May 5, 2020
In this special series on careers in oncology, guest host Dr. Miriam Knoll, radiation oncologist at the John Theurer Cancer Center at Hackensack Meridian Health, interviews a wide range of oncologists who discuss their greatest challenges and the decisions that have shaped their careers. In this episode, we hear from Dr. Vinay Prasad, hematologist-oncologist, author, and associate professor of medicine at the University of California San Francisco, and host of the podcast, Plenary Session. (This podcast was recorded while Dr. Prasad was at the Oregon Health & Science University School of Medicine).
Dr. Miriam Knoll: Welcome to the ASCO Daily News podcast. I'm Dr. Miriam Knoll, and I'm delighted to be the Daily News guest host for a special podcast series that explores the full spectrum of oncology careers.
Dr. Miriam Knoll: I'm an early career radiation oncologist. And in this series, I will bring you interviews with a wide range of oncologists to hear about their diverse experiences, their greatest challenges, and the unforgettable moments that have shaped and continue to shape their careers. In today's episode, I'm so excited to welcome my friend and colleague, Dr. Vinay Prasad, a medical oncologist and associate professor of medicine at the Oregon Health and Science University School of Medicine.
Dr. Miriam Knoll: He's also an author and host of the podcast, Plenary Session. Dr. Prasad and I report no conflicts of interest relevant to this podcast. Full disclosures relating to all Daily News podcasts can be found in our Episode pages. Dr. Prasad, welcome.
Dr. Vinay Prasad: Thank you so much, Miriam, for having me. It's a pleasure to be here with you.
Dr. Miriam Knoll: Amazing. So my first question is, I wanted to ask you when you first started off as an early career oncologists. And actually, you still are an early career oncologist. Would that be fair to say?
Dr. Vinay Prasad: I guess. I hope so. But I'm five years in the job. So take it for what it is.
Dr. Miriam Knoll: I guess it depends on the exact definition.
Dr. Vinay Prasad: Yes.
Dr. Miriam Knoll: But when you actually started in your first year, you already had a large following on social media. And you were very vocal then, and now, about how we should improve cancer care and cancer research. And you're the host of the very popular podcast, Plenary Session, which I was actually interviewing on about a year ago.
Dr. Vinay Prasad: Yes, you were a lovely guest. Yes.
Dr. Miriam Knoll: Thank you. And so my question is, did you ever consider then, and now, how social media could impact your early career?
Dr. Vinay Prasad: That's a great question. I guess I would say I didn't consider then. It has been a total surprise.
Dr. Vinay Prasad: And just to give you a little bit of background, I started on faculty in 2015. So it's my fifth year as a faculty member, and it's my first job out of fellowship. So listeners will decide if that's early or mid-career.
Dr. Vinay Prasad: But I went back and I looked at it. One of the first things I did as a faculty member was we did a paper that came out in JAMA Internal Medicine about financial conflicts of interest for doctors on Twitter, medical oncologists on Twitter. And in doing that project, we kind of based it off my Twitter account at the time. And it might surprise you to know that, at that time when I started, I had about 1,000 followers.
Dr. Vinay Prasad: So I think that's some following, but I don't know if that would be considered a large following. And from there to five years later, it really has kind of grown. And it surprised me that people are interested in the kinds of issues that I want to discuss, which are very technical issues about drug development, clinical trials, and medical evidence.
Dr. Vinay Prasad: And it kind of led me to think about doing something else, reaching out to people. And that led to the podcast, Plenary Session. And I guess I would say, the honest reason why I started making a podcast was, because I, myself, really enjoy listening to podcasts. I have a lengthy commute, and I listen to all sorts of shows. And I really do like shows that are done by technical experts, which also try to reach a broad audience.
Dr. Vinay Prasad: So shows that you know don't dumb things down, but also try to be accessible and engaging. And I thought that there will be some opportunity to do that in oncology. And we've been doing the show now for over a year, and it's been great.
Dr. Miriam Knoll: So would it be fair to say that you got involved in social media and continued to do it, because you were excited about it, and found it really interesting, and enjoyed it?
Dr. Vinay Prasad: I guess, I would say, yes. It's a mix of emotions, as you'll know from being on it. When I started, I think being-- the reason I opened a Twitter account-- and I'm not a social media type, and I don't have a Facebook page, and I'm not on Instagram.
Dr. Vinay Prasad: The reason I created a Twitter account was because somebody assigned it to me in a class. I was taking my MPH degree. And I think I spent a year or two years just kind of being a lurker, just kind of seeing what people are saying, and not even checking it all that frequently.
