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.
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.
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.
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
10xers are companies whose performance beat their industry indexes by a minimum of ten times over fifteen yearsSuccessful 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.
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
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
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
When a patient with chronic paraplegia is admitted to a hospital due to a severely infected wound, he is shocked to be offered the option of comfort care by the admitting hospitalist. Although this palliative choice was undoubtedly offered with the best of humane intentions, to a previously independent adult facing a long course of expensive unreimbursed treatment with uncertain outcome, this represented denial of the value of the life he had chosen to pursue. The fact that the patient did not consider himself terminally ill underlies the unintended consequences of this discussion. This real case, which was reported in the July, 2012, Hastings Center Report, raises important questions about the potential consequences when comfort care measures are inappropriately or insensitively suggested to patients with chronic progressive illnesses such as cancer. When end-of-life symptomatic care is offered in a way that does not address the patient's pre-existing understanding, it has the potential to rob patients of self-esteem. In some cases it may communicate that their life does not have value, just as the offer of comfort care did for the patient with paralysis.In discussions with Oncology colleagues in community practice it is very clear that hospitalists inexperienced in care of patients with cancer as well as other hospital team members (most notably discharge planners) often approach patients with the option for hospice-based comfort care in situations where treatment proven to have significant benefit may be available. This occurs before the patients as well as their families and oncologists might consider them “terminally” ill. While on the surface this seems harmless, it may raise questions in patients' minds about the value of their lives. This may have a profound effect on a patient’s feeling of self-worth and the quality of his remaining life, particularly in an elderly patient who may worry about the burden he places on his family. This is not to suggest that oncologists and palliative care specialists should not offer comfort care to terminally ill patients. However, sensitivity to the context of the discussion is essential. In an era of increasing pressure to control the cost of cancer care by avoiding futile and sometimes harmful therapy at the end of life, safeguards are necessary to prevent well-meaning but under-trained caregivers from prematurely or ineptly offering an alternative that could suggest to patients that they are no longer worthy of the care they have been receiving. This conversation, shifting from active treatment to comfort care, should be reserved for caregivers who have been involved in the patient’s care previously so that the change in direction is not viewed as abandonment or loss of worth. Although oncologists have been correctly criticized for delaying end-of-life care discussions with patients who would have been better served by earlier discontinuation of toxic interventions, the harm of prematurely and insensitively offering comfort care must be considered as well. Our duty to our patients goes beyond delivering the right treatment to the right patient at the right time in the right way. We can learn a great deal from the paralyzed patient’s experience and need to assume the responsibility of sharing these lessons with hospitalists, emergency department staff and discharge planners as well as other members of the cancer care team to help protect our patients from harm done inadvertently in the name of compassion.- Rich Leff, MD
The Right People The ability to attract and retain the right people is the key to a company’s success:Those who build great companies understand that the ultimate throttle on growth for any great company is not markets, or technology, or competition, or products. It is one thing above all others: the ability to get and keep enough of the right people.Jim Collins, Good to Great.As CEO of Conisus, I realize this now more than ever. Our company places strong emphasis on succession planning at all levels of the organization. This requires all of our leaders (including myself) to understand that we are all replaceable. During our business careers “life happens”: people get transferred, sick, married, divorced, etc. All of these can be life-altering, can cause a person to temporarily or permanently leave a position to focus on more important things in life. Companies that proactively plan for these life events with a strong cadre of successors are able to endure and prevail over the long-term. It takes a very secure person to realize that everyone is replaceable and to prepare others to take his or her role. The ultimate compliment for great leaders is an organization’s continued success long after their exit.Whenever I participate in the interview process at Conisus I tell prospective candidates, “If you have any doubt about how important people are to our company, look no further than the team that reports directly to me, including our VP of HR, because I am sincerely committed to ensuring we attract, retain, and develop the right people.”- Jeff Giampalmi