A Day in the Life of a Community Practitioner

Excerpt from Achieving Career Success in Oncology: A Practical Guide, Chapter 2, by Jennifer J. Griggs, MD, MPH, Gregory A. Curt, MD, Kathleen A. Cooney, MD, and Douglas W. Blayney, MD

Life in the office

Care of the cancer patient in the modern era occurs almost exclusively in the outpatient setting. Consequently, the outpatient setting—whether the classic physician office, the cluster of exam rooms serving a large group practice, or the hospital outpatient department—is organized to deliver customer-friendly patient care and to make the function of the most expensive member of the team—the oncologist—most efficient. The core services delivered by the oncologist are usually delivered onsite: evaluation and management services (including new-patient consultations, return patient visits, telephone calls from patients or family for questions and for symptom management) and usually chemotherapy delivery. The office can be in a professional office building adjacent to or near a hospital or in a large medical complex, but more recently medical oncologists are seeing patients in a free-standing cancer center. These individual cancer centers feature work spaces for other members of the cancer care team, including radiation oncologists, chemotherapy infusion nurses and pharmacists, and other support personnel including dietitians, social workers and data managers and clinical trial coordinators. For most community practitioners, the day is organized around the office.

Often the professional day starts with hospital rounds. There may have been a patient admitted with a complication of cancer or its therapy during the night. Usually this will be a patient known to you or to one of your colleagues, so the visit can be short. If it's a new patient to the practice, often the visit is short and introductory, and a more formal consultation can be arranged later in the day after you have reviewed the pathology material and the radiologic images. Many hospitals serve a breakfast in a private area for the medical staff. It is a good idea to make a practice of checking in for coffee for "face time"-to make contact with other members of the medical staff, to bring them up to date on mutual patients, to review medical staff activities and new treatment methods, and, especially for new physicians, to get to know other members of the medical staff who may refer patients to the practice. For hospitals still using paper records, a stop in the medical record room can be a convenience. A stop to review images and slides with the pathologist and the radiologist can often be done at this time.

Arriving on time at the office—whether it is near or far from the home or hospital—gives the oncologist time to preview patients on the schedule, instruct the staff how to work into the day the patients who called overnight with an urgent problem, and to prepare for the patient who will need extra time that day—the patient whose cancer is relapsing, who is newly diagnosed, whose family is coming from out of town, or any of the myriad other problems that will need solving. It is also time to divide up the patients with nurse practitioner or physician assistant, if you have one.

The office is usually one patient after another. It's actually enjoyable to meet new patients, to follow up on patients who are doing well, and to exercise your diagnostic and therapeutic skills on life-threatening problems and see the results unfold. One of our colleagues, who has practiced general pediatrics for thirty years, often reminds us that "behind every door there's a story." The stories are not only about illness and cancer, but also about our patient's lives. Most people have interesting stories to share, and hearing them is one of the daily satisfiers of practice.

Some oncologists reserve time to see new patients either early or late in the office session. Most see twelve to sixteen return visits each half-day and allocate 30-60 minutes for each new patient. Although this sounds like a short time, there is always pre-appointment and post-visit work to be done when the office is not in session - reviewing reports and images, documenting the interaction, and discussing with colleagues. Much of the time patients are in the office they are interacting with other members of the staff, learning about side effects of treatment or discussing financial, social, or psychosocial issues. Well-run offices are organized to assure that the oncologist delivers maximum value to the patient during the face-to-face interaction; other tasks should be delegated to easily available specialists in their areas of expertise.

Lunchtime can be used to answer telephone calls from the morning session, to eat lunch with professional colleagues (more "face time"), to catch up on documentation tasks from the morning clinic session, or to make hospital rounds. The rhythm of the day, for a specialist, is that new inpatient consultations often come in in the afternoon hours, after the pathology reports have been posted and the surgeons, internists, family practitioners, hospitalists, and pulmonologists have made their morning rounds and decided that an oncology consultation will be helpful.

