Chapter 05: Surgery in Transition to Multi-disciplinary Collaboration
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Description
In this chapter, Dr. Goepfert observes that he came to MD Anderson during a time when cancer treatment was expanding beyond surgery to include chemotherapy. He gives a brief overview of the treatment practices at the time and notes that specialties debated who would administer chemotherapy. While Dr. Goepfert was a Senior Fellow in Surgery at MD Anderson, he observed that hematologists were activity involved in redefining who administered treatment (not the case at UCLA). (He also notes that he wanted to leave Chile for a fellowship in the US because of the “dismal state” of cancer therapy.) He witnessed the evolution of multi-disciplinary cancer treatment while working with Dr. Gilbert Fletcher. Dr. Goepfert notes that he established the “Thursday Afternoon Planning Conferences in the Department of Head and Neck Surgery in 1982, where multidisciplinary treatment plans were created. These sessions became a model for the entire institution. Dr. Goepfert then shares memories of Dr. Fletcher’s influence on his own thinking about how disease processes respond to radiation, how important give and take is in interdisciplinary care, and how critical it is to establish liaisons with basic scientists. He notes that he took part in the initial efforts at MD Anderson to establish a track for physician-scientists, mentioning the key roles of Dr. Garth Nicholson and Dr. Josh Fidler. He explains how a tone was set for the interdisciplinary management of head and neck cancers. He describes the working relationship between Dr. Fletcher and the gifted surgeon, A.J. Ballantyne. He notes that the process of establishing multidisciplinary care was not as “bumpy” at MD Anderson as in other parts of the country. He credits R. Lee Clark’s vision in setting up the remuneration system at MD Anderson for smoothing this process.
Identifier
GeopfertH_01_20120827_C05
Publication Date
8-27-2012
City
Houston, Texas
Interview Session
Helmuth Goepfert, MD, Oral History Interview, August 27, 2012
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; Overview; Definitions, Explanations, Translations; The Researcher; The Clinician; Professional Path; Portraits; Understanding the Institution; Building/Transforming the Institution; Multi-disciplinary Approaches
Transcript
Tacey Ann Rosolowski, PhD:
Let me ask you a quick question, because in ’66, when you were in UCLA—well, let me backtrack a little bit. When I interviewed some people here about the use of chemotherapy here at MD Anderson around that time, they were talking about how there was some tension between people who were interested in using chemotherapy and surgeons, because surgeons kind of felt that tumors needed to be treated surgically. So, what was your experience with that?
Helmuth Goepfert, MD:
No, the experience was that this was a transition. Now, when I came to UCLA I was put in charge of the solid tumor chemotherapy clinic. Look at where this was in those days, okay? When I came here, I came with the specific purpose of working on regional chemotherapy and intra-arterial chemotherapy. In those days, it’s the isolated perfusions that still were done to some extent and the intra-arterial infusion, which in those days there was not the Seldinger Technique that is done today by interventional radiologists, but you sort of cannulated the arteries by open procedure. You went here with a local anesthetic, found the artery, put the catheter in and tied it in and left it there and gave the drug.
Tacey Ann Rosolowski, PhD:
And just for the sake of the recorder, you’re pointing at your temples, so you literally go through the—?
Helmuth Goepfert, MD:
Go through the arteries. You find the artery and do a retrograde catheterization, test if it is in the appropriate place based on a fluorescent test, and we left the catheter there and hopefully it would not dislodge or something. Then it would stay in there for so long, and the drug would be infused. In those days what was infused was fluorouracil, and they usually gave concomitant chemotherapy with that. The other tension of course still was not so much who will treat the patient but who will give the drug, and of course the medical oncology at this institution became quite strong because of the leaders it had. The track record, especially in hematology malignant tumors—leukemias and lymphomas—basically were a very strong point for them to build on that and then take over the management of the so-called adenocarcinomas—breast, colon, lung, and what have you.
Tacey Ann Rosolowski, PhD:
Now, at UCLA, that wasn’t the same situation? Or it was the same situation?
