Meet The Owners of an Independent Oncology Practice

Four oncologists share their stories and the motivation behind their decision to become owners of an independent oncology practice in a changing world of medicine and cancer treatment. Meet Dr. Maurer, Dr. Menachery, Dr. Whitehurst, and Dr. Vaughn as they roundtable their path to oncology and the patient-focus behind independent practices. 

Dr. Christopher Vaughn: Welcome to Cancer Shop Talk: Behind the Diagnosis.  I am your host, Dr. Christopher Vaughn, physician and owner at Hematology-Oncology Associates of Fredericksburg in Virginia.  We are re-defining the conversation about cancer through the lens of an independent oncology practice. Thank you for joining us. 

As an oncologist, one of the attractions that got me into the profession and specialty was I think the ability to bond and develop rapport and special connections with our patients and families, and I’m privileged here to have several of our oncologists at Hematology-Oncology Associates of Fredericksburg.  And I want to kind of delve into some of the personal decisions that drove them into oncology, how certain things have evolved over time and changed how they practiced and delivered care to the patients. And I’m honored here to have some of my good friends and colleagues with me: Dr. Charles Maurer, Dr. Sudeep Menachery, and Dr. Matt Whitehurst.

I’d just like to open up a fairly broad question but I think it hits home.  What drove you – we’ll start with you Dr. Maurer – what drove you into the specialty of oncology?

Dr. Charles Maurer: Thank you Chris.  So in terms of oncology and hematology, in medical school in my second year, one of the things that you know we will learn is the physiology of the blood, and sometimes you also learn the pathology at a later point.  And one that I felt was really neat was as we deal with particular blood disorders every day that you could go from what we call the bench to the bedside. So you could look at a blood slide and make a diagnosis and go right upstairs and see the patient and execute therapy as needed.  I thought that was really neat. So that’s that technical portion of hematology and oncology.

And then one of my colleagues during residency in internal medicine in Rochester who also decided to go into oncology, I think he said it best.  He said it really blends the best of both the art of medicine as well as the science, and I thought that really captured the essence of what we do every day, how we practice.

Dr. Christopher Vaughn: Agree.  Sudeep, any thoughts?

Dr. Sudeep Menachery: Yes.  Probably the reason I got into medicine and oncology if I remember, is when I was in medical school, probably it was the fourth year, I was actually just trying to fill a board of doing a rotation and hematology/oncology was an option.  And a lot of what I had seen in hematology/oncology was on the inpatient side, and as most people can sort of attest, a lot of the outcomes are not that great. And it was actually then when it opened my eyes that there are so many well people who have cancer that come to the office, physician’s office, get their treatment, go home; and they’re not as sick as what we’d ordinarily see when patients are in the hospital.  And that’s actually probably one of the sparks of what made me think oh; this is actually really sort of an advanced field and it’s not just everybody that’s sick and dying and where you can actually make an impact in trying to keep patients out of the hospital. Now as I think back in the last 15 years of practice and how much things have changed, that only becomes more and more important. Trying to help patients with their quality of life and keep them out of the hospital.

Dr. Matthew Whitehurst:  I couldn’t agree more.  Thanks Dr. Vaughn for having me on my first ever podcast.  I’m happy to share. 

Dr. Vaughn: You’re starting well.

Dr. Whitehurst: That’s right.  Through training I always enjoyed taking care of a variety of different patient types and individuals unique with their medical issues.  And I feel like the field of hematology/oncology really is a diverse field. I think you get to see patients with a variety of different illnesses and who really do need help.  I used to remember, I went through training, internal medicine training, and you see different patients about the floor. But you go into a cancer patient’s room and there’s tons of family members there; there’s support; there’s people ready to rally behind that patient.  And I always wanted to be a part of that; be a part of that unique plan for a patient, because it really is a unique plan, especially in this exploding field. Everybody’s different and what works for one person one time is not going to work for another patient at the same time.  It’s truly been a very rewarding field and I’m thrilled to help different people and patients every day.

Dr. Maurer: I think that rewarding component really strikes home.  When I was a resident in medicine, I was in a residency that rarely was specialty driven.  So most of those doctors would go on to do many different specialties and some would go on to oncology and hematology.  And other residents, they would kind of joke around a bit with the oncologists and kind of jab them and say you know why would you go into oncology – this is years ago – there’s really not much you can offer those patients.  And a lot of these doctors were maybe going into cardiology or study of the heart, or nephrology with the kidneys. And nephrology had their kidney transplants and dialysis and cardiology had their heart bypass; and I said oncology is going to have its day.  That the science that’s going on now will come to fruition; it’s just not there yet. And what a great thing to be a part of it as it’s happening. Isn’t that a reason to go into medicine, because you need to make that change? So that rewarding comment made me think of that and really drives home why we do what we do.  If you’re going spend your career in a field, you should invest it in an area that you can really make a change.

Dr. Whitehurst: Absolutely; I couldn’t agree more.  The field has really exploded and what you thought you knew six months ago is now different and different for the better.  Patient choices are becoming much more broad and we have these non-chemotherapy options for patients that have really revolutionized their treatment.

