’s new perspective and energy will guide the further development of Hematology News for the benefit of our readers.
As editor in chief, I have had the opportunity to write essays for Hematology News that reflect my experience as a leader in an academic medical department. By doing so, I was trying to summarize some of what I learned along my career path. In my final essay, I want to direct some of these nuggets of wisdom directly to aspiring leaders who are closer to the beginning of their career journey than I am.
My junior colleagues are very interested in developing their careers to maximize opportunities in leadership, and I have coached many to try to understand that the path to leadership is not always straight, may be difficult, and does not always end comfortably. While the goal may seem to be in one direction, the path may lead to another. That is what has happened to me.
I did not seek to be Chairman. The opportunity came to me while I was busy doing other things. As I expressed in an earlier editorial (Seeking the chair), those who are diligent about their work without actively trying to rise through the leadership hierarchy are the ones who seem to rise more often.
Ambition is overrated. The ambitious find it harder to accept failure, and some degree of failure is likely. In his book “Falling Upward: A Spirituality for the Two Halves of Life,” Father Richard Rohr suggests that failure is required in order to mature from someone whose life centers on self to someone whose self centers on life.
Junior faculty tend to focus on self. They try to excel at whatever they attempt as they always have. Whether that is teaching, performing research, or treating patients, they try to be the absolute best teacher, researcher, or practitioner they can be. Many try to do all three well. Rare are those who can perfectly balance all three endeavors. Tension results, both at work and at home. Here is where failure often happens. The student disappoints, the paper is rejected, the grant isn’t funded, the patient relapses, and the family wishes you were home more. This confluence of difficulties challenges our concept of self. Maybe we aren’t perfect after all. Perhaps for the first time, failure looms.
In my experience, the usual solution to the possibility of failure is a desire to reduce patient care responsibilities. Academic faculty cherish their protected time and usually look for ways to increase it rather than to balance it (Professional time). Academic careers require thick CVs, not satisfied patients. A talk on leukemia at a major conference is more valued than talking to a patient about their leukemia. The cognitive dissonance between what we think is important and what is actually important challenges our personal sense of identity. The resulting burnout represents the necessary failure required to then mature spiritually and reprioritize our ambitions.
On some level, then, the path most of us are on is the time-honored – but painful – journey that must be traveled in order to attain peace.
I also recommend planning a career path with quality work, not a future title, as the goal. Quality work implies measurable objectives. For teachers, work could be measured by teaching scores and student accomplishments. For researchers, work could be measured by published papers, grants received, and invited lectures. For practitioners, work could be measured by outcomes, particularly patient-reported outcomes. Once work is measured, continuous improvements can be made and tracked. Highly reliable teachers, researchers, and practitioners who value quality work will be rewarded both personally and professionally (Defining high reliability).
There is a difference, however, between trying to be the best and trying to improve. The former implies competition with someone else, while the latter involves only one person. Competition can be motivating, but can also undermine interpersonal relationships while causing unhealthy behaviors like overworking and sleep deprivation. If the position sought requires selfish and destructive behaviors, it is not a position worth seeking (Rat race).
By doing quality work – not just more work – leadership positions will inevitably follow. Once a position is obtained, the work increases because a leader is now responsible for others. There are some easy-to-learn tools that can help with that responsibility. I find them very useful for helping colleagues work through interpersonal struggles and resource issues (Leadership hacks: The drama triangle; Leadership hacks: Structural tension).
Success as a leader is harder to measure, but many institutions employ engagement surveys similar to job satisfaction surveys. Leadership scores are generally accurate reflections of leader effectiveness, as are 360-degree surveys of those who work with you. Of course, being a leader also means holding those in your charge accountable for their behaviors (The white wall; Full disclosure). Leadership is no place for someone unwilling to hold crucial and difficult conversations with colleagues.
Success, of course, begets success and additional leadership roles are offered to successful leaders. Meanwhile, the work you started in order to get to the leadership position will probably need to be scaled back as excellence in teaching, research, patient care, and leadership is daunting, difficult to manage, and threatens work-life balance. The ability to say “no” is a valuable skill to learn as leadership roles increase.
Even though none of us work alone, academic medicine generally rewards only the individual. Yet, the camaraderie developed over time working together helps balance work and life roles. To advance as a leader, learning to work in a team is a critical ability. There is a science behind teamwork and aspiring leaders should acquaint themselves with it (Successful teams). While you may be rewarded as an individual, your success will be dependent on your ability to work on a team.
Finally, at least for clinicians, our obligation to our patients largely supersedes all our other commitments. Knowing the most, or being the most technically gifted, is not what patients value. They value empathy and relationships. We need to develop care designed for them, not us (Timed perfectly). We need to communicate with them on their terms, not ours (Pathologic superstition). We must walk with patients on their path, not ours. A patient-centered approach to care and career can take you far. Good luck on your journey.
Dr. Kalaycio is the outgoing editor in chief of Hematology News. He is a hematologist-oncologist at the Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Along with resigning as chairman of the department of hematology and medical oncology at the Cleveland Clinic (Reunion), I am also resigning as editor in chief of Hematology News. In contrast to the drawn out process of choosing the next department chairman, however, I was in the enviable position of being able to hand pick my successor as editor in chief. I am proud to announce that Ifeyinwa (Ify) Osunkwo, MD, MPH, will be the new editor in chief of Hematology News. Dr. Osunkwo’s new perspective and energy will guide the further development of Hematology News for the benefit of our readers.
As editor in chief, I have had the opportunity to write essays for Hematology News that reflect my experience as a leader in an academic medical department. By doing so, I was trying to summarize some of what I learned along my career path. In my final essay, I want to direct some of these nuggets of wisdom directly to aspiring leaders who are closer to the beginning of their career journey than I am.
My junior colleagues are very interested in developing their careers to maximize opportunities in leadership, and I have coached many to try to understand that the path to leadership is not always straight, may be difficult, and does not always end comfortably. While the goal may seem to be in one direction, the path may lead to another. That is what has happened to me.
I did not seek to be Chairman. The opportunity came to me while I was busy doing other things. As I expressed in an earlier editorial (Seeking the chair), those who are diligent about their work without actively trying to rise through the leadership hierarchy are the ones who seem to rise more often.
Ambition is overrated. The ambitious find it harder to accept failure, and some degree of failure is likely. In his book “Falling Upward: A Spirituality for the Two Halves of Life,” Father Richard Rohr suggests that failure is required in order to mature from someone whose life centers on self to someone whose self centers on life.
Junior faculty tend to focus on self. They try to excel at whatever they attempt as they always have. Whether that is teaching, performing research, or treating patients, they try to be the absolute best teacher, researcher, or practitioner they can be. Many try to do all three well. Rare are those who can perfectly balance all three endeavors. Tension results, both at work and at home. Here is where failure often happens. The student disappoints, the paper is rejected, the grant isn’t funded, the patient relapses, and the family wishes you were home more. This confluence of difficulties challenges our concept of self. Maybe we aren’t perfect after all. Perhaps for the first time, failure looms.
In my experience, the usual solution to the possibility of failure is a desire to reduce patient care responsibilities. Academic faculty cherish their protected time and usually look for ways to increase it rather than to balance it (Professional time). Academic careers require thick CVs, not satisfied patients. A talk on leukemia at a major conference is more valued than talking to a patient about their leukemia. The cognitive dissonance between what we think is important and what is actually important challenges our personal sense of identity. The resulting burnout represents the necessary failure required to then mature spiritually and reprioritize our ambitions.
On some level, then, the path most of us are on is the time-honored – but painful – journey that must be traveled in order to attain peace.
I also recommend planning a career path with quality work, not a future title, as the goal. Quality work implies measurable objectives. For teachers, work could be measured by teaching scores and student accomplishments. For researchers, work could be measured by published papers, grants received, and invited lectures. For practitioners, work could be measured by outcomes, particularly patient-reported outcomes. Once work is measured, continuous improvements can be made and tracked. Highly reliable teachers, researchers, and practitioners who value quality work will be rewarded both personally and professionally (Defining high reliability).
There is a difference, however, between trying to be the best and trying to improve. The former implies competition with someone else, while the latter involves only one person. Competition can be motivating, but can also undermine interpersonal relationships while causing unhealthy behaviors like overworking and sleep deprivation. If the position sought requires selfish and destructive behaviors, it is not a position worth seeking (Rat race).
By doing quality work – not just more work – leadership positions will inevitably follow. Once a position is obtained, the work increases because a leader is now responsible for others. There are some easy-to-learn tools that can help with that responsibility. I find them very useful for helping colleagues work through interpersonal struggles and resource issues (Leadership hacks: The drama triangle; Leadership hacks: Structural tension).
Success as a leader is harder to measure, but many institutions employ engagement surveys similar to job satisfaction surveys. Leadership scores are generally accurate reflections of leader effectiveness, as are 360-degree surveys of those who work with you. Of course, being a leader also means holding those in your charge accountable for their behaviors (The white wall; Full disclosure). Leadership is no place for someone unwilling to hold crucial and difficult conversations with colleagues.
Success, of course, begets success and additional leadership roles are offered to successful leaders. Meanwhile, the work you started in order to get to the leadership position will probably need to be scaled back as excellence in teaching, research, patient care, and leadership is daunting, difficult to manage, and threatens work-life balance. The ability to say “no” is a valuable skill to learn as leadership roles increase.
Even though none of us work alone, academic medicine generally rewards only the individual. Yet, the camaraderie developed over time working together helps balance work and life roles. To advance as a leader, learning to work in a team is a critical ability. There is a science behind teamwork and aspiring leaders should acquaint themselves with it (Successful teams). While you may be rewarded as an individual, your success will be dependent on your ability to work on a team.
Finally, at least for clinicians, our obligation to our patients largely supersedes all our other commitments. Knowing the most, or being the most technically gifted, is not what patients value. They value empathy and relationships. We need to develop care designed for them, not us (Timed perfectly). We need to communicate with them on their terms, not ours (Pathologic superstition). We must walk with patients on their path, not ours. A patient-centered approach to care and career can take you far. Good luck on your journey.
Dr. Kalaycio is the outgoing editor in chief of Hematology News. He is a hematologist-oncologist at the Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Treat or treat
In Charles M. Schulz’s “It’s the Great Pumpkin, Charlie Brown,” the Peanuts gang goes trick or treating door to door. While everyone else gets candy, chewing gum, and chocolate bars, Charlie Brown just gets a bag of rocks. Everyone got treats except Charlie Brown, who only got tricks. Sometimes it seems that my patients are trick or treating, too. Sadly, the tricks come way too often.
Linus tried to avoid tricks by staking out a sincere pumpkin patch in the hope that the Great Pumpkin would rise and deliver him candy and toys. Alas, our patients sometimes sincerely believe things like alkalinization, naturopathy, and antineoplastons will deliver the treats they need to cure their cancer. They will be similarly disappointed.
Most patients depend on us to skew the treat to trick ratio favorably. They trust us to know what to recommend to lengthen life and reduce suffering. Their faith is both a profound privilege and a daunting responsibility.
My patient was hospitalized with hypercalcemia, the latest complication deriving from a decade of progressive multiple myeloma. He was on his 11th line of therapy complicated by at least a grade 3 neuropathy resulting in an unstable gait, chronic pain requiring opioid analgesia, two hospitalizations in the last year for severe infections, and venous thromboembolism on anticoagulation, all resulting in an ECOG performance status no better than a 2. He stabilized and then we needed to talk about next steps.
A clinical trial would be ideal, but he would be excluded from any that we have open and travel isn’t really an option for him. I could choose to treat him with selinexor. It is approved by the Food and Drug Administration and has about a one-in-four chance of producing a short remission in a population of patients that would not include my patient. It also has a three-in-four chance of significant side effects. I could also create a combination regimen with drugs that he has already been exposed to, knowing that response is unlikely and side effects are certain.
This situation is not unique; in fact it is an all too frequent occurrence. The easiest path forward for me would be to recommend treatment. The patient expects treatment and would readily consent to whatever regimen I proposed. He would bear whatever side effects resulted as an expected consequence of therapy. On the surface, this easy path appears to be the proverbial “treat.” But really, further treatment is the “trick” because it is not known to prolong life and would certainly add side effects. The problem, of course, is knowing both when treats become tricks and how to let patients know this, too.
No one knows exactly when treats become tricks, least of all me. Every month I get a report updating me on the status of a former patient being treated elsewhere. This is someone who I thought had no more treatment options. I am humbled every time a colleague, or fellow, recommends a treatment I had never considered. I am not perfect; I do the best I can. My recommendation might be wrong.
Yet I have watched my patient steadily deteriorate and cognitively decline no matter what treatment I employed, whether or not the monoclonal spike decreased. There is no evidence that treatment under such circumstances benefits the patient at all. Moreover, I have sat through many morbidity and mortality conferences where the conclusion was that we should have consulted hospice sooner. Like so many hematologists and oncologists every day, I needed to have a goals-of-care conversation with my patient knowing that treatment could possibly help, but probably would not.
Crucial conversations like these are difficult for everybody. There are techniques to employ that my palliative care colleagues recommend. I tried to remember them as I started talking to my patient and his wife. He listened and clearly understood the gravity of the situation and the resulting poor prognosis regardless of treatment. I recommended hospice. He declined.
Getting to this point was uncomfortable enough, but then I came to a decision that I am still struggling with – acquiesce to his wishes and treat while feeling that I should not, or decline to treat further and transfer his care to someone more willing? This is not the kind of trick or treat I enjoy.
I look forward to the day when discussions of end of life are less awkward. Small movements have started to bring these conversations into the open. One such movement choreographs a dinner to encourage frank and open discussion of death (https://deathoverdinner.org/). Another reimagines the doula – a childbirth coach – as a coach at the end of life (https://www.agentlerparting.com/). Another provides a step-by-step approach to generating an end-of-life conversation (https://theconversationproject.org/). These, and many other efforts, did not occur in a vacuum. They emerged because of the growing recognition that the modern delivery of health care, and the culture it created, is inadequate for the end of life.
Until our culture changes, though, we are left with tough conversations and tougher decisions with our patients who are at the end of their cancer journey. I wish I could tell my junior colleagues that it gets easier with experience. In many ways it gets worse because of the long relationships we develop. As long as the rewards of treats are greater than the disappointments of tricks, though, I will continue trick or treating in my white coat costume.
Dr. Kalaycio is editor in chief of Hematology News. He is a hematologist-oncologist at the Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
In Charles M. Schulz’s “It’s the Great Pumpkin, Charlie Brown,” the Peanuts gang goes trick or treating door to door. While everyone else gets candy, chewing gum, and chocolate bars, Charlie Brown just gets a bag of rocks. Everyone got treats except Charlie Brown, who only got tricks. Sometimes it seems that my patients are trick or treating, too. Sadly, the tricks come way too often.
Linus tried to avoid tricks by staking out a sincere pumpkin patch in the hope that the Great Pumpkin would rise and deliver him candy and toys. Alas, our patients sometimes sincerely believe things like alkalinization, naturopathy, and antineoplastons will deliver the treats they need to cure their cancer. They will be similarly disappointed.
Most patients depend on us to skew the treat to trick ratio favorably. They trust us to know what to recommend to lengthen life and reduce suffering. Their faith is both a profound privilege and a daunting responsibility.
My patient was hospitalized with hypercalcemia, the latest complication deriving from a decade of progressive multiple myeloma. He was on his 11th line of therapy complicated by at least a grade 3 neuropathy resulting in an unstable gait, chronic pain requiring opioid analgesia, two hospitalizations in the last year for severe infections, and venous thromboembolism on anticoagulation, all resulting in an ECOG performance status no better than a 2. He stabilized and then we needed to talk about next steps.
A clinical trial would be ideal, but he would be excluded from any that we have open and travel isn’t really an option for him. I could choose to treat him with selinexor. It is approved by the Food and Drug Administration and has about a one-in-four chance of producing a short remission in a population of patients that would not include my patient. It also has a three-in-four chance of significant side effects. I could also create a combination regimen with drugs that he has already been exposed to, knowing that response is unlikely and side effects are certain.
This situation is not unique; in fact it is an all too frequent occurrence. The easiest path forward for me would be to recommend treatment. The patient expects treatment and would readily consent to whatever regimen I proposed. He would bear whatever side effects resulted as an expected consequence of therapy. On the surface, this easy path appears to be the proverbial “treat.” But really, further treatment is the “trick” because it is not known to prolong life and would certainly add side effects. The problem, of course, is knowing both when treats become tricks and how to let patients know this, too.
No one knows exactly when treats become tricks, least of all me. Every month I get a report updating me on the status of a former patient being treated elsewhere. This is someone who I thought had no more treatment options. I am humbled every time a colleague, or fellow, recommends a treatment I had never considered. I am not perfect; I do the best I can. My recommendation might be wrong.
Yet I have watched my patient steadily deteriorate and cognitively decline no matter what treatment I employed, whether or not the monoclonal spike decreased. There is no evidence that treatment under such circumstances benefits the patient at all. Moreover, I have sat through many morbidity and mortality conferences where the conclusion was that we should have consulted hospice sooner. Like so many hematologists and oncologists every day, I needed to have a goals-of-care conversation with my patient knowing that treatment could possibly help, but probably would not.
Crucial conversations like these are difficult for everybody. There are techniques to employ that my palliative care colleagues recommend. I tried to remember them as I started talking to my patient and his wife. He listened and clearly understood the gravity of the situation and the resulting poor prognosis regardless of treatment. I recommended hospice. He declined.
