Seeking Serenity With Influence

The serenity prayer has long been recognized for the impossible wisdom it provides: “Grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference.” Business has captured this wisdom in defining spheres of control—recognize what issues you completely control versus those that you impact because of your influence versus a third group that you cannot control or influence. The truism of being effective is to enlarge the sphere of influence and to let go of issues outside of this sphere. Often physicians focus on the outside issues that they have no control over, leading to frustration and a sense of futility. All of medicine is multidisciplinary, though oncology is the most demanding—requiring multiple voices to effectively manage patients. There are few decisions or areas of patient care or practice where oncologists are soul controllers. In most areas we are simply influencers, but that term does not capture the depth of our profession's interactions. This month, Neuss emphasizes in his column that oncology is a collaborative, a team sport. The most effective physicians and practices are ones that embrace collaborativeness. In this issue of Journal of Oncology Practice, a series of papers outlines the critical need and roles that our colleagues—nonphysician providers (NPPs)—are playing in oncology. Researchers from the Institute of Medicine outline the challenges of workforce (Levit et al). Britell presents the results of a project funded in part by an ASCO state affiliate grant to determine what roles NPPs are playing in Washington state. Polansky et al discuss the roles of physician assistants, and Nevidjon et al outline the contributions of advanced practice nursing. Collaboration is a key attribute of our profession if we are to provide access to quality oncology care for our patients. Some have seen the growing influence of NPPs on care as a threat to the control of the physician. Others emphasize collaborative models of multidisciplinary care and point to the improvement in patient satisfaction and perception of caring when these providers are well integrated in our clinics. However, challenges abound. NPPs are not uniformly trained. There are no educational standards that a specialty practice can use to judge the preparedness of an individual to step into the care of patients and assist. There is variability on how well practices integrate NPPs. There are few best practices to follow. Added to these practical challenges are the regulatory and legal tensions as our professions grapple with their respective spheres of control, as physicians and NPPs wish to have a say in how educational standards and scope of practice is defined. But in the end, workforce, the complexity of our science, and the demands of practice will drive us together into collaborative practice. We must embrace the journey together to make this work for the betterment of our patients. Workforce issues and the increasing numbers of survivors in oncology practices also press us to understand how to collaborate with primary care. Emphasizing the complexities of the care delivery team, Brazil et al point out the challenges of integrating the primary care physician in the mix. Their Canadian perspective can teach those of us in the United States. Legant offers a commentary on their manuscript. The Institute of Medicine has highlighted the need for psychological support for oncology patients. Hendrick et al present a model to integrate psychosocial support into oncologic care. In this issue, the reader will be challenged by Neubauer et al. In what is believed to be the first presentation of data to demonstrate proof of principle, the authors outline the impact a rigorous, prospective pathway program can have on adherence to evidence-based therapy, and on limitations of futile care. Such programs have been developed in several settings (both academic and community), but attempts to codify benefits have been lacking. In an era of emphasis on comparative effectiveness, such programs are going to gain importance. Continuing contributions to JOP include ongoing series on exemplary attributes of effective research practices, challenging ethics vignettes, and practical tips (this month highlighting the challenges of recent rules on infusion pumps). Such is the diverse, yet hopefully helpful, content in JOP. Good reading, and please forward comments or challenges to me at gro.ocsa@ksedsrotidepoj.

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