Chapter 11: As a Young Faculty Member: the Medical College of Wisconsin and Columbia Presbyterian
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Description
In this chapter, Dr. Komaki talks about two faculty positions she held prior to coming to MD Anderson. She first talks about her return to the Medical College of Wisconsin, Milwaukee. She talks about her shift to a focus on gynecologic cancers and applying what she learned about case management during her fellowship at MD Anderson. She also describes the challenges she confronted when advocating for this type of approach to the department chair and how she found a strategy to encourage buy-in from resistant clinicians.
Next, Dr. Komaki notes that she married James Cox, MD [oral history interview] on 27 January 1987, explaining that she arranged her career to be independent of him, rather than attempting to benefit from marriage to someone at a higher administrative level. She talks about their move to New York City and the new Radiation Oncology department at Columbia Presbyterian, where she served as Clinical Chief and Program Director of the Residency Program (’85-’88), focusing on gynecologic malignancies, breast cancer, and lung cancer.
Dr. Komaki next sketches how this was a “very difficult time” because the conservatism at Columbia Presbyterian did not offer an environment where she could conduct the type of research that would allow her to set up prospective trials. She notes that Dr. Cox was promised support to develop the new department, but these came to nothing.
Identifier
KomakiR_03_20181219_C11
Publication Date
12-19-2018
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; Professional Path; Evolution of Career; Multi-disciplinary Approaches; MD Anderson Impact; MD Anderson Impact; The MD Anderson Brand, Reputation; The Researcher; Professional Practice; The Professional at Work; Experiences Related to Gender, Race, Ethnicity; Personal Background; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care
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:
Now you --at the end of your fellowship period at MD Anderson, because you were there from ’79 to ’80, I mean that was a one-year time, you actually went back to the Medical College of Wisconsin and became...
R. Komaki, MD:
Assistant professor [in July 1980], right.
T.A. Rosolowski, PhD:
Yeah, so tell me about going back and what you brought back to the institution after being at MD Anderson.
R. Komaki, MD:
When I went back to Medical College of Wisconsin, I emphasized that I was specializing in GYN, to treat cancer of the cervix, cancer of the endometrium and ovarian cancer. Not much to do with ovarian cancer by radiation treatment, but I was telling all the attendings at GYN Oncology, including Dr. Richard Mattingly. He was the chairman of the OB/GYN at the Medical College of Wisconsin, and he was the authority of everything about gynecologic oncology. I had to prepare to argue with him that patients with cancer of the cervix stage 3-A or B, or stage 2-B should be treated by radiation treatment. He always talked about bad side effects of the radiation treatment. So I had to prepare [my slides, of the references and protocols for the GYN conference at] ten o’clock in the morning Friday. We always had a GYN conference every Friday at 10 am, and all the medical students and residents, they were there. So that morning, I woke up at like three o’clock in the morning, prepared all the slides and all the cases to present in front of him and the residents and medical students. I had to prepare, but I was really a junior attending. I emphasized, “At MD Anderson, they treat patients this way by Radiation Therapy and that this multidisciplinary approach has shown incredible results.” I emphasized that the way they treat the patients at MDACC, they put aside their own egos and they treat the patient based on [the results of the prospective trials and] best care for the patients if they were not treated on protocols. Even MD Anderson, all those faculty members, they were very famous, but once they talked about the patient care, they put their egos aside and what’s the best for the patients. They were so open and they were really emphasizing the patient care, less toxicity but the best to get rid of cancer. What’s the best? How we can combine with surgery and the radiation or chemotherapy? What’s the best way? That’s what I [have learned at MDACC and emphasized at the GYN conference of MCW].
T.A. Rosolowski, PhD:
How was that received?