Getting to this point was uncomfortable enough, but then I came to a decision that I am still struggling with – acquiesce to his wishes and treat while feeling that I should not, or decline to treat further and transfer his care to someone more willing? This is not the kind of trick or treat I enjoy.
I look forward to the day when discussions of end of life are less awkward. Small movements have started to bring these conversations into the open. One such movement choreographs a dinner to encourage frank and open discussion of death (https://deathoverdinner.org/). Another reimagines the doula – a childbirth coach – as a coach at the end of life (https://www.agentlerparting.com/). Another provides a step-by-step approach to generating an end-of-life conversation (https://theconversationproject.org/). These, and many other efforts, did not occur in a vacuum. They emerged because of the growing recognition that the modern delivery of health care, and the culture it created, is inadequate for the end of life.
Until our culture changes, though, we are left with tough conversations and tougher decisions with our patients who are at the end of their cancer journey. I wish I could tell my junior colleagues that it gets easier with experience. In many ways it gets worse because of the long relationships we develop. As long as the rewards of treats are greater than the disappointments of tricks, though, I will continue trick or treating in my white coat costume.
Dr. Kalaycio is editor in chief of Hematology News. He is a hematologist-oncologist at the Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
In Charles M. Schulz’s “It’s the Great Pumpkin, Charlie Brown,” the Peanuts gang goes trick or treating door to door. While everyone else gets candy, chewing gum, and chocolate bars, Charlie Brown just gets a bag of rocks. Everyone got treats except Charlie Brown, who only got tricks. Sometimes it seems that my patients are trick or treating, too. Sadly, the tricks come way too often.
Linus tried to avoid tricks by staking out a sincere pumpkin patch in the hope that the Great Pumpkin would rise and deliver him candy and toys. Alas, our patients sometimes sincerely believe things like alkalinization, naturopathy, and antineoplastons will deliver the treats they need to cure their cancer. They will be similarly disappointed.
Most patients depend on us to skew the treat to trick ratio favorably. They trust us to know what to recommend to lengthen life and reduce suffering. Their faith is both a profound privilege and a daunting responsibility.
My patient was hospitalized with hypercalcemia, the latest complication deriving from a decade of progressive multiple myeloma. He was on his 11th line of therapy complicated by at least a grade 3 neuropathy resulting in an unstable gait, chronic pain requiring opioid analgesia, two hospitalizations in the last year for severe infections, and venous thromboembolism on anticoagulation, all resulting in an ECOG performance status no better than a 2. He stabilized and then we needed to talk about next steps.
A clinical trial would be ideal, but he would be excluded from any that we have open and travel isn’t really an option for him. I could choose to treat him with selinexor. It is approved by the Food and Drug Administration and has about a one-in-four chance of producing a short remission in a population of patients that would not include my patient. It also has a three-in-four chance of significant side effects. I could also create a combination regimen with drugs that he has already been exposed to, knowing that response is unlikely and side effects are certain.
This situation is not unique; in fact it is an all too frequent occurrence. The easiest path forward for me would be to recommend treatment. The patient expects treatment and would readily consent to whatever regimen I proposed. He would bear whatever side effects resulted as an expected consequence of therapy. On the surface, this easy path appears to be the proverbial “treat.” But really, further treatment is the “trick” because it is not known to prolong life and would certainly add side effects. The problem, of course, is knowing both when treats become tricks and how to let patients know this, too.
No one knows exactly when treats become tricks, least of all me. Every month I get a report updating me on the status of a former patient being treated elsewhere. This is someone who I thought had no more treatment options. I am humbled every time a colleague, or fellow, recommends a treatment I had never considered. I am not perfect; I do the best I can. My recommendation might be wrong.
Yet I have watched my patient steadily deteriorate and cognitively decline no matter what treatment I employed, whether or not the monoclonal spike decreased. There is no evidence that treatment under such circumstances benefits the patient at all. Moreover, I have sat through many morbidity and mortality conferences where the conclusion was that we should have consulted hospice sooner. Like so many hematologists and oncologists every day, I needed to have a goals-of-care conversation with my patient knowing that treatment could possibly help, but probably would not.
Crucial conversations like these are difficult for everybody. There are techniques to employ that my palliative care colleagues recommend. I tried to remember them as I started talking to my patient and his wife. He listened and clearly understood the gravity of the situation and the resulting poor prognosis regardless of treatment. I recommended hospice. He declined.
Getting to this point was uncomfortable enough, but then I came to a decision that I am still struggling with – acquiesce to his wishes and treat while feeling that I should not, or decline to treat further and transfer his care to someone more willing? This is not the kind of trick or treat I enjoy.
I look forward to the day when discussions of end of life are less awkward. Small movements have started to bring these conversations into the open. One such movement choreographs a dinner to encourage frank and open discussion of death (https://deathoverdinner.org/). Another reimagines the doula – a childbirth coach – as a coach at the end of life (https://www.agentlerparting.com/). Another provides a step-by-step approach to generating an end-of-life conversation (https://theconversationproject.org/). These, and many other efforts, did not occur in a vacuum. They emerged because of the growing recognition that the modern delivery of health care, and the culture it created, is inadequate for the end of life.
Until our culture changes, though, we are left with tough conversations and tougher decisions with our patients who are at the end of their cancer journey. I wish I could tell my junior colleagues that it gets easier with experience. In many ways it gets worse because of the long relationships we develop. As long as the rewards of treats are greater than the disappointments of tricks, though, I will continue trick or treating in my white coat costume.
Dr. Kalaycio is editor in chief of Hematology News. He is a hematologist-oncologist at the Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Reunion
We were catching up during our 35th college reunion at our old fraternity house overlooking Cayuga Lake in Ithaca, N.Y. About 50 of us lived in the Tudor-style house, complete with secret basement room, and there was a ladder that allowed access to the relatively flat, painted aluminum roof. When the weather allowed, we climbed the ladder to sun ourselves on top of the house. We also flung water balloons at unsuspecting pedestrians with a sling shot device made by attaching rubber tubing to a funnel. The “funnelator” was very accurate to about 50 yards away. We were kids, and climbing that ladder meant fun, and we climbed it as often as we could.
Despite what many would have predicted when we graduated, my fraternity brothers became a very successful group of CEOs, vice presidents, doctors, lawyers, chairmen, and consultants. Our house was just off Cornell University’s campus at the top of Ithaca Falls, an idyllic setting on a beautiful June evening for my brothers to sit around, laugh about the old times, and philosophize about life. We recounted our life after college and reveled in each others’ accomplishments.
After climbing the roof ladder for fun, we had each climbed a different kind of ladder to success in our respective fields. We all really enjoyed the climb. I don’t think it is a coincidence that many of my brothers and I are now done climbing our ladders. Many of us are getting out of the rat race.
One of my friends is resigning as chairman of an academic ENT department. I remember his discipline in college, leaving the house after dinner every night to climb the hill where he studied in the quiet of Uris Library, which is attached to the iconic McGraw Tower. His hard work paid off with an acceptance to a prestigious medical school where he continued to excel. The author of more than 200 published manuscripts, with four senior-authored papers already this year, he is at the pinnacle of his academic success. Yet, he resigned.
Similarly, another of my fraternity brothers had recently resigned from his position as Senior Vice President and Chief Medical Officer for a large health care system. He would have been in line for the CEO position had he stayed. He has written well-received books on leadership and financial acumen for physicians. As a result, he is a frequent public speaker on similar topics. Yet, he resigned.
They were not the only ones resigning positions that others covet. I, too, resigned my position as Department Chairman earlier this year. None of us were fired, none of us were asked to leave, and none of us are burned out. So here we were, three accomplished physicians all resigning from powerful posts at the same time for what turns out to be similar reasons. Our priorities changed as our children moved out.
I would like to say that we all had the wisdom to know that our leadership skills were deteriorating and that we all wanted to get out while we are at the top of our game. Had Arthur Brooks written “Your Professional Decline Is Coming (Much) Sooner Than You Think” in The Atlantic (July 2019) before we made our decisions, I may have made that argument, but it would not have been true. All three of us feel like we have accomplished what we sought to achieve when we took our respective roles and now we wanted to leverage that experience into something different, if not better. None of us have settled into new roles yet, and all of us are still trying to define exactly what it is we want to do next, but all of us agree that we are no longer interested in driving ourselves to succeed at the expense of our family, friends, and relationships.
My fraternity brothers and I gushed with pride talking about our children and their success. Our progeny are starting their individual climbs up the ladder of opportunity in whatever field they have chosen. My friends and I, on the other hand, had already climbed a ladder and feel comfortable stopping. Or maybe we just want to start climbing a different ladder.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
We were catching up during our 35th college reunion at our old fraternity house overlooking Cayuga Lake in Ithaca, N.Y. About 50 of us lived in the Tudor-style house, complete with secret basement room, and there was a ladder that allowed access to the relatively flat, painted aluminum roof. When the weather allowed, we climbed the ladder to sun ourselves on top of the house. We also flung water balloons at unsuspecting pedestrians with a sling shot device made by attaching rubber tubing to a funnel. The “funnelator” was very accurate to about 50 yards away. We were kids, and climbing that ladder meant fun, and we climbed it as often as we could.
Despite what many would have predicted when we graduated, my fraternity brothers became a very successful group of CEOs, vice presidents, doctors, lawyers, chairmen, and consultants. Our house was just off Cornell University’s campus at the top of Ithaca Falls, an idyllic setting on a beautiful June evening for my brothers to sit around, laugh about the old times, and philosophize about life. We recounted our life after college and reveled in each others’ accomplishments.
After climbing the roof ladder for fun, we had each climbed a different kind of ladder to success in our respective fields. We all really enjoyed the climb. I don’t think it is a coincidence that many of my brothers and I are now done climbing our ladders. Many of us are getting out of the rat race.
One of my friends is resigning as chairman of an academic ENT department. I remember his discipline in college, leaving the house after dinner every night to climb the hill where he studied in the quiet of Uris Library, which is attached to the iconic McGraw Tower. His hard work paid off with an acceptance to a prestigious medical school where he continued to excel. The author of more than 200 published manuscripts, with four senior-authored papers already this year, he is at the pinnacle of his academic success. Yet, he resigned.
Similarly, another of my fraternity brothers had recently resigned from his position as Senior Vice President and Chief Medical Officer for a large health care system. He would have been in line for the CEO position had he stayed. He has written well-received books on leadership and financial acumen for physicians. As a result, he is a frequent public speaker on similar topics. Yet, he resigned.
They were not the only ones resigning positions that others covet. I, too, resigned my position as Department Chairman earlier this year. None of us were fired, none of us were asked to leave, and none of us are burned out. So here we were, three accomplished physicians all resigning from powerful posts at the same time for what turns out to be similar reasons. Our priorities changed as our children moved out.
I would like to say that we all had the wisdom to know that our leadership skills were deteriorating and that we all wanted to get out while we are at the top of our game. Had Arthur Brooks written “Your Professional Decline Is Coming (Much) Sooner Than You Think” in The Atlantic (July 2019) before we made our decisions, I may have made that argument, but it would not have been true. All three of us feel like we have accomplished what we sought to achieve when we took our respective roles and now we wanted to leverage that experience into something different, if not better. None of us have settled into new roles yet, and all of us are still trying to define exactly what it is we want to do next, but all of us agree that we are no longer interested in driving ourselves to succeed at the expense of our family, friends, and relationships.
My fraternity brothers and I gushed with pride talking about our children and their success. Our progeny are starting their individual climbs up the ladder of opportunity in whatever field they have chosen. My friends and I, on the other hand, had already climbed a ladder and feel comfortable stopping. Or maybe we just want to start climbing a different ladder.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
We were catching up during our 35th college reunion at our old fraternity house overlooking Cayuga Lake in Ithaca, N.Y. About 50 of us lived in the Tudor-style house, complete with secret basement room, and there was a ladder that allowed access to the relatively flat, painted aluminum roof. When the weather allowed, we climbed the ladder to sun ourselves on top of the house. We also flung water balloons at unsuspecting pedestrians with a sling shot device made by attaching rubber tubing to a funnel. The “funnelator” was very accurate to about 50 yards away. We were kids, and climbing that ladder meant fun, and we climbed it as often as we could.
Despite what many would have predicted when we graduated, my fraternity brothers became a very successful group of CEOs, vice presidents, doctors, lawyers, chairmen, and consultants. Our house was just off Cornell University’s campus at the top of Ithaca Falls, an idyllic setting on a beautiful June evening for my brothers to sit around, laugh about the old times, and philosophize about life. We recounted our life after college and reveled in each others’ accomplishments.
After climbing the roof ladder for fun, we had each climbed a different kind of ladder to success in our respective fields. We all really enjoyed the climb. I don’t think it is a coincidence that many of my brothers and I are now done climbing our ladders. Many of us are getting out of the rat race.
One of my friends is resigning as chairman of an academic ENT department. I remember his discipline in college, leaving the house after dinner every night to climb the hill where he studied in the quiet of Uris Library, which is attached to the iconic McGraw Tower. His hard work paid off with an acceptance to a prestigious medical school where he continued to excel. The author of more than 200 published manuscripts, with four senior-authored papers already this year, he is at the pinnacle of his academic success. Yet, he resigned.
Similarly, another of my fraternity brothers had recently resigned from his position as Senior Vice President and Chief Medical Officer for a large health care system. He would have been in line for the CEO position had he stayed. He has written well-received books on leadership and financial acumen for physicians. As a result, he is a frequent public speaker on similar topics. Yet, he resigned.
They were not the only ones resigning positions that others covet. I, too, resigned my position as Department Chairman earlier this year. None of us were fired, none of us were asked to leave, and none of us are burned out. So here we were, three accomplished physicians all resigning from powerful posts at the same time for what turns out to be similar reasons. Our priorities changed as our children moved out.
I would like to say that we all had the wisdom to know that our leadership skills were deteriorating and that we all wanted to get out while we are at the top of our game. Had Arthur Brooks written “Your Professional Decline Is Coming (Much) Sooner Than You Think” in The Atlantic (July 2019) before we made our decisions, I may have made that argument, but it would not have been true. All three of us feel like we have accomplished what we sought to achieve when we took our respective roles and now we wanted to leverage that experience into something different, if not better. None of us have settled into new roles yet, and all of us are still trying to define exactly what it is we want to do next, but all of us agree that we are no longer interested in driving ourselves to succeed at the expense of our family, friends, and relationships.
My fraternity brothers and I gushed with pride talking about our children and their success. Our progeny are starting their individual climbs up the ladder of opportunity in whatever field they have chosen. My friends and I, on the other hand, had already climbed a ladder and feel comfortable stopping. Or maybe we just want to start climbing a different ladder.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Timed perfectly
When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.
As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.
As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.
This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.
My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.
Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.
However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.
We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).
These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.
Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.
Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.
Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.
The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?
If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.
We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.
As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.
As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.
This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.
My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.
Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.
However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.
We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).
These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.
Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.
Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.
Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.
The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?
If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.
We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
When I entered the examination room, I saw his alma mater’s logo on his wristwatch. He was a retired physician with a new diagnosis of leukemia who drove to see me, even though he lived closer to his beloved medical school where he had practiced his entire career.
As is frequently the case, he came to see me because he could not get the appointment he wanted in his university’s clinic for another 6 months. He called us on Friday, and 3 days later, he and I were meeting. He is still an ardent supporter of his institution, but I am now his hematologist.
As it turned out, his leukemia was asymptomatic, indolent, and required no treatment. He could have waited 6 months to be seen. But, no; he couldn’t.
This story repeats itself over and over again. A sick patient calls to be seen and is told there is no availability for weeks or months. I do not understand how health care facilities, my own included, find this acceptable.
My father was very proud of his policy to see every patient in his waiting room no matter how long his office needed to stay open. He felt that access was of primary importance to his patients and to his practice. If he didn’t see them, somebody else would. Those of us working in large academic centers do not always feel the financial consequences of patients lost because of poor service.
Luckily, I work in a large cancer center that values access as much as a small practice would. When a patient calls us with a hematologic problem, we see them in less than 7 days, unless the patient prefers a different time frame. We monitor the time it takes to see patients and proactively assess upcoming appointments to ensure insurance coverage and the availability of records. If an obstruction is identified, the case is escalated to administrative leadership to be addressed and resolved. We are very proud of this work.
However, our focus on access does not end there. Once seen, we expedite patient evaluation by assessing workflows to obtain all necessary testing as quickly as possible. By doing so, we accelerate the time it takes from diagnosis to the time we start treating (time to treat). We have always tried to reduce time to treat for acute leukemia and we have applied those lessons to patients with lymphoma and solid tumors, resulting in a 33% improvement over the last 5 years.
We not only lessen the anxiety that comes with a scary diagnosis, emerging data indicate outcomes are improved with faster treatment, too (PLoS One. 2019 Mar 1;14(3):e0213209. doi: 10.1371/journal.pone.0213209).
These efforts will be criticized by those who feel the delivery of medical care should be structured more around the physician than the patient. Certainly, the system has developed to support a mindset of “physician first.” Not only do patients have to make an appointment for the privilege of seeing us, they have to navigate significant geographic and financial hurdles for that privilege.
Once at the appointment, physicians have historically been the provider giving the “orders” while others correct them, carry them out, follow-up on the results, manage phone calls, and schedule follow-up. This hierarchy has served physicians very well, but the pyramidal structure of health care is on the verge of being upended.
