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Pharmacy Practice in Focus: Oncology
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In business, growth for the sake of growth mirrors the ideology of the cancer cell.
In T.S. Eliot's Murder in the Cathedral, martyred Archbishop Thomas Becket states, “The last temptation is the greatest treason: to do the right deed for the wrong reason.”1 For me, these lines capture the current state of pharmacy practice. Patient care should be our first aim, but our day-to-day work is consumed by financial questions: How much does this drug cost? Does insurance cover it? What does the patient have to pay? Are we being reimbursed for this counseling visit? In my experience, it is quite the mental dichotomy to be part of a system that pays lip service to the goal of patient care while pursuing something else altogether. The result can lead to despondency: It feels inorganic, unoriginal, repetitive, and even sleazy at times. Our institutions can appear resistant to change that disturbs the status quo. As a result, participation in modern pharmacy and health care often feels hollow, stale, and even abhorrent.
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Joseph A. Kalis, PharmD, BCOP, is an ambulatory oncology pharmacist at UCHealth in Colorado Springs, Colorado, where he is gloriously belittled and minimized by the surrounding geography. He aims to guide others in separating truth from dogma.
Health care is indeed a business, but this business should not be at the expense of patient care; however, this can be difficult to avoid with the cost of care today. We cannot deny the role of finances in health systems operations: It is part of the price to play. But I question why our profession has become consumed by the pursuit of financial ends. Every day, I contend with knowing what the right thing to do is, but I do not know how to achieve it due to the Byzantine web of what health care has become. The focus is no longer on the patient. It is on metrics, money, and the finances and balance sheets required to run an organization. In the United States, the cultural focus is on short-term financial gain and not on the long-term larger picture of the needs of our society. In health care, it is the same.
Eliot’s line resoundingly resonates with me: Caring for people is indeed the right deed. But is caring for people at the center of all our actions in health care today, or are our actions meeting an arbitrary metric that serves the bottom line? The line between these 2 endeavors can sometimes be blurry, but the difference for our patients is vast. In practice, caring for patients because it is the right thing to do is not the same as caring for patients to fill out a balance sheet. That is where the treason lies. Patient care is an end unto itself, not a means to another end.
But let’s back up. How did a field promising opportunity to help and heal come to this? How did a calling turn crass? This is not resentment about a perceived loss of prestige—show me someone who got into health care for the prestige, and I will show you a hypocrite. I am concerned with providing the best care that we can to people and having the time and resources to do so. However, current pharmacy practice leverages the pursuit of patient care for financial gain. I saw the mirage for what it has always been, and it changed me.
It has been more than 15 years since I started as a pharmacy technician. At that time, working at CVS, it was easy to blame our corporate overlords for pushing profit, prescription counts, and influenza shots over patient counseling and guidance. After all, the softer-skilled acts did not pay—they were just part of being human and professional. Some people I worked with embraced the human side despite the pressure to be a living rubber stamp in a prescription mill; others were consumed by that same pressure. I told myself that although I could perform this work and find value in it, I sought a higher purpose. Hospital or health system pharmacy seemed to offer that—caring for people without money being at the center of focus. A mentor told me that “in retail pharmacy, price and money are what the patient sees. They’re focused only in the moment on what they have to pay in order to try and feel better. In a hospital, they’re focused on the immediate problem of getting better.” Like a good altruist, off to health system pharmacy I went.
Pharmacy school rotations offered a chance to reaffirm I was on a philosophically and morally correct path. Community pharmacy did not feel right to me—I would be helping individual people, but my day-to-day livelihood would be consumed by fulfilling what someone else had decided was important. I recognized that others found value and meaning and fulfillment serving in these areas, but I was to follow a different path. My clinical rotations showed me another way, a way offering avenues of patient care with higher use and development of clinical expertise. Coincidentally or not, my institution of higher learning steered many of us down a path of residencies and health systems; it was portrayed as the honorable, higher calling choice to make over selling out for a quick buck of low repute.
I settled on oncology as a path to follow, for I could serve my gods of science and human connection and communication all at the same time. I could pursue science by helping drive the needle of cancer care and treatment further via clinical trials and studies, applying the latest data to real patients. I could pursue human connection and communication by explaining the findings of that data altars to patients, tailoring the technical into something human. Seeing the light bulb of understanding go off in a patient’s eyes following a formed connection and personalized analogy was a high, and an honorable one for me. I had found my place, my calling, all in one fell swoop. I dedicated myself to the sacrifices necessary to become competent in health system and oncology pharmacy, becoming cannon fodder in the churning mill of competition for PGY-1 and PGY-2 residencies. This was the way. It hurt at times, so I knew it was real. Chasing a lofty defined goal, none of the sacrifices seemed too much. Looking back, they really were not—just temporary fasting and abstinence, delayed gratification in pursuit of future enlightenment. I followed the path and made my ablations. I could enter practice anointed as having earned a minimal level of competency in my chosen field. If this sounds ungrateful or sarcastic, please know that it is not intended as such. Rather, the words here reflect my state of mind both now and at the times in reference.
If they offend, if they provoke, consider why that is—what experiences and emotions are the words causing you to recall, to relive? What assumptions of yours are they challenging? Do your prior conclusions still ring true? And if they do not, what is stopping you from confronting your own thinking and forging a new path? What is stopping you from reexamining your motives?
