Lessons From the World of Fashion: Intro

I am reading an inspiring book called Always in Fashion by Mark Weber. Mark is the former CEO of Louis Vuitton Moët Hennessy, USA and former Chairman and CEO of Donna Karan International Inc. I am intrigued by the pragmatic business lessons Mark writes about and am using this book as a teaching tool for some of my company’s employees. Although our businesses focus on the biopharmaceutical sector, many of the insights are transferable outside of the fashion world.

On page 26, Mark states, “I had absolutely no personal agenda when it came to my job. I had only one interest: What’s best for the company?” This point is one of the most important in the entire book. I have often encountered people who are more focused on making themselves look good and on personal career advancement rather than on what is good for the company. Unfortunately, I have observed this type of behavior more often than I would have liked during my business career. Confident leaders are objective and unselfish and always make decisions that are in the best interests of the company rather than for their own or others’ personal gain. This unselfishness is something I look for when reviewing succession plans for our organization.

Mark Weber, Always in Fashion

Jeff Giampalmi

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Conisus was invited to present at the CIT 9th Annual Healthcare Conference in New York City

Conisus was invited to present at the CIT 9th Annual Healthcare Conference in New York City on April 22, 2015. The CIT Healthcare Conference brings together some of the most influential executives and investors in middle-market healthcare in the U.S. to meet and exchange ideas. CIT presenters are innovators, quality leaders, consolidators, and job creators in critically important sectors of the healthcare industry. The conference also included a private equity panel and robust discussion on regulatory issues within the post-acute care market.

Jeff Giampalmi, CEO of Conisus, a leading provider of strategic medical communication services to the biopharmaceutical industry, focused on his company’s expertise in providing outsourced services to the world’s leading biopharmaceutical companies. Conisus continues to expand its client base and is one of the largest privately held strategic medical education providers serving the oncology, hematology, and specialty product pharmaceutical markets.

 

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Improving Value—What else can ASCO do?

Congratulations to the ASCO staff and leadership for a meaningful, interesting and thought-provoking 2014 Annual Meeting.  The theme of value in cancer care was evident throughout the meeting.  It is certainly an important issue.  Among the focuses of discussion both before and during the meeting , control of growing treatment costs, elimination of diagnostic tests which do not affect treatment decisions and avoidance of treatments without benefit near the end of life have been appropriately highlighted.  ASCO’s leadership is very determined to establish ASCO and its members as leaders in measuring and improving quality and value of care as a central element of health care reform.  It is difficult to argue with this strategy.

ASCO has another opportunity to lead in the arena of value.  As a large professional organization, it can lead other similar groups in evaluating and improving the value of medical specialty groups—specifically the cost and outcome of large annual meetings.

If ASCO is to assume a prominent role in improving the value of cancer care and reforming health care delivery, we and our leadership will need to demonstrate that we not only “talk the talk” but also “walk the walk” as individual physicians and as an organization.  With that in mind, I wonder if it is time to evaluate and improve the value of the Annual Meeting.  The 2014 meeting attracted over 28,000 cancer professionals.  Adding in support staff and pharmaceutical industry personnel, the attendance was probably somewhere between 35,000 and 40,000.  Whether we like to admit it or not, the cost of the millions of airplane miles traveled, the hundreds of thousands of meals consumed, the tens of thousands of hotel rooms rented and the thousands of bus and taxi trips to and from the convention center in many cases directly and indirectly contributes to the cost of cancer care.  The city of Chicago estimates that spending in the Chicago area associated with the 6-day Radiological Society of North American meeting of 40 to 45 thousand physicians and exhibitor attendees is around $125 million.  Our meeting is smaller and shorter but the spending is certainly substantial.  Realistically, that local spending represents only a fraction of the total cost of preparation and travel that occurs with any large international medical meeting.  Is there a less expensive way to do this which can serve the goals of the meeting and our organization while preserving or improving the effectiveness of the medical education and professional communication?

About 25 years ago, acknowledging that what happens at our Annual Meeting affects the cost of care as well as the perception of the “outside world” about oncologists and our organization, ASCO’s leadership, in partnership with pharmaceutical partners, led a trend in the broader medical community by appropriately limiting the extent of entertainment offered to Annual Meeting attendees.  Although it would not be accurate to label our Annual Meeting in 2014 as entertainment, isn’t it appropriate to once again re-evaluate our meeting to see how we might improve its value by looking at both cost and quality outcomes?

ASCO has aggressively adopted new technologies that facilitate remote learning and has provided post-meeting regional Best of ASCO sessions that have great value to attendees. With these types of advances in mind, isn’t it time to look for other ways to meet our educational goals at a lower cost while allowing rededication of some of the hundreds of millions of dollars spent in conjunction with the Annual Meeting to efforts that more directly improve the value of the research we conduct and the care we provide?