R. Komaki, MD:
At the beginning, not so great. Dr. Mattingly called me in the middle of the night and he said, you know this patient you treated? You caused a small bowel obstruction, because this patient had lymph nodes at the para-aortic lymph nodes metastasis, very advanced squamous cell carcinoma of the cervix. Although this patient was very young, like 32 years old, and her OB/GYN physician, he ignored her bleeding. Her private gynecologist said, “Well , you are having some hormonal changes, just take this medication.” There was delay of the diagnosis, like at least six months, and by the time she was found to have cancer of the cervix, it was very advanced and it was already metastasized to the para-aortic lymph nodes. I had to treat those lymph nodes and the pelvic primary in the cervix, and [she was] cancer free, but she developed a small bowel obstruction. So Dr. Mattingly was operating on this patient because of the small bowel obstruction and he said, “You should come here and see what I found.” I said, “Thank you for calling me about this patient’s case, but I know this is almost the middle of the night and you are operating on the patient. By the time I get there, I’m sure you’ll have closed the operating bed, so it might be too late.” He always pointed the bad side effect of the radiation treatment.
T.A. Rosolowski, PhD:
What was your impression of what the cause of the obstruction might have been?
R. Komaki, MD:
Because the Radiation Treatment field … [If have to radiate para-artic lymph nodes,] we usually cause some toxicity including [small bowl damage and also the toxicities would be depend on the dose, fractionation and the equipment. If she were treated for early stage cervical cancer, the probability of complication would have been much less. She sued the private OB/GYN physician.]
T.A. Rosolowski, PhD:
I think you—
R. Komaki, MD:
Earlier stage, we can cure without complications, but once the stage advances, we have to go to higher doses and a bigger field, and it will cause small bowel obstruction. The small bowel, it’s very sensitive to radiation, but if the cancer is right there, there is no way we can avoid that.
T.A. Rosolowski, PhD:
I think you spoke about this case, because you were called as an expert witness.
R. Komaki, MD:
Right, so that’s the case. So what I started to think about, you know the chief, the chair of the Gynecologic Oncology Department, he’s always so critical about the radiation complication and he does not really respect my opinion. So I decided to do some retrospective study, cancer of the endometrium, when is the best time to give post-op radiation treatment, and I put his name on it because he’s the one who operated in most of the cases, and that’s a very reasonable thing to do. After I published the paper, he became my friend, so he realized that I’m not really attacking him, I tried to collaborate with him, and so we became good friends. I realized, when I was a junior attending --or even when I was a resident, I was born in Japan, my English was not perfect, and to argue those authorities, what’s the best way? I decided to write a paper, one paper per month, to convince them. So, to convince all those people, I have to show what I have done, rather than just arguing with them. I had to show the evidence, what I know or what I have analyzed. I decided to be more scientific and to show the evidence, rather than just arguing, so that’s my approach. I started to write and write and write, and so I have ended up with like six hundred papers by this time.
T.A. Rosolowski, PhD:
So from ’79, or from basically ’80, to ’85, you were at the Medical College of Wisconsin.
R. Komaki, MD:
That’s right.
T.A. Rosolowski, PhD:
So that’s like five years that you were going through this process. So how did things change over that time, in terms of acceptance...?
R. Komaki, MD:
You know, I got married to Jim Cox, like January 27, 1979, but I tried not to get any benefit just because I was his wife. Because he was my chairman. I really tried to be independent and I tried to publish papers, and I really tried to show the evidence, my care for the patients, and writing papers, to get involved in clinical trials. That’s what my passion was. Then we decided to go to Columbia, because the younger children went to East Coast, and Jim was recruited. He [was considered to be one of candidates for] the chairman of the joint center in Boston after Dr. Sam Hulman decided to go to Memorial Sloan Kettering, so he was interviewed there and also, he was interviewed at the Columbia Presbyterian Medical Center. That was 1985. He decided to go to Columbia Presbyterian Medical Center because of Dr. Eric Hall, who was a very, very famous radiation biologist and very interested in fractionation of the radiation treatment and also, Dr. Chu Chang [wanted Jim Cox to be the chair of the Radiation Oncology Department]. Dr. Chu Chang was section chief of Radiation Oncology under Department of Diagnostic Radiology. So, because of Jim Cox coming to Columbia, they created a new department separated from Diagnostic Radiology. [A new Department of Radiation Oncology was created 40 years after the last new Department of Anesthesiology was created]. Radiation Oncology Department. It was very difficult to create a new department at Columbia.
T.A. Rosolowski, PhD:
What was the new department created? What was the name of the new department created?