Dr. Vaughn: Yeah.  I mean I vividly remember when I chose oncology.  For one, in medical school, you guys can attest to knowing me,  I’m not a fan of early conferences, so I knew surgery was not going to happen; you have to wake up too early.  So then I thought of cardiology, get to wear some scrubs, that was pretty cool. But my first – I remember because I was at UVA, just in the doldrums of winter, and I did an oncology rotation.  And kind of sometimes just things happen where you’re – you know who your mentor is, and it was just an amazing month. I mean there was a bone marrow transplant; it was a very vigorous course of interning and I had to be the first one there.  So you’re there before sunrise and leaving and it’s already sundown, so it’s a long rotation. But I think it was that special connection with patients, with families. It felt like you were involved with every decision making; whether you were an intern, resident or the fellow.  And really from that point it was like what’s involved here? And then I started with the outpatient rotations and you realized how much was moving in the field. And that was in 2002 so to me that was just starting where the gold standard for templated drugs, for targeted therapy was stuff had just started.  So I think I was lucky to kind of see the kind of beginning, sort of the new biological therapies and it just all happened I guess at the right time for me. And it was kind of that rotation I think that started it, because I was heading down the path of cardiology or something; kind of narrow, but life-changing moment.  I think that one of the big things for me then was to figure out – because I loved the academic center at UVA where I trained and to go gosh, do I want to stay in an academic center or do you want to move out and join a community practice? And that has been one of the more rewarding decisions also was to – I’ve got a fetish for joining a practice where you’re able to do everything.  You have benign hematology stuff and you have breast cancer, lung cancer; so it feels – you get a good breadth of everything, which keeps me on my toes. And so I don’t know if any of you have opinions on that; why you liked going to a teeny practice from upstate New York.

Dr. Maurer: So I came down to fellowship from Rochester and if one goes into oncology, there’s positions available all over the country.  I wanted to stay a little bit more on the Eastern seaboard where family was located. And I think what really struck me, particularly coming from this area; I have to really credit Dr. Muir.  And he blended – I think a lot of what he just brought up where we trained in the academic center and Dr. Muir was an MD/Ph.D. so he had his doctorate in genetics, a very bright gentleman; and trained also in Rochester a number of years ago so I thought oh, this is good.  And he really created this practice and was building that combination of an academic component as well as the art of medicine, and in a community that really needed that oncology support. And his balance of medicine I thought was just fantastic. I was actually on the dotted line to another practice; had not signed it; came down to this area sort of on short notice.  And I called my wife from the airport at DCA and I said you need to come here. You need to look at this place. This little town in Fredericksburg that actually was a little dot on the map – back then we used maps; we didn’t have GPS. And she did and then the rest is history.

Dr. Menachery: When I was in Philadelphia and had the opportunity to stay on, I wasn’t really sure that I wanted to just do one or two fields of oncology and I liked the idea of doing general oncology and I started interviewing.  Charlie, like yourself, we have a lot of family on the Eastern seaboard and kind of really knew I wanted to be on the East coast. I grew up in South Carolina; I have a couple of older sisters in various places along the east side.  And my wife grew up in Alexandria, Virginia so she really wanted to be in this area. But I also wanted to pick the right job. So I had interviewed for quite a few places and there were some good jobs and there were some not so good jobs.  And when I came down here, hands down it was really the best practice that I had seen. When I interviewed with you and Dr. Muir, and I sort of remember you taking me out and showing me around town, I remember telling my wife the same thing; this is the best practice that I’ve interviewed at.  It’s a small town; gives me a chance to do everything medically, oncologically, career wise. And Fredericksburg was just continuing to grow and back then, people would probably say it was getting pretty big, but in regards to now, I think it was probably obviously a lot smaller. And then my wife got a chance to come down and take a look, and once again, she started to fall in love with the place as well.  And then since I’ve been here and it just continued to see the growth, and also being able to practice general oncology, general hematology, the complexity and the challenging cases that we see. I’ll be honest with you; oftentimes more challenging that what I saw in my fellowship. And it forced you to stay on top of your medicine. You were reading all the time, you were on the internet all the time, you were phoning a friend and calling colleagues, talking amongst ourselves.  And it was just fun medicine. Scary at times, but it was fun and but once again, it was just the art of medicine as you say.

Dr. Maurer: It’s interesting you say in terms of fun medicine.  Because I think that was one of the hallmarks of the practice was that there was this sense of comradery and collegiality and respect for each other.  And you can bounce ideas and often we would have journals thrown across desks and we’d be looking things up, especially because we didn’t have the instant internet like you have now and you would have to phone a friend, send patients maybe to someone you knew or call them up.  And you really were able to make a solid difference and the environment that we practiced in was just so collegial. And Dr. Muir, he said Sudeep; we should give him a chance. And I said okay. He seems like a good guy. And that relationship then started to build with you and it just built off of that and was really exciting as the practice grew.

