Chapter 17: The Texas Cancer Council and the Texas Cancer Pain Initiative

Chapter 17: The Texas Cancer Council and the Texas Cancer Pain Initiative

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Description

In this chapter, Dr. Hill talks about his appointment (by Lt. Governor Bill Hobby) to the Texas Cancer Council (President, 1992-94, 1994-6) and sketches his work starting up the Texas Cancer Pain Initiative (which began in the 1980s with an organizational meeting funded by the Hobby Foundation), an organization that lent its name to the attempts Dr. Hill and others were making to revise legislation with an impact on pain management. Reviewing the organization’s educational efforts (in the late 80s or early 90s), he explains the political and financial reasons why it is more difficult to change pain management practices now than in the past.

Identifier

HillCS_03_20120220_C017

Publication Date

2-20-2012

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Professional Service beyond MD Anderson; Overview; The Clinician; The Administrator; The Educator; Activities Outside Institution; Career and Accomplishments; Post Retirement Activities; Definitions, Explanations, Translations; The Healthcare Industry; Politics and Cancer/Science/Care; Fiscal Realities in Healthcare

Transcript

Tacey Ann Rosolowski, PhD:

We’re at about 4:30, and I was wondering if you have the energy to answer just a few final questions?

C. Stratton Hill, MD:

Sure, sure.

Tacey Ann Rosolowski, PhD:

Okay. I wanted to ask some observations about what you’re doing now that you’re retired, but first, maybe a little bit of reflection on what you did at MD Anderson. Of all of the roles that you served, what are you most pleased with as you look back?

C. Stratton Hill, MD:

It would be really hard for me to choose because I’ve had just, to me, phenomenal things that have happened, and I’ve made connections and friends all over, everywhere. What I’ve done for different reasons has taken me all over the world, and so a lot of my patients have become friends, and we visit with them. My son lives in San Salvador, and I’ve had a whole lot of patients from down there, so that’s helped him down there. We spent two weeks down there at Christmastime. I did a lot of work in the political arena getting these regulations and laws passed. I learned a lot about that. I made a lot of friends. I got appointed to the Texas Cancer Council. It seemed like I had about—I know I had two terms. It seemed like to me I was on that thing for about 16 years, and so that kept me in touch with a lot of things.

Tacey Ann Rosolowski, PhD:

What was your role on the Texas Cancer Council?

C. Stratton Hill, MD:

The Texas Cancer Council was organized to provide seed money for startup projects across the state in prevention and diagnosis. Not so much treatment, because you brought people into going institutions for treatment, but we were the granting agency for the money that we had. We started out with $11 million for the first year, and then we got various amounts, but it was in the millions. Every time we’d have to give it away, people would write for grants, and we’d have to look at the grants and decide who got the money. That was what the Texas Cancer Council did.

Tacey Ann Rosolowski, PhD:

How did you become involved with it? Was it an appointment?

C. Stratton Hill, MD:

Yeah, Bill Hobby appointed me. He was a friend of mine. He called me up one time. I didn’t even know— I knew that there was such a thing, but, I don’t know, I guess he couldn’t find anybody else, so he called me and asked me. He didn’t run, so I thought, “Well, I’ll just let this term go out,” and Bob Bullock came along as the lieutenant governor. But then Jim Dannenbaum was president of the Texas Cancer Council, and he said, “No, I want you to stay on here.” And I said, “Well, I’ve already said I’m going to quit. They’ve already given me a gavel.” He said, “That doesn’t matter. I’m going to put you up here, and I’m going to get some people to talk to Bob Bullock.” He said, “You just write Bob Bullock a letter and tell him you’re willing to do it.” I did, and so Bob Bullock appointed me, too, to the Texas Cancer Council, and I got to meet a lot of people all over. Another thing that we did—and I don’t know that I’ve mentioned this at all—is that I started the Texas Cancer Pain Initiative. Did I talk about that? That was—

Tacey Ann Rosolowski, PhD:

I’m not sure I’m recognizing the name. No.

C. Stratton Hill, MD:

I don’t think I did talk about that, but I got that—

Tacey Ann Rosolowski, PhD:

I have the Texas Pain Society.