Helmuth Goepfert, MD:
At UCLA there was basically the perfusions and the infusions—the isolated perfusion and the infusions. The hematologists were doing the first attempts to participate in solid tumor chemotherapy but were not really interested in it because probably the limited availability of effective drugs. I mean, at UCLA I still was using nitrogen mustard for intravenous chemotherapy in some of the tumors. Cytoxan existed, fluorouracil, nitrogen mustard, vincristine, Velban, methotrexate certainly was there and melphalan. That’s about it, so there was not the large amount of drugs, and we really didn’t know what would work, so the first trials of vincristine were done in those days.
Tacey Ann Rosolowski, PhD:
What were some big lessons you learned at that fellowship that really helped you in that next move?
Helmuth Goepfert, MD:
The reason I took one of the fellowships is because I saw the dismal state of cancer therapy in Chile. The horrendously advanced cancers that I saw in the clinic or that my dad took care of, particularly of the breast, I said, “There has to be a different way to treat this.” So, as I said, yes, in those days the whole issue of prevention and so forth was not there. Then, of course, the radiation therapy that was given then was called orthovoltage therapy, and it was not the best in the city where I was working. I wanted to see something that would be a step forward, and, yes, in my limited experience I considered that a step forward, and, yes, I saw that there was a lot that could be done with the availability of these drugs, but still it was limited.
Tacey Ann Rosolowski, PhD:
Now, so you went back? Well, in ’67 you went to MD Anderson, so you really had—
Helmuth Goepfert, MD:
No, it was ’66-’68 I was here. The first year I was a research project investigator, and the second year Dr. White, who was the chair of surgery, offered me a senior fellowship in surgery, so I was basically in surgery. In those days you rotated through colorectal, breast, soft-tissue sarcomas, and melanoma. As a senior surgeon I did not really participate in the care of lung cancer—senior fellow of surgery—but it was those—and the team leaders in those days were Dr. Richard Martin and Dr. John Stehlin. Now, when Dr. John Stehlin left, Charles McBride came to be one team leader there. I left in 1968 to go back home.
Tacey Ann Rosolowski, PhD:
You refer to these team leaders, and in using that term are you referring to kind of interdisciplinary care teams?
Helmuth Goepfert, MD:
No, surgery teams.
Tacey Ann Rosolowski, PhD:
Okay. Surgical teams.
Helmuth Goepfert, MD:
Pure surgery teams. The first interdisciplinary activities really happened in Head and Neck Surgery way back then. It started between Dr. [William] McComb and Dr. Gilbert Fletcher, but it then really became more organized under Dr. Richard Jesse, and when Dr. Jesse died and I became the chairman, I made sure that the so-called interdisciplinary planning process would take place. So ever since then, the Thursday Afternoon Planning Conference exists in this institution, and it was the model after which all the other ones were modeled at MD Anderson.
Tacey Ann Rosolowski, PhD:
Really? So that—wow.
Helmuth Goepfert, MD:
Yeah. So that was the beginning of it, and that was in 1982. One of the important teachers I had in the whole issue of oncology was actually the chief of radiation oncology then, Dr. Gilbert Fletcher. He was a great teacher in showing you how cancer sort of evolved in a sense of how it was important to observe what was going on in order to plan the right treatment. Great lessons were learned in that he already had a planning clinic that was exclusively for radiation therapy. You probably have heard that he used to have, every morning at 8:30, one to three patients presented to him, and in front of the whole department they were discussed and what was the treatment recommended.
Tacey Ann Rosolowski, PhD:
I hadn’t heard that.
Helmuth Goepfert, MD:
Yeah. And he was a hothead, but he knew what he was talking about. He was really a wonderful teacher, and he deserves to be credited with many of the later advances. Nowadays nobody knows anymore who Gilbert Fletcher was. Only the elderly know who he was and worked with him.
Tacey Ann Rosolowski, PhD:
What were some of the strategies that you learned by observing him work with patients?
