10Qs Senator John Crown MD speaks to John Campion

Campion: What were you doing when you were 22?

Crown: When I was 22 I was transitioning Fourth Med to Final Med in UCD. I spent the summer working in a mission hospital in Tanzania with fantastic people. That gave me great insight into a lot of the issues of global medicine and I guess my life was pretty much focused on getting through final med then.

 

Campion: How did you get to where you are today?

Crown: I was born in Brooklyn, an only child to Irish immigrant parents. I grew up in Brooklyn until I was 10. I came back to live in Ireland and went through the Irish education system from fifth class through medical school, through five years of postgraduate medical training in Ireland. I became pretty Irish at that stage. I went to school in Singh Street and Terenure College: one public school and one private. That was a very important part of my development as what I am and in seeing how the system works here. I was lucky in that I knew I wanted to be an oncologist pretty much from the first day I was in medical school. In fact I had a pretty good notion that I wanted to be involved in cancer medicine or cancer research in some way even before I was in medical school. I just found the area very interesting. After internship I did one year in the lab doing a B.Sc, then did two years of general medical rotations with the Federated Dublin Voluntary Hospitals, including one very exciting opportunity to spend six months of that as a Registrar in Guys’ Hospital in London, which was great. I then came back to Dublin for one more year as an oncology and haematology registrar (’84-‘85). Then I went to Mount Sinai School of Medicine on an oncology fellowship, where I worked with one of the really inspirational leaders in oncology, Dr Jim Holland, who is still alive and still practising in his late 80s. He was among the early group of researchers that were involved in the research that cured childhood leukemia and other cancers. Then I moved on to Memorial Sloan-Kettering Cancer Center where I did two years of fellowship and then joined the faculty for a further four years. It is the world’s biggest and I believe best cancer hospital and research centre. I loved it then and I love it now. It was the makings of me. I came back to Ireland in 1993. I was then one of four medical oncologists in the country, which was a bit of a disaster. I had by this stage built up quite an interest in clinical research, and wished to get it started in Ireland. It was very difficult to do because we hadn’t enough oncologists. They had crushing patient loads so they didn’t really have time to be doing research but we persevered, we set up the Irish Cooperative Oncology Research Group in 1997. This group has now been around for 15 years and has survived through difficult circumstances and has thrived recently; it has 7,500 Irish patients on the study. It is now open in every hospital in the country, bringing cutting edge new treatments to Irish patients. It has saved quite a few lives because of drugs that were made available here earlier than would have been the case otherwise and I’m delighted that we’re now presenting at major international meetings. We’ve put Ireland on the map in clinical research. Similarly, about three years ago I set up Molecular Therapeutics for Cancer Ireland, which was more of a lab-focused cooperative group, bringing lab scientists together. That has been hugely successful.  A lot of publication and a lot of research is occurring as a result.

 

Campion: Who has been the most influential person in your life so far and why?

Crown: Well, the most influential person in my personal life was clearly my mother, and anyone with a nodding acquaintance with my personality will see that. She was a nurse. She has a very enquiring mind. One very highly developed side, which I certainly have inherited from her, is the idea that life is not a popularity contest. Sometimes you have to say and do things which are not popular, but need to be said and done. I think I have inherited that in spades from her. Professionally then, the three big professional influences I had in Ireland were Dr Sean McCann, who was my boss in James’s as a registrar. I worked with Jim Holland in Mount Sinai, Larry Norton was my boss in Sloan-Kettering: a lovely man, involved in breast cancer. I think the chance to work with Jim and Larry was what made my career. Subsequently, I’ve fallen heavily under the influence of Dr Doctor Slamon from UCLA, who really was instrumental in getting me to reformat my own research career away form pure clinical research into a more clinical/translational lab interface. I had the privilege of being involved with him on a drug called Herceptin, which has been a big help. I had a very small part in its development compared to him.

 

Campion: If there was anything you could change about the Irish political system, what would it be and why?

Crown: It’s a bit like saying “You have three wishes” when the genie hands you the lamp and I say that my first wish is a thousand wishes: the one thing I would do is reform the constitution. That would achieve several things I would like to see. One is a system of electing our parliament which downplays the primacy of parochial interests. The second thing is reform of the system to elect our government ministers, to allow for the appointment or election of people who are truly expert in their area, from a gene pool which is considerably wider than the one given to us now; Oireachtas Éireann. Thirdly, I’d like to see a system which totally downplayed the role of partisan, internecine, meaningless, basically tribal and club-like party politics in this country; basically to end the whip system. I’d like to see a system more like the American system. There is a division in US politics which, for all its alleged dysfunctionality, at least reflects a genuine ideological division in the country and you know people do cross the floor and vote against the whip on many occasions in the US if they feel that, in principle, they must do it. Here, that is impossible.