Too few physicians for an increasing demand for medical attention has led to the rise of advanced practice providers (APPs), who often serve as the only provider a patient may have, particularly in rural areas. In our center, we evolved from thinking of APPs as similar to house-staff who saw patients with us and did most of the work, but could not bill, to independent providers who work with us, do most of the work, and bill for their efforts. This slow transformation of our practice will soon seem quaint as we face the rapid disruption coming to our current conception of the health care delivery system.
Technologically savvy patients already demand immediate access to unlimited supplies of consumer goods, video, audio, books, magazines, and just about anything else you can think of. Immediate access to health care at a time convenient to the patient also will become an expectation because plenty of health care delivery models already are providing it. The local pharmacy or retail store may have a physician or APP right there ready to see a patient at any time. Some physicians are already online ready for an electronic interaction. See MDLIVE and Teladoc as examples.
The nimble cancer center that embraces these trends to become more patient-centric will be the center that captures national – if not international – market share, as insurance companies and governments adjust their reimbursement models to include these services. With blood work obtained just about anywhere, what would keep a patient with immune thrombocytopenic purpura from consulting with any online hematologist she chooses, whenever she chooses?
If first impressions are important, then patient access is important. Refrains of “I don’t have clinic that day,” “the pathology has not yet been reviewed,” and “that is not a disease I take care of,” ring as hollow to me as I suspect they do to our patients. When someone in my family has a significant illness, I want them to be seen now, not later. I believe we all would want prompt, efficient service.
We should strive to provide the same level of care to our patients as we expect for our family. Patients do not know that chronic leukemia is not an emergency. Time may not be critical to us, but it is to them. The perfect time to meet their needs is now.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Rat race
My son and I used to play a game called CASHFLOW. It was invented by Robert Kiyosaki, the real estate magnate who originated the “Rich Dad Poor Dad” book series to educate the masses on the basics of real estate investing.
The object of the game was to acquire enough passive income to become independent of active income like salary. The hope was that by playing the game, participants would recognize the advantages of passive income and become entrepreneurs in real estate or business. The winner was no longer an employee, but happily self-employed and out of the rat race.
Alas, the lesson was lost on me and my son. Both of us are still very much in the rat race and dependent on salary.
But a rat race can be more than just a competitive quest for financial gain. In politics, the quest is more for power. In sports, the quest includes championships. In academic medicine – and hematology is usually practiced in an academic setting – the quest is often for power and prestige. Training for our hematologic quest began in high school.
In high school, superior grades were a given, but we also worked to excel in sports, extracurricular activities, and standardized tests in order to get into the best universities. The cycle was then repeated to allow entry into the best medical schools. The old adage that students who finished last in their medical school class are still addressed as “Doctor” notwithstanding, most of us pushed ourselves beyond good grades to volunteer work, research activities, and prestigious clerkships to ensure that we matched at the best residency programs. There, those inclined to hematology cozied up to influential faculty by helping with their research in order to obtain the cherished letter of recommendation that promised admission to the best fellowship program, where the cycle was again repeated in the hope of landing a position in the best academic medical center.
Through these pursuits, young recruits to medical academia are primed and ready to enter a rat race of individual accomplishment. The academic rat race is a particularly pernicious result of our training to be the best, and the “best” hematologists are found at the podium, not in the exam room.
Not content to be recognized for clinical excellence by their patients, academic hematologists often aspire more to be recognized for content expertise by their peers. Through the noble pursuit of advancing science, peer recognition bestows prestige and power in the form of promotions, grants, advisory boards, consultancies, and speaking opportunities all over the globe. For some, the academic rat race validates a life dedicated to being the best.
However, the demands of patient care can interfere with academic pursuits and stand as impediments to the march of science, with its attendant rewards in power and prestige. The most common complaint I get from my team is the inability to fully participate in all that is required to succeed academically because of clinical responsibilities. The difficulty is worsened when financial realities require even more time spent in the clinic to generate income. This makes it hard enough to keep a healthy balance between research and patient care. When the pressures of clinical and academic hematology are combined with the responsibility of family, the rat race can begin to lead to burnout.
A rat race forces us to compare ourselves to others, and we often find ourselves wanting. There is always someone who seems wealthier and wiser than we are. Our training often compels us to compete with whoever it is we are comparing ourselves to. That competition simultaneously drives us toward a laudable goal and away from a balanced, happy life.
Theodore Roosevelt said “Comparison is the thief of joy,” and that certainly seems to be the case among medical professionals. As physicians, we do not lack for wealth, unless we compare ourselves to those who have more. We do not lack for wisdom, unless we compare ourselves to those who have more. We’d see that we really lack very little and occupy a privileged place in society if we only took the time to be grateful for having had the talent and support to do so.
I enjoyed playing CASHFLOW when I was younger and naively thought that either my son or I might materially benefit from its lessons. I realize now that the real enjoyment of playing was not to win or to get rich, but rather to spend time with my son. Likewise, our training got us where we are, and it will sustain a happy fulfilling career, but it will also consume us if we let go of why we started playing the game in the first place.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
My son and I used to play a game called CASHFLOW. It was invented by Robert Kiyosaki, the real estate magnate who originated the “Rich Dad Poor Dad” book series to educate the masses on the basics of real estate investing.
The object of the game was to acquire enough passive income to become independent of active income like salary. The hope was that by playing the game, participants would recognize the advantages of passive income and become entrepreneurs in real estate or business. The winner was no longer an employee, but happily self-employed and out of the rat race.
Alas, the lesson was lost on me and my son. Both of us are still very much in the rat race and dependent on salary.
But a rat race can be more than just a competitive quest for financial gain. In politics, the quest is more for power. In sports, the quest includes championships. In academic medicine – and hematology is usually practiced in an academic setting – the quest is often for power and prestige. Training for our hematologic quest began in high school.
In high school, superior grades were a given, but we also worked to excel in sports, extracurricular activities, and standardized tests in order to get into the best universities. The cycle was then repeated to allow entry into the best medical schools. The old adage that students who finished last in their medical school class are still addressed as “Doctor” notwithstanding, most of us pushed ourselves beyond good grades to volunteer work, research activities, and prestigious clerkships to ensure that we matched at the best residency programs. There, those inclined to hematology cozied up to influential faculty by helping with their research in order to obtain the cherished letter of recommendation that promised admission to the best fellowship program, where the cycle was again repeated in the hope of landing a position in the best academic medical center.
Through these pursuits, young recruits to medical academia are primed and ready to enter a rat race of individual accomplishment. The academic rat race is a particularly pernicious result of our training to be the best, and the “best” hematologists are found at the podium, not in the exam room.
Not content to be recognized for clinical excellence by their patients, academic hematologists often aspire more to be recognized for content expertise by their peers. Through the noble pursuit of advancing science, peer recognition bestows prestige and power in the form of promotions, grants, advisory boards, consultancies, and speaking opportunities all over the globe. For some, the academic rat race validates a life dedicated to being the best.
However, the demands of patient care can interfere with academic pursuits and stand as impediments to the march of science, with its attendant rewards in power and prestige. The most common complaint I get from my team is the inability to fully participate in all that is required to succeed academically because of clinical responsibilities. The difficulty is worsened when financial realities require even more time spent in the clinic to generate income. This makes it hard enough to keep a healthy balance between research and patient care. When the pressures of clinical and academic hematology are combined with the responsibility of family, the rat race can begin to lead to burnout.
A rat race forces us to compare ourselves to others, and we often find ourselves wanting. There is always someone who seems wealthier and wiser than we are. Our training often compels us to compete with whoever it is we are comparing ourselves to. That competition simultaneously drives us toward a laudable goal and away from a balanced, happy life.
Theodore Roosevelt said “Comparison is the thief of joy,” and that certainly seems to be the case among medical professionals. As physicians, we do not lack for wealth, unless we compare ourselves to those who have more. We do not lack for wisdom, unless we compare ourselves to those who have more. We’d see that we really lack very little and occupy a privileged place in society if we only took the time to be grateful for having had the talent and support to do so.
I enjoyed playing CASHFLOW when I was younger and naively thought that either my son or I might materially benefit from its lessons. I realize now that the real enjoyment of playing was not to win or to get rich, but rather to spend time with my son. Likewise, our training got us where we are, and it will sustain a happy fulfilling career, but it will also consume us if we let go of why we started playing the game in the first place.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
My son and I used to play a game called CASHFLOW. It was invented by Robert Kiyosaki, the real estate magnate who originated the “Rich Dad Poor Dad” book series to educate the masses on the basics of real estate investing.
The object of the game was to acquire enough passive income to become independent of active income like salary. The hope was that by playing the game, participants would recognize the advantages of passive income and become entrepreneurs in real estate or business. The winner was no longer an employee, but happily self-employed and out of the rat race.
Alas, the lesson was lost on me and my son. Both of us are still very much in the rat race and dependent on salary.
But a rat race can be more than just a competitive quest for financial gain. In politics, the quest is more for power. In sports, the quest includes championships. In academic medicine – and hematology is usually practiced in an academic setting – the quest is often for power and prestige. Training for our hematologic quest began in high school.
In high school, superior grades were a given, but we also worked to excel in sports, extracurricular activities, and standardized tests in order to get into the best universities. The cycle was then repeated to allow entry into the best medical schools. The old adage that students who finished last in their medical school class are still addressed as “Doctor” notwithstanding, most of us pushed ourselves beyond good grades to volunteer work, research activities, and prestigious clerkships to ensure that we matched at the best residency programs. There, those inclined to hematology cozied up to influential faculty by helping with their research in order to obtain the cherished letter of recommendation that promised admission to the best fellowship program, where the cycle was again repeated in the hope of landing a position in the best academic medical center.
Through these pursuits, young recruits to medical academia are primed and ready to enter a rat race of individual accomplishment. The academic rat race is a particularly pernicious result of our training to be the best, and the “best” hematologists are found at the podium, not in the exam room.
Not content to be recognized for clinical excellence by their patients, academic hematologists often aspire more to be recognized for content expertise by their peers. Through the noble pursuit of advancing science, peer recognition bestows prestige and power in the form of promotions, grants, advisory boards, consultancies, and speaking opportunities all over the globe. For some, the academic rat race validates a life dedicated to being the best.
However, the demands of patient care can interfere with academic pursuits and stand as impediments to the march of science, with its attendant rewards in power and prestige. The most common complaint I get from my team is the inability to fully participate in all that is required to succeed academically because of clinical responsibilities. The difficulty is worsened when financial realities require even more time spent in the clinic to generate income. This makes it hard enough to keep a healthy balance between research and patient care. When the pressures of clinical and academic hematology are combined with the responsibility of family, the rat race can begin to lead to burnout.
A rat race forces us to compare ourselves to others, and we often find ourselves wanting. There is always someone who seems wealthier and wiser than we are. Our training often compels us to compete with whoever it is we are comparing ourselves to. That competition simultaneously drives us toward a laudable goal and away from a balanced, happy life.
Theodore Roosevelt said “Comparison is the thief of joy,” and that certainly seems to be the case among medical professionals. As physicians, we do not lack for wealth, unless we compare ourselves to those who have more. We do not lack for wisdom, unless we compare ourselves to those who have more. We’d see that we really lack very little and occupy a privileged place in society if we only took the time to be grateful for having had the talent and support to do so.
I enjoyed playing CASHFLOW when I was younger and naively thought that either my son or I might materially benefit from its lessons. I realize now that the real enjoyment of playing was not to win or to get rich, but rather to spend time with my son. Likewise, our training got us where we are, and it will sustain a happy fulfilling career, but it will also consume us if we let go of why we started playing the game in the first place.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematology and medical oncology at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Monoclonal gammopathy of undetermined significance: A primary care guide
MGUS is present in 3% to 4% of the population over age 50 and is more common in older men, African Americans, and Africans.1–6
The overall risk of progression to myeloma and related disorders is less than or equal to 1% per year depending on the subtype of the M protein (higher risk with IgM than non-IgM and light-chain MGUS).7,8 While the risk of malignant transformation is low, multiple myeloma is almost always preceded by the presence of an asymptomatic and often unrecognized monoclonal protein.
WHEN SHOULD WE LOOK FOR AN M PROTEIN?
An M protein is typically an incidental finding when a patient is being assessed for any of a number of presenting symptoms or conditions. A large retrospective study9 found that screening for MGUS was mostly performed by internal medicine physicians. The indications for testing were anemia, bone-related issues, elevated creatinine, elevated erythrocyte sedimentation rate, and neuropathy.
A low anion gap is not a major indicator of an M protein unless in a high concentration, in which case other manifestations would be present, such as renal failure, which would guide the diagnosis. Polyclonal hypergammaglobulinemia as a cause of low anion gap is far more common than MGUS.
HOW SHOULD WE SCREEN FOR AN M PROTEIN?
Serum protein electrophoresis is an initial test used to identify an M protein and has a key role in quantifying it (Figure 2). An M protein appears as a narrow spike on the agarose gel and should be distinguished from the broad band seen in polyclonal gammopathies associated with cirrhosis and chronic infectious and inflammatory conditions, among others.12 A major disadvantage of serum protein electrophoresis is that it cannot detect an M protein in very low concentrations or determine its identity.
Serum immunofixation is more sensitive than serum protein electrophoresis and should always be ordered in conjunction with it, mostly to ensure detecting tiny amounts of M protein and to identify the type of its heavy chain and light-chain components.13
The serum free light-chain assay is also considered an essential part of the screening process to detect light-chain MGUS and light-chain myeloma. As many as 16% of myeloma patients secrete only light chains, which may not be identified on serum immunofixation.3,6,7,10,14,15 In general, a low kappa-lambda ratio (< 0.26) indicates the overproduction of lambda light chains, and a high ratio (> 1.65) indicates the overproduction of kappa light chains.
The serum free light-chain assay helps detect abnormal secretion of monoclonal light chains before they appear in the urine once the kidney tubules become saturated and unable to reabsorb them.
Of note, the free light-chain ratio can be abnormal (< 0.26 or > 1.65) in chronic kidney disease. Thus, it may be challenging to discern whether an abnormal light-chain ratio is related to impaired light-chain clearance by the kidneys or to MGUS. In general, kappa light chains are more elevated than lambda light chains in chronic kidney disease, but the ratio should not be considerably skewed. A kappa-lambda ratio below 0.37 or above 3 is rarely seen in chronic kidney disease and should prompt workup for MGUS.16
Tests in combination. The sensitivity of screening for M proteins ranges from 82% with serum protein electrophoresis alone to 93% with the addition of serum immunofixation and to 98% with the serum free light-chain assay.15 The latter can replace urine protein electrophoresis and immunofixation when screening for M protein, given its higher sensitivity.15,17 An important caveat is that urine dipstick testing does not detect urine light chains.
Table 3 lists the initial laboratory tests required in patients with MGUS.
WHAT IS THE DIFFERENTIAL DIAGNOSIS OF MONOCLONAL GAMMOPATHIES?
that feature an M protein and would otherwise require treatment (Table 4). The differential diagnosis includes smoldering multiple myeloma, symptomatic multiple myeloma, Waldenström macroglobulinemia, light-chain amyloidosis, low-grade B-cell lymphoproliferative disorders, a variety of monoclonal protein-related kidney disorders, and plasmacytomas.10,14
MGUS
Based on the International Myeloma Working Group consensus, a formal diagnosis of MGUS is established when a serum M protein is detected and measured at a concentration less than 3 g/dL on serum protein electrophoresis along with less than 10% clonal plasma cells in the bone marrow.1–6,14,18,19 Nevertheless, bone marrow biopsy can be omitted in certain patients as discussed below. The absence of myeloma-related organ damage—particularly osteolytic bone lesions, anemia, otherwise unexplained renal failure, and hypercalcemia—is fundamental and necessary for a diagnosis of MGUS.
Smoldering multiple myeloma
Compared with patients with MGUS, patients with smoldering multiple myeloma have higher M protein concentrations (≥ 3 g/dL) or 10% or more clonal plasma cells in the marrow or both, and are at higher risk of progression to symptomatic multiple myeloma. Nevertheless, like patients with MGUS, they have no myeloma symptoms or evidence of end-organ damage.
Symptomatic multiple myeloma
By definition, patients with multiple myeloma develop organ damage related to their malignancy and need therapy to halt disease progression. Multiple myeloma causes clinical manifestations through cellular infiltration of the bone and bone marrow (anemia, osteolysis, and hypercalcemia) and light chain-induced toxicity (renal tubular damage and cast nephropathy).
In 2014, the definition of multiple myeloma was updated to include 3 new myeloma-defining events that herald a significantly higher risk of progression from smoldering to symptomatic multiple myeloma, and now constitute an integral part of the diagnosis of symptomatic multiple myeloma. These are:
- Focal lesions (> 1 lesion larger than 5 mm) visible on magnetic resonance imaging
- ≥ 60% clonal plasma cells on bone marrow biopsy
- Ratio of involved to uninvolved serum free light chains ≥ 100 (the involved light chain is the one detected on serum protein electrophoresis and immunofixation).14
Bone pain, symptoms of anemia, and decreased urine output may suggest myeloma, but are not diagnostic. Although the “CRAB” criteria (elevated calcium, renal failure, anemia, and bone lesions) define multiple myeloma, the presence of anemia, hypercalcemia, or renal dysfunction do not by themselves mark transformation from MGUS to multiple myeloma. Thus, other causes need to be considered, since the risk of transformation is so low. Importantly, hyperparathyroidism must be ruled out if hypercalcemia is present in a patient with MGUS.10
Waldenström macroglobulinemia
Waldenström macroglobulinemia, also called lymphoplasmacytic lymphoma, is an indolent non-Hodgkin B-cell lymphoma that can invade the marrow, liver, spleen, and lymph nodes, leading to anemia and organomegaly. It features a monoclonal IgM protein that can be associated with increased blood viscosity, cold agglutinin disease, peripheral neuropathy, and cryoglobulinemia.
