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Leading with Relationships

Toufic Kachaamy, MD

A conversation with Toufic Kachaamy, MD, of City of Hope.


MCMS: What’s your average day?

Dr. Kachaamy: Today is a normal day. There's always something going on, which for me is exciting. I love patient care, but I also like the diversity. Diversifying your self-worth is probably the best way I'll describe it. If you're involved in a lot of things and some things don't work out, you still have things to feel good about.

MCMS: Dr. Kachaamy, you have two roles. You're Chief of Medicine and Director of Gastroenterology and Endoscopy. Let's talk first about Chief of Medicine, a big job. What do you do?

Dr. Kachaamy: The Chief of Medicine is a relatively new job for me. We are in transition from being Cancer Treatment Centers of America to City of Hope. All the leadership positions, jobs, and job descriptions are being defined. I can tell you what I do today but what I’ll be doing six months from now is to be determined. City of Hope also moved from California to being a nationwide cancer provider, so all these structures are being defined now and reporting structures and specific job descriptions are in flux. Almost all the partners that are non-surgical eventually report back to me from the clinical standpoint, whether it’s psychiatry, endocrinology, pulmonary, or GI. They are also involved in the design of services, how the services run, in the strategy for every department, in recruitment, and quality metrics. Quality is probably the part that consumes most of my time and overseeing physician performance, giving feedback to physicians. One of the projects that I have this year is to create a kind of personalized but somewhat standardized format to report back to the physicians on their performance. That's a personal metric, not something to be advertised like Press Ganey, which creates a score for physicians. I think once something gets to Press Ganey, you are being reactive and one of the ways of being proactive is figuring out where your strengths are, where your weaknesses are before you get to a point where the patient is unhappy or before you get to a point where there's a safety event. I think the best way of providing that is collecting good information on processes and quality and reporting back to the physician in a non-threatening, constructive, positive way.

MCMS: That can be difficult because physicians want to know if ratings are weighted in one way or another or if their job is on the line.

Dr. Kachaamy: Yeah, it is difficult. In management classes, we talk about sandwiching feedback as positive, negative, positive. Science talks about four positives to one negative to be neutral. As a leader giving feedback, the optimal for positive is 10 to 1. Our brain is designed to remember the negative. If you didn't remember where the rose was, you would still survive, but if you didn't remember where the lion was, then you were eaten. You really have to overwhelm with positive if you want any negative feedback that is constructive. I'm very cognizant of that. That's why before it gets to Press Ganey, we want to tackle it in a way where it's not threatening to the physician. Is it hard? Absolutely. Does that make it more fun? Absolutely. You know, easy things are not that rewarding to do.

MCMS: We've talked to a lot of clinics, group practices, and others about value-based care and the metrics they track. One group had physicians in green, yellow, and red. They were more surgical, and they wanted to find ways to move the docs who were red to yellow or green, keep them there, not lose money, and ensure that quality of care is being delivered. Have you thought about what would go into the City of Hope quality metrics?

Dr. Kachaamy: As an oncology hospital and a cancer center, we have quality metrics called QOPI. They are process metrics. I think process metrics have their pluses and minuses. They're easier to measure, but these are standardized quality metrics for a cancer center. Press Ganey measures patient satisfaction, rehospitalization, and surgical complications within 30 days, stuff like that. There are a lot of metrics that are already there that are outward facing. What I'm trying to create for us, in conjunction with our leader in HR is internal quality metrics that are non-threatening. Just the thought of having physicians in red, in my opinion, is the wrong way of doing it. Red stimulates your amygdala. You lose that engagement. My goal is to provide internal metrics for us that are non-threatening. I’ll go to a physician and have a one-on-one conversation, but I don't want it to go elsewhere. We want to tackle quality issues early and maybe the quality is fantastic, and it’s a question of how we get to the next level, to make it fantastic.

MCMS: Is that possible in a larger system?

Dr. Kachaamy: We still have some local autonomy. I like to test things.