As part of our professional role, in the current era we all must take the responsibility to evaluate and improve the value of the care we provide.  Limiting this effort to the examination of cost and utilization of diagnostic technology, treatments and supportive care ignores some smaller but significant opportunities.  ASCO has the opportunity to lead.  The Annual Meeting might be a good place to start.

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What Makes Oncology Special?

Sometimes with all of the stresses of battling the system to help our patients and assure that our practices will survive, we need to be reminded about why we choose oncology—the special patients and families we get to work with.  The following email sent by the husband of a patient who had recently died with breast cancer eloquently tells the story of what makes oncology a special opportunity for all who choose it as a profession. (The names have been changed to protect privacy.)

Dear Dr. M:

It is with an unbearable heavy heart that I need to let you know that we lost Kay yesterday afternoon. After a long 10 day battle in ICU, she died in our arms peacefully and with no unnecessary life support.

I want you to know how much my family appreciates the work that you and your team did for Kay and for all affected by this disease. Because of your and others dedication to curing and treating, Kay LIVED (not survived) for 15 years post diagnosis in 1999. She saw our son graduate from high school, graduate from college, graduate from grad school and most important to her, see our only child’s wedding. For that, I thank you.

As late as this week, she would call other Docs “Dr. M”. You had that much impact on my family. You convinced her and gave her hope that it was possible to beat this and she took that and ran with it. She did beat it.

Kay didn’t let the cancer define her, she defined it. We will celebrate her life tomorrow comforted by hundreds that she touched.

May God bless you on your journey to end this terrible disease.

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Fixed Skills vs Elastic Skills

Date:

October 4, 2013

A decade of intense competition has forced most organizations to transform from segmented to flat (or at least flatter). They do the same, if not greater, amounts of work than before—but they do it with fewer people who are doing more varied, things.

A world of flat organizations and tumultuous business conditions—and that’s our world—punishes fixed skills and prizes elastic ones. What an individual does day to day on the job now must stretch across functional boundaries. Designers analyze. Analysts design. Marketers create. Creators market. And when the next technologies emerge and current business models collapse, those skills will need to stretch again in different directions.

—Daniel H. Pink, To Sell is Human.

That concept of fixed vs elastic skills is one of the most important in Pink’s book. I continue highlighting the importance of “blended” individual capabilities as opposed to a narrow and myopic focus on one skill. Today’s business environment demands flexibility, adaptability, and elasticity. Fixed skills and an unwillingness to cross functional areas are anachronistic, particularly in the medical education industry.

Jeff Giampalmi

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Successful leaders maintain a “productive paranoia” about their business even in good times

10xers are companies whose performance beat their industry indexes by a minimum of ten times over fifteen years

I am accused frequently of worrying a lot about my business. I worry about attracting and retaining top talent, a dynamic business environment, competitors, cash flow, and others risks both known and unknown. I have had this “healthy paranoia” for a long time. It enables me to be prepared for “Black Swan” events that are unpredictable and can be disruptive to the business.

10Xers remain productively paranoid in good times, recognizing that it’s what they do before the storm comes that matters most. Since it’s impossible to consistently predict specific disruptive events, they systematically build buffers and shock absorbers for dealing with unexpected events. They put in place their extra oxygen canisters long before they’re hit with a storm.

Jim Collins, Morten T. Hansen Great By Choice.

Jeff Giampalmi

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Why do some leaders succeed during times of uncertainty and others do not?

10xers are companies whose performance beat their industry indexes by a minimum of ten times over fifteen years

Successful leaders are not…

We all have a vision about successful leaders and the characteristics that should or should not define them. Collins’ research of successful CEOs (he labels them 10xers) highlights traits that successful leaders do not exhibit (relative to their peers) and his findings may surprise you.

Let’s first take a look at what we did not find about 10xers relative to their less successful comparisons.

They’re not more creative.
They’re not more visionary.
They’re not more charismatic.
They’re not more ambitious.
They’re not more blessed by luck.
They’re not more risk seeking.
They’re not more heroic.
They’re not more prone to making big, bold moves.

To be clear we’re not saying that 10xers lacked creative intensity, creative ambition, or the courage to bet big. They displayed all these traits but so did their less successful comparisons [ie, CEOs from comparison companies]. So then, how did the 10xers distinguish themselves? First, 10xers embrace a paradox of control and non-control. 10xers then bring this idea to life by a triad of core behaviors: fanatic discipline, empirical creativity, and productive paranoia.

Jim Collins, Morten T. Hansen Great By Choice.

