Chapter 17: Changes in MD Anderson Culture with a New Administration

Chapter 17: Changes in MD Anderson Culture with a New Administration

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In this chapter, Dr. Keating offers his views on how MD Anderson has changed since Dr. Ronald DePinho took over as the institution’s fourth president in 2011.

He begins by talking about the CLL Moon Shots Program, noting that it has become increasingly evaluated by individuals with little experience with clinical research and who are primarily concerned with generating income. Dr. Keating states that MD Anderson finds itself at a crossroads following the transfer of leadership to Dr. DePinho. To set context for his evaluation, he first speaks about the institution as Dr. R. Lee Clark, MD set it up and changes that come when Dr. Charles LeMaistre (interviewed for the oral history project) and Dr. John Mendelson (interviewed for the oral history project) were each installed as presidents. Under Dr. Mendelsohn, he states, the institution became very legalistic and self-protective, and a corporate mentality evolved. He tells a story related to the donation of funds by T. Boone Pickens, who gave funds to be matched: Dr. Keating states that Dr. Mendelsohn drew the matching funds from the Physicians Referral Service. He talks about the purpose of the PRS. Next, he talks about the growth of institution bureaucracy and compares it to Memorial Sloan-Kettering Cancer Center.

Next, Dr. Keating talks about the shift in perspective on research, stating that Dr. DePinho stresses science over clinical perspectives. He also mentions an ongoing controversy of awarding tenure.

Dr. Keating then evaluates the progress of the Moon Shots Program, noting that the expectation for success was too high at the outset. He provides an example from the Lung Cancer Moon Shot to illustrate. He recalls his first impressions on meeting Dr. DePinho during his interview process.

Identifier

KeatingM_02_20140520_C17

Publication Date

5-20-2014

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Critical Perspectives on MD Anderson; Critical Perspectives; Critical Perspectives on MD Anderson; MD Anderson Culture; MD Anderson History; Controversy; Portraits; Obstacles, Challenges; Post Retirement Activities; MD Anderson in the Future

Transcript

Michael Keating, MD:

So that led to our ability to compete for the Moon Shot Program for CLL. I worry at the present time that the whole Moon Shot Program is getting more and more structured.

Tacey Ann Rosolowski, PhD:

It is structured and was from the beginning structured very differently, as I understand it, from most research.

Michael Keating, MD:

Mm-hmm.

Tacey Ann Rosolowski, PhD:

Tell me about that. What’s—

Michael Keating, MD:

Well, I think it was this sense that if you were doing something well, they would get some more resources for you to move it more quickly. But more and more, it got to the point where, “Well, we have to have this check and balance and this check and balance and this check and balance,” and—

Tacey Ann Rosolowski, PhD:

What kind of check and balance are you talking about?

Michael Keating, MD:

Well, of course, you know, one thing is that you have to have everything that you propose, like the flagship projects, have to be reviewed by a committee of people, and the initial evaluation was done by a combined internal-external group, but increasingly, we’re being evaluated by people in-house, and there’s very, very little clinical input into that process. They’re almost all laboratory investigators or executive vice presidents, so that the decision makers are the people that are the chief financial officer and the chief legal officer and all these people that know diddley about research, but they’re always on the lookout for how do we generate more income for the institution. They use the term that the institution has to be “sustainable” or research has to be “sustainable.” There’s an article in the—I think it was The New York Times yesterday that was saying that doctors’ salary is such a trivial part of healthcare these days and the number of people that are making much more money than the most highly paid clinical person here. You know, head of neurosurgery, that’s the top of the world as an individual. They’re the most highly skilled activity at the number-one Cancer Center here, and he gets out-salaried by many, many people here, and they were people that were never top of their class, because the top of the class were all out in corporate America. So that I think that we’re at a real crossroads at Anderson as to whether we shift from being a fairly altruistic organization where people stay because of their passion, to the point where you become providers and not doctors, and patients become clients rather than patients, and it’s all in the interest of seeing more and more patients and generating more and more income. And I think it’s a real crossroads that we’re at right now. I don’t care if anything like that gets quoted, because I keep on telling people, including Dr. DePinho, that there’s a development of a corporate mentality here.

