Are You Special? Should We All Be Special?

Rebecca Bechhold, MD

There is an ophthalmology group in my city with dozens of highly trained experts in eye diseases. They are each subspecialized. Cornea, retina, glaucoma, neurologic disorders-if you are referred there they know exactly whom you should see for your specific problem. It is a pleasure to work with them, and patients feel very comfortable being referred even if I cannot tell them specifically who will treat them. I trust the group to know how to match my patient to the correct physician.

It is similar in the orthopedic groups. They are each focused on a joint of interest and do not waver from that. Kudos to them. They develop tremendous expertise and are truly experts in what they do.

Oncology is becoming so complex, I wonder how one can stay proficient in every type of cancer. Just think of all the new “-ib” and “-ab” targeted therapies that have flooded the market. I made a two-page list of as many as I could come up with and quizzed some of my partners. It was impressive how many they could match with the corresponding disease, but just as impressive was how many they had not heard of and had never used or expected to use. Much of the joy and excitement of oncology is all of the new tools we have to treat this disease. It is astonishing to look back to when I started oncology practice in the 80s and see how different and vastly improved our stockpile is for antineoplastic and supportive therapy now. But be honest, don’t you sometimes look through a journal and see an ad for a drug and think, “when did that come out and what is it for?”

If you need an operation, you seek out the surgeon who does that specific procedure dozens of times a month. They and their team are going to be well rehearsed in that process. They will anticipate problems and know instinctively how to prevent bad outcomes in most cases. Practice. Practice. Practice. It may not make perfect every time, but it will come closer than “somewhat familiar with.”

Patients have been instructed to ask “How many cases like this have you treated?” If you don’t see that particular tumor type all that often, do you say that? Our practice is diligent about getting patients in for consultation as soon as possible even with a different doctor than the one to which they may have been referred. But this can lead to seeing cases that are uncommon to certain oncologists. Many of us have developed an expertise in certain tumor types and are probably better versed in their management than someone who rarely sees them. Though we use many of the same drugs for a variety of tumors, and we handle a host of drug side effects no matter what the underlying disease, I am feeling more and more comfortable with my chosen tumor type and less confident with things I just don’t see as much.

Some oncologists resist this idea for fear of losing patients or not seeing another breast patient if they turn one down, even though they haven’t treated much breast cancer for years. Is this fair to the patient? Do we need to declare ourselves and direct patients to the person who can best serve them? Certainly, you can be highly competent in more than one tumor type, but can we honestly claim to be an expert in every liquid and solid tumor? We haven’t even mentioned blood disorders-hemophilia, sickle cell, and coagulopathies.

There are some things I just won’t see because I think it is unfair to the patient. I am fortunate to be in a large (45 doctors) group and we have an expert in pretty much anything including hematology and bone marrow transplantation. It does not hurt my ego to say that. I do think I am better at my area of interest than some others and would not think less of them if they transferred a patient to me. We could all be a lot more collegial and a bit less competitive with referrals and difficult cases. Patients love to hear that you discussed their case with others. They see it as fresh eyes, a second opinion, and it gives them confidence that you are exploring all possibilities for them. I have had patients I treated for one thing, whom I referred to a partner after they developed a new problem that I do not commonly see. We both follow them for different things and make an effort to do it efficiently without causing extra charges to the patient.

If you or your loved one had cancer, how would you go about picking their treating oncologist? What would you want to know about their experience in that disease? And if a patient asks you how many cases you have treated with their diagnosis, will you look at them and be totally honest?