Dr. Whitehurst: And then they gave Dr. Vaughn a chance, and then they gave me a chance.

Dr. Vaughn: Yeah, I agree 100%.  So one of the fun and I want to give Dr.Muir is getting a lot of credit here – but one of the things when I interviewed a lot of places; and I really wasn’t planning on coming to Fredericksburg to be honest with you, but I took a call and said let me just check this out; it’s kind of close by Charleville.  So we had a wonderful dinner with you guys.

Dr. Maurer: Oh, I remember that night.

Dr. Vaughn: And you could tell – you know going around and you get this snapshot when you’re on interviews for jobs and you’re looking to leave the academia where you are, you only get just a snapshot of time to make a big decision.  And within those six or seven hours you just felt there was something special about the practice. You know as you mentioned the collegiality; that was genuine. You could feel the pulse and you could see this interaction at dinner.  We had such a good time and then on our ride back Jody, my wife, said yeah, well I’m glad we’re coming to Fredericksburg. She already committed that night. And Dr. Muir always said well if you can get to the spouse, good. But it was a sense of the culture you could feel and I think it’s something I’ve been proud of.  I’m the third on the totem pole here. But it’s something we continue to develop and I think it’s the foundation of what drives our culture of what we bring. And I think you can pick that up within six hours, in the afternoon I spent. So for sure I’m proud of that. Hopefully Dr. Whitehurst is that same way.

Dr. Whitehurst: Absolutely, I feel the same way.  My wife and I were looking around to establish some great work and my career after my training at Moffitt Cancer Center in Tampa.  And I loved every minute of it there; I thought my training was excellent. And as I look back, how I decided a private practice was right for me; basically you kind of go through your day and you’re either reading, you’re seeing patients or you are writing.  And I did all three of those, I think we all did, and if anyone were ever to ask me what would you want to be doing it is for sure seeing patients, for sure. And so I think the private practice really fit the mold for me. I share Dr. Menachery’s thought which is I like the broad variety of taking care of people and different diseases as opposed to niche oncology.  So we looked here and I can remember, and I think as we started putting the feelers out, this might have been a cold call here actually.

Dr. Maurer: It was a cold call; it was.  I remember when you called me because it was a little bit early in the standard season and I said whoa, this guy is pretty motivated.

Dr. Whitehurst:  It was one of those where we wanted a community that was just the right size and in just the right location for us, and something that could really go the distance for my wife and I and family, and coming here, it really hit the jackpot.  It was a pleasure to meet everybody and talk with not only the partners here and the docs, but also the nursing staff and our colleagues, our colleague physicians, our primary care providers, nurse practitioners. This is a very unified community and I’m thrilled to be part of it.

Dr. Maurer:  I really felt like this was an area that I could make that difference; that I was – at that point when I started with four Oncologists in the area that’s growing pretty quickly.  And I looked at many practices where I’d be the 35th oncologist. And coming out of training and saying – you know when I think of going through school for so many years and residency and spending so many years where you’re absorbing, you’re learning.  And yes you’re taking care of patients but you’re also taking things; you’re taking all this knowledge. Now you’re at this juncture in your life where you get to give back and decide where and what setting you want to do that. And I thought this area really works.  The practice situation that was here, the community that was here to raise your family, I thought the hospital structures were willing to invest in the infrastructure in other sub-specialty areas that are going to influence what we do were willing to make those investments.  And I had been to places that really weren’t. And I said I think this is the right place, so the rest is history.

Dr. Vaughn: Yeah, I think that’s one of the benefits of being here at HOAF; I think being a community practice and not tied into a hospital system or an academic system, we have the power ourselves to make changes happen.  In my time we’ve evolved; we’ve done things. For instance for me one of the passionate things was bringing research here, and we were able to do that. We didn’t have to fight the bureaucracy in trying to set that up.  We’ve made changes, you know palliative care clinic. Anything – we can do things rather quickly to help our patient needs. And for me personally it’s one of the big benefits, I think, of being a community practice is we have the autonomy and can change things rather quickly for the good of our patients, and sometimes in some places you don’t have that opportunity.

Dr. Maurer:  I think research-wise you can choose trials, clinical trials that are very relevant to our particular community and also at the latest forefront and frontier of where their field is at.  And provide that where people don’t have to travel so far and they can get that great care, that option. They have that option for that trial, and that’s a great thing to do, to have available.

Dr. Menachery: And I think that’s what we’ve tried to do here.  I was actually thinking that our practice is 31 years old.

Dr. Maurer: So Dr. Menachery, you mentioned a really good point; that the practice is now 31 years old.  And I think one of the areas that we’ve talked about and have touched on is Dr. Muir, and I think it’s important to really know that Dr. Muir had started a practice here in 1988 as an independent provider in oncology.  He had come from academics down in Cleveland, Ohio, had been working in the field of oncology and genetics, and decided to make a change in his career and come to the small town of Fredericksburg at the time. And he really saw an area that he could develop and completely make a shift in the practice of medicine, and that’s such a huge thing to be able to do and start it from scratch.  And he brought that aspect that we had talked about of that perfect balance of art and science and academics and collaboration. And it was so vividly clear when I interviewed with him and I thought what a great person to be in practice with. I had been to a number of practices and many of them were very good, but none of them had quite that touch. And it really struck me. And he’s – as the founder of the practice, I think we owe a lot of credit to that spark that really inspires the practice today.  

