The “What is an IO Practice?” blog (Sept. 24) stimulated a lively discussion among European practitioners on WCIO’ s Linked In site about the challenges carving out an identity for IO. From Germany, to Greece, to Serbia, common themes included lack of potent data supporting clinical effectiveness, cost-effectiveness, and quality of life; lack of integration into tumor boards and care plans; late referral of end-stage patients for palliative procedures after the medical oncologists have given up (see “DNR-IR”, Oct. 26); lack of awareness of IO among doctors and patients; and lack of an IO clinical practice.
These issues plague the growth of IO worldwide. Each must be attacked systematically. The IO identity issue in Europe is further handicapped by the belated recognition of IR in general, which only recently became its own medical specialty with board certification, and still lacks a standardized, credentialed training scheme in most countries. Nonetheless, anyone with the skill and the will can and should establish an IO office practice, whether in an academic medical center or in a community setting. Every other oncologic specialist does it. With the right resources, it is no harder for an IO to do this. All you need is the fire in your belly to put it together.
You do not want to reinvent the wheel. When I started my practice 21 years ago, it was in an old-school model of the IR as technician. There was no IR clinical service. I did everything myself for the first few years, until I had enough financial data to convince the chairman to provide space and nurses for a clinic. You cannot provide high quality care nor be economically viable alone. A clinic infrastructure is essential: a secretary/scheduler, receptionist, clinical nurses and nurse practitioners, physician assistants, EMR or transcription service, billing service, office space. With adequate resources, the practice exploded. For my current 10-physician IR practice, we have 10 support staff. Each physician spends one-half or a full day a week in the office seeing patients. It takes about four years for each new physician to build a full practice.
A clinical office infrastructure already exists in most medical facilities. It is often possible to obtain office hours within an existing oncology clinic, which has the added benefit of increasing your visibility and allowing for immediate cross-consultations among oncology specialists. Patients love this, and your oncologic colleagues will quickly come to appreciate it (and you) as well.
Even if you are leveraging an existing clinic infrastructure, you will need mid-level practitioners dedicated to your practice. Clinic nurses or NP’s handle outpatient and inpatient care issues, providing superior high quality care and communication while you are busy doing procedures. Take your nurses to tumor boards -- they know the oncology nurses, and provide a second network of communication that facilitates patient care and new referrals. Physician assistants can do high-volume, low-reimbursement “tube & vein” work, allowing MD’s to maximize time doing what they are uniquely skilled and compensated for: consultation and delivery of high-tech cancer therapies. The economics of mid-level practitioners vary with the local health care structure. At a minimum they reduce costs and improve efficiency and quality. If there is professional reimbursement, they turn loss-leading procedures into profitable ones. In the practice of one of my colleagues, it takes only 15 venous access procedures a week to cover a mid-level’s salary; everything after that is profit to the practice.
Having a web presence is crucial. Cancer patients and their families are highly motivated and troll the internet looking for help. You don’t need referral from medical or surgical oncologists if the patients come to you directly and you can provide the care they need. Bringing in your own patients gives you credibility with the hospital, justifies your clinic infrastructure, and allows you to refer patients to your medical and surgical colleagues, which is the root of successful collaborative practice. Send a surgeon a trisegmentectomy and he will send you 20 ablations. Send your post-ablation patients for adjuvant chemotherapy, and your medical oncologist will start to think about ablation in his care plans.
Recognition of the value of IO will only occur when interventional oncologists behave like other oncologists. Use fire in your belly to light a flame for the world to see. If you build it, they will come. If WCIO can help you in any way, please let us know through IO Central.