MCMS: If they work here, then maybe you tell others to try it out.

Dr. Kachaamy: Yeah, but now we don't have that solution. We don't have a not published quality metric that is internal stuff like physician development. Physicians get traumatized in medical school, in my opinion. We lose a lot of our emotional intelligence and social skills because we are all work, work, work. If you tell an engineer that we have to cap you at 80 hours, they’ll say what are you talking about? But for us, capping at 80 hours, which is twice the average work time and when you look at science, 40 hours is even more than what's optimal for human production. Probably between 30 to 35 hours is where we peak in terms of productivity and, after that, it's downhill. For physicians, we set them up at 80, and we all know it's not really 80, it's 90 and 100. So, the human aspect of being a physician, in my opinion, in this day and age needs to be rebuilt. And that's what I call physician development like being a good husband, a good father, taking care of your physical health and your mental health is required to be a good physician. These are not in silo. If you have an argument with your wife in the morning, your patient will feel it and you can't expect the healers to be sick. Everyone talks about physician burnout. I blame physicians for part of it, but the other part of it is the wrong incentives are also there, which set us up for not having an optimal life. In my department that is not something that I'm going to accept. I need a non-threatening physician development forum, not a carrot and stick.

MCMS: And you need top cover from management when you’re saying we need people to have a good balance or, otherwise, they're going to reduce their hours or quit. In extreme cases, docs make mistakes with patients and the worst-case scenario, physicians kill themselves when it gets incredibly bad.

Dr. Kachaamy: We're seeing it more. The 80-hour work week came because of mistakes. So really even the 80-hour work week, the physician was not at the center. It wasn’t because the hours were inhumane. They said you're making too many mistakes, so we need to cut your hours. Physicians need to go back to being the leaders they went to medical school to be in society and being a leader is more than taking care of a patient. It’s also being a good example about having the balanced life that people look up to and say, hmm, this is how it should be done.

MCMS: That's one side of your day job. You’re also in charge of gastroenterology. How do you balance those and how does that divide on a normal day?

Dr. Kachaamy: Delegation, delegation, delegation to people who you trust. One of my hires was an experienced GI nurse practitioner and we trained her on the oncology and gastroenterology care of cancer patients and now she's probably managing 70 or 80% of the clinic work. As you have more hats to wear, your inner circle should be someone who has your back, lifting you up and alerting you. She will say, “Hey, this patient I need you to call today, and these patients had some concerns. There are things that didn't make sense to them. I need you to call these patients.” My junior partner is taking more ownership of running the endoscopy. As my role gets bigger in medicine, my role in gastroenterology will pass on to the next leaders in the field, but I've built this practice. I've been here 10 years, so I've built it from scratch. And I'm building the endoscopic oncology field for the nation, which is something that I'm proud about. That goes beyond the work here, but it mimics the work here, showing colleagues we’re successful and what it means to work in a cancer center as a gastroenterologist. We have training programs, guidelines and literature that support what we do.

MCMS: Who else works on that gastro team?

Dr. Kachaamy: We are two MAs, two RNs, two nurse practitioners, two gastroenterologists, two and a half techs, two endoscopy nurses. And then we have pre op and PACU and pre-endoscopy care. We’re around 15 people.

MCMS: That's great. You've been here about 10 years. Why did you choose then CTCA, now City of Hope?

Dr. Kachaamy: The number one reason for me was I felt I will have a balanced life working here.

MCMS: What does that mean to you?

