First, What’s the Problem?: Generating a Problem List and SOAPing to the Solution

First, What’s the Problem?:
Generating a Problem List and SOAPing to the Solution


Leonard Zwelling

         Reading the latest reports from Anderson via the Chronicle
and various emails that I have received, I continue to be struck by how poorly
the cause for the turmoil at Anderson is understood or articulated. It’s really
not a mystery.

         As someone who worked at Anderson for 29 years, I had been
through periods of good times and bad and seen the pendulum swing from one to
the other. What has been curious is the inability for the current leadership to
understand their own culpability in the problem or, the lack of accountability for
the poor morale at Anderson that has never been placed on the prior administration. After all, some
of the prime offenders of the last gang are still on watch today.

         This does get rather complex and we Duke house officers were taught in our
internships that the very first thing one must do in working up an ill patient
is to define the patient’s problems to the most detailed extent possible and
then plan further diagnostic and therapeutic options to reach a conclusive
diagnostic and treatment plan. It was fashionable back in the 1970’s to use
Lawrence Weed’s system called SOAP. Findings for each problem in the problem
list were evaluated Subjectively and Objectively, Assessed to the fullest
extent possible and then a Plan made for each problem with the full knowledge
that some of the problems might coalesce over time. For example the bone pain
and the proteinuria might become multiple myeloma, but that had yet to be
proven and the plan was made without lumping problems together until there was
further objective evidence to do so.

         So what is the real MD Anderson problem list?

1. People who work there are discontented. This is
reflected in the various morale surveys and subjectively every time you get in
an elevator with no vice president aboard and someone is complaining.

2. The information systems and all operations simply do
not support the clinical enterprise in a modern fashion. Everything is too hard
to get done.

3. There is no clarity as to strategy. Is it to give the
best care or the most so that income can be maximized? Make no mistake. This is
a requisite choice.

4. Is there really the transparency in financial,
employment, tenure and personnel matters the leadership claims there is?

5. Is there any trust in anything at the Anderson?
Colleagues, department chairs, Division Heads, VPs, the Faculty Senate or executive leadership?

Problem 1: Discontent

        S: Continuous grousing 

Faculty Senate letters to UT leadership and too many stories in the Chronicle
and Cancer Letter

People aren’t happy working at Anderson

Either get new leadership or the current leadership needs to articulate a plan
that is more credible than whatever the current one is perceived to be, if
there is one.

Problem 2: Antiquated

         S: The feeling of being overwhelmed by process and paper is

         O: The computer systems supporting research were developed
on my watch 20 years ago. Surely they are outdated by now.

         A: A complete lack of modernization

         P: Get on with it BEA–BEFORE EPIC ARRIVES.

Problem 3: Strategy

         S: If no one can articulate it, it doesn’t exist and Making
Cancer History is not a strategy.

         O: Simply put, there is claim of clinical outcome
superiority that is not supported by any objective data. Patient satisfaction
is doo-doo. Patients know more about their cell phones than they do about their

         A: Choose a strategy, either broad market, low cost or product
differentiation, high quality?

         P: Only the second is possible in academia with its huge inherent fixed costs, so get on with it.

Problem 4: Lack of

         S: Both in terms of the lengths proposed to shut me up and
the latest insult to the former Head of Pediatrics when her faculty was lied to
about the reasons for her resignation, these guys have a way to go.

         O: Does anyone really know the financial status of MD

         A: There is no transparency

         P: Let’s see if the leadership will ever get around to
telling the truth about what they do and how they do things.

Problem 5: Lack of

         S: No one believes anything they are told and only half of what they see.

         O: This is probably a reasonable stance given the recent
prevarications associated with the actions of the leadership.

         A: There is no trust because the leadership has chosen not
to have any in the faculty

         P: Something’s gotta give.

         The patient that is MD Anderson is sick and getting sicker.
Talking around the problem list rather than facing it, making the tough calls
and being honest about why they were made is the only way the patient will

         I cannot see this occurring any time soon, but there is
always hope. This patient won’t fit into the ICU, but she needs that level of
intensive care.

         Or, I will revert to what the late, great Dr. Eugene Stead,
the former Chief of Medicine at Duke was famous for saying:

         “What this patient needs is a doctor!”



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