Chapter 08: Mentors, Unusual Challenges, and Striving to Establish Credibility
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Description
Dr. Komaki begins this chapter with discussions of James Cox, MD and others who influenced her career at that time. She then talks about an unusual situation of responsibility when she was a resident—explaining treatments to surgeons as the only available radiation oncologist. She explains that she became very good at working with surgeons and developing true multi-disciplinary treatment plans because of her close study of surgical procedures and their complications, as well as the details of treatments in her own field.
Dr. Komaki touches on how being a foreign national and a woman led certain people to doubt her ability. This leads to a discussion first of how Dr. Komaki made a plan to develop her credibility. Dr. Komaki gives examples of how her credentials have been ignored or diminished over the course of her career.
Identifier
KomakiR_02_20181128_C08
Publication Date
11-28-2018
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - Professional Path; Experiences Related to Gender, Race, Ethnicity; Personal Background; Definitions, Explanations, Translations; Professional Path; Evolution of Career; Mentoring; On Mentoring
Creative Commons License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.
Disciplines
History of Science, Technology, and Medicine | Oncology | Oral History
Transcript
T.A. Rosolowski, PhD
Interesting. Now, you eventually married Jim Cox. So here, you’re starting to have this working relationship and how, how did that all evolve, like what were the compatibilities in your approach to radiation? Was he your mentor? How did that working relationship evolve?
R. Komaki, MD
He was my mentor. I always respected him, he was so generous, his time, and to my questions. He always guided me how to do clinical trials, that was his passion. He was an incredible clinician, so kind to the patients, and he was an incredible teacher. He never said oh, read my textbook or anything like that. He always taught why we are doing this and he learned everything, how to teach, from Juan Del Regato, who was a teacher. He was Jim Cox’s mentor. I learned everything from him and also my attending, Larry Kun, who was a pediatric oncologist and a radiation oncologist.
T.A. Rosolowski, PhD
I’m sorry, what was that name again?
R. Komaki, MD
Larry Kun, K-u-n. He taught me the pediatric oncology, yeah he’s the one who took me to Milwaukee Children’s Hospital after 6:00 p.m., and I worked until 10:00 p.m. When I was rotating pediatric oncology, he was just an amazing person. He just passed away this year, from melanoma, brain mets, yeah he became—that was 1984, just one year before we left the Medical College of Wisconsin, he took a job. He became director of St. Jude and he was there, I don’t know how many years, and he retired to UT Southwestern, but he was my mentor for pediatric oncology and he taught me all this pediatric cancer.
T.A. Rosolowski, PhD
Now in terms of philosophy of treatment, how did you and Dr. Cox harmonize in that direction?
R. Komaki, MD
Jim knew anatomy and surgery [so well that] I [was taught the anatomy and the cancer biology during the first year of residency]. [ ] At that time, I had to cover several hospitals because we had no other other residents [ ] [in 1974.] When Dr. Tony Gueninger died [by the autobile accident], Jim Cox, he had to cover six hospitals [including County General Hospital, Milwaukee Children Hospital, Deaconess Hospital, West Allis Hospital, St. Mary’s Hospital and VA Hospital], so I was left alone at the County General Hospital in Milwaukee, as the [the first year and only] resident. So I had to learn everything so quickly. Eventually, all new attendings came and they taught me. But I really had to learn how to deal with surgeons, medical oncologists, pulmonologists, [pathologists and Diagnostic Radiologists] and you name it. I had to [discuss,] argue or collaborate with them and I was really scared to death at the beginning. I was treating a lot of patients with GYN malignancies around that time, such as cancer of the cervix, cancer of the endometrium, cancer of the ovaries. The chairman of the OB/GYN, he was very famous, Dr. Richard Mattingly. He was the editor in chief of the green journal, Journal of Obstetrics & Gynecology. He had so much power, authority, and he hated radiation treatment. He always said that [ ] radiation treatment always causes the small bowel complications, [diarrhea and bladder problems. I had to argue with him that radiation treatment would not be harmful if it was given with adequate technique and fractionations.] Once I became the fourth year resident, I was interested in GYN, [but also I became interested in Hodgkin’s Disease and Leukemia]. However Larry Kun took over leukemia, lymphoma, Hodgkin’s disease, since those patients were --according to him-- all pediatric patients.
So I specialized the gynecologic radiation oncology. Richard Mattingly was a professor of OB/GYN and he had Friday morning conference at ten o’clock every Friday. All the medical students showed up, and I’m the only one radiation oncologist to attend, and they presented new cases. I had to show the slides, I had to explain why we are giving radiation treatment for cancer of the cervix and endometrium, and ovarian cancer. So I prepared those cases. Three o’clock in the morning, I woke up and I prepared and depending on cases, and I had to make sure all the pathology [slides of the presented cases and slides of indication of the radiation treatment and] how to treat those patients by radiation treatment, post-op, [pre-op or definitively ready to be shown at the GYN tumor board]. [ ] I concentrated my effort to do a multidisciplinary approach for GYN oncology. I became very good at it, and so I created some of the protocols for the RTOG, [Radiation Therapy Oncology Group] with Jim Cox. He became the chair of the RTOG, in 1985 but he always helped me to create the protocols.