Dr. Menachery:  And I think some of the goals of the practice have been about the community.  How can we help our patients receive their care here? And there are some rare instances where they may need a bone marrow transport or a complex surgery, or they may need to go elsewhere.  But how can we can we continue to help facilitate this complex care and even things like research here locally? A lot of people know cancer is not just a stress on the patient, but the support group, the families; they’re also sitting in, taking their loved ones to and from appointments, sometimes taking time off from work.  So to be able to receive that care here I think is such a benefit for our entire community. As the practice has grown we’ve had a chance to evolve and I think we continue to do more and more treatments in or office. I’m sort of recollecting that there are some chemotherapeutic regimens that we almost have to do at a hospital.  But now once again we’ve been able to – as patients are well, we’ve been able to help modify that in such a way that we can give them this exact same chemotherapy as an outpatient; keep them out of the hospital; keep them well and keep them at home.

Dr. Maurer: I think you just mentioned something I think that is really key, and that’s that family atmosphere.  I think that’s one of the senses that the practice had at the start and even though we’ve grown, still has today.  Literally one of the last patients I just saw today was a young woman who has breast cancer that we’ve administered curative therapy to and she’s been with our practice now nearly a year.  She’s had surgery, she’s had different chemotherapy, she’s had biologic therapies. And she’s there with her mom and she said Dr. Maurer, I’m part of your family here. And she was talking about how she works for the Defense Department and her job position may move a little bit up north; and she said but I’m still going to come for follow-up appointments here because you’re part of my family and I really feel like you all take care of me so well.  And I thought that really struck home; that here 19 years later we’re doing the exact same thing that we started out with, those same goals and mission that for them are relevant now.

Dr. Whitehurst: Yeah, I think the reason this practice excels is the balance we strike, and that’s of seeing enough patients to be competent, thorough, cutting edge; but not too many such that when patients are parking their car and they’re walking into the building, before they even enter, the front desk knows them by name, they are checking them in, they are known to us and we take pride in that.  So striking that balance I think is what we do best here.  

Dr. Vaughn: Yes.  I think it’s one of the challenges for our practice, but I think we do a great job of as you grow how do you still keep that sort of family feel.  And that I think – when I look at what are the challenges moving forward that is one I think we do a great job and we’ve always got to keep that on the forefront of our mind because that’s what’s special about our practice.  And I had the same thing. I just saw a lady last week; she moved to North Carolina but she still comes here every six months you know. Just because – not only the relationship with me but with our staff; just during that time an experience with cancer is so frightful that there are just these special connection and patients want to stay with the team.  And we are part – it’s our understanding we are part of the family. And it’s really amazing to see and it’s rewarding to see patients come back, stay with us and talk about their experience. But I still think – which I’m so proud of – I still think we are a full family practice that offers specialized care that I would say would beat other academic centers.  But yet we know every patient’s name, smile as patients come through the door, patient appreciation day; I know we do these things with our patients because our patients are so involved in the practice.

Dr. Maurer: They really are.  Isn’t that amazing?

Dr. Whitehurst:  That’s another – kind of indirectly our patients can drive a lot of stuff that happens here if we allow it and they’re just such a voice, a positive voice that’s always rewarding. And there’s nothing to be missed out on.  We do run clinical trials here that are cutting edge, trying to be forward thinking or improving their quality of life but also it’s a control.  And all of us here will be the first to send patients elsewhere if there is something better. And that’s huge; we take ownership. They’re our patients and if there are clinical trials that are better elsewhere absolutely that’s going to be talked about and that referral is going to go out if that’s what needs to happen.  We take pride in that.

Dr. Maurer:  That’s interesting.  I have a gentleman with multiply myeloma and he’s been through a number of treatments.  I’ve taken care of him for four or five years now and there’s a type of treatment that may be really very rewarding and an excellent option for him; it’s still in the clinical trial.  And I called the center that started this type of therapy and I spoke to basically the top researcher there and spoke to him personally and said I really want you to see my patient and see if you can help him.  He just happened to have family up in that area in Philadelphia and I think that’s the way he’s going to go; they had a trial for him. So I think patients get to rely on us that we’re going to steer them in a direction that if it’s here, great; but if it’s needed elsewhere, we’re going to arrange that.  We’re going to help them with that; we’re going to support them; when they come back we’re going to support them; we’re always there for them and their families.