Dr. Vinay Prasad: But I kind of got pulled out of my shell, drawn into it a little bit, when one day a paper we had published, I noticed a bunch of academics were discussing it. And they were a little bit critical about some things, which I thought were an unfair criticism. And that's kind of what pulled me out, out of the shadows, and into the arena of the discussion on social media.
Dr. Miriam Knoll: Wow, that's a great story. Would you say that social media has helped your career?
Dr. Vinay Prasad: That's a good question. I think it is a double-edged sword. It has certainly helped in many ways, which is that you're invited to give a lecture, or go talk to somebody.
Dr. Vinay Prasad: It's led to a collaboration with people with whom I never would have worked with. We published papers. So there are all these ways in which it connects you to this community of oncologists. So that's all the plus side of it.
Dr. Vinay Prasad: I think the minus side of it is people think of me as a social media person, and maybe for better or worse, they think of me as somebody who does that kind of stuff. But that may mean that they're likely to ignore that I do a lot of academic work too, and published a few hundred papers, and have two peer review books in the academic literature. And so I think it can be used as a tool to disparage or trivialize something you're doing. And so I think that's why it kind of cuts both ways.
Dr. Miriam Knoll: That's very interesting. I hadn't thought about it that way. But I wonder if that's an impression that someone who is not involved in social media would have, and not something that someone who is involved would think.
Because I can't imagine anyone thinking that about you. But then again, maybe that person who would think that has never been on Twitter before, so doesn't actually know what it's about. You know?
Dr. Vinay Prasad: I agree. I think there a lot of people who aren't on Twitter who have misconceptions about it. But I'll just give you one good example, which is Bob Califf, who is the former Commissioner of the FDA, a senior cardiologist; he just wrote an editorial in a cardiology journal critical of the Kardashians, he calls it, which are people who have far more Twitter followers than they have cumulative career citations.
Dr. Vinay Prasad: And I guess even though I've published a lot of papers, I'm in that camp. Because cumulative career citations only accrue on the order of decades, and Twitter followers come much more rapidly. And so the whole Kardashian index, I think, is a term that people have created to disparage and criticize the changing power dynamics that have happened through social media. It's a fictitious invented scale that accomplishes that goal.
Dr. Miriam Knoll: Yeah. Well, I think this is a discussion that we should definitely continue. But I just have so many other questions to ask you about jobs. But before we go to the next question, I just want to make sure that you and I clarify that we don't think that's the case, right?
Dr. Vinay Prasad: Yeah. And I think the benefits certainly outweigh any negative ideas that someone who has no idea about anything about social media may think about it.
Dr. Vinay Prasad: Social media, it's-- what all scientists want, what all you know academics want, is for their ideas and the work they're doing to reach the broadest and most receptive audience. And this is just a tool, perhaps the most powerful tool we have, that accomplishes that goal. And so anyone who's sort of anti-social media I think is missing the printing press of the modern age. And in retrospect, they're not going to do so well in the history books.
Dr. Miriam Knoll: I could not agree more. And I think also that some of the hesitation that people have to using it is because their only exposure to social media is the Kardashians. So they haven't met people like you who are sharing real data and thought-provoking information that they can't find anywhere else. So it's even beyond the typical printing press, because you can share information that there's really no other platform for.
Dr. Vinay Prasad: That's a great point, yeah.
Dr. Miriam Knoll: Tell me about the process of changing jobs and academic centers. Because, congratulations, I heard that you're going to be switching over to UCSF. So I'd love to hear about that transition for you.
Dr. Vinay Prasad: Oh, thank you. Yeah, I guess I'm still in the midst of it, because I haven't finished packing my desk here, but it's imminent. It's going to be happening in the next eight weeks or so.
Dr. Vinay Prasad: I guess I would say that the biggest question that faces a researcher is-- actually, let me pause. Let me actually start by something that somebody told me. When I took my first academic job, I had a very senior faculty member at the NCI, where I did my fellowship, pulled me aside and say, congratulations on your job. That's a great five-year job.
Dr. Vinay Prasad: And I said, excuse me? What do you mean, a five-year job? And he said, think about the first academic job as-- not in everybody, but in many people-- people work in that job four or five years, and they end up making a switch. And it won't surprise me if you're one of those people.
Dr. Vinay Prasad: And I thought it wouldn't happen to me-- absolutely not the case. It's not going to happen to me. I didn't see that in my future.
