Office of Health Promotion Research
NCI Prevention Fellowship Means New Career Direction for Ted Marcy, MD
Article from INNOVATIONS
(A publication of the VERMONT CANCER CENTER at the University of Vermont, Spring 2000)
This past December, the National Cancer Institute (NCI) notified UVM Associate Professor of Medicine and Fletcher Allen Health Care pulmonologist Theodore "Ted" Marcy, MD, that his application for a Cancer Prevention Fellowship had been granted. For new VCC member Marcy, who had been able to devote only a small amount of time to his research on smoking cessation and tobacco control, the news represented an excellent opportunity for him to pursue a major interest.
Ninety-one individuals applied for an NCI Cancer Prevention Fellowship in 1999, and Marcy was one of only 13 who received the prestigious award. According to NCI Office of Preventive Oncology Program Coordinator Barbara Redding, Marcy's application was unique for two reasons: "We don't usually receive applications from someone at such a senior level. Secondly, he made a special request to be allowed to undertake part of the program in Vermont; this will involve a lot of traveling to and from NCI, which is in Maryland. His case is an exception, due to his level of experience."
Marcy's application represents a dramatic shift in career focus from clinical duties to behavioral science research. A 13-year attending physician in both pulmonary and critical care medicine, he thinks he was an attractive candidate to NCI for just this reason. VCC Director David Yandell, ScD, agrees, pointing out that"clinicians who conduct public health research are very much needed and somewhat endangered species."
Marcy is due to begin the three-year program in September of this year, at which time he will go on educational leave from UVM and significantly reduce his commitments to Fletcher Allen. However, he looks forward to having "protected time to do research without the demands of a full-time clinical practice."
During the first year, he will earn a master of public health degree, which will provide him with a broad foundation in behavioral research statistics, public health policy, and research design and analysis. He hopes to attend either Harvard or Boston University, as he plans to take classes on Mondays through Thursdays, and commute back to Vermont to maintain his outpatient clinic on Fridays.
In the summer of 2001, he will go to NCI to attend a six-week course in preventive oncology that addresses principles of cancer statistics, genetics and cancer biology, diet and chemoprevention, health promotion, and community intervention. During this time, Marcy expects to form collaborative relationships with NCI faculty.
For the remainder of his fellowship, his "special" arrangement will permit him to continue his tobacco control research in Vermont through UVM's Office of Health Promotion Research (OHPR) and VCC's Cancer Prevention and Control Research Program (CPCRP). He will be mentored by OHPR Director Brian Flynn, ScD, a UVM research professor of family practice and the CPCRP leader; Laura Solomon, PhD, a research professor of psychology; and Roger Secker-Walker, MD, a professor of medicine. All three of Marcy's mentors are VCC members.
"Vermont is a very good place for me to conduct my research, because of the state's commitment to spend significant amounts of its national tobacco settlement dollars on tobacco prevention programs," say Marcy.
Marcy explains that the tobacco settlement has been harshly criticized by many individuals due to what they perceive to be a serious flaw-the settlement does not preclude states from using the funds to pay for roads, taxes, schools, or whatever else they may choose. In Marcy's eyes, Vermont's commitment to spend 100% of the settlement funds on healthcare, and one-third of those funds on tobacco control and prevention, is admirable. During his fellowship, he wants to take advantage of the rich research opportunities that will be available in Vermont where multiple, comprehensive tobacco control programs will be underway.
Marcy's research--in broad terms--is somewhat atypical in that it focuses on primary care physician behavior in assisting smokers to give up tobacco, as opposed to the behavior of the smoking population itself. As he explains,"the question is not whether physician intervention helps people quit; we already know that. The question is, 'How do we enable physicians to do what's already proven to be effective?"
Specifically, Marcy will concentrate on how to help primary care physicians adhere to the federal guidelines for smoking cessation. Published in 1996 by the Agency for Health Care Policy and Research (AHCPR), these guidelines encourage physicians to "ask questions of," "advise," "assist," and "arrange follow-up for" their patients who smoke.
"My past research has shown that most physicians adhere to the first two "A's," but fall down on the latter two," Marcy says. "The challenge is how to translate assistance and follow-up into physicians' daily practices in a way that is practical under the constraints of managed care. Secondly, it's about helping more physicians to understand the informational basis that led to the AHCPR guidelines, and getting them to believe that their intervention is very important. In terms of a cost-benefit analysis, tobacco control is one of the most cost-effective interventions physicians can do."
In 1999, Marcy and Secker-Walker received a grant from the Robert Wood Johnson Foundation (RWJF) to evaluate the affect of a smoking cessation telephone resource on smoking physicians' compliance with the AHCPR guidelines. This experience confirmed Marcy's interest in the problem of incorporating preventive care into practice. It also served as a foundation for the program of work he presented to the NCI.
While the RWJF grant supported the design of the program, putting the pilot program into practice required additional funding. In a virtually unprecedented occurrence, Marcy gained the cooperative financial support of Vermont's three major managed care organizations-Vermont Managed Care, MVP, and BlueCross-BlueShield of Vermont-to fund the pilot program as a whole, not just for individuals covered by them. These competing entities recognized, Marcy believes, that in a state as small as Vermont,"There's a reasonable chance that a person who's not on your plan might well be someday in the future...so everyone would benefit by working together."
In developing the telephone resource, Marcy and his colleagues obtained input from physicians, the three participating managed care organizations, the Vermont Department of Health, and patients. The phone resource was administered by another key group in the consortium: the American Lung Association of Vermont (ALA of Vt.). The pilot program incorporating the phone resource was conducted at three Vermont primary care clinics chosen by each of the participating managed care organizations.
"We designed a referral service whereby a physician would say 'I'd like to have the ALA of Vermont give you a call to talk about your smoking,'"; explains Marcy. "After obtaining patient consent, the physician's office would fax a referral form to the ALA. ALA staff would then call the patient and complete a screening questionnaire designed to assess the patient's smoking behavior and intention to quit. Based on the person's responses, the ALA would offer motivational literature, a self-help kit, or the opportunity to participate in a peer telephone-support group. If the person selected the support group, support people trained by Laura Solomon would call weekly to provide encouragement and advice as the person attempted to quit."
At the end of the four-month study, the availability of a phone resource resulted in a significant increase in provider adherence to the AHCPR guidelines. Providers were more likely to assist and arrange follow-up for their patients. The best results were with the two clinics where Marcy had been able to solidly engage with the physicians, obtain their opinions about how they wished the service to operate, and orient them to the service before the program began.
Marcy is hopeful about the opportunities his future will hold after he completes his NCI fellowship. He envisions continuing to devote 30 percent of his time to clinical activities, while spending the remainder of his time focused on effecting broad changes in public health through his research.
"Down the road, it would be interesting to look at how to encourage patients to ask their physicians for help in their own behavior change," says Marcy. "For instance, how can we motivate more patients to go to doctors and say 'I really want to quit smoking, how can you help me?' We could have a large impact on the population of smokers by developing media messages that motivate patients to seek physicians'; assistance in quitting. Most successful tobacco control programs are comprehensive-they give multiple messages, by multiple messengers, in multiple ways. I'm very interested in how all the pieces can work together."
Last modified May 07 2013 03:14 PM