Dr. Vaughn: That is true.  I think we are sort of at times the quarterback.  And in real life, if we can do things here we do it; they have the comfort of being home.  But when we need to look for something different at a center that we can’t offer we are always the first ones to try to get them to where they need to be.  I think it’s something initially patients may just be concerned about. Like gosh, why would I want to go to that practice when the advertisement that popped in for Fairfax and specialty centers?  But in the long run, if we can do everything the same, but if we need to we can always reach out. And I think we’re able as you were saying, steer them in the right direction. And I think it’s something we also have to fight against on these inpatient big centers, but I think we can offer just as good care close to home; offer the family and all these other stressors that go along with battling cancer, but yet still be able to reach out if we need help.

Dr. Maurer: Well, I think that really hits a good point; that we’ve been practicing here for a while within the region and we really kind of know who’s who in the specific areas of oncology.  So I just recently saw a patient with a rare form of lymphoma and one of the world experts in this very unique, rare lymphoma is just a couple of hours away. And I said why don’t you go see this doctor; I said there’s several options we can pursue; I kind of have an idea, this is kind of what it think, but let’s see what he says.  And the patient went and saw him and they offered him a clinical trial; but he decided against that trial but we wound up pursuing that therapy locally here. And at the end of the day, I think he really appreciated the fact that I was willing to say hey, why don’t you go and meet this doctor; I know him well; we’ve talked before; we’ve shared many different patients together.  And I think that’s one of the strengths that we have to offer here in Fredericksburg, and I think maybe perhaps people don’t really understand that. They don’t really know that we’re kind of really looking out for them in many dimensions.

Dr. Vaughn:  Let me pose this to you guys.  If I were a patient and I was just diagnosed; let’s say I had a chest x-ray, just diagnosed, gosh it looks like lung cancer.  Why would I want to come to HOAF as a patient? If I was a new patient, what would be your goals that you’re seeing me for the first time?  And that’s open to anyone.  

So I think that’s important.  I think that’s one of the things I get asked a lot.  I think the first visit with a patient is critical and I think there’s certain things – as oncologists as I said, it’s kind of one of the things; you really want to establish this relationship; at least you try first visit.  And one of the things, and maybe it evolves over time, it probably does. You’re probably much more comfortable after you’ve been in this a lot longer, but there are always certain things I try to establish with a patient the first time, coming in anxious of course with a diagnosis of cancer and their family’s there.  What do you guys try to accomplish for the first visit?

Dr. Maurer: The very first day that I think about is they have an understanding of really why they’re there.  What was found, what’s the situation, what’s the problem, what’s on their mind? And because they come into the office with maybe a diagnosis of lung cancer; or it could be just a blood problem and maybe they don’t have cancer.  There’s a good chance they may not. But if they do, let’s say they have a situation in their lung, what do they understand about that process? That’s the key starting point. And then kind of taking and working off of that and the key is so that they have a good understanding of what’s going on.  And then where do we go from here? What’s the next step? How do we help guide them with that process of the next step? And helping organize that process, because you kind of, I think, mentioned that word is quarterback. Doctors like to think – all different specialties think they’re the most important person.  But we personally – I think we think we are the main quarterback and tell the surgeons that. But we do feel like we quarterback much of the care that happens, and I think that’s one of the great things that patients do appreciate is that we will help organize that process of the next step. And then bring them back and review what’s been found, and then go do they need treatment, what type, where do we go from here?  That’s a good starting point.  

Dr. Menachery: I saw a patient yesterday and it was a new patient I was seeing for an esophageal mass.  A lot of times what I do when I go into a patient’s room; after I do introductions and go through meeting not just the patient but whoever else may be there, there are two main questions I always ask.  Who sent you to see us and did they tell you why? And sometimes they have that understanding of I have a mass in my esophagus and I was told I have cancer. And then we have to sort of delve into it. Sometimes it’s trying to establish what type of cancer it is, do we have an expectation about what stage of cancer it is, and how the stage of the cancer often dictates what we’re going to recommend.  For this gentleman with esophageal cancer, the only procedure that had been done was the endoscopy with the biopsy. And he was diagnosed with what’s called an adenocarcinoma of the distal esophagus and he was just having a lot difficulty with swallowing, and mainly solids and not so much liquids. But we did not have any other scans on him.  

The reason this is important is once again, this could be, if it is localized to the esophagus we’re maybe talking about surgery.  And even before surgery we may be talking about a combination of chemo and radiation therapy. But if it’s advanced, it is metastatic, we’re not going to be talking so much about surgery, probably not about radiation therapy, but rather chemotherapy.  We’re also trying to establish expectations. Yes, there are some cancers that are curable and obviously all of our patients want to be as aggressive as possible and know what path they’re going down.  