C. Stratton Hill, MD:

No, that’s different. The Texas Cancer Pain Initiative was the group at the University of Wisconsin. I think I did mention that.

Tacey Ann Rosolowski, PhD:

Yeah, you mentioned Wisconsin.

C. Stratton Hill, MD:

They started what they call the Wisconsin Cancer Pain Initiative, and I had written an editorial for the JAMA, and what was the name of that editorial? Oh, I wrote— They had a thing where you could write a little vignette, and I’ve forgotten the name of what they call that column. I wrote it about pain and the problem with pain treatment, and that’s when they called me. That’s how I got started on that, and then it kind of got momentum going. I guess that was probably in the ‘80s. And then everybody thought, well, we had a cancer pain initiative here, and actually, we just sort of did it and never did organize it formally, and so—

Tacey Ann Rosolowski, PhD:

What were the goals?

C. Stratton Hill, MD:

The goal was to improve the treatment of cancer pain. I went to the Hobby Foundation and asked them to fund a meeting to be held in Austin, and I got Kathy Foley to come down. By that time, I had made connections with the Narcotics Division of the Texas Department of Public Safety and had—what was his name?—Captain—I can’t think of it right now. Anyway, I had all these people coming—we invited a lot of people to come—and we were able to pay from that grant from the Hobby Foundation to bring a lot of people from Anderson over to that meeting. We had an organizational meeting, and we started it up and formally got a charter from the state and incorporated, became a 501(c)3 corporation. And then we did a lot of things, and we had meetings. I never will forget we had a yearly meeting of the Texas Cancer Pain Initiative, and I got Reginald Ho, who was the national president of the American Cancer Society, to come to the meeting here for the Texas Cancer Pain Initiative. We were putting on a meeting every year, and I would get speakers to come. We also lent our name to all the stuff that we were doing with the legislature, the Texas Cancer Pain Initiative, and so forth, and I got different people. There was a book called The Culture of Pain that was written by—his last name is Morris. Anyway, I had him come speak one time. He was a professor of literature, David Morris, and since then he’s spoken at many, many pain meetings. He’s become very— His father was a doctor, and he became a university professor at the University of Virginia. A university professor is almost like being God. I mean, you can do anything you want to. You’ve got tenure. You can teach in any department you want. I never knew that. And he was a writer; he quit teaching to be a writer. He’s written a lot of different things. He was talking about— His big thing was the narrative of pain, and of course, being a writer, that’s kind of normal. Are you familiar with the Rockefeller—? [Rockefeller Foundation] I don’t know what it’s called. It’s an old monastery, I guess, in Bellagio, Italy, on Lake Como. Are you familiar with it?

Tacey Ann Rosolowski, PhD:

Yeah, it’s that residency program.

C. Stratton Hill, MD:

Yeah, right, where you go and you can submit that you want to do a book, and then you go there. Well, he did that, and that was after I was out of things.

Tacey Ann Rosolowski, PhD:

Yeah, that’s very prestigious.

C. Stratton Hill, MD:

Oh, yeah. He did that, and there’s a book that came out from that, but that was after I had retired and everything. We did things like that. I got grants, and we got money to do a lot of research. That’s the way I could pay these students to do things, research. We worked with the Sunset Commission, and I paid the law student out of that. I paid the law student here, and let’s see, what else came out of that?

Tacey Ann Rosolowski, PhD:

If I could interrupt you, I was wondering, from a slightly different perspective, what was the significance for Texas of having a pain initiative like Wisconsin had? Do you think it helped speed education?

C. Stratton Hill, MD:

I’ll tell you what we did. The biggest project we took on with the Texas Pain Initiative—and this is where we found out a lot about the politics too—decided that we were going to get a doctor, a pharmacist, and a nurse in every major city in Texas. We got money to pay for them to come to a meeting in Austin, and I brought the people down from Wisconsin to teach. The purpose was that they were going to go back and teach this course, because we had money to give to them to pay locally. Well, for instance, in El Paso, when I talked to somebody there to get it set up, they said, “You’re going to have to have two here because if you invite one group of doctors, the other group won’t come and vice versa.”