Dr. Vinay Prasad: But nevertheless, five years later, this person's words rang really true. And I guess I would say that the process of switching jobs or thinking about that has to do with you really want-- you really reach a point where you have a clear sense of what you want to do, what you aspire to do, and what you hope to do in the future, what you're good at doing, and you also know what you're not good at doing. I think that comes out in the first few years of a job.
Dr. Vinay Prasad: And that's a time where you might think to yourself, you want to be at a place where your goals and the central goal of the organization or the institution are really aligned. And you see opportunity for growth, opportunity for collaboration, you see that what you do is going to be really valued and respected. And so at the end of the day, what I want to do is oncology policy work, work that aligns cancer medicine with I think patients' best interests. I also enjoy teaching and working with trainees. And I really felt like UCSF is a place with just such a strong, strong history of doing all those things-- a huge policy group, a really strong program of education, and really strong training in epidemiology and bio statistics, which is the department that I'm joining.
Dr. Miriam Knoll: So you shared with us what the mindset would be for switching jobs. What about the nitty-gritty? Is it generally someone reaches out to you, you reach out to someone else? What advice would you have to other early career or even at any point in someone's career? And how does that work?
Dr. Vinay Prasad: I think that's a great question. I guess I'd say, the nitty-gritty is when you in your mind start to open your mind up to the possibility of looking for another job. So for me, I don't even-- my mind was not even open to that for the first 3 and 1/2, four years even.
Dr. Vinay Prasad: Then I think you start taking a look at job post websites. You start looking on institutional websites. You start listening to word of mouth, what different divisions or groups are looking for. And you get wind of jobs here or there.
Dr. Vinay Prasad: And I think it's reasonable that, even if you're not super serious about leaving, to go on some interviews. You don't know what's out there unless you go look. And it's a long process.
Dr. Vinay Prasad: In my case, it was like over, I don't know, maybe about a year from-- maybe over a year-- from my first toe in the water to actually committing to make the move. And so I think it is kind of a slow process. But in my mind, the mental attitude to consider it is the first step.
Dr. Vinay Prasad: And then the logistics of it is just to keep an eye open. But nobody approached me in this particular situation. Although, I'm aware, and I've heard, that there are people who get approached with job offers, but that wasn't my case.
Dr. Miriam Knoll: That's really, really great advice. So thank you for that. Can you tell us about your second book, which I've already preordered on Amazon?
Dr. Vinay Prasad: Thanks.
Dr. Miriam Knoll: What advice can you give our listeners about the process of writing a book and becoming a published author?
Dr. Vinay Prasad: So you're referring to the book, called Malignant.
Dr. Miriam Knoll: Yes, Malignant.
Dr. Vinay Prasad: And I learned a lesson from the first book, Ending Medical Reversal, which needs a punchier title. So Malignant is really everything I know about cancer policy in one book. I guess, let me separate the two again-- so the process of doing the book and the reason why you might want to write a book. So I guess, let me take the process one.
Dr. Vinay Prasad: The process is, it's a long process to write a book. And you'll see when you read this book, and you'll read something in the chapter that I've written, and it says, "at the time of this writing, 2017," and you're going to say, boy, it's 2020 now. But that's really how long the process takes. It takes several years.
Dr. Vinay Prasad: The process of writing a book is you have to, I think, first, have a clear idea of what you want to talk about, what you want to write. Second, you've got to draft a proposal, which is very different than a book itself. It's kind of a succinct summary of what you hope to do.
Dr. Vinay Prasad: Third, you have to find an agent, which can take on the order of years. And then the fourth thing is you have to sell the book to a publisher, which can take on the order of years again. And then you've got to write it, which is the most important, but often the shortest period of time. And then you got to edit it, and proof it, and all those sorts of steps.
Dr. Vinay Prasad: And in my case, I have a publisher that is a peer review publisher. So this book is peer reviewed in triplicate, which adds, just like an academic article, all that back and forth peer review. So it's time-consuming. So that's the process of how to do it, and it takes, I think, a long time.
Dr. Vinay Prasad: But let me talk about the reason why to do it. I think you write a book when you have something to say that you just can't say more succinctly. And in my case, for years we've been working on so many different spaces that seem like they're not interconnected.
Dr. Vinay Prasad: So we then work on financial conflict of interest. We'd done work on how the FDA approves drugs with the use of surrogate endpoints, the control arms of clinical trials, crossover. We have done work on the cost of cancer drugs, and how Medicare reimburses for it.