Midday is also a popular time for hospital medical staff committee meetings. Medical staff have governance structures composed of physicians whose staff work (notification of meeting time and place, publishing the agenda and minutes, and arranging for attendance) is usually accomplished by hospital employees. Physician participation and oversight is necessary for credentialing new members of the medical staff, for establishing and reviewing quality of care indicators, for advising the hospital's lay governing bodies (the board of directors), and for discipline and other sanctions of members. Service on hospital committees is a duty of self-governance, can be rewarding in and of itself, and is also a way to meet new physicians who might be referral sources. If one practices in a satellite office, or one has several offices or hospitals, midday can also be travel time. The afternoon can be a repeat of the morning, seeing office patients, or can be set aside for hospital rounds and consultation.

Most oncologists develop some open time, down time, or "office time" in their day and in their week. Early in the career, the open time can be for business development: meeting new physicians, reviewing operations, or reading about challenging cases. Mid-career practitioners use this time for honing office operations, for interviewing new personnel, or for developing new skills or hobbies. Unscheduled or office time is also used for catching up on professional obligations: charting, reading medical journals, or writing. Family and personal time should also be built into the day. Some practitioners use lunchtime as a personal time, exercise time, or nap time. Afternoons are often the time for children's sports or other activities, or for being home with children after school. Meetings to begin new projects, to work on performance improvement, investment or other projects can be planned during nonscheduled afternoons. Evenings can either be family time, or a time for meetings, or a combination of both.

Night call, often one of the loathsome parts of medical training, remains a necessary component of community practice. Call is usually taken in some sort of rotation. Calls come from patients, from hospitals, and from hospital emergency rooms. Some practices will have a triage system, with nurses as the first point of contact. Others will use the physician members in rotation. Patients are usually reluctant to disturb physicians at home at night. Hospitals usually have some form of triage as well, so repeated calls about the same patient are rare. Calls from hospital emergency rooms still occur, and may necessitate a trip to the hospital.

Community Service

At some point, you should plan on being a prominent member of some aspect of the community in which you live or practice. Community service is a very satisfying part of community practice. It's a good way to meet other members of the town where you practice, of keeping in contact with business, social and political developments outside of the practice or medical community, and as a break from the sometimes difficult aspects of oncology practice. Community service can draw on your medical training (e.g., volunteering for athletic physical examinations, at a "free clinic," or on a foreign mission) or it can be completely unrelated (e.g., roles in your religious institution, your child's school or sports team, local civic organizations or government). Some oncologists find great satisfaction in organizations devoted to their hobbies. Community involvement of this type may help your practice grow. But keep in mind that, in contrast to primary care specialties, most oncology specialists find their practices growing through professional referrals, not through community or family contacts.

Recognize that this involvement may come in stages and in varying intensity as the demands of practice and family life change. By virtue of your education and experience, and the people's lives you touch daily, you will be viewed as a potential leader; often a philanthropic leadership as well as a personal leadership role will be expected. Volunteer involvement and leadership is a great way to evaluate whether a philanthropic role is likely to be valuable. You'll have an opportunity to assess the soundness and effectiveness of an organization before committing funds to it.

Service to the Medical Community

One way to partially fulfill your mission to become a local or regional expert is to serve your local or regional medical community. Hospital medical staff membership, leadership of hospital committees, and membership and leadership of local, regional, or national professional organizations are all available and can be a source of personal and professional satisfaction. In contrast to community activities, local hospital medical staff committees and leadership are good ways to cultivate referral of patients and to get to know the specialists to whom you may refer patients for assistance in management. Involvement in local, regional, or national oncology or medical organizations is a great way to potentially influence policy and practice, and to continually reassess your own skills and knowledge.

Teaching physician, mid-level provider, and paramedical trainees

Teaching physician, mid-level provider, and paramedical trainees is possible in a community practice. Trainees may be taught in your own office (particularly mid-level and paramedical trainees) and often with minimal involvement from the physician. (The fully trained members of those professions can often provide the minute-by-minute training and supervision required.) Not only can this be satisfying, but a training program is a useful way to spot emerging talent and can be a source of new hires who are already familiar with the practice and the work environment. Teaching physician trainees can also be done in the outpatient practice setting, in your own hospital (if it has a training program), and as a visiting or voluntary faculty member of a local training program. Satisfaction comes from dealing with new people with fresh ideas (particularly the trainees, but also faculty members of the program) and from an opportunity to assess and recruit new physicians for the practice.