Waldenström macroglobulinemia should be suspected in any patient with IgM type M protein and symptoms related to hyperviscosity (headache, blurry vision, lightheadedness, shortness of breath, unexplained epistaxis, gum bleeding); systemic symptoms (fever, weight loss, and night sweats); and abdominal pain (due to organomegaly).23
Monoclonal gammopathy of renal significance
Monoclonal gammopathy of renal significance (MGRS) is a newly recognized entity defined by kidney dysfunction associated with an M protein without evidence of myeloma or other lymphoid disorders.24 Multiple disorders have been included in this category with different underlying mechanisms of kidney injury. This entity is beyond the scope of this discussion.
Light-chain amyloidosis
Misfolded light-chain deposition leading to organ dysfunction is the hallmark of light-chain amyloidosis, which constitutes a subset of MGRS. An abnormal light-chain ratio, especially if skewed toward lambda should trigger an investigation for light-chain amyloidosis.10
Abnormal light chains may infiltrate any organ or tissue, but of greatest concern is infiltration of the myocardium with ensuing heart failure manifestations. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a sensitive marker for cardiac amyloidosis in the presence of suggestive features on transthoracic echocardiography (eg, left ventricular hypertrophy) but is not specific as it can be elevated in heart failure regardless of the underlying cause.10
Glomerular injury with nephrotic syndrome may also point toward renal involvement by light-chain amyloidosis and establishes a key distinctive factor from myeloma in which tubular injury is the main mechanism of kidney dysfunction.
Clinical clues for light-chain amyloidosis include heart failure symptoms, neuropathy, and macroglossia. If any of these symptoms and signs is present, we recommend electrocardiography (look for low voltage in limb leads), transthoracic echocardiography, measuring the NT-proBNP level, and urinalysis to look for albuminuria. Notably, carpal tunnel syndrome may be a very early clinical manifestation of amyloidosis, but by itself it is nonspecific. Light-chain amyloidosis is a common cause of macroglossia in adults.10,25
Neuropathy associated with M proteins is a clinical entity related to a multitude of disorders that may necessitate treating the underlying cellular clone responsible for the secretion of the toxic M protein. These disorders include light-chain amyloidosis, POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes or sclerotic bone lesions) syndrome, and IgM-related neuropathies with anti-myelin-associated glycoprotein antibodies.3,10,11,14
Notably, weight loss and fatigue in a patient with MGUS may be the first signs of light-chain amyloidosis or Waldenström macroglobulinemia and should prompt further evaluation.25
HOW ARE PATIENTS WITH MGUS RISK-STRATIFIED AND FOLLOWED?
Research has helped to refine the diagnostic workup and recognize subsets of patients with MGUS at different risks of progression to myeloma and related disorders. Factors predicting progression are 1,6,7,26,27:
- The amount of the M protein
- The type of M protein (IgG vs non-IgG)
- An abnormal free light-chain ratio.
Half of patients with MGUS fall into the low-risk category, which is defined by IgG-type serum M protein in a concentration less than 1.5 g/dL and a normal serum free light-chain ratio (kappa-lambda 0.26–1.65).5,27 The absolute risk of progression at 20 years is only 5% for patients with low-risk MGUS, compared with 58% in patients with high-risk MGUS (positive for all 3 risk factors).5
The presence of less than 10% plasma cells in the bone marrow is required to satisfy the definition of MGUS, but bone marrow biopsy can be omitted for patients with low-risk MGUS, given the slim chance of finding a significant percentage of clonal plasma cells in the marrow and the inherently low risk of progression.5,10 Skeletal surveys are often deferred for low-risk MGUS, but we obtain them in all our patients to ensure the absence of plasmacytomas, which need to be treated (typically with radiotherapy). Importantly, patients with unexplained bone pain (mostly in long bones, ribs, and spine, whereas joints are not typically involved) and a normal skeletal survey should undergo advanced imaging (whole-body magnetic resonance imaging or whole-body positron emission tomography and computed tomography) to detect bone lesions otherwise missed on plain radiography.28,29
Most of the recommendations regarding follow-up are based on expert opinion, given the lack of randomized data. Most experts agree that all patients should be reevaluated 6 months after an M protein is detected, with laboratory surveillance tests (complete blood cell count, serum creatinine, serum calcium level, serum protein electrophoresis, and serum free light chains). Low-risk patients with a stable M protein level can be followed every 2 to 3 years.
Suspect malignant progression if the serum M protein level increases by 50% or more (with an absolute increase of ≥ 0.5 g/dL); the serum M protein level is 3 g/dL or higher; the serum free light-chain ratio is more than 100; or the patient has unexplained anemia, elevated creatinine, bone pain, fracture, or hypercalcemia.
Patients at intermediate or high risk should be followed annually after the initial 6-month visit.5,7,10
A recent study highlighted the importance of risk stratification in reducing the costs associated with an overzealous diagnostic workup of patients with low-risk MGUS.30 These savings are in addition to a reduction in patient anticipation and anxiety that universally occur before invasive procedures.
THE ROLE OF THE PRIMARY CARE PROVIDER AND THE HEMATOLOGIST
Once an M protein is identified, a comprehensive history, physical examination, and laboratory tests (serum protein electrophoresis to quantify the protein, serum immunofixation, serum free light chains, complete blood cell count, calcium, and creatinine) should be done, taking into consideration the differential diagnosis of monoclonal gammopathies discussed above. After MGUS is confirmed, the patient should be risk-stratified to determine the need for bone marrow biopsy and to predict the risk of progression to more serious conditions.
Referral to a hematologist is warranted for patients with intermediate- and high-risk MGUS, patients with abnormal serum free light-chain ratios, and those who show evidence of malignant progression. Patients with intermediate- and high-risk MGUS could be referred for bone marrow biopsy before assessment by a hematologist. The primary care provider may continue to follow patients with low-risk MGUS who do not display clinical or laboratory evidence of myeloma or related disorders.
The importance of educating patients to report any new worrisome symptom (eg, fatigue, neuropathy, weight loss, night sweats, bone pain) cannot be overemphasized, as some patients may progress to myeloma or other disorders between follow-up visits.
- van de Donk NW, Palumbo A, Johnsen HE, et al; European Myeloma Network. The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: recommendations from the European Myeloma Network. Haematologica 2014; 99(6):984–996. doi:10.3324/haematol.2013.100552
- International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 2003; 121(5):749–757. pmid:12780789
- Rajan AM, Rajkumar SV. Diagnostic evaluation of monoclonal gammopathy of undetermined significance. Eur J Haematol 2013; 91(6):561–562. doi:10.1111/ejh.12198
- Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance. Br J Haematol 2006; 134(6):573–589. doi:10.1111/j.1365-2141.2006.06235.x
- Kyle RA, Durie BG, Rajkumar SV, et al; International Myeloma Working Group. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors for progression and guidelines for monitoring and management. Leukemia 2010; 24(6):1121–1127. doi:10.1038/leu.2010.60
- Bird J, Behrens J, Westin J, et al; Haemato-oncology Task Force of the British Committee for Standards in Haematology, UK Myeloma Forum and Nordic Myeloma Study Group. UK Myeloma Forum (UKMF) and Nordic Myeloma Study Group (NMSG): guidelines for the investigation of newly detected M-proteins and the management of monoclonal gammopathy of undetermined significance (MGUS). Br J Haematol 2009; 147(1):22–42. doi:10.1111/j.1365-2141.2009.07807.x
- Rajkumar SV, Kyle RA, Buadi FK. Advances in the diagnosis, classification, risk stratification, and management of monoclonal gammopathy of undetermined significance: implications for recategorizing disease entities in the presence of evolving scientific evidence. Mayo Clin Proc 2010; 85(10):945–948. doi:10.4065/mcp.2010.0520
- Kyle RA, Therneau TM, Rajkumar SV, et al. A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 2002; 346(8):564–569. doi:10.1056/NEJMoa01133202
- Doyle LM, Gundrum JD, Farnen JP, Wright LJ, Kranig JAI, Go RS. Determining why and which clinicians order serum protein electrophoresis (SPEP), subsequent diagnoses based on indications, and clinical significance of routine follow-up: a study of patients with monoclonal gammopathy of undetermined significance (MGUS). Blood 2009; 114(22):Abstr 4883. www.bloodjournal.org/content/114/22/4883. Accessed December 4, 2018.
- Merlini G, Palladini G. Differential diagnosis of monoclonal gammopathy of undetermined significance. Hematology Am Soc Hematol Educ Program 2012; 2012:595–603. doi:10.1182/asheducation-2012.1.595
- Glavey SV, Leung N. Monoclonal gammopathy: the good, the bad and the ugly. Blood Rev 2016; 30(3):223–231. doi:10.1016/j.blre.2015.12.001
- Dispenzieri A, Gertz MA, Therneau TM, Kyle RA. Retrospective cohort study of 148 patients with polyclonal gammopathy. Mayo Clin Proc 2001; 76(5):476–487. doi:10.4065/76.5.476
- Merlini G, Stone MJ. Dangerous small B-cell clones. Blood 2006; 108(8):2520–2530. doi:10.1182/blood-2006-03-001164
- Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014; 15(12):e538–e548. doi:10.1016/S1470-2045(14)70442-5
- Kyle RA, Gertz MA, Witzig TE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003; 78(1):21–33. doi:10.4065/78.1.21
- Hutchison CA, Harding S, Hewins P, et al. Quantitative assessment of serum and urinary polyclonal free light chains in patients with chronic kidney disease. Clin J Am Soc Nephrol 2008; 3(6):1684–1690. doi:10.2215/CJN.02290508
- Katzmann JA, Dispenzieri A, Kyle RA, et al. Elimination of the need for urine studies in the screening algorithm for monoclonal gammopathies by using serum immunofixation and free light chain assays. Mayo Clin Proc 2006; 81(12):1575–1578. doi:10.4065/81.12.1575
- Berenson JR, Anderson KC, Audell RA, et al. Monoclonal gammopathy of undetermined significance: a consensus statement. Br J Haematol 2010; 150(1):28–38. doi:10.1111/j.1365-2141.2010.08207.x
- Mangiacavalli S, Cocito F, Pochintesta L, et al. Monoclonal gammopathy of undetermined significance: a new proposal of workup. Eur J Haematol 2013; 91(4):356–360. doi:10.1111/ejh.12172
- Bianchi G, Kyle RA, Colby CL, et al. Impact of optimal follow-up of monoclonal gammopathy of undetermined significance on early diagnosis and prevention of myeloma-related complications. Blood 2010;116:2019–2025. doi:10.1182/blood-2010-04-277566
- Rosiñol L, Cibeira MT, Montoto S, et al. Monoclonal gammopathy of undetermined significance: predictors of malignant transformation and recognition of an evolving type characterized by a progressive increase in M protein size. Mayo Clin Proc 2007; 82(4):428–434. doi:10.4065/82.4.428
- Vanderschueren S, Mylle M, Dierickx D, et al. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84(9):842–845. doi:10.4065/84.9.842
- Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance and smouldering multiple myeloma: emphasis on risk factors for progression. Br J Haematol 2007; 139(5):730–743. doi:10.1111/j.1365-2141.2007.06873.x
- Leung N, Bridoux F, Hutchison CA, et al; International Kidney and Monoclonal Gammopathy Research Group. Monoclonal gammopathy of renal significance: when MGUS is no longer undetermined or insignificant. Blood. 2012; 120(22):4292–4295. doi:10.1182/blood-2012-07-445304
- Merlini G, Wechalekar AD, Palladini G. Systemic light chain amyloidosis: an update for treating physicians. Blood 2013; 121(26):5124–5130. doi:10.1182/blood-2013-01-453001
- Dispenzieri A, Katzmann JA, Kyle RA, et al. Prevalence and risk of progression of light-chain monoclonal gammopathy of undetermined significance: a retrospective population-based cohort study. Lancet 2010; 375(9727):1721–1728. doi:10.1016/S0140-6736(10)60482-5
- Rajkumar SV, Kyle RA, Therneau TM, et al. Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood 2005; 106(3):812–817. doi:10.1182/blood-2005-03-1038
- Dimopoulos MA, Hillengass J, Usmani S, et al. Role of magnetic resonance imaging in the management of patients with multiple myeloma: a consensus statement. J Clin Oncol 2015; 33(6):657–664. doi:10.1200/JCO.2014.57.9961
- Dimopoulos M, Kyle R, Fermand JP, et al. Consensus recommendations for standard investigative workup: report of the International Myeloma Workshop Consensus Panel 3. Blood 2011; 117(18):4701–4705. doi:10.1182/blood-2010-10-299529
- Pompa T, Maddox M, Woodard A, et al. Cost effectiveness in low risk MGUS patients. Blood 2016; 128:2360. http://www.bloodjournal.org/content/128/22/2360. Accessed December 4, 2018.
MGUS is present in 3% to 4% of the population over age 50 and is more common in older men, African Americans, and Africans.1–6
The overall risk of progression to myeloma and related disorders is less than or equal to 1% per year depending on the subtype of the M protein (higher risk with IgM than non-IgM and light-chain MGUS).7,8 While the risk of malignant transformation is low, multiple myeloma is almost always preceded by the presence of an asymptomatic and often unrecognized monoclonal protein.
WHEN SHOULD WE LOOK FOR AN M PROTEIN?
An M protein is typically an incidental finding when a patient is being assessed for any of a number of presenting symptoms or conditions. A large retrospective study9 found that screening for MGUS was mostly performed by internal medicine physicians. The indications for testing were anemia, bone-related issues, elevated creatinine, elevated erythrocyte sedimentation rate, and neuropathy.
A low anion gap is not a major indicator of an M protein unless in a high concentration, in which case other manifestations would be present, such as renal failure, which would guide the diagnosis. Polyclonal hypergammaglobulinemia as a cause of low anion gap is far more common than MGUS.
HOW SHOULD WE SCREEN FOR AN M PROTEIN?
Serum protein electrophoresis is an initial test used to identify an M protein and has a key role in quantifying it (Figure 2). An M protein appears as a narrow spike on the agarose gel and should be distinguished from the broad band seen in polyclonal gammopathies associated with cirrhosis and chronic infectious and inflammatory conditions, among others.12 A major disadvantage of serum protein electrophoresis is that it cannot detect an M protein in very low concentrations or determine its identity.
Serum immunofixation is more sensitive than serum protein electrophoresis and should always be ordered in conjunction with it, mostly to ensure detecting tiny amounts of M protein and to identify the type of its heavy chain and light-chain components.13
The serum free light-chain assay is also considered an essential part of the screening process to detect light-chain MGUS and light-chain myeloma. As many as 16% of myeloma patients secrete only light chains, which may not be identified on serum immunofixation.3,6,7,10,14,15 In general, a low kappa-lambda ratio (< 0.26) indicates the overproduction of lambda light chains, and a high ratio (> 1.65) indicates the overproduction of kappa light chains.
The serum free light-chain assay helps detect abnormal secretion of monoclonal light chains before they appear in the urine once the kidney tubules become saturated and unable to reabsorb them.
Of note, the free light-chain ratio can be abnormal (< 0.26 or > 1.65) in chronic kidney disease. Thus, it may be challenging to discern whether an abnormal light-chain ratio is related to impaired light-chain clearance by the kidneys or to MGUS. In general, kappa light chains are more elevated than lambda light chains in chronic kidney disease, but the ratio should not be considerably skewed. A kappa-lambda ratio below 0.37 or above 3 is rarely seen in chronic kidney disease and should prompt workup for MGUS.16
Tests in combination. The sensitivity of screening for M proteins ranges from 82% with serum protein electrophoresis alone to 93% with the addition of serum immunofixation and to 98% with the serum free light-chain assay.15 The latter can replace urine protein electrophoresis and immunofixation when screening for M protein, given its higher sensitivity.15,17 An important caveat is that urine dipstick testing does not detect urine light chains.
Table 3 lists the initial laboratory tests required in patients with MGUS.
WHAT IS THE DIFFERENTIAL DIAGNOSIS OF MONOCLONAL GAMMOPATHIES?
that feature an M protein and would otherwise require treatment (Table 4). The differential diagnosis includes smoldering multiple myeloma, symptomatic multiple myeloma, Waldenström macroglobulinemia, light-chain amyloidosis, low-grade B-cell lymphoproliferative disorders, a variety of monoclonal protein-related kidney disorders, and plasmacytomas.10,14
MGUS
Based on the International Myeloma Working Group consensus, a formal diagnosis of MGUS is established when a serum M protein is detected and measured at a concentration less than 3 g/dL on serum protein electrophoresis along with less than 10% clonal plasma cells in the bone marrow.1–6,14,18,19 Nevertheless, bone marrow biopsy can be omitted in certain patients as discussed below. The absence of myeloma-related organ damage—particularly osteolytic bone lesions, anemia, otherwise unexplained renal failure, and hypercalcemia—is fundamental and necessary for a diagnosis of MGUS.