Tacey Ann Rosolowski, PhD:

Yeah, I was going to ask you about some key shifts. And I have a feeling that we’re going to embark on a conversation that may go beyond four-thirty. Is that okay with you?

Michael Keating, MD:

Mm-hmm.

Tacey Ann Rosolowski, PhD:

Okay, because I wanted to ask you about some shifts with change of administration. I mean, you’ve seen all four presidents at this point. So talk to me a bit about the transformation of the institution under different leadership.

Michael Keating, MD:

Well, I think that Dr. Clark had it easy in some ways in that there was no structure that was put in place at all, and he had great intuition as to the sort of people that he wanted to hire. He didn’t have a big or administrative structure, that he ran things with a kitchen cabinet of about five people, that someone would come and tell him they had this little problem, and he would send someone out to find out what the problem was and solve it. And that worked pretty well. I think he was also the first to say that, okay, well, surgery is what we do now for cancer, we chop it out, or we do bigger and bigger operations that are more destructive to the human body. Then he said, well, you can limit that by doing radiation as well, so he went and found, by the sniff test, the most imaginative radiation therapist in Dr. Gilbert Fletcher, and seduced him to come here from France and build that up. Then when he found out that people weren’t doing well on chemotherapy, particularly the kids, he raided the National Cancer Institute and got Drs. Frei and Freireich to come down and recruit their different people, and so that that led to a filling of the bill of the major modalities. When Dr. LeMaistre came down, he came as a physician but not a cancer doctor, and he was very much from the administrative structure of University of Texas. He was either the vice chancellor or some term like that, and he was a master of the organizational chart, and he said we need to have little modules, rather than just this vibrant group that people were becoming jealous of because they got famous. So he shifted things and put people in charge, and I think that was a fairly good thing, because many of the people who were put in charge developed very effective programs. So that when Dr. Mendelsohn took over, I think that’s the wave of buildings, that we got bigger and bigger and bigger. You know the saying, well, size doesn’t matter, well, it does matter from the point of view of the bigger you are, the more difficult it is to administer.

Tacey Ann Rosolowski, PhD:

What were some changes that you noticed in those practicalities and also in the culture?

Michael Keating, MD:

Well, I think that, unfortunately, Dr. Mendelsohn had two issues. One was the Imclone scandal, and then there was the Enron activity that he was involved with. And I think that then we became very legalistic, that we had to protect from anything that smelled bad, and so that our little legal department got to be a large legal department and that it was then that the corporate mentality began to be experienced, because if you’re going to build buildings, some of it goes from donations, but some of it was coming from patient-care revenue, even in the situation from the Pickens thing. The history of the Pickens donation is fascinating, in that he said, “We’re going to give you all these millions of dollars, but you have to match it by a certain period of time,” and so that the matching, for some reason that I’m not aware of, Dr. Mendelsohn felt that we had to match it in a short period of time, so he took funds from the Physicians Referral Service bank and used it to match it so that he didn’t have to worry about that anymore, and the—

Tacey Ann Rosolowski, PhD:

What was the reaction to that?

Michael Keating, MD:

Anger. You know, we worked hard for that. And it was one of those things that it was arranged at a time when hardly anyone turned up for the meeting except the administrative people, and the vote was put in place.

Tacey Ann Rosolowski, PhD:

And the purpose of the Physicians Referral Service was what—is what?

Michael Keating, MD:

It’s our practice plan, so that basically it provides the resources for your insurance and all the things that would normally be covered by yourself having a private practice. But you get paid a lot less in private practice, so it’s a retirement fund and all those other things. But they also provide funding for support of the laboratory scientists, so that even though laboratory scientists are not bringing funds in, they get a proportion of their retirement and their bonuses, etc., paid from that. So that the mentality there from the Physicians Referral Service and from patient-care revenue was to support the patient-care activity and the scientific thing.

Tacey Ann Rosolowski, PhD:

I can well imagine there would be anger.