Dr. Vinay Prasad: And so it seems like these are projects all across cancer medicine, but they're like intertwined braids, and they tie together. And when you twist them all together, I think you start to see the full story of why the system is set up the way it is, and how so much cancer policy fails, I think, people with cancer. And so me writing the book was a recognition that I was never going to persuade people. I was never going to get people to see this whole tapestry until I got all the strands and tried to weave them together in front of you.
Dr. Vinay Prasad: And so that was why I wrote the book. And I guess I would say, when you want to talk about writing a book, I think you have to realize that a book is an intermediary endpoint. It's a surrogate endpoint of itself.
Dr. Vinay Prasad: The goal of the book is so that there are people out there who will read this, and I think it'll change the way they see cancer medicine. That's the goal. And the book is just a vehicle to do it.
Dr. Miriam Knoll: I cannot wait to read it. And I'm hearing you speak, and it's echoing a conversation that you had on Plenary Session. It was a few weeks ago. I forget which episode it was.
Dr. Miriam Knoll: But it was about careerism, and the idea that you write papers because you have something that you want to say, not because you want to write papers.
Dr. Vinay Prasad: Right, that's an important thing, yeah. I'm a vocal critic of this careerism movement that I see all around me.
Dr. Miriam Knoll: Do you think that it's a new movement?
Dr. Vinay Prasad: I think it's been-- I guess I'm so new myself. I don't know if it's always been there. But I think it's been amplified in a way that is unprecedented. And it's amplified, I think, in part-- social media, of course, a double-edged sword. It also amplifies careerism.
Dr. Vinay Prasad: And just for your listeners' sake, let me separate the two things. So there are the things you want to do in life, and there is the things you do for your career. And to me, careerism is advice about careers.
Dr. Vinay Prasad: That is, how can I give more lectures? How can I have more followers? How can I sit on panels? How can I be a consultant for pharmaceutical companies? How can I network? How can I be successful?
Dr. Vinay Prasad: Those are all sort of the arbitrary brass rings that people chase. And I think that they're all misguided. Because the more and more you talk about how to achieve those goals, you miss the entire purpose of the whole enterprise, which is, what do you want to accomplish?
What issues matter to you? What topics interests you? What skills do you uniquely bring to them?
Is your work accurate or truthful? Does your work matter? Is this what you want to do with your life?
Those are the real questions, I think, that define our career. You have to think, what are you passionate about, and what can you do that others can't do? And then you just do it.
Dr. Vinay Prasad: And if along the way you get these rewards of you give lectures, you get the invited consultancies, you get all that stuff, so be it. But if you don't get it, you shouldn't feel bad at all if what you're doing is what you really want to do. And if what you're wanting to do is challenging, I think, the status quo, then don't be surprised if you don't get it, you get some pushback. But I think that's something worth taking on, that's worth fighting for, if what you're doing is what you believe you ought to do with your career and your life.
Dr. Miriam Knoll: I totally agree with you. And I think that people who really understand that are less likely to separate their life into their work life, and their life life, and their personal life. Because it's all one thing.
Dr. Miriam Knoll: You do it all, all of it-- family, hobbies, career. You do it all, because you feel strongly about it, because that's what you want to do. So there's no reason to separate them.
Dr. Vinay Prasad: I love the way you put that, because that's what I'm trying to say, yeah. You feel strongly about it, and that's why you do it. And that's what you want in a career.
Dr. Vinay Prasad: You and I, we pursued the career of medicine, and we're really lucky to do it. Because we're some of the few people, I think, who get to do something day in and day out that doesn't feel like work. It feels like a joy. It feels like the thing that you want to do, you want to get out of bed and do, and that's a tremendous privilege in this world.
Dr. Vinay Prasad: And the more you chase the brass rings, and the less you forget about what you want to do with the brief time we have on this planet, I think the more you're prone to burn out, the more you'll want to separate things. And I think recognizing that, if you chase what you really want to do, those things will naturally fall into place.
Dr. Miriam Knoll: And that was one of the goals of my doing this podcast series, was to allow people that have-- people like yourself-- who are excelling in many different ways of being an oncologist and are passionate about it, and being able to share the ways that being an oncologist can be fulfilling in many different ways from each other. And it's very personal. So I want to ask you another more personal career question, which is, what is the best career advice that you remember that you've been given?
Dr. Vinay Prasad: I guess I would say that the best career advice came to me from a wise man, who is a professor at University of Chicago, Adam Cifu. And he's a kind guy, because I think he's tweeted out a slide he calls "Career Advice," and he's put this out on the internet for all people to see. And here's his career advice.