Tacey Ann Rosolowski, PhD:

Local politics.

C. Stratton Hill, MD:

“You’re going to have to have two groups, one from each one of those.” So we said, “Okay, we’ll do that.” We did that and then—

Tacey Ann Rosolowski, PhD:

What year was this that you—?

C. Stratton Hill, MD:

This was—oh, it probably was in the late ‘80s. No, it probably was in the early ‘90s, because Nora Janjan took that over, and she was here at the time. I didn’t know her, but there was an article about pain in Newsweek or Time or one of those magazines, and it had my picture in there and Nora’s picture in there. That all occurred about the same time that we were having that. She was at Wisconsin then, and then she came here in radiation therapy. She’s retired from MD Anderson now. But that unfortunately fizzled out. It didn’t keep going. The concept was great, but it takes a lot of funding. Then we began to run into all the cultural barriers and all the legal stuff, and we’re worse off now than we were before we started doing all this because the DEA came down on all of this. I convinced the powers that be in the DEA that we ought to look at this, and they even had me come to Annapolis, Maryland, to speak to all of their supervisors from all over the United States.

Tacey Ann Rosolowski, PhD:

You were going to educate them about the cultural issues.

C. Stratton Hill, MD:

About the need for it, because as far as they were concerned, narcotics had no useful purpose; it was all criminal. So I got the most egregious slides I could find of just terrible cases that we had, and I showed those to them. I remember after the talk and everything— And a lot of the guys had family members who had pain that wasn’t unrelieved, so they kind of were saying “Yeah, there’s something to this.” But when I got the final comment, as I was talking to the guy in charge who was kind of the public relations officer for the DEA, I said, “What do you think they thought about the program?” He said, “Well, they think you’re a nice guy, but you’re full of shit.” (laughs)

Tacey Ann Rosolowski, PhD:

It’s an uphill battle.

C. Stratton Hill, MD:

Anyway, the Cancer Pain Initiative, then what I tried to do was— But this time, we said, “Look, we’re making too narrow a focus on cancer pain. We now should just make it pain.” I then reorganized the thing, and we called it the Confederation for the Relief of Pain or something like that. And one branch of it was going to be for cancer pain. The other would be non-cancer pain. In the meantime, the American Cancer Society Texas Division was interested in pain relief. By the way, I got the National American Cancer Society Humanitarian Award one year.

Tacey Ann Rosolowski, PhD:

I was going to ask you about that. I have that— That’s really quite an honor.

C. Stratton Hill, MD:

Well, I was surprised about that.

Tacey Ann Rosolowski, PhD:

That was in 1996, the year you retired, that you got that.

C. Stratton Hill, MD:

Yeah, I had to go to Chicago to get that.

Tacey Ann Rosolowski, PhD:

When did you get the news? I mean, how did you get the news?

C. Stratton Hill, MD:

My secretary— I didn’t get the news until a lot later. I remember one time my secretary said, “Have you got anything going on in—?” whatever month it was. I said, “I don’t know. Not that I know of.” They told her to keep my calendar open, and so she did. Finally they— I remember because I had to go to Atlanta for that, and Dr. LeMaistre went over there because he was bucking for the presidency of the American Cancer Society at the time. He became president shortly after that. I don’t know which time, but I know that— It seemed like to me there was somebody else that got an award from Anderson at the same time that I got that other one. No, wait a minute. I don’t know. I went to get that in Chicago. I don’t know what that was in Atlanta. I can’t remember. But the Cancer Pain Initiative—that was a very important step to get that going. We officially got that going, I think, in 1991. Everybody thought, “Well, you’ve had one going for a long time,” and I said, “Well, not formally,” but we got it done at that time. And then the American Cancer Society Texas Division kind of just— I don’t know whether they’re still running one that’s called that or not, but because the pain is broader than it was to begin with, it’s not as focused on cancer pain. The Texas Pain Society doesn’t confine things to cancer pain.

Tacey Ann Rosolowski, PhD:

And you found that was a politically savvy move to get by in?

