Chapter 13: Developing the Ambulatory and Supportive Care Oncology Research Program

Chapter 13: Developing the Ambulatory and Supportive Care Oncology Research Program

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Description

In this chapter, Dr. Elting talks about her roles as Director of Clinical Epidemiology and Informatics within the evolving Ambulatory and Supportive Care Oncology Research Program (1992 – 1998), housed in the Department of General Internal Medicine.

She explains the vision and goals of this new research program, designed to provide data to guide initiatives to de-hospitalize chemotherapy patients to outpatient status and she brought quantitative methods to this clinical department.

Dr. Elting talks about research conducted when a new group of antibiotics became available, making it easier to treat infections and fevers in chemo patients. She explains that the research conducted in the new program shifted the standard of care from inpatient to outpatient treatment. She notes that this was considered “a wild and crazy thing to do,” very risky and dangerous.

Dr. Elting talks about how the study offered a leadership opportunity. She reflects on the success of the program.

Identifier

EltingL_03_20150326_C13

Publication Date

3-26-2015

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; The Researcher; The Administrator; Patients; Patients, Treatment, Survivors; Discovery and Success; MD Anderson Impact; Leadership; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; The Professional at Work

Transcript

Tacey A. Rosolowski, PhD:

And we strategized a bit before we started, and we're going to be talking today about your administrative role. So I was gonna kind of go through chronologically, if that's okay with you, and kind of get youryou know, what I'd like, is sort of what your role was, what your vision was, what you felt you accomplished. And the first one, Director of Clinical Epidemiology and Informatics in the Ambulatory and Supportive Care Oncology Research Program. And you were in what department in that time, that was the department you were in? And thatjust to get names.

Linda S. Elting, DrPh:

The department was General Internal Medicine.

Tacey A. Rosolowski, PhD:

Okay. All right. Soso let's see, you held that role between 1992 and 1998, and how did you come to occupy that directorship position?

Linda S. Elting, DrPh:

It was a new research program that was developing in general internal medicine, which was a clinical department. They providedthey oversaw the ambulatory treatment center, the emergency center, the sort of general internist's view of all our patients. And they gave all the chemotherapy that was not given as an inpatient. So all the outpatient chemotherapy was given there[coughs]excuse me, and there was more and more interest inin dehospitalizing people with cancer, and treating them in the outpatient setting. And so, the chairman of that department, Ed Rubenstein, was very interested in accompanying his trials of dehospitalizing care and treating in the outpatient setting with a collection of good data, with documenting the outcomes, and potentially identifying groups of people who were good candidates for treating in the outpatient setting. So the first few studies we did, we just sort of chose criteria out of our heads. Who would be safe to treat in the outpatient setting? But then, as more and more information accumulated, we began to be able to specify some very clear criteria, clinical criteria for safe treatment outside. So, he started putting together a team to do good work in that are. So I came in; I moved from Infectious Diseases to General Internal Medicine, primarily to oversee the first trials of outpatient treatment of fever and infection, which was pioneered in this institution. After the observation from all of us that, for example, the majority of breast cancer patient who were getting chemo who got fever were put into the hospital, and for about three or four, or seven days, we pushed their IV poles around the hall and walk up and down the street on Holcombe, and there was no reason for them to be in the hospital. It was just the standard of care, and everybody was afraid not to. And most of them would have been much more comfortable at their own home. So we started--

Tacey A. Rosolowski, PhD:

You seem very emphatic about that.

Linda S. Elting, DrPh:

Oh yeah. Yeah, it was real obvious; the patients would tell you, "Why do I have to be here? I feel better; I'm fine." Usually, they were afebrile by the next day. So, they were ready to get up and go and do their thing again, and we were keeping them in the hospital for five to seven days on IV antibiotics for really no reason other than nobody had ever tried doing it outside.

Tacey A. Rosolowski, PhD:

Why do you think that was, and what madewhy was MD Anderson the place where that happened first?

Linda S. Elting, DrPh:

Ia couple of reasons. I think that originally, when we used to treat patients with infection, who had cancer, and had gotten chemo, a lot of them were leukemia patients, and those patients tended to get real low white counts that stayed really low for a long time. And they had really terrible infections that often killed them. When MD Anderson started doing chemotherapy in people who had solid tumors, particularly early in the course of their treatment, not late when they were really debilitated, but early in the cacourse of their treatment, they were pretty healthy. And the regimens that we used for chemo didn't cause your counts to be low for a really long time. And so, we had a population of people who was pretty healthy to start with. Their chemo was not keeping their counts low for a long time, and most of them were out of the hospital to get their chemo. So they didn't have hospital-acquired infections that were hard to treat. Most of them responded to one dose of antibiotics. So, I think those observations were made, and at the same time, frankly, we needed the beds. You know, all we ever do is add beds, and add beds, and add beds, and if you fill up all the beds with a bunch of people who don't need them, then surgeries get delayed, and there are all kinds of problems. So there was a real interestI think the third thing that happened around the same time was that a bunch of newer antibiotics that were very broad spectrum, covering lots of organisms, were very effective, were available orally, as opposed to IV. So that made treatment in the outpatient setting a lot more practical. So, Dr. Rubenstein just decided he would try. And he treated two or three people as a pilot, and usually what he would do, is they typically were at home, so they would come into the emergency room because they were told to do that if they got a fever. They would put them in the emergency room in the bed, give them a dose of IV antibiotics, and observe them for some number of hours. Usually their fevers went right back down, and then they would send them home with oral antibiotics, and tell them to come back in two days. And they would call them at home a couple times a day to be sure they're doing all right, find out what their temperatures were. And they did okay, so he developed a protocolwe developed a protocol together to do that, and toto begin testing that. It was considered a wild and crazy thing to do. There were people, particularly in the northeast part of this country, who thought that it was unethical. Far too risky, too dangerous. Andbut it turned out to be doable, and it's now the standard of care throughout the world. But there was a goal to do this kind of work. And so, he wanted to beef up the science part of his faculty. So, I joined that faculty, and we also had a statistician, who was hired to join the faculty there. And we started doing trials and research. It was a good opportunity for me, because it pushed me to develop to think strategically. I had done a lot of management of people; you know, keeping all the balls in the air, and keeping the studies going, and that sort of thing, previously. What I hadn't done was really lead, and think strategically about what was a good direction to go, and what wasn't. And so, that was a real good experience for me.