R. Komaki, MD:
Radiation Oncology Department, separated from the Diagnostic Radialogy Department.
T.A. Rosolowski, PhD:
Okay, I understand now.
R. Komaki, MD:
It used to be together. So that’s the way we went.
T.A. Rosolowski, PhD:
What was the significance of doing that, of separating the two?
R. Komaki, MD:
Because the chairman of Diagnostic Radiology does not care much what kind of equipment we have and how we treat cancer patients, since they are diagnostic imaging people. So we had to emphasize we are oncologists, and we belong to how to treat the cancer patients, rather than reading the diagnostic imaging. Which is very important, but they were interpreting diagnostic films. We are specializing in the treatment.
T.A. Rosolowski, PhD:
Right.
R. Komaki, MD:
So we really had to separate our specialties.
T.A. Rosolowski, PhD:
That’s a significant move.
R. Komaki, MD:
Diagnostic Radiology, it became so sophisticated [by reading an incredible detailed] CT scan to find tiny drizzles, or PET scan, and MRI. But the radiation oncologists specialize in the treatment side. [All of the technique and equipment became so sophisticated that Diagnostic Radiologists could not comprehend the techniques such as 3 dimensional RT (3DRT) or Intensity Modulated RT (IMRT) , Stereotactic Body Radiation Treatment or 4 D simulation.] Rather than previously used low energy, orthovoltage equipment or cobalt, we used to use like 50 years ago, it doesn’t exist anymore. They really had to separate the Radiation Oncology Department from the Diagnostic Department because we belong to treatment oncologists rather than therapists. [That’s why 50 years ago they started to separate Therapeutic Radiology (Radiation Oncology) from Diagnostic Imaging Radiology in the United States.] And the specialty board examination to obtain certificate to treat cancer patients separated from diagnostic Radiology board examinations.
T.A. Rosolowski, PhD:
Interesting. So your role, when you went to Columbia Presbyterian, what was your role?
R. Komaki, MD:
When I went there, I was associate professor of Radiation Oncology and my role was clinical chief of Radiation Oncology. Also, I was the program director of the residency program and I was mainly treating gynecologic malignancy and breast cancer, and lung cancer. I did have some head and neck cancer, because there were only four or five attendings in that department.
T.A. Rosolowski, PhD:
So you guys were there for three years. So what do you feel, how do you feel that period of time affected you?
R. Komaki, MD:
Very difficult.
T.A. Rosolowski, PhD:
Very difficult, how so?
R. Komaki, MD:
Very difficult. Very opinionated surgeons. They never tried to do multidisciplinary clinics. They did not appreciate radiation oncology. When I talked to some of the breast surgeons, he said, “When did you become radiation oncologists? We used to call you radiation therapists.” I said, “Our therapists took radiation therapist’s name so we had to separate from them to avoid confusion. We are no longer radiation therapists, we are radiation oncologists.” But they thought radiation oncology does not have anything to do with management of cancer, and they kept referring very old fashioned radiation treatments. One of the most difficult things [was that I could not find an adequate tumor registry and what kind of chemotherapy they received when] I tried to analyze breast cancer patients. [ ] The information was not in the hospital chart. The chemotherapy regimen was kept in private practice offices. As long as they don’t lose their hair, they were getting non toxic chemotherapy such as cyclophosphamide rather than optimal chemotherapy, they were getting low dose of cyclophosphamide forever. I thought, that this was not the place where I can perform prospective clinical trials or analyze all the data about what they had done. Because my passion was [to develop prospective clinical trials based on analysis of] patterns of failure. I wanted to set up prospective clinical trials, that was my goal. But I realized that I was against the totally hard wall. My husband, he was told that he could get the high energy radiation therapy equipment. Nothing was done regarding all promises [they made when he was recruited to be the chair of Radiation Oncology Department] for three years. So we left.
Recommended Citation
Komaki, Ritsuko MD and Rosolowski, Tacey A. PhD, "Chapter 11: As a Young Faculty Member: the Medical College of Wisconsin and Columbia Presbyterian" (2018). Interview Chapters. 1292.
https://openworks.mdanderson.org/mchv_interviewchapters/1292
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