C. Stratton Hill, MD:

Yeah, because they then formed the Alliance for Cancer Pain Initiatives. June Dahl was the person behind that. She was a professor of chemistry at the University of Wisconsin, but she was on the Controlled Substance Board of Wisconsin, and they wanted to legalize heroin. She got interested in why. They were making the case that that was so much better for pain control than other drugs and so forth. She was a chemist, and she couldn’t see that it was any better, and that’s true. It’s not better. It’s more lipophilic. It’s more soluble in fat, and nervous tissue is mostly fat, so it gets there quicker. It gives you the rush, and people like it better. Anyway, that’s how she got into this—that book that I published—that we published.

Tacey Ann Rosolowski, PhD:

That Volume 11 of—

C. Stratton Hill, MD:

Yeah, when we began. We brought the people from Wisconsin. We brought the people from all over, and that was the first attempt to really make this a meaningful multidisciplinary approach, including the social sciences. It wasn’t just medical or the scientific part of it. It was getting the anthropologists in and psychologists and all the other people that had a role in this.

Tacey Ann Rosolowski, PhD:

What’s been the fate of that multidisciplinary approach? What’s happening now with that?

C. Stratton Hill, MD:

Well, that to me is a problem because one of the problems that you have in terms of getting pain treatment is who is going to pay for it? And who is going to pay for having—? If you’re going to have a psychologist and say an orthopedic surgeon and a neurosurgeon and a neurologist and a physiatrist and an anesthesiologist to get together and talk about a patient, who pays? And then if your patient doesn’t have an orthopedic problem, why should you pay the orthopedic guy? But then if he’s coming there and he’s taking time away from his practice—so you have a hard time with the logistics of that, and so I know that was— And I’m not sure whether or not Medicare pays in their hospice mode for after care. In other words, your expenses ought to stop when you die, but what about grieving? And I think that they do pay something for grieving after the person dies, so that means that expenses don’t stop, but they don’t just keep on paying. It’s just a certain limit, so that’s been a problem. My whole question is that all of these in this Institute of Medicine paper they’re talking about, well, we need more of the multidisciplinary approaches to this problem. There’s no question to what you do, but then how are you going to pay for it? And how do you decide what’s effective, who gets what, and so forth? There is an article also in the—I think it was in either the Houston paper or the Wall Street Journal, talking about this business of [President Barack] Obama dictating about contraceptive payment and so forth, that this is just the beginning because you’re going to have committees that say these are the criteria for this resource, A, B, and C. You don’t meet those criteria, you don’t get the resource. You can get it, but you’ve got to pay for it, and it says it’s going to be all over the place. I think that’s true, particularly with the emphasis on evidence-based medicine, because evidence-based medicine is not a, shall we say, poured-in-the-concrete, scientific endeavor. There are too many variables that you can explain, like, say for instance, the placebo effect. Somebody might just do well on— I’ve had patients say, “I don’t want this one here. I want that one over there.” “Okay, that one over there is ibuprofen, and this over here is morphine. You’d rather have the ibuprofen than the morphine?” “Yes, that helps me better.” So I give them what? I give them the ibuprofen. They say, “I’m not paying for that.” When you make evidence-based such a rigid criteria you’re going to get into deep trouble because of the nature of the pain problem itself. It’s just like the watermelon story I told you. You can’t explain it. So that’s what I see coming on board. It’s like, for instance, before we had payment for medication, you could get a pump for a patient that would pump the morphine intrathecally. The pump costs $10,000. The surgery to put it in there was maybe $4,000 or $5,000 and so forth. You could get that paid for by Medicare, but you couldn’t get $5 worth of morphine pills. There are all kinds of little things like that that are going to be a problem.

Tacey Ann Rosolowski, PhD:

Can I ask you about your post-retirement activities?

C. Stratton Hill, MD:

Yes. What I did, basically like I told you, I did a lot of testifying. I continued to do that because, by this time, I had a reputation. By the way, I forgot to call that guy. I’ve got to call him—the guy that called me from Wichita Falls about his daughter. By this time, I had a reputation, so I was doing a lot of testifying.

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Chapter 17: The Texas Cancer Council and the Texas Cancer Pain Initiative

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