Dr. Kachaamy: It means I am in an organization that values you as a human and not just as a worker. The chairman that started CTAA at the time called everyone stakeholders, not employees and I noticed that when he would walk into the room or walk into the building, he would go give hugs to environmental services. When he had the Christmas party, everyone was there from the security people to the physicians. That showed me that this organization values every human. When you are working in a hospital, whether you make sure the doors are locked or the electricity is running or fill prescriptions for the pharmacy, everything you do impacts patients, and everyone should be valued. And I saw this organization valuing everyone. At the end of the day, we're as strong as the weakest link. If the people who are cleaning my scopes don't feel valued, then my scopes might not be as clean as they should be, and then I'll have an infection and I can be the best endoscopist, but my patients are dying from infection from unclean scopes. That's the aura that I felt when I interviewed here that everyone's valued. This is a place where I can build a team. I've had zero turnover from my team in 10 years, except the people that got promotions like one of my techs last year left to become a part of industry, which is a big promotion for him. I’m very happy for him. I have not had someone say I don't like my job. We invest in each person and that's the main reason why I came here. I felt the organization valued that, and if you look at current City of Hope, it's the same philosophy. On their website today they are highlighting the scheduler. Not many places do that, which is unfortunate.

MCMS: Congratulations. You found a good home. What do you think makes City of Hope different from other hospitals in the region?

Dr. Kachaamy: I think it starts in the name, calling it City of Hope. We approach patient care with positivity. What do I mean by that? A lot of people think of cancer as a wakeup call. They wonder how am I going to make the best out of my years remaining in life or months remaining? And if I make it and I get past that, how do I become a better human after this? The philosophy in this hospital is how do we make that wakeup call full of hope for the patients. For some patients, it’s the hope of making it to their daughter’s graduation or to live five years and for some it’s the hope of dying with dignity. We are happy to partner with all these patients. That level of commitment to what the patient values is what the healthcare system, in general, is missing. We care about metrics. We care about productivity. We care about pleasing the administrator. Where is the patient in this? We are here to serve the patient. We work for the patient. Imagine going to a restaurant where the waiter says, “Oh, you're hungry again. Why are you coming back?” I hope you never need the healthcare system, but if you needed the healthcare system in the last 10 years, you don't feel welcome. They'll say, hey, thank you for trusting us when you're sick and feel crappy and you're vomiting, and you didn't shower and you're embarrassed and you are trusting us with your care. When was the last time you had an experience like this in healthcare?

MCMS: It’s not like an airline that says thank you so much for choosing us and we’re going to take care of you. Customer service in healthcare needs to improve.

Dr. Kachaamy: We call someone a difficult patient if they have a lot of problems. But why do we exist if you don't have problems. I have patients apologizing for having that many problems. I don't work in the circus. I don't expect you jumping. This is a hospital. You are here because you have problems, so don't apologize. And that aura is what we have that very few places have.

MCMS: What feedback do you get? What do patients or families tell you about the impact that your team has had on their lives?

Dr. Kachaamy: The best message or my favorite message that we get is family members of patients who pasted away, and I get a text from a patient’s caregiver after three years and they say they’re visiting, and can I come to say hi because we have fond memories of the center. For me, and I'm getting goosebumps, this is the biggest testament of the impact we have. If their loved ones were here struggling and passed away and they still have fond memories of being here because they were not treated with dignity somewhere else, but they found dignity here, or we helped put a smile on their loved one's face, even though they were suffering. That is the best feedback I can get, when the outcome wasn't what you wanted, when the patient didn't make it, but the family members are still saying they would like to come say hi to the team. It matters, making them feel welcomed, showing that their suffering is something we take seriously, and we don't think of them as annoying. It makes the patient feel that we are part of one family, that we are all in the same struggle, even when the outcome is not what you wanted and what you were hoping for, that they still feel that we were there for them. That’s probably the best feedback that I get, or my team gets.

MCMS: I’m sure there are plenty of moments in oncology when you don’t have rosy outcomes. How do you go about bringing new staff on board and balancing the weight on your heart of caring for cancer patients?