So we’re going to start off by getting a PET scan and I was trying to prepare him that because he’s not having a lot of symptoms, I’m cautiously optimistic that he’s not advanced or Stage 4; but we have a lot of testing to do if that PET scan comes back as being good.  By that I mean we need to get him back to see the GI doctor for an endoscopic ultrasound; I need to get him to see a radiation doctor for the potential for chemo and radiation therapy; I need to get him to see a thoracic surgeon in preparation for the possibility of surgery later on.  And we are the ones that help coordinate for all of that to happen, and just describing sort of the process A to Z, we may be only involved as far as treatment in part of that; but helping guide and manage that treatment, making sure there are no snags along the way, that testing is getting done in a very expeditious fashion, the consultations are being done in an expeditious fashion.  So there’s not that perception that we’re waiting and there’s a delay in care. Because I can only imagine when anybody’s told that they have cancer and I’m sure that first night that they go to bed they’re not really sleeping; they’re tossing and turning. And I feel like yeah, we have a lot of those answers to those questions that they have and you want to try to help dispel some myths and help establish them.  And the couple, they were just so appreciative. They just had a clearer understanding of what’s going on right now and how this one test will help dictate other things to come; and they feel confident that we are going to get them to exactly where they need to go.

Dr. Maurer: So I think what you just did there is that fear of that unknown.  You just helped to completely as much as possible eliminate that. So with that understanding it’s not as scary and they can go forward and really think more clearly and be proactive.  And one of the things that we’re doing at the same time at that visit is discussing their swallowing and how do we help improve that. And some the things I think about with that new patient is what is their nutrition like; what’s their support system like; who are they coming with; who needs to be there that might not be there; do I need to get that person on the phone?  What are their motivations in this process? People come in with different philosophies and understanding that patient perspective of where they’re coming from really helps a lot.  

Dr. Whitehurst: Absolutely.  I usually start off by acknowledging that this is a whirlwind coming at them and this is just one thing after another.  It’s usually one test showing this and then they’re sent for more tests, and it’s overwhelming. So start by acknowledging that and settling down that worry and that fear is really important.  And you know Patty is our new patient coordinator and she’s come to me many a time and said this patient just called and I said well have them come in today. Let’s get this settled today; let’s get them on the right track today.  And I think nobody likes to come to a place like this, that’s for sure; but helping them through this difficult time is really what they need. I’m big into writing down things. I like to draw, I like to set things on paper, it helps; it helps me, I think it helps a lot of folks in the room.  And the reason is you don’t know what questions you have until you have them, and those questions happen at the time of the visit, those questions happen later, those questions happen after you get home and you talk with your family; and by jotting down a few things of a general roadmap plan I think really goes a long way.  Because it is; like I said before, it’s a whirlwind and a lot of things need to happen to make sure the right treatment is set forth. I think we do that well here.

Dr. Vaughn: Yeah, I think it’s – as you were pointing out, I think it’s important to sort of speak the language that everyone can understand.  Because if you’re over the top it only creates more questions, more doubts when patients leave not knowing, not understanding. So I always try to make sure we – the basic level of what we’re dealing with as best as they can understand it.  It’s always nice, as you were mentioning, the patient – you can tell if they have someone with them. It’s always nice to have family in the room; it always helps on that first visit to have an extra set of ears and eyes. I think one of the motivations I have with a new patient and try – what are their philosophies or principles; what drives them, what are their hobbies; just something that you can kind of connect with and talk about.  I had a lady with breast cancer and she was harpist so she was – like her tactile sensation was very important to her and what she does. Unfortunately our chemotherapies can cause some damage to that. So a lot of times sort of the art of what we do is how we can incorporate treatments. There’s not always one to do it; I used to make – incorporate things that hopefully have an efficacious effect on the cancer but also don’t damage what someone likes to do and what their hobbies are.  So that’s always important I think to know what people like to do. You want to kind of – when I talk to a patient and try to keep their life as normal as possible. I think that helps to know what kind of drives them.

Dr. Maurer: I just recently had a patient who is retired who was an avid golfer and really loved to get out there on the golf course.  And he was having some challenges and really couldn’t get out there on the golf course at the time. But we said this is going to be our goal.  This is where you’re at now but we’re going to – our goal is to get you out on the golf course and when can we do it by? It may be here, it might be in a certain time period, maybe a few months, but that’s going to be our goal.  And knowing where he was coming from and that was a driving force for him. And that’s something he looked forward to. And it could be any number of things; getting on a trip to visit the grandkids or just being able to – I have a lot of patients who take care of their grandkids every day and that’s their motivation.  I’ll come any day doc for treatment, but I’m not coming on Tuesdays; that’s with my granddaughter. Okay, we’re not doing Tuesdays. You know? She’s not doing that on Tuesdays, and that’s good because that keeps them going.  And listening to them and seeing where they’re coming from.

Dr. Whitehurst: Sure.  They’re always worried about – you know some people are worried about canceling vacations.  And I never cancel vacations; that is a pet peeve. I will do whatever needs to happen for them not to cancel vacations.  We work around vacations, that’s for sure. Vacations are important; family is important.

Dr. Vaughn: According to my patients I’m welcome to take a vacation.  You can tag along. I’ve always wanted to take that cruise.

Dr. Maurer: The cruise oncologist, right?

Dr. Vaughn: Yeah, that job’s available.  Yeah, I have a lot of patients that play golf and it is amazing.  On chemotherapy they still tend to play better than I am, so it’s amazing.  But I think having that connection with patients is something special; I mean it’s that bond that you’re talking about with them.  They still hold certain things high and you want to make sure you maximize that on treatment; whether it’s chemotherapy or hormonal therapy or whatever the mode is of treatment.