Successful leaders take responsibility for their actions but understand that they can’t control market factors. Paradoxically, successful leaders reject the notion that their success is determined by these uncontrollable market influences and embrace the idea that they determine their own fate.

Jeff Giampalmi

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Are Oncologists More Open Minded Than Cardiologists?

How open minded are we as physicians and scientists?  With the rapid change and improvement in cancer knowledge and treatment do oncologists see the world differently than other specialists?

Last week at the American Heart Association annual meeting, a study of chelation therapy after acute MI showed a statistically significant decrease in cardiac events (HR 0.82, P=0.035) in a well-designed randomized trial including over 1700 patients followed for an average of 4 years.  As with many studies, this one left many questions unanswered.  The reactions to the study, however, provided an interesting commentary about how our biases affect interpretation of data.  Although the study was appropriately designed and conducted, based on their reactions to the results the investigators apparently had a preexisting bias against the investigational arm.  The positive findings were reportedly a surprise to investigators and an embarrassment to cardiologists and the AHA.  When chelation therapy was shown to be superior, the reaction of cardiologists was to dismiss the results based on lack of a good explanation of mechanism of action and failure to fit into their set of long-held beliefs.   No one advocated a change in standard post-MI therapy and there was apparently no serious discussion about a follow up study to verify the results.  So much for believing in the value of randomized studies with valid statistical endpoints!

While reading the account of the reaction of cardiologists to this study, I had to question how oncologists would react to a similar situation.   As we all know, many of the most important things we learn are taught to us by our patients, including the value of an open mind.  Once upon a time, I cared for an interesting patient with mesothelioma (or perhaps, more correctly, helped her care for herself).  She chose an unusual treatment course that started with an industry-sponsored trial (with disease progression as the outcome) followed months later by a course of serum infusions produced and administered by a practitioner in the Bahamas.  To help my patient better understand (i.e. discourage) the role of the alternative treatments she chose to pursue, we obtained chest CT scans immediately before and 2 months after her trip to the Bahamas.  To my surprise (and her understandable delight) the post treatment scan showed dramatic improvement (as interpreted by a radiologist completely blinded to the interval events).  This was not a scientific experiment and didn’t prove that this type of treatment was effective in mesothelioma, but it certainly helped force me to reconsider the role of complementary treatments that I might previously have written off.

How would oncologists react to a positive study for a treatment they didn’t believe in?  My experience suggests that we wouldn’t differ much from the cardiologists.  Medical marijuana may serve as good evidence.   A few weeks ago I had the pleasure of hosting a webinar about medical uses of marijuana with Dr. Donald Abrams.  Dr. Abrams is the Chief of Hematology-Oncology at San Francisco General Hospital and Director of Clinical Programs at the Osher Center for Integrative Medicine at UCSF.  His scientific and medical background is impressive and he has led and participated in numerous landmark studies in cancer and AIDS.  Along with these studies he has designed and conducted several studies of use of marijuana in patients with cancer or AIDS.  His studies (as well as those of other investigators) and the accompanying preclinical science suggest that active agents in marijuana may be very helpful in reducing pain (including neuropathic pain), improving appetite and decreasing distress.  These results are drawn from carefully controlled small trials, not anecdotal reports.   The studies demonstrate a significantly better outcome with marijuana than we usually expect with pharmaceutical cannabinoid preparations. The preclinical evidence suggests that our pharmaceutical cannabinoids may not achieve most of these results due to selection of individual agents which do not have the overall effect of the combinations found in nature.  I have to admit that I was surprised by the data as well as by the scientific rigor of the studies.

Why are none of these data presented at ASCO meetings?  The apparent answer is both surprising and distressing.  ASCO leadership has reportedly considered and rejected the idea of an educational session about medicinal marijuana.  Maybe it is politically too sensitive or not considered serious enough for our annual meeting.  Perhaps there is not enough perceived interest.  Based on a discussion on our Oncology online community, SPhase.com, many oncologists have dismissed marijuana as unnecessary and perhaps even harmful.  Unfortunately, I would guess that most of them are unaware of the available data which suggest otherwise.  Certainly the data are not definitive proof that marijuana should be used as an adjuvant for pain, anorexia, nausea or anxiety, but ASCO is committed to encouraging exchange of information among cancer experts that might help accelerate advances in cancer treatment.   We will never know for sure how helpful marijuana might be unless we ask the right questions and create and support the right studies.  Medical use of marijuana is currently legal in 17 states.  Isn’t it time that ASCO provided some scientific education to its members about this agent or must we depend on our patients to teach us?