Smoldering multiple myeloma
Compared with patients with MGUS, patients with smoldering multiple myeloma have higher M protein concentrations (≥ 3 g/dL) or 10% or more clonal plasma cells in the marrow or both, and are at higher risk of progression to symptomatic multiple myeloma. Nevertheless, like patients with MGUS, they have no myeloma symptoms or evidence of end-organ damage.
Symptomatic multiple myeloma
By definition, patients with multiple myeloma develop organ damage related to their malignancy and need therapy to halt disease progression. Multiple myeloma causes clinical manifestations through cellular infiltration of the bone and bone marrow (anemia, osteolysis, and hypercalcemia) and light chain-induced toxicity (renal tubular damage and cast nephropathy).
In 2014, the definition of multiple myeloma was updated to include 3 new myeloma-defining events that herald a significantly higher risk of progression from smoldering to symptomatic multiple myeloma, and now constitute an integral part of the diagnosis of symptomatic multiple myeloma. These are:
- Focal lesions (> 1 lesion larger than 5 mm) visible on magnetic resonance imaging
- ≥ 60% clonal plasma cells on bone marrow biopsy
- Ratio of involved to uninvolved serum free light chains ≥ 100 (the involved light chain is the one detected on serum protein electrophoresis and immunofixation).14
Bone pain, symptoms of anemia, and decreased urine output may suggest myeloma, but are not diagnostic. Although the “CRAB” criteria (elevated calcium, renal failure, anemia, and bone lesions) define multiple myeloma, the presence of anemia, hypercalcemia, or renal dysfunction do not by themselves mark transformation from MGUS to multiple myeloma. Thus, other causes need to be considered, since the risk of transformation is so low. Importantly, hyperparathyroidism must be ruled out if hypercalcemia is present in a patient with MGUS.10
Waldenström macroglobulinemia
Waldenström macroglobulinemia, also called lymphoplasmacytic lymphoma, is an indolent non-Hodgkin B-cell lymphoma that can invade the marrow, liver, spleen, and lymph nodes, leading to anemia and organomegaly. It features a monoclonal IgM protein that can be associated with increased blood viscosity, cold agglutinin disease, peripheral neuropathy, and cryoglobulinemia.
Waldenström macroglobulinemia should be suspected in any patient with IgM type M protein and symptoms related to hyperviscosity (headache, blurry vision, lightheadedness, shortness of breath, unexplained epistaxis, gum bleeding); systemic symptoms (fever, weight loss, and night sweats); and abdominal pain (due to organomegaly).23
Monoclonal gammopathy of renal significance
Monoclonal gammopathy of renal significance (MGRS) is a newly recognized entity defined by kidney dysfunction associated with an M protein without evidence of myeloma or other lymphoid disorders.24 Multiple disorders have been included in this category with different underlying mechanisms of kidney injury. This entity is beyond the scope of this discussion.
Light-chain amyloidosis
Misfolded light-chain deposition leading to organ dysfunction is the hallmark of light-chain amyloidosis, which constitutes a subset of MGRS. An abnormal light-chain ratio, especially if skewed toward lambda should trigger an investigation for light-chain amyloidosis.10
Abnormal light chains may infiltrate any organ or tissue, but of greatest concern is infiltration of the myocardium with ensuing heart failure manifestations. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a sensitive marker for cardiac amyloidosis in the presence of suggestive features on transthoracic echocardiography (eg, left ventricular hypertrophy) but is not specific as it can be elevated in heart failure regardless of the underlying cause.10
Glomerular injury with nephrotic syndrome may also point toward renal involvement by light-chain amyloidosis and establishes a key distinctive factor from myeloma in which tubular injury is the main mechanism of kidney dysfunction.
Clinical clues for light-chain amyloidosis include heart failure symptoms, neuropathy, and macroglossia. If any of these symptoms and signs is present, we recommend electrocardiography (look for low voltage in limb leads), transthoracic echocardiography, measuring the NT-proBNP level, and urinalysis to look for albuminuria. Notably, carpal tunnel syndrome may be a very early clinical manifestation of amyloidosis, but by itself it is nonspecific. Light-chain amyloidosis is a common cause of macroglossia in adults.10,25
Neuropathy associated with M proteins is a clinical entity related to a multitude of disorders that may necessitate treating the underlying cellular clone responsible for the secretion of the toxic M protein. These disorders include light-chain amyloidosis, POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes or sclerotic bone lesions) syndrome, and IgM-related neuropathies with anti-myelin-associated glycoprotein antibodies.3,10,11,14
Notably, weight loss and fatigue in a patient with MGUS may be the first signs of light-chain amyloidosis or Waldenström macroglobulinemia and should prompt further evaluation.25
HOW ARE PATIENTS WITH MGUS RISK-STRATIFIED AND FOLLOWED?
Research has helped to refine the diagnostic workup and recognize subsets of patients with MGUS at different risks of progression to myeloma and related disorders. Factors predicting progression are 1,6,7,26,27:
- The amount of the M protein
- The type of M protein (IgG vs non-IgG)
- An abnormal free light-chain ratio.
Half of patients with MGUS fall into the low-risk category, which is defined by IgG-type serum M protein in a concentration less than 1.5 g/dL and a normal serum free light-chain ratio (kappa-lambda 0.26–1.65).5,27 The absolute risk of progression at 20 years is only 5% for patients with low-risk MGUS, compared with 58% in patients with high-risk MGUS (positive for all 3 risk factors).5
The presence of less than 10% plasma cells in the bone marrow is required to satisfy the definition of MGUS, but bone marrow biopsy can be omitted for patients with low-risk MGUS, given the slim chance of finding a significant percentage of clonal plasma cells in the marrow and the inherently low risk of progression.5,10 Skeletal surveys are often deferred for low-risk MGUS, but we obtain them in all our patients to ensure the absence of plasmacytomas, which need to be treated (typically with radiotherapy). Importantly, patients with unexplained bone pain (mostly in long bones, ribs, and spine, whereas joints are not typically involved) and a normal skeletal survey should undergo advanced imaging (whole-body magnetic resonance imaging or whole-body positron emission tomography and computed tomography) to detect bone lesions otherwise missed on plain radiography.28,29
Most of the recommendations regarding follow-up are based on expert opinion, given the lack of randomized data. Most experts agree that all patients should be reevaluated 6 months after an M protein is detected, with laboratory surveillance tests (complete blood cell count, serum creatinine, serum calcium level, serum protein electrophoresis, and serum free light chains). Low-risk patients with a stable M protein level can be followed every 2 to 3 years.
Suspect malignant progression if the serum M protein level increases by 50% or more (with an absolute increase of ≥ 0.5 g/dL); the serum M protein level is 3 g/dL or higher; the serum free light-chain ratio is more than 100; or the patient has unexplained anemia, elevated creatinine, bone pain, fracture, or hypercalcemia.
Patients at intermediate or high risk should be followed annually after the initial 6-month visit.5,7,10
A recent study highlighted the importance of risk stratification in reducing the costs associated with an overzealous diagnostic workup of patients with low-risk MGUS.30 These savings are in addition to a reduction in patient anticipation and anxiety that universally occur before invasive procedures.
THE ROLE OF THE PRIMARY CARE PROVIDER AND THE HEMATOLOGIST
Once an M protein is identified, a comprehensive history, physical examination, and laboratory tests (serum protein electrophoresis to quantify the protein, serum immunofixation, serum free light chains, complete blood cell count, calcium, and creatinine) should be done, taking into consideration the differential diagnosis of monoclonal gammopathies discussed above. After MGUS is confirmed, the patient should be risk-stratified to determine the need for bone marrow biopsy and to predict the risk of progression to more serious conditions.
Referral to a hematologist is warranted for patients with intermediate- and high-risk MGUS, patients with abnormal serum free light-chain ratios, and those who show evidence of malignant progression. Patients with intermediate- and high-risk MGUS could be referred for bone marrow biopsy before assessment by a hematologist. The primary care provider may continue to follow patients with low-risk MGUS who do not display clinical or laboratory evidence of myeloma or related disorders.
The importance of educating patients to report any new worrisome symptom (eg, fatigue, neuropathy, weight loss, night sweats, bone pain) cannot be overemphasized, as some patients may progress to myeloma or other disorders between follow-up visits.
MGUS is present in 3% to 4% of the population over age 50 and is more common in older men, African Americans, and Africans.1–6
The overall risk of progression to myeloma and related disorders is less than or equal to 1% per year depending on the subtype of the M protein (higher risk with IgM than non-IgM and light-chain MGUS).7,8 While the risk of malignant transformation is low, multiple myeloma is almost always preceded by the presence of an asymptomatic and often unrecognized monoclonal protein.
WHEN SHOULD WE LOOK FOR AN M PROTEIN?
An M protein is typically an incidental finding when a patient is being assessed for any of a number of presenting symptoms or conditions. A large retrospective study9 found that screening for MGUS was mostly performed by internal medicine physicians. The indications for testing were anemia, bone-related issues, elevated creatinine, elevated erythrocyte sedimentation rate, and neuropathy.
A low anion gap is not a major indicator of an M protein unless in a high concentration, in which case other manifestations would be present, such as renal failure, which would guide the diagnosis. Polyclonal hypergammaglobulinemia as a cause of low anion gap is far more common than MGUS.
HOW SHOULD WE SCREEN FOR AN M PROTEIN?
Serum protein electrophoresis is an initial test used to identify an M protein and has a key role in quantifying it (Figure 2). An M protein appears as a narrow spike on the agarose gel and should be distinguished from the broad band seen in polyclonal gammopathies associated with cirrhosis and chronic infectious and inflammatory conditions, among others.12 A major disadvantage of serum protein electrophoresis is that it cannot detect an M protein in very low concentrations or determine its identity.
Serum immunofixation is more sensitive than serum protein electrophoresis and should always be ordered in conjunction with it, mostly to ensure detecting tiny amounts of M protein and to identify the type of its heavy chain and light-chain components.13
The serum free light-chain assay is also considered an essential part of the screening process to detect light-chain MGUS and light-chain myeloma. As many as 16% of myeloma patients secrete only light chains, which may not be identified on serum immunofixation.3,6,7,10,14,15 In general, a low kappa-lambda ratio (< 0.26) indicates the overproduction of lambda light chains, and a high ratio (> 1.65) indicates the overproduction of kappa light chains.
The serum free light-chain assay helps detect abnormal secretion of monoclonal light chains before they appear in the urine once the kidney tubules become saturated and unable to reabsorb them.
Of note, the free light-chain ratio can be abnormal (< 0.26 or > 1.65) in chronic kidney disease. Thus, it may be challenging to discern whether an abnormal light-chain ratio is related to impaired light-chain clearance by the kidneys or to MGUS. In general, kappa light chains are more elevated than lambda light chains in chronic kidney disease, but the ratio should not be considerably skewed. A kappa-lambda ratio below 0.37 or above 3 is rarely seen in chronic kidney disease and should prompt workup for MGUS.16
Tests in combination. The sensitivity of screening for M proteins ranges from 82% with serum protein electrophoresis alone to 93% with the addition of serum immunofixation and to 98% with the serum free light-chain assay.15 The latter can replace urine protein electrophoresis and immunofixation when screening for M protein, given its higher sensitivity.15,17 An important caveat is that urine dipstick testing does not detect urine light chains.
Table 3 lists the initial laboratory tests required in patients with MGUS.
WHAT IS THE DIFFERENTIAL DIAGNOSIS OF MONOCLONAL GAMMOPATHIES?
that feature an M protein and would otherwise require treatment (Table 4). The differential diagnosis includes smoldering multiple myeloma, symptomatic multiple myeloma, Waldenström macroglobulinemia, light-chain amyloidosis, low-grade B-cell lymphoproliferative disorders, a variety of monoclonal protein-related kidney disorders, and plasmacytomas.10,14
MGUS
Based on the International Myeloma Working Group consensus, a formal diagnosis of MGUS is established when a serum M protein is detected and measured at a concentration less than 3 g/dL on serum protein electrophoresis along with less than 10% clonal plasma cells in the bone marrow.1–6,14,18,19 Nevertheless, bone marrow biopsy can be omitted in certain patients as discussed below. The absence of myeloma-related organ damage—particularly osteolytic bone lesions, anemia, otherwise unexplained renal failure, and hypercalcemia—is fundamental and necessary for a diagnosis of MGUS.
Smoldering multiple myeloma
Compared with patients with MGUS, patients with smoldering multiple myeloma have higher M protein concentrations (≥ 3 g/dL) or 10% or more clonal plasma cells in the marrow or both, and are at higher risk of progression to symptomatic multiple myeloma. Nevertheless, like patients with MGUS, they have no myeloma symptoms or evidence of end-organ damage.
Symptomatic multiple myeloma
By definition, patients with multiple myeloma develop organ damage related to their malignancy and need therapy to halt disease progression. Multiple myeloma causes clinical manifestations through cellular infiltration of the bone and bone marrow (anemia, osteolysis, and hypercalcemia) and light chain-induced toxicity (renal tubular damage and cast nephropathy).
In 2014, the definition of multiple myeloma was updated to include 3 new myeloma-defining events that herald a significantly higher risk of progression from smoldering to symptomatic multiple myeloma, and now constitute an integral part of the diagnosis of symptomatic multiple myeloma. These are:
- Focal lesions (> 1 lesion larger than 5 mm) visible on magnetic resonance imaging
- ≥ 60% clonal plasma cells on bone marrow biopsy
- Ratio of involved to uninvolved serum free light chains ≥ 100 (the involved light chain is the one detected on serum protein electrophoresis and immunofixation).14
Bone pain, symptoms of anemia, and decreased urine output may suggest myeloma, but are not diagnostic. Although the “CRAB” criteria (elevated calcium, renal failure, anemia, and bone lesions) define multiple myeloma, the presence of anemia, hypercalcemia, or renal dysfunction do not by themselves mark transformation from MGUS to multiple myeloma. Thus, other causes need to be considered, since the risk of transformation is so low. Importantly, hyperparathyroidism must be ruled out if hypercalcemia is present in a patient with MGUS.10
Waldenström macroglobulinemia
Waldenström macroglobulinemia, also called lymphoplasmacytic lymphoma, is an indolent non-Hodgkin B-cell lymphoma that can invade the marrow, liver, spleen, and lymph nodes, leading to anemia and organomegaly. It features a monoclonal IgM protein that can be associated with increased blood viscosity, cold agglutinin disease, peripheral neuropathy, and cryoglobulinemia.
Waldenström macroglobulinemia should be suspected in any patient with IgM type M protein and symptoms related to hyperviscosity (headache, blurry vision, lightheadedness, shortness of breath, unexplained epistaxis, gum bleeding); systemic symptoms (fever, weight loss, and night sweats); and abdominal pain (due to organomegaly).23
Monoclonal gammopathy of renal significance
Monoclonal gammopathy of renal significance (MGRS) is a newly recognized entity defined by kidney dysfunction associated with an M protein without evidence of myeloma or other lymphoid disorders.24 Multiple disorders have been included in this category with different underlying mechanisms of kidney injury. This entity is beyond the scope of this discussion.
Light-chain amyloidosis
Misfolded light-chain deposition leading to organ dysfunction is the hallmark of light-chain amyloidosis, which constitutes a subset of MGRS. An abnormal light-chain ratio, especially if skewed toward lambda should trigger an investigation for light-chain amyloidosis.10
Abnormal light chains may infiltrate any organ or tissue, but of greatest concern is infiltration of the myocardium with ensuing heart failure manifestations. N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a sensitive marker for cardiac amyloidosis in the presence of suggestive features on transthoracic echocardiography (eg, left ventricular hypertrophy) but is not specific as it can be elevated in heart failure regardless of the underlying cause.10
Glomerular injury with nephrotic syndrome may also point toward renal involvement by light-chain amyloidosis and establishes a key distinctive factor from myeloma in which tubular injury is the main mechanism of kidney dysfunction.
Clinical clues for light-chain amyloidosis include heart failure symptoms, neuropathy, and macroglossia. If any of these symptoms and signs is present, we recommend electrocardiography (look for low voltage in limb leads), transthoracic echocardiography, measuring the NT-proBNP level, and urinalysis to look for albuminuria. Notably, carpal tunnel syndrome may be a very early clinical manifestation of amyloidosis, but by itself it is nonspecific. Light-chain amyloidosis is a common cause of macroglossia in adults.10,25
Neuropathy associated with M proteins is a clinical entity related to a multitude of disorders that may necessitate treating the underlying cellular clone responsible for the secretion of the toxic M protein. These disorders include light-chain amyloidosis, POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes or sclerotic bone lesions) syndrome, and IgM-related neuropathies with anti-myelin-associated glycoprotein antibodies.3,10,11,14
Notably, weight loss and fatigue in a patient with MGUS may be the first signs of light-chain amyloidosis or Waldenström macroglobulinemia and should prompt further evaluation.25
HOW ARE PATIENTS WITH MGUS RISK-STRATIFIED AND FOLLOWED?
Research has helped to refine the diagnostic workup and recognize subsets of patients with MGUS at different risks of progression to myeloma and related disorders. Factors predicting progression are 1,6,7,26,27:
- The amount of the M protein
- The type of M protein (IgG vs non-IgG)
- An abnormal free light-chain ratio.