Where were we? Ah, yes. A freshly knighted pharmacist emerges from the hallowed halls of residency and experiential learning, seeking gainful employment. A place where I could put my earned knowledge and skills to good use while receiving a paycheck reflecting my credentials. A chance to create what I thought was the change I saw in the world. A chance to use who I was and what I knew to truly help others. I found some of this in my first big-boy job, along with things I did not expect. There were things whose existence I willfully ignored: department politics, colleagues uncomfortable with how my presence challenged their worldview, organizational choices altering my opportunities and career path. All things out of my control. So, I controlled what I could: my reactions, principles, and agency. I sat for the board exam and credentials that set me apart on paper, proving that on some minimally equivalent level, I knew what I was talking about. The beginning of my malcontent traces to this first job, the place where I began to see that the world was not how I thought it should be. Perhaps this is just the natural reckoning of an idealist. And yet, I kept hoping that I could change it.
Amid my considerations, a call came in one day. There was an opportunity to return to a familiar institution and join a program apparently aligning with my own ideals. Voting with my feet, I seized the chance. Surely this would heal my wounds. It could be an albatross, but the chance of promise and fulfillment was worth taking. It was here that the seed bore fruit. I learned who I was as a clinician. I learned who I was as a preceptor, a colleague, an employee. I learned I had a voice. I cast my first principled salvoes against authority and misguided decisions. I learned that not everyone thought like me, walked like me, talked like me. Acolytes accrued from those I taught, an irony that still fuels me. To paraphrase climber and philosopher Mark Twight, “I learned the rules, practiced them until I understood them, and they became ingrained. Then, and only then, did I let the rules go. I made my own rules.”2 This process of discovering the world enabled me to start shedding rampant imposter syndrome, although I know it will never fully leave. I uncovered my mission: to educate others to lead, to let them know they are not alone in thinking thoughts at the margins.
As time and experience and accomplishments grew, so too did gnawing discontent. I remained in place, passions restrained by the promise of achieving enough career longevity for the millstone of student loans to disappear. I was miserable, but I knew how it worked, so I felt compelled to stay. I became, as Friedrich Nietzsche wrote in Twilight of the Idols, “fruitful only at the cost of being rich in contradictions.”3 Being of the millennial generation, I talked to others about what I was going My priest says it is a sign of needing deeper faith and trust in God. My wife thinks it is a midlife crisis, but I hope 38 years is not the middle of life. The professional psychological diagnosis I received for this is a “phase of life change.” At the end of the day, they are all right. It is a “me” problem—the world is the way it is. Health care and insurance and C-suite profiteers are the way they are. I know who I am: I have eclectic interests, a stormy mind, and a need to write plainly and honestly. I cannot abate an existential problem with chemicals. Acknowledging my state afforded me an opportunity to reframe the issues facing corporate health care.
Leadership and we frontline folks see the same reality but in different ways. We have different means to different ends. We are each trying to create something relevant to our experience of the world, reflecting our values and spirit. Each of us experiences the illusion of perspective. There are grains of truth in each viewpoint, and each person justifies their approach. The collective soul of my generation of pharmacists cannot step outside of the moment we were born into. Generational theory indicates we are the fourth generation of pharmacy: We know pharmacy practice has lost the vitality it had when we entered it but are not yet sure what should replace it. But we know institutional health care and pharmacy have lost sight of what is crucial. Our institutions have forgotten the original mission. Our field is in a state of crisis, awaiting revolution around a new belief that can unify us.4
Why can’t this new belief be simply taking care of patients as best we can? Why can’t we organize all of pharmacy practice around this principle? We have lost our way down side quests of proper reimbursement and billing and provider status. Chasing the specters of finances while couched in the trappings of “nonprofit” organizations: Who does this really serve? Hint: It sure isn’t patients. As long as leaders are solely focused on finances, everything will always come back to the bottom line. I sense that I am not alone in thinking and feeling as I do, so my purpose in sharing these thoughts is to help shape the zeitgeist of this generation in pharmacy and help us find our way. Do I blame our forebears? No. They are experiencing the same events and cultural undercurrents we are, but in a way that makes sense to them. I do rebel against them, but our differences are subtle. They want to make money by caring for patients. I want to care for patients first and let finance sort itself out. The nuance here is everything: Change the philosophy, and everything else will follow. We will not stay in peril for long. Good people and the human spirit will not allow it. The underlying spirit, the unconscious attraction in pharmacy leadership and culture toward goals centered around finances, is revealing. It is time to take another road. It is time to recenter pharmacy practice around the ideal of what is best for the patient. This guiding light will serve to order our decisions, organizing them around a common shared principle.
So, where does that leave us in the here and now? The world of health care is unaligned and incoherent. The aims of patient care and profit motive stem from opposite ends of the spectrum. The dissonance for those in between is deafening: How can one goal be made to serve the other? I argue that the lack of adherence to the dictum of “do what is in the best interest of the patient” allows the financial to consume all else. Remember, growth for the sake of growth is the ideology of the cancer cell. While the eyes of the great are elsewhere, we can always do what is in the best interest of the patient. No matter the depth or breadth of the decision, that one principle affords great clarity for the path of correct action. We need to restore a culture of innovation and open thinking. The function of the health care system will then follow its form, restoring a “system that serves the individual and therefore holds hope the individual will serve it in turn,” to paraphrase Vaclav Havel.5
I will continue to recover my true self; perhaps you will, too. And maybe, just maybe, health care as an institution will recover its soul. By turning inward, we reflect those values outward. Reflecting those values outward allows us to move onward. And moving onward propels practice upward. Inward. Outward. Onward. Upward.