T.A. Rosolowski, PhD
I’m interested, as you’re describing this residency experience, you know how you really had to speak across these disciplinary boundaries.
R. Komaki, MD
Right, right.
T.A. Rosolowski, PhD
Having to speak to people who might be hostile. What skills do you think you had already inside yourself, that enabled you to be so effective at this?
R. Komaki, MD
The way I decided to do it, when I went to the tumor board, I had to deal with surgeons, medical oncologists, pathologists and diagnostic radiologists. So even though I came from Japan, and was a senior resident --then junior attending eventually --if I know all the details, such as anatomy, how the cancer spread, cancer biology and the imaging studies –[I could speak up and other attending started to listen to me. ] Then, the other thing I really wanted to make sure what type of surgery they do and the complications due to surgery. All those surgeons, whenever a patient developed complication after we gave post-op radiation treatment, they blamed it on radiation treatment. So I decided to check every detail. What type of surgery they usually do and what type of complication they might cause: breast cancer, GYN and the lung and other type of cancer. I read all the details, so when I was at the tumor board, when they started to tell me that, “Well, radiation caused this problem, and I replied, “Well, wait a minute, you did a radical operation that caused edema of the arm. If you removed all the lymph nodes from axilla, that’s a lymphedema due to surgery, not related to radiation treatment”. So I could argue with surgeon, not to just blame it on the radiation treatment. That’s the bottom line:[ to convince them not to blame radiation treatment alone for the complication.] I started to check all the techniques of surgery and complications as well as efficacy. [To give my recommendations for what kind of patients require post-op or pre-op radiation treatment, I had to read many updated articles. It did not make any difference when I was a senior resident. I was the only one, I had to go to the tumor board of some of the private hospitals and those surgeons were so hardheaded. They were kings, and they treated me, oh you cannot argue with me, and so I really had to read every detail [on surgical complication to defend myself].
T.A. Rosolowski, PhD
How long did it take before the surgeons kind of accepted that you knew your stuff and could bring something to them?
R. Komaki, MD
You know, I had to publish papers [to be accepted by them]. So I decided to publish a paper per month. I decided, because my English was not good enough and I looked very young when I was a senior resident then junior attending.
T.A. Rosolowski, PhD
And you’re a woman.
R. Komaki, MD
And nobody listened. I’m a woman, and nobody would listen to me. So I decided to publish a paper and I put Richard Mattingly’s name on it, because all those patients, he operated those patients, so I gave him credit and I put his name on. He totally mellowed after that. So, I had done a lot of [things to convince surgeons and medical oncologists to believe me] but publication is so important. I had to read many papers [before I let them at] the tumor board, read the references. Jim Cox influenced me. He went to the library, read all different kinds of cancer journals [about all sites and all modalities]. Every Saturday and Sunday he was reading all the library’s books related to cancer. What he was reading, that was surgical and medical oncology, as well as radiation oncology. He read all those journals so quickly and around that time, I was reading all cancer textbooks. I was so impressed by his knowledge, putting all those updated information to create multidisciplinary [approach for cancer treatment]. That’s what I wanted to learn and I tried to soak in everything of what he knew. That’s what I wanted to give message to other modality [oncologists].
T.A. Rosolowski, PhD
How long did it take before people began to accept—that you began to establish real credibility?
R. Komaki, MD
It took a long time, it took at least five years. When I started to put their names on for publication, maybe two years, three years. But to really convince them, it took five years. When I went to Columbia University, oh that was a different story, nobody wanted to listen to me.
T.A. Rosolowski, PhD
Now before we embark on that, I wanted to—well, maybe these stories are all tied together. We talked about first of all, professional credibility. Do you know your stuff as an oncologist? But then there’s being a woman, there’s being a foreigner.
R. Komaki, MD
Right.
T.A. Rosolowski, PhD
You know there are all of these reasons why established professionals would dismiss you. What was your experience of that? Did you feel that you were treated differently because you were female, because you were Japanese?
R. Komaki, MD
Oh yes, of course.
T.A. Rosolowski, PhD
Talk to me a little bit about that. I mean that’s the woman in a man’s world kind of thing, but on steroids for you. So tell me about that a bit.
R. Komaki, MD
Well , whenever I tried to develop prospective Phase III trials at the RTOG, there is always obstruction just because I’m a woman. I was never put on as the chair of the Lung Committee, as much as I knew, and always men, [although I proposed many prospective trials and completed several important trials by enrolling many patients to the RTOG trials.] Men took the chair position of the Lung Committee. I was so frustrated and you know, I never became like an ASTRO president, although I was the president of American Radium Society. I’m the first woman clinical radiation oncology, became American Radium Society president, I think that was 2008. I have received a lot of awards, but there is always discrimination. I have written now, six hundred papers, [have treated many patients on the prospective trials and trained our residents and fellows by giving the most updated information]. I have not received a gold medal from ASTRO [although I was nominated], so I always feel that I am discriminated against. [Especially after my husband James D Cox passed away, people who were nominated to received the ASTRO gold medals tuned their back and no support for me except a few good people.] I was happy to treat the patients and get their appreciation. Also, I think I was blessed because, well, I got married with Jim Cox and everybody treated me right, because my husband you know, he treated me right and protected me.
