Pulling a Rabbit Out of the Hat

The expression, to “pull a rabbit out of a hat,” can mean different things, from doing something unexpected or surprising, to solving a problem through unorthodox but eff ective means, to surprising others with a sudden act of skill.¹ Of course, the expression comes from the act of the magician bringing a furry friend seemingly from nowhere.

I recently had the chance to visit The Magic Castle at the invitation of a patient. For those of you who have never been there, The Magic Castle is a grand chateau located in Hollywood, California, that is the performance center and clubhouse for the Academy of Magic Arts. Expert magicians come to perform everything from close-up magic to grand illusions, and their extraordinary skill and mastery is breathtaking.

I visited The Magic Castle the same week that I spent most of my time reviewing the most recent proposed CMS Inpatient Prospective Payment System (IPPS) rule. To say that these 1700 pages made for less than magical reading would be a profound understatement. While the skill and nowledge of those preparing this document is indisputable, a page turner it is not.² Yet, something beyond the absurdist level of contrast between the “castle” and “the rule” began to gnaw at me as I reread portions of “the rule.” It eventually came to me: in a time when innovations in cancer care can produce breathtakingly better outcomes for patients and their families, nothing in the draft rule speaks to the future of oncology. Much of the IPPS rule remains grounded in care and payment models beholden to the past; little of what is here speaks toward a future in which innovative treatments, delivered through the rapidly evolving paradigm of precision medicine, will change patient lives for the better.

Watching a magician literally pull a rabbit out of a hat is an apt metaphor for how we might want to think about the future of oncology, as it is where we embrace a bold, unorthodox mindset to reimagine cancer care delivery. Iterative tweaks to Titanic-sized systems designed for patients without cancer will not bring us closer to the patient-centered/valuebased systems needed to ensure equitable, sustainable access to life saving care. Nor will it provide a means to remediate the continued, profound disparities in access and outcome, faced by toomany patients who must navigate a cancer journey.

This quantum leap will require not only great skill and knowledge, but it will also require clinicians and other stakeholders in cancer care to pursue unorthodox and innovative approaches in care delivery at a pace that cannot be replicated by government payers. In our quest to create the new oncology care paradigm, not every new model will be successful. Some will fail. Some will represent incremental improvements. Some will succeed. There will, however, be little progress until we are emboldened to “fail fast, fail often, but always fail forward.”³

In this month’s edition of Evidence-Based Oncology, we feature oncology thought leaders who are forging new paths forward toward the realization of more effective, more equitable cancer care by working with commercial payers and employers now that CMS is ready to let the Oncology Care Model lapse without a replacement. They are not waiting for instructions or permission to innovate.

What is most striking about the world of magic, is not the superficial glamour of the performance, rather it is the iterative practice, skills, and craft that go on almost invisibly in the delivery of what we see. For our patients and their families, the system mechanics should be just as invisible, as they experience innovative care that is delivered with humility, kindness, and compassion. It is the knowledge, insights, skills, and experiences of cancer care leaders like you that will help bring us to a deeper understanding of how to build the future of oncology. We invite you to share your knowledge and experience with us by submitting an article for publication. Become a part of these conversations that can help drive innovative and unexpected solutions to the question of how to deliver the best, most innovative care possible our patients and their families.

REFERENCES
1. The idioms.com.
https://www.theidioms.com/pull-a-rabbit-out-ofthe-
hat/
Accessed June 2, 2022.
2. Star Wars: Episode VIII – The Last Jedi.
https://www.imdb.com/title/
tt2527336/?ref_=fn_al_tt_1
2017. Accessed June 2, 2022.
3. John C. Maxwell.
https://www.goodreads.com/quotes/1309491-failearly-
fail-often-but-always-fail-forward