 

Campion: What advice would you give to a young Irish university graduate?

Crown: Well I think the advice I’d give to any young person- and it’s a trite cliché for a man in his mid fifties to say this- is don’t waste a minute. Life is there for the taking. I don’t have a Pollyanna-like view that everything in the world is possible; it’s not. There are limitations to what people can achieve. I think you need to do your best, have a bit of fun but do try to achieve everything that you can achieve. Try to push your boundaries and try to leave the world a better place than you found it. That sounds a bit Mom-and-Apple-Pie-ish I guess, I’m sorry. In a more specific sense, as a general principle, I would like to see more people going into science, medicine, technology, engineering etc. I do think that all of the key challenges, which face us as a species, existentially, have some kind of scientific underpinning. The big things that will determine our future are food, water, and energy. I think we need to have a really scientifically informed populace, that people really understand the issues about energy policy, about the necessity of conservation. I think we need to reformat the rewards system in society, away from people who just shuffle other people’s money around, creaming off a percentage commission on it to people who actually genuinely create wealth.

So do you think that a higher base of scientific knowledge is also necessary across the board?

I would make the study of science mandatory for everybody until their last day in school, even if they have no intention of pursuing a career in science, nor any intention of becoming particularly proficient in it. We also need to disconnect it in some sense from matriculation requirements; that people learn science because they need to understand science to live in a world that is governed by science, not merely to get the points to get into architecture school.

 

Campion: Do you see patient advocacy as a fundamental part of a doctor’s job or as a separate role?

Crown: Yes. I have an old-fashioned belief in the professional model that the responsibility any doctor has is to the patient in front of him. He has a secondary level of responsibility to other patients who are out there, whose care may, in some sense, be impinged upon by the resources he is spending on the patient in front of him, but there are lots of people out there whose job it is to redress that balance and if everybody is basically trying to normalise all spending across a range of abstract theoretical patients on a population base and nobody is trying to make sure the patient in front of them has the resources dedicated to him/her that he/she deserves, then you get a fundamentally unbalanced system. The problem is that much of what passes for health policy in these islands and in some parts of the world is based on the assumption that the primacy of the population consideration must at all times be respected by every person, with nobody acting as an advocate for the individual person. I’m not naive; I don’t believe we practise in an economic and social vacuum. There is an economic context to every dollar or euro we prescribe or spend on an operation or a test for a patient in the sense that there is an opportunity cost to it not being used for another patient. It is up to others to redress that balance and if you take away the advocacy role from other doctors then you enter a situation where no one is advocating for the patient. Patients and doctors should be on the same side of the seesaw equilibrium; health economists should be on the other.

So do you think that more doctors should become more vocal patient advocates?

I think it’s more profound than that. I think that many of the people who wish to run medicine are disenfranchised from doing it. We had a big fight over the consultant contracts a few years ago. They wanted to put a gagging clause on it to make consultants… We’re going to our very fundamental philosophical core about how healthcare should be run. I will say this unabashedly, unashamedly; I will say this even though it will make me sound like some kind of throwback; I think it [the healthcare system] should be run by doctors. I happen to believe that you don’t go into a law firm and find that the person who runs the firm is an accountant, you don’t go into an architecture firm and find that the senior partner in the firm is a dentist but we have a healthcare system where the administrator and the leader is typically someone who worked their way up through the ranks and became a hospital administrator, when he or she is surrounded by doctors often of mesmeric brilliance and international expertise, who are relegated to the role of technicians, in a system where the leadership is provided by management. Leadership should be provided by leaders, management should be provided by management. In my ideal hospital, the powerful, vision-generating figure at the top of the tree would be a clinician; not any old clinician; a very special clinician, somebody who, number one, was forged in the fire of peer review, to be really excellent at what they do, and who had shown management skills within their own division, their own section, their own department, their own faculty, until they got to the very top of the tree. [They would be] surrounded by a team of competent managers, who look after things like facilities and plant, human resources, payroll. You need those managers, but what we have here is that at the top is a model where at the top is a manager who provides leadership, who is surrounded by technical support, which includes the boiler cleaners, the kitchen staff, the neurosurgeons… it’s insane.