Dr. Vinay Prasad: Choose the job that promises the best set of colleagues. Choose the better job over the higher paying one. Be honest with yourself about whether you'll be happy with the demands of the job and the level of acuity of the patients.
Dr. Vinay Prasad: Don't trust that your new employers will change the job they offer you to fit your desires. Early in your career, say yes to everything. Later in your career, say no to everything except the things you really want to do. And beware of promotions that take you away from doing what you love. And he has a few others.
Dr. Vinay Prasad: But the reason that really speaks to me is that the theme of everything he's saying is that it's not about the money. It's not about-- it's not about the title. It's not about the promotion. It's about making sure that what you want to do and the job you're signing up for are a good fit.
Dr. Vinay Prasad: And a lot of fit and a lot of job satisfaction is who you surround yourself with, and what are the sort of tasks you are facing. And I think that's the core of his career advice. And I think it's very wise.
Dr. Miriam Knoll: What was the worst career advice you've ever been given?
Dr. Vinay Prasad: Well, I guess I would say the worst career advice I've been given is-- I guess it wasn't to me. It was directed broadly. But I saw it on Twitter recently, and I ended up writing a column in Medscape about it. And it was something like, oncology is a small world. Don't make enemies, is the advice.
Dr. Vinay Prasad: And I guess the reason it's stuck with me was, at first glance, I see that that is incredibly reasonable. It's a small world. There are so few of us in oncology. We all know each other after a period of time.
Dr. Vinay Prasad: Don't make enemies. Try to avoid conflict. But I think the reason it really started to trouble me, the more I thought about it, was that we are in the midst of a crisis in our profession.
Dr. Vinay Prasad: We have more drug approvals than ever, but more of the drugs we have that come to market are drugs that we don't know if they make people live longer or live better. The prices of our drugs are the most they've ever been. The dollar amounts that expert oncologists are taking home from consulting fees from pharmaceutical companies is the highest it's ever been.
Dr. Vinay Prasad: The experts who are conflicted are the ones who write the guidelines. The guidelines often recommend drugs based on weak evidence. Those weak evidence guidelines are tied to CMS and mandate Medicare reimburse for drugs without negotiation.
Dr. Vinay Prasad: Many of the academic papers have flaws. Many are ghost written. Many have medical writers. So what I want to say is that we live in a time where the entire cancer system, in so many ways, is misaligned towards corporate profits over the best interests of patients. And if you really, as a junior person, enter the field with this mantra, that above all else don't make enemies, you're never going to do what it takes to fix this ship, to realign the ship, to correct the serious deficiencies that plague our patients. You're never going to be able to do what we need you to do if you enter this thinking, I don't want to ever have anyone dislike me. You're going to be a part of the problem, not the solution. And so I think that's the worst advice.
Dr. Vinay Prasad: The right advice is, you're not in this business to make friends. You're in this business to do what's best for people. And 30 years sounds like a long time when you start your career. But five years goes by like a flash, and 25 years will go by like a flash too. And before it all ends, the system will just be as entrenched and flawed as it was when you started.
Dr. Vinay Prasad: So if you don't do everything you can every day you can, you're squandering your opportunity. And that's an opportunity that I think when we swore that oath to be a doctor, we swore an oath to do what's best for patients. And so I think that that's bad advice. The right advice is, do what needs to be done, and let people feel how they feel about it.
Dr. Miriam Knoll: And I know that we could continue talking about this for hours and hours. And I know you have amazing advice to give, and I really appreciate your time. So my last question for today is, what advice do you have for trainees and early career oncologists?
Dr. Vinay Prasad: I guess my advice would echo those last comments, which is, you're entering oncology at one of the most exciting times. There's a lot going on. You need to do your best to stay up with oncology in an independent and thoughtful way.
Dr. Vinay Prasad: You've got to read papers yourself. You've got to critically appraise them yourself. You've got to see what the discussions are, the debates are. You've going to make your own decisions.
Dr. Vinay Prasad: And when you see the system fail your patients, you've got to be an advocate. You've got to speak out. And I think we need your voice more than ever. So that's the advice I'd leave them with, which is, it's OK to make enemies, if what you're doing is the right thing.
Dr. Miriam Knoll: Dr. Prasad, thank you so much for this insightful discussion. And thanks so much to our listeners, for you guys, for joining us for this episode of the ASCO Daily News podcast. We'd love to have your feedback, as always. So please, drop us a line at DailyNews@ASCO.org. And of course, don't forget to rate and review us on Apple Podcast.
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