1. Simone, Joseph V. MD

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My wife and I returned recently from a 10-day tour of Italy. We joined a group of mostly older people like ourselves and hit the high spots: Rome, Assisi, Siena, Florence, a Tuscan vineyard that also produces olive oil, Venice, and Lake Como. The trip was made memorable by visiting and often revisiting places such as the Vatican Chapel, the Roman Colosseum, St. Peter's Basilica and Square, Michelangelo's sculptures, and the architectural gems everywhere. Florence and Venice are almost overwhelming in the depth and quality of art and architecture.

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JOSEPH V. SIMONE, MD... - Click to enlarge in new windowJOSEPH V. SIMONE, MD. JOSEPH V. SIMONE, MD, has had leadership roles at St. Jude Children's Research Hospital, Huntsman Cancer Institute, Memorial Sloan Kettering Cancer Center, the University of Florida Shands Cancer Center, the National Comprehensive Cancer Network, and the National Cancer Policy Board, and has served on the NCI's Board of Scientific Advisors.He has been writing this award-winning column since 2003, and welcomes comments and suggestions for this column, as well as for his blog on career development for medical professionals (

In the midst of so much beauty, I began to realize that the emotional and lasting impact elicited by each location differed, sometimes strikingly. The reason for this was not clear to me at first; only after we left those areas did I begin to glimpse what that effect was.


The grandeur of Rome, Florence, and Venice similarly affected me by the scale, by the intricacy of the construction and art, the perfect external and internal arrangements, and the unfathomable genius of the artists and architects. It is safe to say that I was repeatedly awestruck to the point that it became difficult to take it all in.


How often can one say "spectacular" or "amazing" without it becoming a cliche? I can best sum it up by saying that these sights gradually made me feel small and insignificant in comparison to the accomplishments we observed. I was physically the size of a dot on this paper compared with the size of the world created by the artists. In a sense, this was God at work through these men without limits.


But that was not the case with two towns we visited. Siena and Assisi had a different impact on me emotionally and presented quite a different scale of perspective.


Siena, Assisi, and Florence are in Tuscany, which is one of the more beautiful parts of Italy with its rolling green hills and orchards. Dante was born in Tuscany and wrote the Divine Comedy between 1308 and 1321. One can observe the evolution of art there from a flat perspective without depth to a three-dimensional perspective, led by Brunelleschi. The Renaissance also brought the appearance of sculptures of naked or near-naked figures of Greco-Roman style.


Michelangelo's monumental sculpture of David, holding the slingshot over his shoulder, is the epitome of this change. One can easily be overcome by the sheer volume and scale of the sculpture, beautiful churches, and other buildings.


But for me Siena provided a different experience and perspective than Florence. Over the past three centuries, Siena has become well known for staging the oldest continuous horse race in history; it is called the Palio. Bullfights, boxing, and races had been held, but today's races began in 1656 in Siena's campo (town square). Entrants consist of one rider each from the 17 neighborhoods of Siena. Since only 10 horses are allowed for each race, the remaining seven automatically are in for the next race, and three more are chosen by lottery. The race is for three circuits of the track and rarely lasts longer than 90 seconds.


The key here is the neighborhoods (contrada). One's contrada is determined by site of birth, and that identity is strong and lifelong and is not passed down to children who are born in another contrada. Each contrada stages parades and marches with music, and all participants are dressed in the colorful Renaissance costumes with the colors of the contrada. An interesting rule: if the horse throws the rider but continues to run, he can win the race for the contrada without the rider.


What impressed me most about this elaborate 350-year old practice was the contradas' effect of tightly cementing each neighborhood together twice a year. The town has beautiful churches and art like the others in Tuscany, but the Palio is unique. It is a contest, for sure, but more important is the social significance that promotes pride for one's station in the community and one's bond to it.


In other words, Siena came across to me as a beautiful place on a human scale. The dominant perspective was not that of a God and/or genius driven splendor, but with a nod to St. Catherine, the patron saint, the perspective was human and accessible. I could aspire to be a jockey in one of the races if I were born in one of the contradas, but never a Michelangelo or Brunelleschi. In Siena could be included in the intimacy of the environment.


Assisi had a similar effect. It is a very small town on top of a hill. There is a very nice church and some wonderful ancient paintings. St. Francis was born c. 1182, died in 1226, and was canonized as a saint only two years later. So the church and paintings in tribute to him were started in the Medieval Era. Nonetheless, the lack of perspective was not a handicap to the moving beauty of the art and structures. Due to age and style, the decoration was often dark but the message of homage and sanctity peeked through.


There was less hustle and bustle in Assisi. Its hillside locale allowed a breathtaking view of the countryside. The crowds were quieter, as if in respect to the Saint. The scale of the church was ordinary, making it seem more accessible and inviting. There was a sense of peace and gratitude for being there.


Assisi, for very different reasons, was a beautiful place on a human scale. The Saint was the focus of the area, and therefore more accessible. It was also a spiritual experience for me, a great admirer of St. Francis.


How we view or enjoy a particular location depends a great deal on the scale and perspective. I enjoyed every stop on the trip, but I would rather return to Assisi or Siena before the others if I had to choose because of their human scale.


Scale, Scope, and Perspective in Cancer Centers

This effect of scope and perspective is also evident in our cancer centers. I have worked in cancer centers both very large and quite small, in a university structure or freestanding. In the very large institutions, patients, especially those new or with disabilities, are often overwhelmed by the structure, its internal complexity, the rapid flow of different faces around every corner, the seeming chaos.


Centers have worked hard to blunt this impact by heavily staffing entry points and signage. But just as in Rome and Venice, the grand scale cannot be hidden, and in both cases we are obliged to work our way through it using guides or companions.


This scale in large and complex institutions also affects staff and physicians. It takes a long time to acclimate and learn who one's colleagues are in the very large ones.


In fact, for example, Cancer Treatment Centers of America use their smaller, more intimate size and style as a major selling point. The patients interviewed in ads talk of feeling like they have an ample degree of control and access in a friendly and approachable environment. The relatively recent popularity of regional clinics operated by cancer centers helps by having a more intimate and lower key environment, often with easier parking.


So if one wants to impress patients and colleagues with a grand facility that is more efficient for the staff, go big. But if one thinks foremost of the patients' needs and emotional situation, go smaller, even if that smaller footprint is inside a big center.


Scale and perspective do matter to cancer patients; a human scale is greatly appreciated-and easy parking also helps a lot.