 

Can you see there being any positive legacy to the Irish health system from the current economic crisis; what opportunities does it present?

You’re kind of parenthesising the old Rahm Emmanuel phrase that you should never let a good crisis go to waste. I think he’s possibly correct, but I think a more important point is that you should never let a good boom go to waste, and boy, did we do that! We had the opportunity to fix the health service when there wasn’t pressure on it. And what’s more is it would have helped us, it would have sustained us in the crisis because the reforms that people like me were advocating would have increased efficiency. They wouldn’t necessarily have decreased cost but they would have hugely increased efficiency in a system that desperately needs efficiencies now. So, I’m not optimistic. I have some optimism that there may be more of a momentum for reforming the health service now but that’s not because we’re in crisis, it’s because we’ve a minister who understands the problems with the system and has articulated a desire to face them. The big challenge facing the minister is whether he will have the energy and the support to do it or will he be in fact taken prisoner by the civil service.

           

Campion: The ratio of consultants to non-consultant hospital doctors is being increased at the moment…

Crown: In theory, yes, but we’ll see.

Campion: and would you be worried about an oversupply of junior doctors coming out of medical school, as we move to this consultant-heavy model?

Crown: Junior doctors should have one job, and one job only; that’s to train. The system should not depend on the services of junior doctors to work; that’s just wrong. We train people for too long. People should be taking responsibility for their own patients in most specialties about five or six years out of medical school, and we need to have an appropriate career structure in place to allow that, especially in our bigger hospitals, where people that are working there will also have someone they are consulting. They can make decisions about their own patient, but there is someone who is senior to them, who may have some supervisory role as well. For example, in the hospital I worked in New York, Sloan Kettering, which is a totally not-for-profit, charity-run hospital, there is a Physician in Chief, and under him are the Heads of Department, under them are the Heads of Division, under them are the Heads of Section, and so on, all the way down. So, even though I was a consultant, I had a boss, who could hire and fire me. In fact, I had about six layers of bosses who could hire and fire me. In Ireland, once you walk in as a consultant, you have reached the highest level you ever can, that’s just crazy.

 

 

Campion: What standard should be applied to cancer drugs, in terms of pharmacoeconomics?

Crown: Well, there are a couple of ways of answering that. Standard number one is that the very same standard should be applied to everything, that is applied to cancer drugs. At present the metric is a certain drug makes you live typically by a certain number of months longer, on average, so you work out the cost of the drug per annum and you multiply it by that number of months, as a fraction of a year. If something makes you live on average six months longer and costs $50000, you say it costs $100,000 to make people live an extra year. That may be right, but if it is, I want to see it applied to everything in the health service. If we’re going to validate any development in the health service by saying that it’s cheaper- typically than $30,000 per year of life saved- then I want to see them applied to all operations done in hospitals; to hip replacements, to tonsils, to cataract surgery, to everything. By the way, that’s not me saying I think we shouldn’t spend money on those things, because I think those things are essential. Then I think we should start applying it to things like ICU beds. What is the cost per year of life saved of that person spending the last three days of their life in an ICU bed? Then you should apply it to hospital administrators; what’s the cost per year of life saved of having a hospital administrator, what’s the cost per year of life saved of having a PR company or a department of corporate governance, of having the painters come in. Because ultimately the function of a health service should be to prevent premature death. If it can keep people healthy and all that, that’s nice, but ultimately, if a health service can only do one thing, it should keep people alive. If we’ve decided that we’re going to put a cost on that, which stops us from curing lots of people, then I think we need to apply that cost to everything else. But, a more practical approach is that we should educate people about not being wasteful in the health service, because there’s lots of waste… In terms of cancer drugs, we can’t have a blanket rule. As an example, people with metastatic breast cancer used to live a number of months; they now live up to five years and often more. If someone came to me with a drug that could extend your life expectancy from five years to five years and one month, and it was going to cost $100,000, I’d say forget it- trust me, there is such a drug and I’ve stopped using it.  If, on the other hand, someone came up to me and said for malignant melanoma- which, when it is spread, is a uniform death sentence- a drug will make about a seventh of patients have quite a prolonged survival, to the extent where some of them aren’t relapsing and maybe even some of them are cured, I’d say that’s an interesting drug, that’s a good drug, I want to use that drug. If I’ve got a 20 year old, which I have, who’s currently battling metastatic melanoma, and I’ve got a drug which gives her a one in seven chance of being alive in ten years time I’ll say that’s a good drug, let’s try that. If, however, the only metric we use is, as the very unsophisticated health economics in this country uses is to look at the dossier which the drug company provided to the regulatory agency- which is all the drug company is allowed to provide- in which the average prolongation is three months, then you need years of training as a health economist to multiply the three months by four, and then work out what the drug costs at four times that cost? Do you really need to send people to vastly expensive international training to do that and then to come to the conclusion that the cost per year of life saved isn’t worthwhile? Even if you don’t know that the drug actually gives some people a very prolonged survival? There’s something very wrong with that type of analysis.