Rich Leff, MD

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“Faith and Hope: Should Oncologists Discourage Unrealistic Optimism”

Once again, a scientific paper about oncology practice reported in the lay press has led some to conclude that cancer specialists are not honest with their patients with advanced cancer about the incurable nature of their illnesses.   Considering that these same doctors are the ones recommending chemotherapy, many will assume that there must be some connection.  As one Australian radiologist tweeted in reaction to the article: “Alternate title: Many patients receiving chemoRx not adequately informed re ineffectiveness.” What a terrible group of doctors we must be!

The recently published NEJM research article, Patients’ Expectations about Effects of Chemotherapy for Advanced Cancer, authored by Jane Weeks, points out a dilemma that oncologists have recognized dating back to the beginning of modern oncology:  Patients very frequently have unrealistic expectations about the probable outcomes of their treatments for advanced cancers of all types.  In this well designed large study, the investigators found that many patients with metastatic colon or lung cancer believe that their therapies will be curative.  Based on previous studies of what oncologists tell their patients, it is almost certain that most of them were told about the likely outcome of their therapy but either did not understand, consciously chose to not to acknowledge the information during the study or, in a time of extreme stress, demonstrated some degree of denial, perhaps supported by an underlying belief system associated with faith in God, science or both.  Unfortunately, the study did not assess in any way patients’ coping mechanisms or the strength of their religious beliefs.

What does this imply about the decisions patients make about their treatments?  The concept that informed consent about treatment is not truly informed because patients don’t understand the likely outcomes of the therapies is not unique to this study.  Research has shown that cancer patients entering phase I drug development studies are routinely informed about the very low likelihood of personal benefit yet when questioned many express a belief that they are much more likely than everyone else to benefit.  This phenomenon has been described as “the culture of faith and hope” and often reflects an attitude of optimism rather than information level.   It may also reflect the patients’ belief that they are in a battle with cancer and admitting the eventual outcome concedes defeat in their fight.

An interesting correlation was demonstrated in the Weeks paper between the patients’ perceptions of their physicians as communicators and their likelihood of correctly understanding that their treatments were not curative.  Those who did not seem to understand the likely outcome of their treatments were statistically more likely to rate their doctors as excellent communicators.  This suggests that the lack of understanding was not related to inadequate time or effort spent in patient communication and education since in many studies patient satisfaction is related to time spent in communication.    More intriguing is the possibility that extra effort or emphasis on the poor expected outcome might lead to greater understanding but a lower satisfaction with the doctor-patient relationship.  Perceived over-emphasis on the poor prognosis might be viewed as insensitive or uncaring.  Although greater understanding at first glance would appear to be a clearly preferable outcome and denying patients exposure to this information is definitely inappropriate, might there be some patients who would be better off with unchallenged denial and a stronger relationship with their oncologists?

As medical oncologists, how should we react to the study by Weeks?  Should we reinforce our teaching about prognosis, perhaps asking patients to repeat what they have heard?  Should we ask them them sign an informed consent document that acknowledges their prognosis and expected outcome of the treatment? Or should we continue to present the information in a balanced compassionate manner including both the potential short term benefits and the expected longer term outcome, assess how patients are dealing with it, and tailor our discussions to navigate toward appropriate expectations without damaging patients’ coping strategies? Can we still provide help and support for patients whose coping mechanisms include denial of the inevitable outcome of their treatment and disease while we assist them to gradually adjust to the reality of the situation?  The question for which we really need an answer is whether patients who are forced to acknowledge the likely outcome of their illnesses and treatments have any better outcome or quality of life than those who maintain a “chosen” path of faith and hope.  Palliative care specialists might suggest that denial could delay institution of appropriate palliative care but this supportive modality could and should be included regardless of patients’ expectations.  For oncologists, the Weeks paper examines issues objectively that highlight one or our long-standing therapeutic dilemmas.  For me, the goal remains the same because finding the right path for each individual patient, including how and when to challenge unrealistic expectations, remains part of the key difference between treating cancer and caring for patients who have cancer.

– Rich Leff, MD

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The Power of Habit

Habits

We are all creatures of habit and habits drive our behavior.

Cravings are what drives habits. And figuring out how to spark a craving makes creating a new habit easier. It’s as true now as it was almost a century ago. Every night, millions of people scrub their teeth in order to get a tingling feeling; every morning, millions put on their jogging shoes to capture an endorphin rush they’ve learned to crave.

Charles Duhigg, The Power of Habit: Why We Do What We Do in Life and Business. New York, NY: Random House; 2012.

Duhigg’s book has been enlightening. I didn’t realize so much of our behavior is driven by habit. These habits go unnoticed until we decide something needs to change in our lives. About fifteen years ago, I started running to improve my health. Now deeply imbedded into my lifestyle, running is part of my routine, and I do crave the endorphin rush it provides.

Jeff Giampalmi

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