Half of patients with MGUS fall into the low-risk category, which is defined by IgG-type serum M protein in a concentration less than 1.5 g/dL and a normal serum free light-chain ratio (kappa-lambda 0.26–1.65).5,27 The absolute risk of progression at 20 years is only 5% for patients with low-risk MGUS, compared with 58% in patients with high-risk MGUS (positive for all 3 risk factors).5
The presence of less than 10% plasma cells in the bone marrow is required to satisfy the definition of MGUS, but bone marrow biopsy can be omitted for patients with low-risk MGUS, given the slim chance of finding a significant percentage of clonal plasma cells in the marrow and the inherently low risk of progression.5,10 Skeletal surveys are often deferred for low-risk MGUS, but we obtain them in all our patients to ensure the absence of plasmacytomas, which need to be treated (typically with radiotherapy). Importantly, patients with unexplained bone pain (mostly in long bones, ribs, and spine, whereas joints are not typically involved) and a normal skeletal survey should undergo advanced imaging (whole-body magnetic resonance imaging or whole-body positron emission tomography and computed tomography) to detect bone lesions otherwise missed on plain radiography.28,29
Most of the recommendations regarding follow-up are based on expert opinion, given the lack of randomized data. Most experts agree that all patients should be reevaluated 6 months after an M protein is detected, with laboratory surveillance tests (complete blood cell count, serum creatinine, serum calcium level, serum protein electrophoresis, and serum free light chains). Low-risk patients with a stable M protein level can be followed every 2 to 3 years.
Suspect malignant progression if the serum M protein level increases by 50% or more (with an absolute increase of ≥ 0.5 g/dL); the serum M protein level is 3 g/dL or higher; the serum free light-chain ratio is more than 100; or the patient has unexplained anemia, elevated creatinine, bone pain, fracture, or hypercalcemia.
Patients at intermediate or high risk should be followed annually after the initial 6-month visit.5,7,10
A recent study highlighted the importance of risk stratification in reducing the costs associated with an overzealous diagnostic workup of patients with low-risk MGUS.30 These savings are in addition to a reduction in patient anticipation and anxiety that universally occur before invasive procedures.
THE ROLE OF THE PRIMARY CARE PROVIDER AND THE HEMATOLOGIST
Once an M protein is identified, a comprehensive history, physical examination, and laboratory tests (serum protein electrophoresis to quantify the protein, serum immunofixation, serum free light chains, complete blood cell count, calcium, and creatinine) should be done, taking into consideration the differential diagnosis of monoclonal gammopathies discussed above. After MGUS is confirmed, the patient should be risk-stratified to determine the need for bone marrow biopsy and to predict the risk of progression to more serious conditions.
Referral to a hematologist is warranted for patients with intermediate- and high-risk MGUS, patients with abnormal serum free light-chain ratios, and those who show evidence of malignant progression. Patients with intermediate- and high-risk MGUS could be referred for bone marrow biopsy before assessment by a hematologist. The primary care provider may continue to follow patients with low-risk MGUS who do not display clinical or laboratory evidence of myeloma or related disorders.
The importance of educating patients to report any new worrisome symptom (eg, fatigue, neuropathy, weight loss, night sweats, bone pain) cannot be overemphasized, as some patients may progress to myeloma or other disorders between follow-up visits.
- van de Donk NW, Palumbo A, Johnsen HE, et al; European Myeloma Network. The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: recommendations from the European Myeloma Network. Haematologica 2014; 99(6):984–996. doi:10.3324/haematol.2013.100552
- International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 2003; 121(5):749–757. pmid:12780789
- Rajan AM, Rajkumar SV. Diagnostic evaluation of monoclonal gammopathy of undetermined significance. Eur J Haematol 2013; 91(6):561–562. doi:10.1111/ejh.12198
- Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance. Br J Haematol 2006; 134(6):573–589. doi:10.1111/j.1365-2141.2006.06235.x
- Kyle RA, Durie BG, Rajkumar SV, et al; International Myeloma Working Group. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors for progression and guidelines for monitoring and management. Leukemia 2010; 24(6):1121–1127. doi:10.1038/leu.2010.60
- Bird J, Behrens J, Westin J, et al; Haemato-oncology Task Force of the British Committee for Standards in Haematology, UK Myeloma Forum and Nordic Myeloma Study Group. UK Myeloma Forum (UKMF) and Nordic Myeloma Study Group (NMSG): guidelines for the investigation of newly detected M-proteins and the management of monoclonal gammopathy of undetermined significance (MGUS). Br J Haematol 2009; 147(1):22–42. doi:10.1111/j.1365-2141.2009.07807.x
- Rajkumar SV, Kyle RA, Buadi FK. Advances in the diagnosis, classification, risk stratification, and management of monoclonal gammopathy of undetermined significance: implications for recategorizing disease entities in the presence of evolving scientific evidence. Mayo Clin Proc 2010; 85(10):945–948. doi:10.4065/mcp.2010.0520
- Kyle RA, Therneau TM, Rajkumar SV, et al. A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 2002; 346(8):564–569. doi:10.1056/NEJMoa01133202
- Doyle LM, Gundrum JD, Farnen JP, Wright LJ, Kranig JAI, Go RS. Determining why and which clinicians order serum protein electrophoresis (SPEP), subsequent diagnoses based on indications, and clinical significance of routine follow-up: a study of patients with monoclonal gammopathy of undetermined significance (MGUS). Blood 2009; 114(22):Abstr 4883. www.bloodjournal.org/content/114/22/4883. Accessed December 4, 2018.
- Merlini G, Palladini G. Differential diagnosis of monoclonal gammopathy of undetermined significance. Hematology Am Soc Hematol Educ Program 2012; 2012:595–603. doi:10.1182/asheducation-2012.1.595
- Glavey SV, Leung N. Monoclonal gammopathy: the good, the bad and the ugly. Blood Rev 2016; 30(3):223–231. doi:10.1016/j.blre.2015.12.001
- Dispenzieri A, Gertz MA, Therneau TM, Kyle RA. Retrospective cohort study of 148 patients with polyclonal gammopathy. Mayo Clin Proc 2001; 76(5):476–487. doi:10.4065/76.5.476
- Merlini G, Stone MJ. Dangerous small B-cell clones. Blood 2006; 108(8):2520–2530. doi:10.1182/blood-2006-03-001164
- Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014; 15(12):e538–e548. doi:10.1016/S1470-2045(14)70442-5
- Kyle RA, Gertz MA, Witzig TE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003; 78(1):21–33. doi:10.4065/78.1.21
- Hutchison CA, Harding S, Hewins P, et al. Quantitative assessment of serum and urinary polyclonal free light chains in patients with chronic kidney disease. Clin J Am Soc Nephrol 2008; 3(6):1684–1690. doi:10.2215/CJN.02290508
- Katzmann JA, Dispenzieri A, Kyle RA, et al. Elimination of the need for urine studies in the screening algorithm for monoclonal gammopathies by using serum immunofixation and free light chain assays. Mayo Clin Proc 2006; 81(12):1575–1578. doi:10.4065/81.12.1575
- Berenson JR, Anderson KC, Audell RA, et al. Monoclonal gammopathy of undetermined significance: a consensus statement. Br J Haematol 2010; 150(1):28–38. doi:10.1111/j.1365-2141.2010.08207.x
- Mangiacavalli S, Cocito F, Pochintesta L, et al. Monoclonal gammopathy of undetermined significance: a new proposal of workup. Eur J Haematol 2013; 91(4):356–360. doi:10.1111/ejh.12172
- Bianchi G, Kyle RA, Colby CL, et al. Impact of optimal follow-up of monoclonal gammopathy of undetermined significance on early diagnosis and prevention of myeloma-related complications. Blood 2010;116:2019–2025. doi:10.1182/blood-2010-04-277566
- Rosiñol L, Cibeira MT, Montoto S, et al. Monoclonal gammopathy of undetermined significance: predictors of malignant transformation and recognition of an evolving type characterized by a progressive increase in M protein size. Mayo Clin Proc 2007; 82(4):428–434. doi:10.4065/82.4.428
- Vanderschueren S, Mylle M, Dierickx D, et al. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84(9):842–845. doi:10.4065/84.9.842
- Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance and smouldering multiple myeloma: emphasis on risk factors for progression. Br J Haematol 2007; 139(5):730–743. doi:10.1111/j.1365-2141.2007.06873.x
- Leung N, Bridoux F, Hutchison CA, et al; International Kidney and Monoclonal Gammopathy Research Group. Monoclonal gammopathy of renal significance: when MGUS is no longer undetermined or insignificant. Blood. 2012; 120(22):4292–4295. doi:10.1182/blood-2012-07-445304
- Merlini G, Wechalekar AD, Palladini G. Systemic light chain amyloidosis: an update for treating physicians. Blood 2013; 121(26):5124–5130. doi:10.1182/blood-2013-01-453001
- Dispenzieri A, Katzmann JA, Kyle RA, et al. Prevalence and risk of progression of light-chain monoclonal gammopathy of undetermined significance: a retrospective population-based cohort study. Lancet 2010; 375(9727):1721–1728. doi:10.1016/S0140-6736(10)60482-5
- Rajkumar SV, Kyle RA, Therneau TM, et al. Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood 2005; 106(3):812–817. doi:10.1182/blood-2005-03-1038
- Dimopoulos MA, Hillengass J, Usmani S, et al. Role of magnetic resonance imaging in the management of patients with multiple myeloma: a consensus statement. J Clin Oncol 2015; 33(6):657–664. doi:10.1200/JCO.2014.57.9961
- Dimopoulos M, Kyle R, Fermand JP, et al. Consensus recommendations for standard investigative workup: report of the International Myeloma Workshop Consensus Panel 3. Blood 2011; 117(18):4701–4705. doi:10.1182/blood-2010-10-299529
- Pompa T, Maddox M, Woodard A, et al. Cost effectiveness in low risk MGUS patients. Blood 2016; 128:2360. http://www.bloodjournal.org/content/128/22/2360. Accessed December 4, 2018.
- van de Donk NW, Palumbo A, Johnsen HE, et al; European Myeloma Network. The clinical relevance and management of monoclonal gammopathy of undetermined significance and related disorders: recommendations from the European Myeloma Network. Haematologica 2014; 99(6):984–996. doi:10.3324/haematol.2013.100552
- International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders: a report of the International Myeloma Working Group. Br J Haematol 2003; 121(5):749–757. pmid:12780789
- Rajan AM, Rajkumar SV. Diagnostic evaluation of monoclonal gammopathy of undetermined significance. Eur J Haematol 2013; 91(6):561–562. doi:10.1111/ejh.12198
- Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance. Br J Haematol 2006; 134(6):573–589. doi:10.1111/j.1365-2141.2006.06235.x
- Kyle RA, Durie BG, Rajkumar SV, et al; International Myeloma Working Group. Monoclonal gammopathy of undetermined significance (MGUS) and smoldering (asymptomatic) multiple myeloma: IMWG consensus perspectives risk factors for progression and guidelines for monitoring and management. Leukemia 2010; 24(6):1121–1127. doi:10.1038/leu.2010.60
- Bird J, Behrens J, Westin J, et al; Haemato-oncology Task Force of the British Committee for Standards in Haematology, UK Myeloma Forum and Nordic Myeloma Study Group. UK Myeloma Forum (UKMF) and Nordic Myeloma Study Group (NMSG): guidelines for the investigation of newly detected M-proteins and the management of monoclonal gammopathy of undetermined significance (MGUS). Br J Haematol 2009; 147(1):22–42. doi:10.1111/j.1365-2141.2009.07807.x
- Rajkumar SV, Kyle RA, Buadi FK. Advances in the diagnosis, classification, risk stratification, and management of monoclonal gammopathy of undetermined significance: implications for recategorizing disease entities in the presence of evolving scientific evidence. Mayo Clin Proc 2010; 85(10):945–948. doi:10.4065/mcp.2010.0520
- Kyle RA, Therneau TM, Rajkumar SV, et al. A long-term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 2002; 346(8):564–569. doi:10.1056/NEJMoa01133202
- Doyle LM, Gundrum JD, Farnen JP, Wright LJ, Kranig JAI, Go RS. Determining why and which clinicians order serum protein electrophoresis (SPEP), subsequent diagnoses based on indications, and clinical significance of routine follow-up: a study of patients with monoclonal gammopathy of undetermined significance (MGUS). Blood 2009; 114(22):Abstr 4883. www.bloodjournal.org/content/114/22/4883. Accessed December 4, 2018.
- Merlini G, Palladini G. Differential diagnosis of monoclonal gammopathy of undetermined significance. Hematology Am Soc Hematol Educ Program 2012; 2012:595–603. doi:10.1182/asheducation-2012.1.595
- Glavey SV, Leung N. Monoclonal gammopathy: the good, the bad and the ugly. Blood Rev 2016; 30(3):223–231. doi:10.1016/j.blre.2015.12.001
- Dispenzieri A, Gertz MA, Therneau TM, Kyle RA. Retrospective cohort study of 148 patients with polyclonal gammopathy. Mayo Clin Proc 2001; 76(5):476–487. doi:10.4065/76.5.476
- Merlini G, Stone MJ. Dangerous small B-cell clones. Blood 2006; 108(8):2520–2530. doi:10.1182/blood-2006-03-001164
- Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014; 15(12):e538–e548. doi:10.1016/S1470-2045(14)70442-5
- Kyle RA, Gertz MA, Witzig TE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc 2003; 78(1):21–33. doi:10.4065/78.1.21
- Hutchison CA, Harding S, Hewins P, et al. Quantitative assessment of serum and urinary polyclonal free light chains in patients with chronic kidney disease. Clin J Am Soc Nephrol 2008; 3(6):1684–1690. doi:10.2215/CJN.02290508
- Katzmann JA, Dispenzieri A, Kyle RA, et al. Elimination of the need for urine studies in the screening algorithm for monoclonal gammopathies by using serum immunofixation and free light chain assays. Mayo Clin Proc 2006; 81(12):1575–1578. doi:10.4065/81.12.1575
- Berenson JR, Anderson KC, Audell RA, et al. Monoclonal gammopathy of undetermined significance: a consensus statement. Br J Haematol 2010; 150(1):28–38. doi:10.1111/j.1365-2141.2010.08207.x
- Mangiacavalli S, Cocito F, Pochintesta L, et al. Monoclonal gammopathy of undetermined significance: a new proposal of workup. Eur J Haematol 2013; 91(4):356–360. doi:10.1111/ejh.12172
- Bianchi G, Kyle RA, Colby CL, et al. Impact of optimal follow-up of monoclonal gammopathy of undetermined significance on early diagnosis and prevention of myeloma-related complications. Blood 2010;116:2019–2025. doi:10.1182/blood-2010-04-277566
- Rosiñol L, Cibeira MT, Montoto S, et al. Monoclonal gammopathy of undetermined significance: predictors of malignant transformation and recognition of an evolving type characterized by a progressive increase in M protein size. Mayo Clin Proc 2007; 82(4):428–434. doi:10.4065/82.4.428
- Vanderschueren S, Mylle M, Dierickx D, et al. Monoclonal gammopathy of undetermined significance: significant beyond hematology. Mayo Clin Proc 2009; 84(9):842–845. doi:10.4065/84.9.842
- Kyle RA, Rajkumar SV. Monoclonal gammopathy of undetermined significance and smouldering multiple myeloma: emphasis on risk factors for progression. Br J Haematol 2007; 139(5):730–743. doi:10.1111/j.1365-2141.2007.06873.x
- Leung N, Bridoux F, Hutchison CA, et al; International Kidney and Monoclonal Gammopathy Research Group. Monoclonal gammopathy of renal significance: when MGUS is no longer undetermined or insignificant. Blood. 2012; 120(22):4292–4295. doi:10.1182/blood-2012-07-445304
- Merlini G, Wechalekar AD, Palladini G. Systemic light chain amyloidosis: an update for treating physicians. Blood 2013; 121(26):5124–5130. doi:10.1182/blood-2013-01-453001
- Dispenzieri A, Katzmann JA, Kyle RA, et al. Prevalence and risk of progression of light-chain monoclonal gammopathy of undetermined significance: a retrospective population-based cohort study. Lancet 2010; 375(9727):1721–1728. doi:10.1016/S0140-6736(10)60482-5
- Rajkumar SV, Kyle RA, Therneau TM, et al. Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood 2005; 106(3):812–817. doi:10.1182/blood-2005-03-1038
- Dimopoulos MA, Hillengass J, Usmani S, et al. Role of magnetic resonance imaging in the management of patients with multiple myeloma: a consensus statement. J Clin Oncol 2015; 33(6):657–664. doi:10.1200/JCO.2014.57.9961
- Dimopoulos M, Kyle R, Fermand JP, et al. Consensus recommendations for standard investigative workup: report of the International Myeloma Workshop Consensus Panel 3. Blood 2011; 117(18):4701–4705. doi:10.1182/blood-2010-10-299529
- Pompa T, Maddox M, Woodard A, et al. Cost effectiveness in low risk MGUS patients. Blood 2016; 128:2360. http://www.bloodjournal.org/content/128/22/2360. Accessed December 4, 2018.
KEY POINTS
- MGUS is the most common of the monoclonal gammopathies.
- The overall risk of MGUS progressing to myeloma and other lymphoproliferative disorders is 1% per year.