 

Campion: How do you reconcile that view with the precept of justice in medical ethic?

Crown: Well, I don’t think you could make an argument that it’s anything but just!

 

Campion: In terms of using large amounts of money…

Crown:… to save one nineteen-year-old? As opposed to shoving it over to some banker in Frankfurt? No problem with it.

 

Campion: And in terms of the system in which you practise?

Crown: The system in which we practise lives in a context where every year we spend $3.1bn redeeming a promissory note with money that disappears into nothingness in order to keep a group of people who made foolish investments in a cowboy bank in this country happy. And then they tell me that they can’t find an extra two million or three million for a cancer drug that might save the next nineteen-year-old? Or the next twenty-two-year-old? I’m sorry, I have NO problem reconciling that with the notion of justice. None. Zero.

 

Campion: And if you were Minister for Health?

Crown: The Minister for Health cannot fix the problems in our health system in isolation; we need to fix the problems in the public service.

 

Campion: Looking to the USA, do you see the Patient Protection and Affordable Care Act being implemented, and how do you see its impact?

Crown: Well it obviously depends heavily on the forthcoming Supreme Court challenge and it probably depends- but less than people think- on the presidential election. The reality is that Romney has clearly been playing to his lunatic fringe during the Republican primaries and when he’s in the mainstream presidential election, I believe that his views will be substantially moderated. Of course he was the man who brought in a version of Obamacare when he was Governor of Massachusetts which was, kind of, Romneycare. The biggest system of socialised medicine in the world is American Medicare. It is a vast, vast system. There’s an awful lot of the American healthcare system that is good. If you have ordinary, standard health insurance in America, you get better healthcare than you do almost anywhere in Europe. There are some exceptions but I mean you get really good care. When I worked in Sloan-Kettering or when I worked in Mount Sinai, which were fine institutions, the wards were full of bus drivers and firefighters and policemen, because they had the ordinary insurance, which got them access to that level of healthcare. The problem in America is that Americans have never really got their head around the notion that you can be poor without it really being your fault and without it being due to some awful personal moral turpitude. Bad stuff happens to good people, and they and their families still need good healthcare. Collectively, as a society, they’re not quite at peace with that notion yet, so the Obama reforms were a big step and they reflect a change in public opinion, a realisation that we’re all in this together and that yes, you can use the socialism word. There is a degree of socialism involved but, you know, so is there in having a fire department.

Campion: It needn’t be a dirty word.

Crown: Exactly. So the second issue, then, is that the American system is based heavily on incentivised activity and they haven’t been as good at policing that activity as they need to be. The classic example of this is in oncology. This is where the challenge is. Most cancer drugs in America are given in oncology private practices that are owned by doctors. So the doctor sees the patient, prescribes the drug and then effectively sells the drug to the patient through their insurance company. In every other country in the world there has been a fundamental philosophical disconnect between being a doctor and being a pharmacist. In fact, most medical organisations don’t allow you to do both. It’s just the way oncology developed in America. So [in the USA] there is a great deal of supplier-induced demand. They have gone a great way to reigning this in over the past number of years, by greatly reducing the mark-up fees that people make by selling chemotherapy drugs and in fact they’ve made a lot of practices nearly non-viable as a result, which is bad in one way. This is bad in one way, but on the flip side of it, America has the best cancer survival rates in the world and that’s because when the average person goes in to their oncologist, if they need a drug or treatment they will get it because they want it and the doctor wants them to have it. Whereas, if you go into the NHS, the doctor isn’t paid any more if he does or doesn’t take you on as a patient and the hospital loses more money if it gives you a drug. The hospital is incentivised to stay under their 6% annual limit by government statute. So they’ve got these incredible incentives in place in the UK not to treat people and that, I believe, is the core reason why their survival rates are so poor. So, in the US, I am a great supporter of the Obama reforms. I think they’re a great idea. The Americans need to just ‘fess up and admit, “This is socialism and it’s good for us”. It’s an abomination that, in the richest country in the world, there are people who can’t get basic level healthcare. They also need to grasp the nettle of inefficiency in the system, which is at the other extreme of the inefficiencies we have in our system. We love inefficiencies in our system; it makes things cheaper. If you can constrain the cost you spend, all it does is balloon your waiting list, which saves you money. In the American system if you’re being inefficient, then you’re just spending more money. Although, something else must be said here; I’ve a book in me somewhere, called Guerilla Health Economics. No one has ever been able to prove to me that it’s bad for society to spend more on healthcare. So why is it that we’re told, “Great news: the economy’s booming, car sales are up, refrigerator sales are up, house prices are rising (isn’t that fantastic!), high streets are reporting increased business, but we’re spending more money on healthcare… uh oh…! We can’t have that!” I’ve never understood that one.