Michael Keating, MD:

It then shifted over to paying for support of the bureaucracy. And the thing that’s happened during that time and subsequently is the tremendous expansion of the number of vice presidents, and there two ways that you can become a vice president. One is—three. One is if you’re not doing a very good job in a high position, so instead of firing you, they make you a vice president and put you in charge of something that’s not important. The second thing is that if you’re one of the favorite sons of someone, that you become a vice president. The third thing is that if someone says that you have to look after ethnic minorities and women, etc., you have to have an office and a vice president for those activities. So now we have more than 100 vice presidents, and Memorial Sloan-Kettering has ten or eleven. So the justification of that is amazing. I’ve got no idea how they can get away with it. And the shift now is that Dr. DePinho thinks that you can cure cancer just by science, and it doesn’t matter how good the clinical faculty is, because we can always recruit them. So that we have a ton of people that are leaving right now, and they’re not going to be replaced by people of the experience and the quality that we’ve had so far. So that I think that I would be surprised if the present administration survives.

Tacey Ann Rosolowski, PhD:

Really?

Michael Keating, MD:

Yep. In the Cancer Letter this week, there was an autocratic decision for Dr. DePinho to go against the unanimous recommendation for tenure for all our people. And we’re members of the American Association of University Professors, and you’re supposed to follow certain rules if you do you that, and he didn’t. So he doesn’t like following rules or even knows what the rules are, because he micromanages a whole bunch of stuff. And right now my impression is that all the major planks of his initiative are not working.

Tacey Ann Rosolowski, PhD:

Really?

Michael Keating, MD:

And he’s certainly not bringing in the donations to support the Moon Shots.

Tacey Ann Rosolowski, PhD:

Now, do you believe that that expresses or that’s the result of a lack of confidence, or are there pieces in the Moon Shots Program that are simply not working and that’s becoming evident?

Michael Keating, MD:

I think that there were expectations that were way too high. You know, for example, in lung, the thing was we’re going to do all this screening for early detection, and the newspapers and the reports that are being written, “Yeah, we’ll save a few lives, but we can’t afford it, because it’s going to cost billions to do it.” Now the thing is that they say, well, we’ll find biomarkers that will identify the patients that should be screened, but if you don’t hit that mark, if you can’t identify these people and you’re just screening everyone, it just doesn’t work. There’s a lot of discussion now as to whether mammography is actually cost-effective, whether PSAs are an effective way for early detection, whether it saves lives or not. So there are a lot of hypotheses that are being put in place that haven’t paid off historically, but I think there’s this sense that, “I know what’s going on or what will go on. I can predict this, I can predict that.” Before he came down here, I think he was looking after a lab that had about seventeen professionals, and he comes down to run the biggest Cancer Center in the world, and I don’t think he’s ever managed anything like it.

Tacey Ann Rosolowski, PhD:

Did you have any kind—what was your attitude when it was announced that Dr. DePinho was going to be the fourth president of MD Anderson? Had you spoken with him before? What were your impressions?

Michael Keating, MD:

I was part of an interview by the Executive Committee of the Faculty Senate and asked him a few questions, and it was obvious to me that he didn’t know very much about clinical research, so he just threw the question back at me, “What would you do?” So I told him what I’d do and then he moved on to the next area. But, you know, there have been times in the whole history of MD Anderson where the cure was just around the corner, with oncogenes and different other phases of it, this unbridled optimism that was just exaggerated, and I felt that his whole sense that it was all going to be handled by genetics and data management. You know, he often uses me as an example of big data, that if we can capture all the data and feed it into a computer, we’ll be able to analyze the best thing to do for patients everywhere so that we’ll be able to send Dr. Keating’s brain to Timbuktu. The problem is that all the things that we would recommend are not available in Timbuktu, so it doesn’t matter. But I think the idea is that the opinion will be charted for so it will generate more revenue, so it’s using information technology to generate revenue. So it’s becoming a little bit like a lawyer, you know, twelve minutes, so many hundred dollars, etc., and that sort of thing. So I think that there’s a whole sense of what’s going to happen.

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Chapter 17: Changes in MD Anderson Culture with a New Administration

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