- Low-risk MGUS is defined by an immunoglobulin G monoclonal protein at a concentration less than 1.5 g/dL and a normal serum free light-chain ratio.
- Low-risk MGUS carries a much lower risk of progression than intermediate- and high-risk MGUS, may not require subspecialty referral, and can be followed by the outpatient provider.
The white wall
My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.
Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.
There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.
These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.
The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.
Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.
During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.
As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.
We do not have adequate tools to assess clinical competency. As a result, Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?
Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.
Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.
Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.
Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.
We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.
With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.
I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.
Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.
There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.
These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.
The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.
Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.
During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.
As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.
We do not have adequate tools to assess clinical competency. As a result, Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?
Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.
Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.
Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.
Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.
We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.
With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.
I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
My father was a general surgeon in a very small town in West Virginia. He was very successful and his patients loved him. He loved them, too, and chose to practice well into his 70s. In retrospect, he should not have.
Perhaps brilliant in his day, he was less so at the end of his career. I realized his deficiencies when I was in residency. I wondered if, despite his undeniable experience, his age was compromising his clinical acumen.
There are data available that support my suspicions. Investigators from the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health reviewed a random sample of Medicare beneficiaries admitted to a hospital between 2011 and 2014. They hypothesized that physician age may affect outcomes such as 30-day mortality, readmissions, and cost of care. Among the more than 700,000 admissions by more than 18,000 hospitalists, the 30-day mortality rates were significantly higher for physicians aged 60 years and older, compared with younger physicians. Importantly though, there was no difference in mortality for older, but high-volume, physicians, compared with younger ones.
These results were published in the BMJ (2017 May 16;357:j1797. doi: 10.1136/bmj.j1797) by the same group that described a similar reduction in mortality among female versus male internists (JAMA Intern Med. 2017 Feb 1;177[2]:206-13). Both studies attracted widespread media attention.
The BMJ study analyzed outcomes among hospitalists who exclusively manage inpatients. Hematologists, in contrast, are largely based in the outpatient setting or in a lab. Yet, hematologists are often called upon to cover inpatient units of very sick patients. We care for patients with acute leukemia, thrombotic thrombocytopenic purpura, and graft versus host disease, among other debilitating diseases. In that sense, I believe data generated from hospitalists probably apply to inpatient hematology as well.
Having just been the attending on one of these services, I am uncomfortably certain that they apply. I proudly boast that I once attended for 6 months in a year. I was good at it and enjoyed it. With time, though, we hired additional staff and I acquired administrative duties that decreased my attending service time. I now attend for 2 weeks, twice a year.
During the last one of these service times, I began to suspect that I was not as sharp as I once was. I don’t think I missed anything, I just didn’t seem to catch changes in clinical status as quickly as I once did. I was less comfortable with the new medications I was prescribing. I was depending more on the clinical pharmacist and the hematology fellow to keep track of side effects and dose adjustments. I was worried – more than ever – that I would make a mistake. The last thing I want to be is dangerous.
As department chairman, though, it is part of my job to ensure that no one else is dangerous either. The Joint Commission mandates Ongoing Professional Practice Evaluation (OPPE), which is intended to help assess a practitioner’s clinical competence. Yet, the commission recognizes that “Cognitive specialties (internal medicine, family practice, psychiatry, med specialties ...) are very difficult” in terms of identifying meaningful data that can be evaluated.
We do not have adequate tools to assess clinical competency. As a result, Where police departments are accused of hiding behind a blue wall of silence, are physicians guilty of maintaining a white wall of silence?
Of course we are. How many clinically shaky fellows do we graduate into our profession every year? How many of us are aware of colleagues who are unskilled, but are reluctant to speak up about them? Our sins are documented in books such as “Wall of Silence: The Untold Story of the Medical Mistakes that Kill and Injure Millions of Americans” by Rosemary Gibson and Janardan Prasad Singh and “Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care,” by Marty Makary.
Concern for my own competence notwithstanding, medicine as a profession requires reflection on its role in allowing substandard patient care to continue.
Punishment doesn’t seem to be the best way to right wrongs. The punished may not learn the lesson and the unpunished will be less forthcoming with their own errors.
Taking a lesson from highly reliable industries such as airlines, the medical profession is addressing medical errors better. For example, my institution has mandated thorough checklists before any and all invasive procedures, including bone marrow biopsies. Through a morbidity and mortality review of a case of hepatitis, we developed an automatic method of ordering hepatitis panels in every patient treated with monoclonal antibodies. Making systemic changes to prevent error avoids having to punish those who make errors, while holding accountable those who skirt the built-in safeguards.
We are less successful at applying similar error mitigation techniques to individual physicians who may not be clinically excellent. Examples abound of physicians who provide substandard care, but are allowed to continue. The repercussions continue at Wake Forest Baptist Medical Center, where a pathologist misdiagnosed some cancer cases over at least a 2-year period of time. Physicians, as a group, are not as good at certifying competency as are nurses, advanced practice providers, and pharmacists.
With many academic hematologists having relatively small practices, getting older, and getting burned out, the potential for patient harm as a result of medical error increases. Further, these physicians may not realize their increased risk and may be indignant when confronted.
I am interested in best practices that address this difficult and contentious issue. I hope our readers will offer their policies and procedures so that we can learn from each other. Patients should not have to worry about their doctors’ competency and doctors should be able to hold each other accountable by removing the white wall of silence.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Pathologic superstition
When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder
I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.
Superstitions like these are familiar to all of us.
One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.
Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.
Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.
For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.
Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).
These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.
Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.
Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.
Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.
In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.
Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.
During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder
I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.
Superstitions like these are familiar to all of us.
One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.
Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.
Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.
For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.
Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).
These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.
Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.
Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.
Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.
In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.
Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.
During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
When you believe in things that you don’t understand
Then you suffer
Superstition ain’t the way
– Stevie Wonder
I have always found it odd that airplanes don’t have a 13th row and hotels don’t have a 13th floor. Well, of course they do, but they are not labeled that way. Many people would hesitate to sit in the 13th row of an airplane since 13 is such an unlucky number. At least many people in the United States think the number 13 is unlucky. Thirteen is just a number in much of Asia. There, the number 4 is just as threatening as 13 is to us.
Superstitions like these are familiar to all of us.
One of my favorites is the belief that vacuum cups attached to the skin will somehow draw out toxins and generally improve health. “Cupping,” as the practice is known, is endorsed by several celebrities and famous athletes. After the treatment, a cupped patient exhibits circles of hyperemia, and no other apparent harm. I suspect that about a third of cupped patients truly think they have benefited from a good cupping, about the same number that would benefit from an orally administered placebo.
Superstitions are everywhere. Whether it is a black cat in the United States, infinite reflecting mirrors in Mexico, going back to your house after a wake in the Philippines, or whistling indoors in Lithuania, superstitions are pervasive, deeply held, and generally harmless. They are good for a good laugh as we recognize how ludicrous these unfounded fears are.
Some superstitions, though, are no laughing matter. They can be quite harmful. They are pathologic superstitions.
For example, some people believe vaccines cause autism in children. That pathologic superstition has consequences. A recent CDC report revealed that the population of unvaccinated children in the United States has quadrupled since 2001. This comes as no surprise as we hear about more measles outbreaks – and the deaths associated with them – in populations of unvaccinated children every year. A similar and pervasive pathologic superstition is the fear that an influenza vaccine will cause the flu. I wonder how many people die from this misconception.
Other people believe that their cancer can be treated, if not cured, with unproven, unconventional treatments. I cannot understand how this pathologic superstition developed. The purveyors of unconventional treatment hold much of the blame, but gullibility and ignorance may play a larger role. The consequences are tragic. A recent report demonstrated an approximately twofold increased risk of death in patients who used complementary therapies, compared with those who did not (JAMA Oncol. 2018 Oct 1;4[10]:1375-81).
These are sobering data for those of us who have in the past relented when our patients asked if they could take this or that supplement because we did not think they would cause significant harm.
Superstitions apparently are part of the human condition, evolved to attribute causation and provide order. They are a learned phenomenon. They are learned by reasonable people with normal intelligence and rational thinking. A superstition is born when someone is exposed to a false statement by someone or something they trust – a trusted other.
Trusted others exude certainty. Once established, superstitions are regrettably difficult to remove by those who are less certain, like physicians. How willing are we to say that the flu vaccine is 100% safe? Without certainty, how can a physician debunk a superstition? The techniques that we have been taught usually work, but not when faced with a pathologic superstition.
Science and experience teach us that firmly held superstitions cannot be broken with logical, stepwise reasoning. Jonathan Haidt provides a useful metaphor for this problem in his book “The Happiness Hypothesis” (Basic Books, 2006). He describes a rider on an elephant. The rider represents our rational thought and the elephant represents our emotional foundation. The rider thinks he controls the elephant, but the opposite is more likely true. In order to move the elephant in a certain direction, the rider needs to make the elephant want to turn in that direction. Otherwise, all the cajoling and arguing in the world won’t make the elephant turn. A rational argument made to someone emotionally invested in the counter argument will fail. That is why we cannot convince antivaccine parents to vaccinate their children by trying to persuade them with facts. Neither can we convince global warming skeptics to stop burning coal, gun advocates to vote for restrictions on gun ownership, or cancer patients to accept curative treatment if their values and morals are being challenged.
In a later book, “The Righteous Mind: Why Good People Are Divided by Politics and Religion” (Vintage Books, 2012), Mr. Haidt expands his hypothesis to declare that to change minds, we must appeal to underlying moral values. The challenge is to identify those moral underpinnings in our patients in order to develop an appeal likely to resonate with their emotions and values.
Superstition derives from something people learn either from trusted others or from personal experience. It does no good for physicians to deride patient beliefs and denigrate their agency in an attempt to persuade them to abandon what we consider irrational beliefs. For physicians to penetrate pathologic superstitions, they will have to become the trusted other, to understand moral foundations, to emotionally connect. That does not usually happen the first day we meet a new patient, especially a skeptical one. It takes time, and effort, to reach out and bond with the patient and their family. Only then can pathologic superstitions dissolve and a better patient-doctor relationship evolve.
During this season rife with superstition, remember that your patient’s own superstitions are part of their belief system, and your belief system may be threatening to them. Make your beliefs less threatening, become a trusted other, and appeal to their foundational values, and you can successfully break a pathologic superstition.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Full disclosure
I have nothing to disclose.
That is the first line on my second slide in just about every talk I give. I have no financial conflicts of interest. I no longer accept meals from pharmaceutical companies, I no longer conduct pharmaceutical company sponsored research, and I no longer give talks that include honoraria from pharmaceutical companies. I turn down payments from pharmaceutical companies when I participate in drug-monitoring safety boards and advisory committees. I do not have a financial conflict of interest.
Or do I?
In preparing to write this essay, I searched the Open Payments website (www.cms.gov/OpenPayments/index.html) for my name. Open Payments is the product of the Physician Payments Sunshine Act passed in 2010 as part of the Affordable Care Act. The website went live in September 2014 with the intention of making public all payments made to physicians from device and drug makers. I was happy to confirm that I have received no “General Payments,” which are payments for meals, travel, honoraria, consulting, and the like. However, I was surprised to learn that I did receive “Associated Research” payments. According to the website, an Associated Research payment is “funding for a research project or study where the physician is named as a principal investigator.”
I still have a few trials open under my name, but none have accrued a patient in more than 7 years. Nonetheless, I am on record, and publicly so, for accepting an Associated payment for research to the tune of $1,308,360.06.
Upon learning this, my thoughts turned to the New York Times. The Times recently published an expose in cooperation with ProPublica. In it, a prominent cancer researcher at Memorial Sloan Kettering was accused of repeatedly failing to disclose his substantial financial conflicts of interest. The payments creating the conflict were listed on the Open Payments website. Since financial disclosure is almost always required for a manuscript listed in PubMed, a simple comparison of two public websites provided the journalists with nearly all the information they needed to conclude malfeasance in disclosure.
In response, the accused admitted the failure to disclose, but attributed it to an unintentional error. In the frenzy that followed, a man of towering stature, a paragon of cancer research, submitted his resignation. The sequence of events was tragic. Had the payments been for research instead of services rendered would the consequences have been the same?
Most of us believe corporate payments for research are less likely to influence our prescribing and consulting habits than are general payments for entertainment and speaking engagements. I remember receiving my first research grant from the now defunct pharma company Immunex. It was for $10,000 – a paltry sum – but enough for me to set up a clinical trial using Immunex’s drugs. I was flattered, indebted, and conflicted from that point forward. Funded research propels our careers forward. Thinking research payments bias our decision making less than direct payments is naive. Money corrupts, and that is why research dollars need to be disclosed whenever we discuss research at the podium or in print.
With appropriate indignation, I explored the Open Payments website to learn more of my hitherto unknown payment. It was attached to a multicenter, randomized clinical trial for which I served as local principal investigator. The payment was made in January 2017 and our research team cannot verify such a payment was ever received. According to the website, the payment was not disputed. I sought to dispute it.
Our friends at the Centers for Medicare and Medicaid Services do not make filing a dispute easy. I first had to register with my home address and create a new password that, of course, needs to be changed every 60 days. I duly registered and logged into the website as instructed. I followed instructions and filled in data fields for about an additional 10 pages before being informed that I needed to logout, then log back in, to access the Open Payments application. When I did that, I was greeted with instructions to register in the Open Payments system. I then realized that all I had done to that point was register with the CMS.gov portal, not Open Payments. In for a dime, in for a dollar, I registered with Open Payments.
I almost gave up when they asked me to provide a Physician Taxonomy Code. It took me a long time to find it. For those interested, the code for Hematology is 207RH0000X. With that code entered in the right box, I was only two pages away from being registered and ready to open the dispute. Failure hit me like a lake effect snow storm. Despite my diligence, I was not “vetted” and could not file a dispute. I must have done something wrong and cannot seem to investigate the payment further, but I’m sure the New York Times could.
Now, I don’t know if I have anything to disclose or not. I do know that I have to investigate my payment the best I can, that I have to disclose it if it is real, and that I have to check Open Payments every so often to make sure I am not surprised by an investigative journalist’s report in the future. Add these to the pantheon of onerous requirements for a successful academic career.
Many wear their entanglements as a badge of honor on slides highlighting a long list of conflicts. One speaker joked that she had so many conflicts that she had no conflicts. Clearly, much like alarm fatigue, the constant display of financial conflict of interest disclosures rarely raises red flags in an audience of peers. To an audience of interested lay persons, though, those conflicts may be very important and relevant.
It is our duty to accurately account for and report them no matter the difficulty in doing so. Failure to do so can carry tragic consequences.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
I have nothing to disclose.
That is the first line on my second slide in just about every talk I give. I have no financial conflicts of interest. I no longer accept meals from pharmaceutical companies, I no longer conduct pharmaceutical company sponsored research, and I no longer give talks that include honoraria from pharmaceutical companies. I turn down payments from pharmaceutical companies when I participate in drug-monitoring safety boards and advisory committees. I do not have a financial conflict of interest.
Or do I?
In preparing to write this essay, I searched the Open Payments website (www.cms.gov/OpenPayments/index.html) for my name. Open Payments is the product of the Physician Payments Sunshine Act passed in 2010 as part of the Affordable Care Act. The website went live in September 2014 with the intention of making public all payments made to physicians from device and drug makers. I was happy to confirm that I have received no “General Payments,” which are payments for meals, travel, honoraria, consulting, and the like. However, I was surprised to learn that I did receive “Associated Research” payments. According to the website, an Associated Research payment is “funding for a research project or study where the physician is named as a principal investigator.”
I still have a few trials open under my name, but none have accrued a patient in more than 7 years. Nonetheless, I am on record, and publicly so, for accepting an Associated payment for research to the tune of $1,308,360.06.
Upon learning this, my thoughts turned to the New York Times. The Times recently published an expose in cooperation with ProPublica. In it, a prominent cancer researcher at Memorial Sloan Kettering was accused of repeatedly failing to disclose his substantial financial conflicts of interest. The payments creating the conflict were listed on the Open Payments website. Since financial disclosure is almost always required for a manuscript listed in PubMed, a simple comparison of two public websites provided the journalists with nearly all the information they needed to conclude malfeasance in disclosure.
In response, the accused admitted the failure to disclose, but attributed it to an unintentional error. In the frenzy that followed, a man of towering stature, a paragon of cancer research, submitted his resignation. The sequence of events was tragic. Had the payments been for research instead of services rendered would the consequences have been the same?
Most of us believe corporate payments for research are less likely to influence our prescribing and consulting habits than are general payments for entertainment and speaking engagements. I remember receiving my first research grant from the now defunct pharma company Immunex. It was for $10,000 – a paltry sum – but enough for me to set up a clinical trial using Immunex’s drugs. I was flattered, indebted, and conflicted from that point forward. Funded research propels our careers forward. Thinking research payments bias our decision making less than direct payments is naive. Money corrupts, and that is why research dollars need to be disclosed whenever we discuss research at the podium or in print.
With appropriate indignation, I explored the Open Payments website to learn more of my hitherto unknown payment. It was attached to a multicenter, randomized clinical trial for which I served as local principal investigator. The payment was made in January 2017 and our research team cannot verify such a payment was ever received. According to the website, the payment was not disputed. I sought to dispute it.