Dr. Kachaamy: I struggled the first few years. The way I solved that for myself, and I gave the same talk to any team member that joins us, is we're here on a mission. And your mission is to make life better, maybe longer. Maybe to help patients get over a bump that's cancer and go back to their life but whatever you are here for is something to add a positive aspect to the patient’s care, so don't get bogged down with wanting to save everyone. We're all going to die, I guarantee you. Having the mission of helping patients and especially the way they want to be helped is what we focus on and what I try to teach a new member of the team. All you have to do is be better than the previous person. Keep in mind that means better in the way that the patient wants and better in the way that patient values and that doesn't have to be saving everyone. That doesn't have to be curing people. It has to be making their life better. When you have that mindset shift, then it's no longer emotionally draining because you set your expectations in a real way. Cancer is really a few hundred diseases. We call it cancer for simplicity, but it doesn't give it the complexity it deserves. A melanoma of the eye is not the same as lung cancer. We call both cancers. These are two completely different diseases. When you get a urinary tract infection and pneumonia, we don't say I’m going to cure your infection. We call this pneumonia. We call this UTI. And, you know, we do ourselves a disfavor when we call it cancer. That big word is very hard to have a pill that's going to solve all these problems. Because we're trying to solve 300 diseases. We're tackling them a disease at a time. We're not here to change the world overnight. We're here to make the patient, who is in front of us, feel good about what we're doing for them.

MCMS: Looking at the healthcare system writ large, what would you say are one or two of the biggest challenges we need to try to overcome or improve so we can deliver better care for patients?

Dr. Kachaamy: I think the biggest problem we now have in the healthcare system is what people are calling burnout and the reality is it’s an unbalanced life. The physician who is worried about their finances is not the best version of themselves. The physician who doesn't have parenting skills is not the best version of themselves. And because the current education system, from kindergarten all the way to high school, teaches their own skills, in my opinion, you come with the wrong set of tools to tackle modern life and physicians are an extreme version of that because their job is high stakes. One of my missions is to define what it means to have a well physician. For example, one of the markers of stress in your life is lack of control over your life and very few physicians feel that they have control over their schedule, control over processes. You don't have to control others, but you need to have a say in what's happening and how you want your life to run and have the tools. As a society, if the healers are sick, we're in trouble.

MCMS: These days, what motivates you every day to come here and lead your team and provide care for patients?

Dr. Kachaamy: I feel as a leader, my job is to help everyone get better. And what motivates me is the same service I provide to the patients I want to provide for my team. We talk about their retirement plans. We talk about their emotional health. We talk about their emotional intelligence. This is a big family and what motivates me is the relationship that I have with them. I can be the confidante for a team member who is struggling. It may be recommending books, sharing my experiences, how I manage this problem, or guiding them on where to go. I think a team leader who has that view comes highly motivated because, for me, it's where I get my energy from. I come here and I'm helping others and they're helping me and it's really one big family. This is not a job. The biggest marker of human satisfaction is relationships and my relationship with my team is a big source of satisfaction for me, and that's probably what motivates me every day to come here. I love vacations, but I also look forward to coming back and seeing all of them.

MCMS: That's awesome. Arizona Foothills Magazine last year recognized you as one of the valley’s best dads.

Dr. Kachaamy: Oh yeah, yeah. Thank you.

MCMS: What did that mean to you?

Dr. Kachaamy: Responsibility. I have to be a better version of myself when it comes to parenting. My kids have taught me the most about myself and, I have to say, parenting is the process that helped me the most in becoming a better version of me, and that's still a work in progress. It will always be a work in progress, but I think the fact that this was a voted position, the fact that people who are close to me said yes was a huge source of pride for me and a big responsibility to take on more and make sure that I deserve that title. And I see a lot of struggling fathers, mostly because of the lack of skills. And we tend to perpetuate our parents’ behavior and our parents tried the best they can, but there's a lot of information we have today on parenting, on how the mind works, and on how development works that our parents did not have. They did the best they could. But a lot of mistakes get carried over from one generation to another generation, because they get ingrained in us when we were little, and then you keep perpetuating. So being able to break that cycle is not a passive process. It’s a process where you have to work on yourself and I'm fortunate that my kids gave me that opportunity.

MCMS: Thank you, Dr. Kachaamy. Thanks so much for your time.

Dr. Kachaamy: Thank you, this is fantastic.

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