Dr. Maurer: And beyond just the doctor, I think our – one of the things that we’ve done that I think has been really instrumental is creating that feeling within the providers.  And because our nurses and other staff will really get to know that patient and what drives them; they’ll know if they’re looking good that day or something’s bothering them and they get to ferret that out, if they’re having a certain symptom.  And patients really get to rely on our staff. So I think that’s really key is having that team approach to care. I think it allows the patients and their families to really kind of trust their providers and the whole team.

Dr. Vaughn: And I think it helps to have someone who – and that’s someone we have again adapted at HOAF over the past few years; I think having consistency with providers who care, whether it be an infusion nurse or a medical assistant or advanced practitioners.  Knowing the patient very well so you can engage a subtle difference in how someone’s doing, and that’s part of how we’ve made changes of all and just deliver the best quality care we can I think is having consistency. Because if I don’t know a patient; when I see them the first time, they may be fine.  But if you’re seeing him regularly and there’s a change it just helps out.

Dr. Whitehurst: I’ve had a patient or two jokingly say that they tolerate me so they can keep my nurses and my medical assistants.  And that indeed speaks to the nursing quality; they really take ownership and so it’s always funny hearing those sorts of things.  Because they really do; they love the nurses and it’s important. They do; they do notice things; they do bond with patients.

Dr. Menachery: And I feel like we as the oncologists and some of the providers, we’re not the ones directly delivering some of that care.  And to your point about our reception staff and walking them into the office; our nursing staff, our phlebotomist, pharmacy technician, our administrative staff.  There are so many different functions as you’ve said within the practice that goes into delivering care, and a lot of times we’re seeing that small point; a lot of that is done elsewhere in our practice.  And that gives me such great pride when the patients come back to us, they’ve finished up their treatment, and they say doc; your staff is outstanding. I could not have received better care anywhere else.  And I think that they continue, our staff continues to evolve; they want to do better and they’ve been much more proactive where they can try to help patients and family members better than we can.

Dr. Maurer: So much happens behind the scenes.  One example would be our accounts department in terms of finding financial assistance for patients, for various programs, they’re getting authorizations.  I’ve had a patient talk to me and the family say I had this and this, but Joanna or Laurie or any member of the Patient Accounts team; it really felt like they were fighting for them.  And that’s – it’s hard enough to go through everything when we have to go through billing the treatment of various sorts; but also when you have all this insurance confusion, cloudiness sometimes and what do you do there?  And then to have that assistance behind you really is – I can only imagine what patients and their families have to go through with regards to that aspect, and to have that support is key. And a lot of that’s behind the scenes.

Dr. Menachery: It’s behind the scenes, but it goes to show how a lot of the alignment within the practice from A to Z is about that patient and that family and taking care of them; not just medically but emotionally, socially, everything that we can do to try to help. 

Dr. Vaughn: I think of the patient at the end of the little diagram; you know the basic foundation is the patient is at the center and then everything moves from there. And it’s amazing. It’s almost like an engine and all the pistons. You know for everything to work, like Patient Accounts, scheduling, the medical assistants, nursing; everything has to work together and has to work and communicate and talk with each other.  And it works seamlessly. And there’s nothing more prideful to have a patient say they just love our staff and how thankful they are that they’re here. And we get that a lot.

Dr. Maurer:  It’s amazing to see how much it’s evolved over the years.  When I first started, I have to say 19 years ago here in Fredericksburg to now, when we had 8 total staff including the doctors, I always say this and now we’re 90 plus.  But how much that’s grown and evolved. Of all the things that we are able to provide and offer to patients; as you mentioned palliative care, survivorship, we have the acute care clinics, all of those things – the financial support programs, the research, even medical records; just having those records available for that patient when they come in.  I mean a lot of times that’s sort of an undercurrent; sort of the unsaid because it’s always there for you. But what if that information wasn’t there? You didn’t have that technology before; you need to have that scanned image that might have been done somewhere. Then you couldn’t tell that patient what was going on. It’s a piece of information; they’re right there providing that for us.  And they realize the importance, because it could be one of their family members. And so it’s everybody working together.

Dr. Vaughn: Yeah, I’ve been here now, it’s going on 11 years; and I think we continue as we’ve all kind of discussed around the table here – continue to adapt and evolve.  I just would want to get maybe some opinions or thoughts of what are the future directions here at HOAF or where to you see further advancement happening that we can offer our patients?  I always view one of these sort of on the cutting edge; you know offer the best care we can that is novel.