Our friends at the Centers for Medicare and Medicaid Services do not make filing a dispute easy. I first had to register with my home address and create a new password that, of course, needs to be changed every 60 days. I duly registered and logged into the website as instructed. I followed instructions and filled in data fields for about an additional 10 pages before being informed that I needed to logout, then log back in, to access the Open Payments application. When I did that, I was greeted with instructions to register in the Open Payments system. I then realized that all I had done to that point was register with the CMS.gov portal, not Open Payments. In for a dime, in for a dollar, I registered with Open Payments.
I almost gave up when they asked me to provide a Physician Taxonomy Code. It took me a long time to find it. For those interested, the code for Hematology is 207RH0000X. With that code entered in the right box, I was only two pages away from being registered and ready to open the dispute. Failure hit me like a lake effect snow storm. Despite my diligence, I was not “vetted” and could not file a dispute. I must have done something wrong and cannot seem to investigate the payment further, but I’m sure the New York Times could.
Now, I don’t know if I have anything to disclose or not. I do know that I have to investigate my payment the best I can, that I have to disclose it if it is real, and that I have to check Open Payments every so often to make sure I am not surprised by an investigative journalist’s report in the future. Add these to the pantheon of onerous requirements for a successful academic career.
Many wear their entanglements as a badge of honor on slides highlighting a long list of conflicts. One speaker joked that she had so many conflicts that she had no conflicts. Clearly, much like alarm fatigue, the constant display of financial conflict of interest disclosures rarely raises red flags in an audience of peers. To an audience of interested lay persons, though, those conflicts may be very important and relevant.
It is our duty to accurately account for and report them no matter the difficulty in doing so. Failure to do so can carry tragic consequences.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
I have nothing to disclose.
That is the first line on my second slide in just about every talk I give. I have no financial conflicts of interest. I no longer accept meals from pharmaceutical companies, I no longer conduct pharmaceutical company sponsored research, and I no longer give talks that include honoraria from pharmaceutical companies. I turn down payments from pharmaceutical companies when I participate in drug-monitoring safety boards and advisory committees. I do not have a financial conflict of interest.
Or do I?
In preparing to write this essay, I searched the Open Payments website (www.cms.gov/OpenPayments/index.html) for my name. Open Payments is the product of the Physician Payments Sunshine Act passed in 2010 as part of the Affordable Care Act. The website went live in September 2014 with the intention of making public all payments made to physicians from device and drug makers. I was happy to confirm that I have received no “General Payments,” which are payments for meals, travel, honoraria, consulting, and the like. However, I was surprised to learn that I did receive “Associated Research” payments. According to the website, an Associated Research payment is “funding for a research project or study where the physician is named as a principal investigator.”
I still have a few trials open under my name, but none have accrued a patient in more than 7 years. Nonetheless, I am on record, and publicly so, for accepting an Associated payment for research to the tune of $1,308,360.06.
Upon learning this, my thoughts turned to the New York Times. The Times recently published an expose in cooperation with ProPublica. In it, a prominent cancer researcher at Memorial Sloan Kettering was accused of repeatedly failing to disclose his substantial financial conflicts of interest. The payments creating the conflict were listed on the Open Payments website. Since financial disclosure is almost always required for a manuscript listed in PubMed, a simple comparison of two public websites provided the journalists with nearly all the information they needed to conclude malfeasance in disclosure.
In response, the accused admitted the failure to disclose, but attributed it to an unintentional error. In the frenzy that followed, a man of towering stature, a paragon of cancer research, submitted his resignation. The sequence of events was tragic. Had the payments been for research instead of services rendered would the consequences have been the same?
Most of us believe corporate payments for research are less likely to influence our prescribing and consulting habits than are general payments for entertainment and speaking engagements. I remember receiving my first research grant from the now defunct pharma company Immunex. It was for $10,000 – a paltry sum – but enough for me to set up a clinical trial using Immunex’s drugs. I was flattered, indebted, and conflicted from that point forward. Funded research propels our careers forward. Thinking research payments bias our decision making less than direct payments is naive. Money corrupts, and that is why research dollars need to be disclosed whenever we discuss research at the podium or in print.
With appropriate indignation, I explored the Open Payments website to learn more of my hitherto unknown payment. It was attached to a multicenter, randomized clinical trial for which I served as local principal investigator. The payment was made in January 2017 and our research team cannot verify such a payment was ever received. According to the website, the payment was not disputed. I sought to dispute it.
Our friends at the Centers for Medicare and Medicaid Services do not make filing a dispute easy. I first had to register with my home address and create a new password that, of course, needs to be changed every 60 days. I duly registered and logged into the website as instructed. I followed instructions and filled in data fields for about an additional 10 pages before being informed that I needed to logout, then log back in, to access the Open Payments application. When I did that, I was greeted with instructions to register in the Open Payments system. I then realized that all I had done to that point was register with the CMS.gov portal, not Open Payments. In for a dime, in for a dollar, I registered with Open Payments.
I almost gave up when they asked me to provide a Physician Taxonomy Code. It took me a long time to find it. For those interested, the code for Hematology is 207RH0000X. With that code entered in the right box, I was only two pages away from being registered and ready to open the dispute. Failure hit me like a lake effect snow storm. Despite my diligence, I was not “vetted” and could not file a dispute. I must have done something wrong and cannot seem to investigate the payment further, but I’m sure the New York Times could.
Now, I don’t know if I have anything to disclose or not. I do know that I have to investigate my payment the best I can, that I have to disclose it if it is real, and that I have to check Open Payments every so often to make sure I am not surprised by an investigative journalist’s report in the future. Add these to the pantheon of onerous requirements for a successful academic career.
Many wear their entanglements as a badge of honor on slides highlighting a long list of conflicts. One speaker joked that she had so many conflicts that she had no conflicts. Clearly, much like alarm fatigue, the constant display of financial conflict of interest disclosures rarely raises red flags in an audience of peers. To an audience of interested lay persons, though, those conflicts may be very important and relevant.
It is our duty to accurately account for and report them no matter the difficulty in doing so. Failure to do so can carry tragic consequences.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
Seeking the chair
“Before you are a leader, success is all about growing yourself. When you become a leader, success is all about growing others.” – Jack Welch
Serving my colleagues as chairman of the department of hematology and medical oncology at the Cleveland Clinic has been my greatest honor and privilege. I am humbled to lead such compassionate, inquisitive, and accomplished clinician scientists during a time of great change in academic medicine. From the introduction of new therapies to the implementation of new operational processes, my team inspires me to extend my capability beyond what I ever thought possible. I am grateful for the opportunity to grow with them.
Serving as chair can be extraordinarily satisfying, but there are some parts of the job description that an aspiring chairperson should be aware of before seeking the position. These less savory – though necessary – aspects of the job are not explicitly stated in the advertisements in the back of a trade journal. Allow me to translate a typical advertisement. I copied this text from the first advertisement for a department chairperson that I found with a Google search:
Knowledge of and ability to apply professional medical principles, procedures, and techniques. Thorough knowledge of pharmacological agents used in patient treatment. Able to effectively manage and direct medical staff support activities while providing quality medical care. Able to receive detailed information through oral communications; express or exchange ideas by verbal communications. Excellent written and verbal communications, listening, and social skills. Able to interact effectively with people of varied educational, socioeconomic, and ethnic backgrounds, skill levels, and value systems. Performs in a tactful and professional manner. A wide degree of creativity and latitude is expected. Relies on experience and judgment to plan and accomplish goals.
1. “Knowledge of and ability to apply professional medical principles, procedures, and techniques. Thorough knowledge of pharmacological agents used in patient treatment.” You better be a good doctor because …
2. “Able to effectively manage and direct medical staff support activities while providing quality medical care.” You will still be seeing patients while supporting everybody else’s career development, signing off on vacations, setting call schedules, attesting to conflicts of interest, certifying competence, approving research projects, and attending administrative meetings.
3. “Able to receive detailed information through oral communications; express or exchange ideas by verbal communications.” Your team will be paging, calling, and knocking on your door whenever they want to immediately address their latest irritation. Responding to irritation with email is a mistake.
4. “Excellent written and verbal communications, listening, and social skills.” You will write email more than you can possibly imagine, with each one precisely worded and politically correct. When you inevitably screw up one of these communications, often because you responded to someone else’s irritation, you will accept the criticism, apologize to the offended party, and correct the error without being defensive.
5. “Able to interact effectively with people of varied educational, socioeconomic, and ethnic backgrounds, skill levels, and value systems.” You will work with people who do not share your worldview, have problems you cannot begin to fathom, display behavior you cannot understand, and expect you to remember their names.
6. “Performs in a tactful and professional manner.” No matter how much someone angers you, you cannot be a jerk like the last chairperson.
7. “A wide degree of creativity and latitude is expected.” This one is confusing, but I think it means that you need to avoid immediate dismissal of stupid ideas.
8. “Relies on experience and judgment to plan and accomplish goals.” Failure to reach goals set by others is your fault because of inadequate planning.
Who would apply for that job? The only people who should apply are those who are ready to leave their personal comforts behind for the comfort of others.
For those undaunted by the job description, I am frequently asked how a career should develop to maximize the chances of promotion to leadership positions. Should I get my MBA? What committees should I sit on? Who should I get to know and collaborate with? When is the best time to seek promotion? How should I position myself for advantage?
I’m sorry to disappoint, but I find that those who seek promotion the most are the ones least likely to be promoted to the position they want. I recommend being yourself while pursuing goals that interest you, seeking education that stimulates you, working with people who engage with you, and helping others succeed instead of yourself. Promotions will follow.
The key is a serving mindset. No MBA, committee, collaboration, event, or positioning will determine your willingness to serve. All may contribute to a chair’s skill set, but the sense of obligation to develop and lead a team can only come from an altruistic resolve to put others first. It is hard work that requires sacrifice and a willingness to fail so that others may succeed. I recommend it.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
“Before you are a leader, success is all about growing yourself. When you become a leader, success is all about growing others.” – Jack Welch
Serving my colleagues as chairman of the department of hematology and medical oncology at the Cleveland Clinic has been my greatest honor and privilege. I am humbled to lead such compassionate, inquisitive, and accomplished clinician scientists during a time of great change in academic medicine. From the introduction of new therapies to the implementation of new operational processes, my team inspires me to extend my capability beyond what I ever thought possible. I am grateful for the opportunity to grow with them.
Serving as chair can be extraordinarily satisfying, but there are some parts of the job description that an aspiring chairperson should be aware of before seeking the position. These less savory – though necessary – aspects of the job are not explicitly stated in the advertisements in the back of a trade journal. Allow me to translate a typical advertisement. I copied this text from the first advertisement for a department chairperson that I found with a Google search:
Knowledge of and ability to apply professional medical principles, procedures, and techniques. Thorough knowledge of pharmacological agents used in patient treatment. Able to effectively manage and direct medical staff support activities while providing quality medical care. Able to receive detailed information through oral communications; express or exchange ideas by verbal communications. Excellent written and verbal communications, listening, and social skills. Able to interact effectively with people of varied educational, socioeconomic, and ethnic backgrounds, skill levels, and value systems. Performs in a tactful and professional manner. A wide degree of creativity and latitude is expected. Relies on experience and judgment to plan and accomplish goals.
1. “Knowledge of and ability to apply professional medical principles, procedures, and techniques. Thorough knowledge of pharmacological agents used in patient treatment.” You better be a good doctor because …
2. “Able to effectively manage and direct medical staff support activities while providing quality medical care.” You will still be seeing patients while supporting everybody else’s career development, signing off on vacations, setting call schedules, attesting to conflicts of interest, certifying competence, approving research projects, and attending administrative meetings.
3. “Able to receive detailed information through oral communications; express or exchange ideas by verbal communications.” Your team will be paging, calling, and knocking on your door whenever they want to immediately address their latest irritation. Responding to irritation with email is a mistake.
4. “Excellent written and verbal communications, listening, and social skills.” You will write email more than you can possibly imagine, with each one precisely worded and politically correct. When you inevitably screw up one of these communications, often because you responded to someone else’s irritation, you will accept the criticism, apologize to the offended party, and correct the error without being defensive.
5. “Able to interact effectively with people of varied educational, socioeconomic, and ethnic backgrounds, skill levels, and value systems.” You will work with people who do not share your worldview, have problems you cannot begin to fathom, display behavior you cannot understand, and expect you to remember their names.
6. “Performs in a tactful and professional manner.” No matter how much someone angers you, you cannot be a jerk like the last chairperson.
7. “A wide degree of creativity and latitude is expected.” This one is confusing, but I think it means that you need to avoid immediate dismissal of stupid ideas.
8. “Relies on experience and judgment to plan and accomplish goals.” Failure to reach goals set by others is your fault because of inadequate planning.
Who would apply for that job? The only people who should apply are those who are ready to leave their personal comforts behind for the comfort of others.
For those undaunted by the job description, I am frequently asked how a career should develop to maximize the chances of promotion to leadership positions. Should I get my MBA? What committees should I sit on? Who should I get to know and collaborate with? When is the best time to seek promotion? How should I position myself for advantage?
I’m sorry to disappoint, but I find that those who seek promotion the most are the ones least likely to be promoted to the position they want. I recommend being yourself while pursuing goals that interest you, seeking education that stimulates you, working with people who engage with you, and helping others succeed instead of yourself. Promotions will follow.
The key is a serving mindset. No MBA, committee, collaboration, event, or positioning will determine your willingness to serve. All may contribute to a chair’s skill set, but the sense of obligation to develop and lead a team can only come from an altruistic resolve to put others first. It is hard work that requires sacrifice and a willingness to fail so that others may succeed. I recommend it.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.
“Before you are a leader, success is all about growing yourself. When you become a leader, success is all about growing others.” – Jack Welch
Serving my colleagues as chairman of the department of hematology and medical oncology at the Cleveland Clinic has been my greatest honor and privilege. I am humbled to lead such compassionate, inquisitive, and accomplished clinician scientists during a time of great change in academic medicine. From the introduction of new therapies to the implementation of new operational processes, my team inspires me to extend my capability beyond what I ever thought possible. I am grateful for the opportunity to grow with them.
Serving as chair can be extraordinarily satisfying, but there are some parts of the job description that an aspiring chairperson should be aware of before seeking the position. These less savory – though necessary – aspects of the job are not explicitly stated in the advertisements in the back of a trade journal. Allow me to translate a typical advertisement. I copied this text from the first advertisement for a department chairperson that I found with a Google search:
Knowledge of and ability to apply professional medical principles, procedures, and techniques. Thorough knowledge of pharmacological agents used in patient treatment. Able to effectively manage and direct medical staff support activities while providing quality medical care. Able to receive detailed information through oral communications; express or exchange ideas by verbal communications. Excellent written and verbal communications, listening, and social skills. Able to interact effectively with people of varied educational, socioeconomic, and ethnic backgrounds, skill levels, and value systems. Performs in a tactful and professional manner. A wide degree of creativity and latitude is expected. Relies on experience and judgment to plan and accomplish goals.
1. “Knowledge of and ability to apply professional medical principles, procedures, and techniques. Thorough knowledge of pharmacological agents used in patient treatment.” You better be a good doctor because …
2. “Able to effectively manage and direct medical staff support activities while providing quality medical care.” You will still be seeing patients while supporting everybody else’s career development, signing off on vacations, setting call schedules, attesting to conflicts of interest, certifying competence, approving research projects, and attending administrative meetings.
3. “Able to receive detailed information through oral communications; express or exchange ideas by verbal communications.” Your team will be paging, calling, and knocking on your door whenever they want to immediately address their latest irritation. Responding to irritation with email is a mistake.
4. “Excellent written and verbal communications, listening, and social skills.” You will write email more than you can possibly imagine, with each one precisely worded and politically correct. When you inevitably screw up one of these communications, often because you responded to someone else’s irritation, you will accept the criticism, apologize to the offended party, and correct the error without being defensive.
5. “Able to interact effectively with people of varied educational, socioeconomic, and ethnic backgrounds, skill levels, and value systems.” You will work with people who do not share your worldview, have problems you cannot begin to fathom, display behavior you cannot understand, and expect you to remember their names.
6. “Performs in a tactful and professional manner.” No matter how much someone angers you, you cannot be a jerk like the last chairperson.
7. “A wide degree of creativity and latitude is expected.” This one is confusing, but I think it means that you need to avoid immediate dismissal of stupid ideas.
8. “Relies on experience and judgment to plan and accomplish goals.” Failure to reach goals set by others is your fault because of inadequate planning.
Who would apply for that job? The only people who should apply are those who are ready to leave their personal comforts behind for the comfort of others.
For those undaunted by the job description, I am frequently asked how a career should develop to maximize the chances of promotion to leadership positions. Should I get my MBA? What committees should I sit on? Who should I get to know and collaborate with? When is the best time to seek promotion? How should I position myself for advantage?
I’m sorry to disappoint, but I find that those who seek promotion the most are the ones least likely to be promoted to the position they want. I recommend being yourself while pursuing goals that interest you, seeking education that stimulates you, working with people who engage with you, and helping others succeed instead of yourself. Promotions will follow.
The key is a serving mindset. No MBA, committee, collaboration, event, or positioning will determine your willingness to serve. All may contribute to a chair’s skill set, but the sense of obligation to develop and lead a team can only come from an altruistic resolve to put others first. It is hard work that requires sacrifice and a willingness to fail so that others may succeed. I recommend it.
Dr. Kalaycio is editor in chief of Hematology News. He chairs the department of hematologic oncology and blood disorders at Cleveland Clinic Taussig Cancer Institute. Contact him at kalaycm@ccf.org.