 

Campion: Do you think we should revert to Leaving-Cert.-only entry to Medicine or…

Crown: Yes!

Campion: …is there a third way?

Crown: I believe Leaving Cert. entry is the fairest way. Well, no, if you’re going to take kids of school-leaving age into medical school then yes: the Leaving Cert. was a totally fair system that gave us brilliant young medical students. The suggestion somehow seemed to be that if you were capable of getting 600 points in the Leaving then you must, by definition, have a personality disorder which makes you unsuitable for medicine. That’s clearly garbage. The system, which was put in its place, was not a good system. It devalued preparation and study and work and diligence and responsibility and other things in the mix that you’d like to have in a good doctor. I also believe there is no test you can give 17-year-olds that will tell you that, 17 years later, they will be good consultants or GPs. The notion that there is some aptitude test that will determine that is garbage. The system should have smaller holes in the net to identify people early in medical school, who have personality or psychological issues, and encourage them in other directions, which we have not been good at. The notion that there is somehow something wrong with people coming into medical school is not true and it was a very fair system. I think it should be all graduate. I think people are too young because I was picking my Leaving Cert. subjects to set me up for medicine when I was 14. That’s crazy. I think education at secondary school level should be very broad until the end. There’s a lot to be said for getting a broad university degree and then going on to medical school as a graduate. Something else I have to tell you: I don’t believe medicine is an art and a science; it’s a science. It’s a science practised by people that, hopefully, have good, humane values but, as somebody said to me, “If I need to have my aorta fixed, I want it done by a scientist, not an artist.” A lot of what passed for art in medicine in the past was scientific ignorance; a lot of Freudian gobbledygook, which we now know is tosh. As we learn more and more about the molecular biology of psychology, we’ll understand that. I think we should have premedical courses, which have to include science. I’m very uncomfortable with the notion that people can go in to study medicine with a degree in commerce or, you know, Aramaic.

 

Campion: What motivated you to study for an MBA and how do you use it now?

Crown: I was fed-up of bureaucrats dismissively telling me that I wouldn’t understand the arcane complexities of what they did in management and I said, “You know what, I’ll go study it myself”, and I beat every one of them in my class, got first place in the class on the MBA and got on the Dean’s List. Educationally, I learned a lot from it. I’d say the key take-home message from it was differentiating management from leadership. I learnt a certain amount of technical details in terms of health economics and that formal study of health economics was very useful to me. It also gave me all that great jargon.

 

Campion: Do you see yourself staying within the political system to augur for healthcare reform?

Crown: I believe that this is the last Senate. I believe the Taoiseach will bring in a referendum to abolish the Seanad in the course of the current Oireachtas; he has said he will. Maybe I’m politically inexperienced; people have said to me that he’s got so much to do that it might get turfed to the following Oireachtas. I think that if the electorate is confronted with that simple yes/no abolish choice, in the current situation it will be abolished. At present in the country the mood is very anti-politician and there’s a desire to scale it down. The truth is if I was confronted with that choice as a voter I’d say abolish it. I think it’s democratically flawed and often ineffectual and I think that the critique that’s offered of it, which is basically that it has just become another prep school or retirement home for people whose primary focus is to be in the Dail is not without merit. I think there’s a lot to be said for that and I think that’s what it is for a lot of people. I suspect that your question is actually “Do I see myself developing a career for myself in politics instead of in medicine and research?” I’d never say never. I think it’s unlikely. I think I’ve probably left it till I’m too old and the truth is I love the day job.

 

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