Dr. Maurer: I think one of items that Dr. Menachery or Chris may have mentioned is how do we provide the best care for patients, even when it’s sort of beyond our control?  So when patients are – let’s say they present to the hospital and they might be seeing other doctors. How can we help support that? And one of the avenues that we’ve participated with is this oncology care model with Medicare, and it’s truly helped transform our practice.  It has really allowed us to look from 30,000 feet and look at the entire scope of patient care; and what we can provide in terms of keeping people out of the hospital as Dr. Menachery was mentioning, and keeping them home and keeping them as healthy as possible. And with that, how do we provide the absolutely best treatment?  As Dr. Whitehurst was mentioning, the number of medications and treatments that are coming literally off the shelf and being approved by the FDA; pretty much every week there’s a new medicine that seems to be available. How do we integrate that into the infrastructure of what we do so we’re offering the latest care, but also keeping that same personal approach, that family atmosphere as oncology continues to evolve and expand?

Dr. Vaughn: Yeah, I think one of the – as these new drugs are developed, and some are oral medications and just because they’re oral doesn’t mean they don’t have side effects for patients.  In fact sometimes they could be even worse. And how do we continue to maintain and strive for keeping patients out of the Emergency Room and out of the hospital? I think it means a lot to a patient that if they are having trouble we’re the first ones to see them.  I think we manage it the best because we know what the medications can do and what the side effects are. It’s something that’s the sort of the idea of trying to keep patients within the practice, and I think we probably can continue to advance that further. We’ve done a great job, but I think I agree that that oncology care model has kind of given us some ideas, kind of a template going forward.

Dr. Maurer: So Chris, I’m glad you had commented on that surveillance, that acute care clinic.  That is an area that we developed in the last year. Really that was precipitated by one of our key staff members who is our exam manager, and she found that a number of patients were coming into the office who – and they may need some blood work or they may need an injection.  They don’t necessarily have a provider visit, but they have questions; they may have had a symptom; they may need a refill on a special medication. And that often times the other doctors or nurse practitioners or physician assistants may be with other patients. And what we’ve found is some of those patients would have to wait some period of time before they can get their question answered or symptom resolved.  

So there were enough patients that we said you know we could actually have someone available at all times during the day to help really see these patients sooner and answer their questions right there at the moment, and refill their medication and make sure it’s all done properly.  Because one the big areas of medicine is safety and making sure we’re doing everything as safe and as appropriate as possible. And having that time to do it rather than between a busy clinic time when you’re seeing a number of patients; and we really want to say I want to dedicate that time to making sure that this is done right.  So we’ve opened this surveillance/acute care clinic where we can manage all of those patient symptoms, rectify any other problems they may have, and refill their medications. Or just see – go over a sudden scan that may have happened if they have a question. Maybe that person was just in the Emergency Room and they had questions and they didn’t need to be hospitalized primarily because we will see them pretty quickly in the office.  So when they actually come into the Emergency Room on a Saturday or Sunday, and we knew that they had a quick follow-up in our office that’s available for them. So this has been quite successful.

And I think honestly I would say if you have to ask, we’re probably one of the first practices perhaps in the state, if not the country to offer that.  Because I’ve been to a number of meetings and I didn’t really see a lot of other practices offering that. And it really was the brainchild of one of our own staff members.

Dr. Menachery: As technology continues to improve, I remember when you first joined the practice one of the things that you were very proactive about was getting programs.  The immunotherapy has improved for the treatment of prostate cancer, and you felt that hey; we should be doing this here so our patients don’t need to go elsewhere to be able to receive that care.  So my thoughts and hopes for the future as technology continues to refine itself is even some of these treatments that we are referring our patients to, it could be come safer and more logical to do it here.  And we want to stay progressive. We want to stay at the forefront of a lot of these treatments and can we do things closer to home? We definitely know that cancer care delivery closer to home is just – is absolutely best for the patient.  And I think we as a practice have wholeheartedly supported our community to help accomplish that goal.

Dr. Whitehurst: Yeah, I couldn’t agree more.  I think that going forward, I’d describe this place as unique, and unique in our ability to make changes for the better.  And that’s what I want to see going forward is I want better. I want more. I want choices; I want more clinical trials as options.  I want the ability to use this drug because it works in breast cancer, to try it in this field because it’s lung cancer and they have the same mechanism of action against this driver mutation.  That’s what I want. I want more choices for people. And I think us seeing all the different types of cancers out there makes us very open and ready to make that change and so I want more of that coming forward.  That’s what I hope to see – choices.

Dr. Menachery: And to your point I think we’re starting to see that within the last one or two years, where two drugs now have been approved for the treatment of cancer, not based on a site or diagnosis, but an actual mutation or abnormality that was found.  I think that we are harping on sort of a new age of how we diagnose and treat these cancers. This is going to continue to evolve and evolve pretty rapidly.

Dr. Muarer: We keep pushing the bar.

Dr. Whitehurst: That’s great way to phrase it; pushing the bar. 

Dr. Vaughn: Well I hope this was educational and I really appreciate my colleagues here who joined us for our first podcast.  

 
Thanks for listening to Cancer Shop Talk: Behind the diagnosis.  If you enjoy our show and want to know more, check out HOAFredericksburg.com; or leave us a review on I-tunes.  Join us next month when we go Behind Surviving Breast Cancer.