Tacey A. Rosolowski, PhD:

Can you give me an example of that, a kind of strategic thinking that you learned during that time?

Linda S. Elting, DrPh:

I think theI guess what I'm calling "strategic thinking"is taking into consideration what the research program should be, so that[coughs]it leads to the next step. [coughs]

Tacey A. Rosolowski, PhD:

Do you want to pause?

Linda S. Elting, DrPh:

And that'sthat's hard for junior people to learn. You know, you come up with an idea, and then you get the answer, but if it doesn't lead you to the next step, then it's not a program; it's a one-off.

Tacey A. Rosolowski, PhD:

Right, right.

Linda S. Elting, DrPh:

So, and I had all these junior faculty running around[coughs]excuse me.

Tacey A. Rosolowski, PhD:

Do you wantlet's pause just for a second.

Linda S. Elting, DrPh:

Let me get some water, that's--

Tacey A. Rosolowski, PhD:

Sure. [The recorder is paused]

Tacey A. Rosolowski, PhD:

Okay, we're recording again after just a quick, quick stop.

Linda S. Elting, DrPh:

Okay, so I had a bunch of junior faculty who were physicians. They all wanted to become associate professors someday, and they would think up all these ideas based on a patient they saw, or something that piqued their interest. And somehow, I had to get them into some kind of a reasonable program so that people's research complemented each other, so thatand so that we could proceed one step after the other, and it could be viewed as a cohesive program, instead of just some shotgun approach to ideas.

Tacey A. Rosolowski, PhD:

Now traditionally, you know, it's either the myth or reality of academic research that everybody has academic freedom.

Linda S. Elting, DrPh:

Mm-hmm.

Tacey A. Rosolowski, PhD:

And was there resistance to that attempt to get people to coordinate their initiatives, so it was a cohesive program? Or did you not find it a problem to get everybody organized in that way?

Linda S. Elting, DrPh:

[clears throat] I had no problem with that at all, because frankly, I think they would have preferred it if I had just told them what to do, you know, so they could get it done and be on with it. But, I mean, we had to think in terms of what we could fund, what was possible with the available resources, and then making the group look, as a whole, more and more attractive to external and internal funders. And, so I never had any trouble with anybody. They always were delighted to step right into line. Now, frankly I tried to tailor things to their interests.

Tacey A. Rosolowski, PhD:

Can Ijust a quick detail I wanted to go back and catch. What was the name of the biostatistician who was part of that?

Linda S. Elting, DrPh:

Chuck Martin.

Tacey A. Rosolowski, PhD:

Chuck Martin, okay.

Linda S. Elting, DrPh:

He's since left the institution.

Tacey A. Rosolowski, PhD:

Okay. Now what was yourcan youcan you be more specific about what your vision was for this integrated program? What did you want it to accomplish?

Linda S. Elting, DrPh:

[clears throat] Well it was not anything real rocket science-y. The goal was to describe forto first, describe the prevalence of the problems that we saw, and get some feel for what problemswhat clinical problems took up lots of resources, whatand then to move to what clinical problems were perceived by patients to be the worst. Because we were talking about side effects, mostly, in symptoms. And then, my goal was to have three kinds of studies going simultaneously in those areas. Some, just from observation of charts or whatever. Some clinical trials of new drugs, and then some that was collection of outcomes from patients directly, problems and outcomes, and symptoms and severity. So, that's basically what we did. We had thiswe started collecting, you know, just encounters. Why do people come to the emergency room? How long has it been since they were here in the ambulatory treatment center getting their chemo? Whatand then, as we began to see that, and see some patterns, we started going to charts and collecting more detailed clinical information about the clinical problems that were common, or that were really expensive, that were frequently leading to hospitalization. And then, when we would get that far, we would then start another study where we would go directly to the patients and say, "You know, it seems like we've got a lot of people coming in with this problem. You have this problem. Is it because it's a particularly painful thing? Does it make you particularly frightened? You know, do you feel like you don't know what to do about it, or you know, what iwhat's the reason why you're here, and is it worse, for example, than this other problem?" And so, from talking to patients about that, we were able to devise some studies to find out what their perception of the outcomes was, of howof our treatment. So that was athat was a good test ofof whether or not we were really hitting the mark that we were trying to hit.

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Chapter 13: Developing the Ambulatory and Supportive Care Oncology Research Program

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