Helmuth Goepfert, MD:
I learned the fundamental fact that—number one—there are certain disease processes that were better treated by radiation therapy. Number two—that it’s not all or none. Number three—that there is a give-and-take in interdisciplinary care. And number four—and this sort of guided me later in my career—that there was need for establishing a liaison with basic sciences in order to further the knowledge, and that’s where the concept of the physician-scientist came to bear. These were people—I mean—the physician-scientist track was established at this institution, and I must admit, I participated in the initial intents of that with Dr. [Isaiah J.] Fidler, whom I saw today in the hallway, and there was another one that was—he left for California—Nicolson—Garth Nicolson. Garth Nicolson was the other one. They were, I would say, the first members of this team in which we interact with each other in order to train young minds in being tied to basic science and sort of a bridge between basic science and clinical science—for example, Stimson Schantz in our department. One of the early ones that went through this track is Dr. Raphael Pollock, who is at present time the head of surgery. He was one that went through the early phases of this type of training. Now in the department there are several—in the department of head and neck surgery—there are several that were trained on that track—Dr. [Jeffrey N.] Myers, Dr. [Gary L.] Clayman, Dr. [Michael E.] Kupferman, and I think those are the principles that are left here. As I say, my evolution into that—I could never do that because I was involved in a different training. I didn’t get my board certification until I was thirty-eight years old, so it was four or six years later than normally. I had other fights to fight. I was the first chairman of Ears, Nose, and Throat at a new medical school here, where I basically took care of ear, nose, and throat problems over at Hermann Hospital, and at the same time I had a part-time appointment here at MD Anderson in the Department of Head and Neck Surgery. Now, what else did I learn from interaction? As I say, Dick Jesse and Dr. Fletcher sort of—and in those days, Bob Lindberg too, because he was subspecialized in head and neck radiation oncology. He still lives in town here. He retired several years ago. First, he moved to Kentucky and then came back and retired here in Houston. They sort of set the tone for the interdisciplinary management of head and neck surgery, and then gradually medical oncology came in. That started basically with some initial attempts to participate in an interdisciplinary management with earlier disease than the advanced disease that medical oncologists usually take care of. When you get hold of what we are writing with Dr. [Randal S.] Weber—the history—you will recognize how that evolution sort of took place.
Tacey Ann Rosolowski, PhD:
Was it bumpy getting to that point of getting people working together in a smooth way?
Helmuth Goepfert, MD:
It always has been bumpy.
Tacey Ann Rosolowski, PhD:
What were the reasons for the bumps?
Helmuth Goepfert, MD:
Let me put it this way, most of the time it had to do with characters and strong personalities. In the evolution of this institution, it should be recognized that one of the technically more gifted surgeons was Dr. A.J. Ballantyne. A.J. Ballantyne, for example, was the first resident of this institution. He then went to Mayo Clinic for two years, and when he came back, he worked as a head and neck surgeon. He had been trained in general surgery, worked as a head and neck surgeon. He was a great collaborator with Dr. Fletcher in many aspects. But interestingly enough, over the years, the two distanced themselves because Dr. Ballantyne himself sort of felt very strongly that some of the side effects of radiation therapy were too much for the patient to bear and felt strongly that surgery was better, none of which was probably totally true, but nevertheless it was enough for them to split and become very antagonistic at the later time of their careers. So, this is one thing that you would say, yes, it evolved in that form. Bumpy, yes, but not as bumpy as it was in other parts of the country, because the one thing that needs to be said is interdisciplinary care has to thank Dr. [R.] Lee Clark for creating the remuneration principle at this institution in the sense that whoever brings in the money does not control that money; it’s a separate board that controls the disbursement of the these funds. That is the basis of why, at this institution, interdisciplinary care could be given the way it is. That should not be forgotten. You look at Memorial Hospital. They’ve never been able to do that, and they still are separate private practices up there. It was very easy for a surgeon to say, “In reality, I don’t need to operate on this patient. This patient will be better served by radiation therapy.” So that prevailed over the years and has been sort of the motive for all of us that are ever trained here or that still work here.
Recommended Citation
Goepfert, Helmuth MD and Rosolowski, Tacey A. PhD, "Chapter 05: Surgery in Transition to Multi-disciplinary Collaboration" (2012). Interview Chapters. 1004.
https://openworks.mdanderson.org/mchv_interviewchapters/1004
Conditions Governing Access
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