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An Interview With Ravindranath "Ravi" Patel, MD

Ravindranath "Ravi" Patel, MD

JOP: Dr Patel, our readers are always interested in the youthful impulses that led an individual to the practice of medicine.?

I grew up in Johannesburg, South Africa, and as soon as I was old enough, got work in the city's hospitals. It was there that I saw the toll of extreme poverty first hand, and that's what first attracted me to the practice of medicine.Then, as my career progressed, I began to feel that it would be important to have both a deeper understanding of the illness, and a deeper relationship with each patient. If one were to do family practice or general surgery, not that anything is wrong with either, but one would be involved only briefly with each patient's life. Whereas, by specializing in oncology, I could really connect with each patient, because the disease affects their lives so deeply. Oncology is an enduring profession which deepens the doctor-patient relationship. That seemed far more gratifying than just treating a patient for a cough and sending them on their way.

JOP: Did you study medicine in South Africa?

I did 2 years of undergraduate work in South Africa, and then obtained my MBBS degree in India. From there, I came to the US to intern at the University of Illinois. I did a fellowship in hematology/oncology at Loyola University in Chicago. You could get very good hot dogs across the street!

JOP: So why on earth did you go to Bakersfield, California?

My wife. Much as we loved Chicago, we wanted to be in a place where we could enjoy the outdoors. She's a cardiac anesthesiologist, and was offered a job with a cardiovascular surgery group in Bakersfield. At more or less the same time, I was invited to join a local [hematology/oncology] practice. So we both accepted.At that time, Bakersfield had only two oncologists, and shortly after I joined, the gent I was practicing with decided to leave the city. My wife tends to be very conservative, but at that moment, she encouraged me to take the risk of forming my own practice. So I did. I am now managing partner of a 16-person practice of seven medical oncologists, four radiation oncologists, three pain specialists, an infectious disease specialist, and a clinical pathologist. I started in a 1,000-square-foot office, and we now occupy a 48,000-square-foot facility and employ about 215 people.

JOP: That's quite a success story. Do you have any single, guiding business principle?

If there's a new, high-tech, cutting-edge technology, and the patients need it, and if the economics even just allow us to break even, then we'll go for it.

JOP: Could you give an examplew?

When we started out, sophisticated care was really not available in this community, and there appeared to be a big need. We wanted to introduce state-of-the-art radiation equipment, so we went ahead and bought the most technologically advanced Varian equipment. This was a big win for both the patients and the practice. That was our first big business decision, and it turned out to be a good one.Most recently, we have decided to add CT/PET equipment [computed tomography/positron-emission tomography], because that technology is becoming so useful in detecting cancers earlier, detecting recurrences, and helping plan radiation therapy. We actually already have a standard PET scanner. But we looked at the numbers of patients who would benefit from CT/PET, and that led us to get the new equipment.

JOP: These machines aren't cheap.

We have good banking relationships. Being out in the country, if you will, you get to know everybody, and they know you. The banks know us well, and are willing to finance our growth. But at the same time, we try to keep debt to a minimum, so we're not always under pressure to meet payments.

JOP: Understood. Your practice group has a wide range of specializations. Will you add others in the coming years?

We would like to. Anything related to oncology, we want to do. Our facility is attractive to patients because it's a one-stop cancer center where they can have access to anything and everything related to cancer. When they come in with a diagnosis, we have a pathologist to review their material. If the patient needs further staging, that can be done on site. After the staging is completed, all the treatment, whether radiation or chemotherapy, can likewise be done on site. The patients love it, and for us, it's a pleasure to practice cutting-edge oncology.If at some point, the unfortunate situation arises where the patient just does not respond to treatment, and the cancer continues to progress, we offer clinical trials. So the patients have access to newer drugs which they normally would have difficulty accessing. We do a lot of clinical trials, and these have included all the major drugs which have been approved by the FDA in, say, the last 7 years. We are probably the top enrollers in the country for many studies.

JOP: I understand that you're a site of the UCLA [University of California, Los Angeles] network, as well as for trials coordinated by pharmaceutical companies and other sponsors.

Correct. About a decade ago, the big academic centers began to have difficulty accruing sufficient numbers of patients to clinical trials. In about 1994, UCLA decided to branch out of the Los Angeles area and look for satellites for clinical research. We were one of the first sites they selected, and that collaboration has been very rewarding for both of our organizations. We've gotten access to the newer molecules, which would normally be difficult to get in a small community like Bakersfield. Patients would have had to travel all the way to Los Angeles. UCLA in turn has realized an increase in patient numbers. Based on how well this relationship was going, UCLA decided to develop other satellite sites.