T.A. Rosolowski, PhD
How did the marriage affect that. And understand, I am recognizing the irony of that, that in order to be credible, you have to be married to a man, a man who has a reputation.
R. Komaki, MD
It’s good or bad, because I had incredible experience. I treated a very young woman at the Medical College of Wisconsin. She developed—she was only like 32 years old and she had cancer of the cervix, and she was bleeding [for 6 months before she got the correct diagnosis]. Her OB/GYN private practice physician said, “Oh, you have just hormonal change,” and he didn’t pay much attention to her complaints. Then several months after, she was still bleeding, so finally, he did a biopsy. She was found to have cancer of the cervix, but it was very advanced, not operable, because the lymph nodes spread to the paraaortic lymph nodes, so she was not operable case. I had to treat her by radiation treatment by using extended field [ ] in the paraaortic lymphnodes and pelvic area. With the primary cancer of the cervix, I did an [implant to the primary. She developed small bowel complication. The cancer was gone, but] she sued this original OB/GYN private practitioner based on his negligence and she wanted me to be the witness. He ignored her complaints when she started to have the bleeding.
T.A. Rosolowski, PhD
Wow.
R. Komaki, MD
So, six months passed and when I gave treatment, she developed some small bowel complication. I had to explain the way we had to treat, because the cancer was already advanced. I wish she had a little bit earlier stage, and when she started to have bleeding, she should have had early diagnosis [of the cervical cancer]. At that time when [she started to have abnormal bleeding], they should have done the biopsy. I had many phone calls from her lawyer who was [one of my friends during my residency program at MCW. But] at that time, I was already at Columbia Presbyterian Medical Center, so I got the world renowned radiation biologist to bring this to this trial, and I was the expert witness[ as a GYN Radiation Oncologist. Regarding to the delayed original diagnosis,] the lawyer who was defending this OB/GYN physician, he said, “Well, you went to Columbia University just because you are Jim Cox’s wife,” rather than [you have your own] reputation. So, I had to say, “Yes” or “No”. Well, I was married, and that’s why I went there, but also, they accepted me to be the associate professor there. But they always tried to ignore my credentials [and eliminate my reputation]. I was just Jim Cox’s wife: that’s why you got your credit [and reputation]. It was always like that. Then, this lawyer said, that okay, there is no experiments in human beings, if the cancer was found [earlier, she had early stage cervical cancer]. Well, I showed all those doubling time of cancer of the cervix in vitro or vivo. If you ignore cancer for six months it will grow, but he said that there were no experiments. “When she was found six months earlier, did she have stage one? You cannot say that, you cannot have this human being’s cancer of the cervix, there is no evidence of the doubling time of, that’s all animals vitro or vivo”.
T.A. Rosolowski, PhD
What happened with the—how was the case resolved?
R. Komaki, MD
She lost.
T.A. Rosolowski, PhD
She lost, yeah.
R. Komaki, MD
She lost. Yeah.
T.A. Rosolowski, PhD
Yeah, it sounded like that was where it was going.
R. Komaki, MD
So when I was [facing to this lawyer’s questions, I was thinking that] this guy, he has done this previously, but you cannot argue with him. It’s all based on lawyers’ [intent to disqualify your reputation], you know?
T.A. Rosolowski, PhD
Right.
R. Komaki, MD
O.J. Simpson got out, being a murderer and [everybody knows that he got the very expensive lawyer who could make him as a innocent for the murdering his wife and her boyfriend]. [Depending] on which lawyer you hire, [you can get out of being criminal]. So around that time I thought, oh my gosh, this is just amazing, but many, many times, I was not credited just because I’m his wife.
T.A. Rosolowski, PhD
What was Dr. Cox’s attitude about this?
R. Komaki, MD
He felt so bad, he always tried to... That’s why he didn’t really force me to put his name, you know, Ritsuko Cox. He said for your credentials, you keep your name, because I already started to write my papers, Komaki. He said don’t change that. When I came to MD Anderson, I asked Dr. Lester Peters, at that time he was a chairman and [Division Head ]of Radiation Oncology, “Dr. Peters, shall I change my name to Dr. Cox?” He said, “Well, it might get too complicated, don’t do that,” and so my passport, it said Ritsuko Komaki-Cox, that’s my social, official name, but my professional name, my husband and Lester Peters, they wanted me to just keep Komaki, so it doesn’t make everything confused. So that’s the way it went. I was not really credited just because [I was the wife of Division Head and Chairman of Radiation Oncology] [ ]
Recommended Citation
Komaki, Ritsuko MD and Rosolowski, Tacey A. PhD, "Chapter 08: Mentors, Unusual Challenges, and Striving to Establish Credibility" (2018). Interview Chapters. 1289.
https://openworks.mdanderson.org/mchv_interviewchapters/1289
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