JOP: Would you recommend this arrangement to JOP's readers?

Yes. From our standpoint, the trials have become very useful. Forging a relationship with an academic center is very useful. In fact, as far as I know, UCLA is willing to establish relationships with other people also across the country. Their program is called Translational Oncology Research International [TORI].

JOP: Explaining consent can be delicate. Have you developed any special ways to explain it?

In a community like Bakersfield, when a patient hears the words "clinical trial," they think either "placebo" or "guinea pig."So when we have a patient who has failed standard therapy, we introduce the idea of a trial very slowly. First, we reassure the patient that they are not going to be deprived of standard treatment, and that there is no pressure whatsoever to participate in any study.Most of the time, we are doing phase II or phase III studies, and we explain to the patients that the drugs have characteristics we understand and know about. The oncologist explains this, the research coordinator explains it, and after all that, we let the patient go back and think it over. In this way, they can make a more informed decision about consent.I have to say that in this day and age, when the economics are changing, clinical trials not only benefit the patients, they may help compensate the practice to some degree for loss of revenue in other areas.

JOP: And what institutional review board [IRB] do you use?

We've used Western IRB for years. The group we are working with at UCLA, called TORI, also has started using Western IRB.It's also interesting that even though we are connected with UCLA, pharmaceutical companies approach us regularly to do clinical trials on our own. Many have visited our facility, and after they see the cancer center, they always want to establish a connection with us. They feel very comfortable doing clinical trials with us because we have seven people devoted to that full time. So we do a lot of private pharmaceutical research, and as a result, have been able to get major molecules from private pharmaceuticals.

JOP: Do all the members of your group participate in the clinical trial approval process?

Yes, they all do. They're all interested in clinical trials. It's good to see that all of them make an effort to put patients on the studies.

JOP: Bakersfield was traditionally an oil field and farming economy. Is the economy healthy?

People think of Bakersfield as a truck stop town, and we want them to continue to think that, so it doesn't get flooded with new people and new houses! But the truth is, it's one of the fastest-growing cities in the US.There is managed care in the county, and they control quite a bit of the patient population. But so far, we have managed to do okay without them.Years ago we had a contract with Kaiser [Permanente], and when we severed that, we were wondering how we would do. Fortunately, it did not affect us. We incurred some decrease in revenue the first year, but by the second year we were back to where we'd started, and since then, we have continued to do okay. I think that the patients know the quality of cancer care they want, and if we match their needs, even if they are on HMOs [health maintenance organizations], they will leave the HMO and sign up with regular insurance so they can come to us. And that sometimes pays off better than staying signed up with the HMO!

JOP: And with the number of different specialties in your practice, how do you deal with reimbursement issues?

Most of the time, we make sure that any services we provide have a covered diagnosis. For example, if we refer the patient for pain management, it's a covered service, and therefore, the pain specialist will get reimbursed on a consultation for seeing the patient. The pain management specialists often have new and different ideas to benefit the patient, such as an epidural, or a pain pump, or any one of the newer ways of managing pain. Having a covered diagnosis is the key to reimbursement.

JOP: Speaking of management, do you still manage the practice personally?

I'm one of the managing partners and actually manage most of the practice. We don't use contract management.

JOP: Is reaching consensus ever an issue?

No, fortunately. We have a good group of physicians. There will always be differences of opinion, but we've never had any major differences. When we want certain things done, the group looks at what is good for the patients, and at the same time, [what] makes good economic sense. This decision making helps everybody—the patients, the physicians, and the practice.

JOP: How do you recruit and hire new associates or practice partners?

That has been a bit of a problem, because many people don't want to come to Bakersfield.When we look at a new associate, number one, he should be a quality physician, interested in the patient's well being. We look closely at references and training. We also make sure that the candidate understands the economics of modern-day oncology, and the direction things are going. Unfortunately, this has become a reality.Using our chemoinfusion center for chemotherapy may not always be the best thing to do. Under the current economic environment, we may have to admit the patient to the hospital. Are they going to be willing to do that? Issues like that will be increasingly important as oncology changes over the next few years.

JOP: And looking back, is there any one milestone you recognize in your career or in the development of your practice?

Our decision to provide better care through ancillary services has paid off immensely. Also, listening to my wife. When it came time to set out on my own, she said, "just try it out, and see how it goes." And so I did. That was the best advice I ever got.

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