Chapter 18: Surgical Oncology, Board Certification, and Working to Define the Field
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Description
In this Chapter, Dr. Pollock first explains that the Department of Surgical Oncology is about to move forward with Board Certification. As a member of the Surgical Oncology Advisory Committee of the American Board of Surgery, he has been involved with defining the field of Surgical Oncology and with determining the parameters for certification. Dr. Pollock explains how the training of surgeons at MD Anderson has changed –and will change—as a result of this process. Training periods will be longer, but some of activities that currently generate more income for fellows will be reduced, requiring that the institution hire part time assistants. Dr. Pollock describes the advantages of certification, despite some disadvantages. He then notes that he has been a member of the Committee for the past twelve years: he and his collaborators have successfully defined the role of the surgical oncologist as an orchestrator of multidisciplinary care. The certification process attests to the fact that Surgical Oncology is a full-fledged discipline.>/P>
Identifier
PollokRE_03_20121119-C18
Publication Date
11-19-2012
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Raphael Pollock, MD, Oral History Interview, November 19, 2012
Topics Covered
The University of Texas MD Anderson Cancer Center - An Institutional UnitThe AdministratorBuilding/Transforming the InstitutionMD Anderson ImpactThe MD Anderson Brand, ReputationUnderstanding Cancer, the History of Science, Cancer Research The History of Health Care, Patient CareContributions Activities Outside InstitutionOverviewEducationProfessional Practice The Professional at WorkUnderstanding the Institution
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
Tacey Ann Rosolowski, PhD:
Yeah. That’s pretty amazing. How do you see the department evolving in the next years here at MD Anderson? You talked about the field, but what about the specific department? What do you think is going to happen?
Raphael Pollock, MD:
The Department of Surgical Oncology as compared to the Department of Neurosurgery? Okay. I think one of the big developments where I have had a very strong role nationally is that we are about to move forward for the first time ever with board certification in surgical oncology. So the way that surgical oncology training happens in the United States is about to undergo some pretty remarkable accreditation, centralization, standardization processes, and our group certainly will not be exempt from it. As a matter of fact, we’re providing national leadership. So I think that how surgeons are trained is going to change. There will be more specialization even within surgical oncology. It’s quite possible, given the eighty-hour work week, that the training programs will need to be increased in their length from two to perhaps four years, with specialization within that period of time. By the same token, it’s quite possible that general surgery residency programs will be truncated such that after two or three years of general surgery training, you would move into a fellowship program that might be four or five years long, resulting in the same eight or so years as a surgical trainee but with a much earlier focus on training towards the activities that an individual anticipates being involved with when they become and independent practitioner. So there’s that aspect that I think is going to be very important. And as part of that process, I anticipate that the department itself will have stronger and stronger section and decentralization of activities to accommodate where the discipline as a whole is going. It’s even possible that in the future, given the magnitude of the Department of Surgical Oncology, with over forty faculty now, that this ultimately becomes a division in its own right. We could easily countenance a situation where there would be a Division of Surgical Specialties and a Division of Surgical Oncology to accommodate these types of shifts. And hopefully, if that is necessitated by the way that the disciplines themselves evolve, hopefully the institution will see the wisdom of increasing the administrative support that would be necessary, would be mandated, were that to happen.
Tacey Ann Rosolowski, PhD:
That’s been a recurring theme in interviews—just how a field changes and how the administrative structure then has to change in response to that. So this is a situation where you really see that the specificity of each of these more focused practices means that each of those practices has to define its own practices, have its own governance structure.
Raphael Pollock, MD:
Correct.
Tacey Ann Rosolowski, PhD:
What is the process that you’re going through in order to become accredited? Are there some special things that you have to do?
Raphael Pollock, MD:
Yeah. The ACGME—The American Commission for Graduate and Medical Education—I don’t know if the C is commission or council. You’d have to check that out. The ACGME is an accrediting organization, and it has very strict requirements that have in some ways forced us to change how we approach our fellowship training programs if our program is to be credited by the ACGME. There’s a connection here because without ACGME accreditation, the American Board of Surgery, which is sponsoring the certification exam, will not allow a program to have its candidates sit for the examination. So, there’s a power of the pulpit here—the bully pulpit—that we have to pay attention to. And that’s made a difference in our own institution. For example, one of the requirements of the ACGME is that a trainee cannot receive any salary supplementation on the basis of clinical revenues that they are generating. Even if we chose to call the trainee an instructor or gave them an academic title, if they are preponderantly a trainee, they cannot accept any resources from such activities. In the past, the need for central venous access for chemotherapy requires placement of as many as 300-500 central lines a month, and that works out to almost $3 million of clinical revenue that, with this new requirement, is not going to be able to be generated with some of that revenue being given to the trainees to augment their salaries. That’s not going to be allowed.
Tacey Ann Rosolowski, PhD:
So what’s the wisdom of that?
Raphael Pollock, MD:
The wisdom of that is in much smaller programs where there may be one or two surgical oncologists and concern that those individuals would hire someone ostensibly as a fellow but really just use them as cheap labor or apprenticeship and pay them out of their practice rather than having a separate funding mechanism set up. So that’s the reason why that stipulation is in place. Another stipulation that is going to change how we approach things is that the eighty-hour work week requirements will apply to surgical oncology fellows as well. Up to now, they have not. That has important implications because heretofore, to provide coverage of the hospital at night, we have basically allowed our fellows to internally moonlight and provide that coverage for which they receive compensation—had some compensation, I might add. Well, now those hours spent performing that service counts against the eighty-hour limitation, and so we will no longer be able to have our trainees performing that service, lest they compromise their availability for actual fellowship training. And that’s very unfortunate because the trainees frequently are covering patients that they operated earlier in the day, and so for a patient who is now fresh, first postoperative night after a complex operation, having an individual who knows their case in the house, available thirty seconds away, at whatever the cost is really priceless, and that’s going to go away unfortunately.
Tacey Ann Rosolowski, PhD:
So how are you going to deal with something like that?
Raphael Pollock, MD:
Don’t know. That will be a physician-in-chief responsibility to figure that out. Hospitalists, people who are paid shifts, shift work, which means that individuals who are not involved in the patient’s care during the day and frequently have no conception of what actually took place during the operation will be making critical decisions on our patients. I guess they call it progress.
Tacey Ann Rosolowski, PhD:
I guess they do. So the advantages of accreditation in light of all that are?
Raphael Pollock, MD:
Well, we feel that the advantages outweigh the disadvantages. The discipline has matured to the point where it is a genuine medical specialty with a corpus of knowledge as well as some specific surgical techniques and operations that are uniquely performed by surgical oncologists. So it’s acknowledging reality. That’s one issue. The other issue, of course, is that because all the other programs are likewise going to be moving in this direction, it would put us at a very strong competitive disadvantage if our programs were not ACGME accredited and therefore our fellows couldn’t sit for this exam and therefore couldn’t be board certified, because in the future, that may be a very important credential regarding staff privileges at one or another institution. The way that this process is being set up, there is not grandfathering, meaning that no one will become a board-certified surgical oncologist unless they have graduated from an ACGME approved fellowship and passed what will be a written and an oral exam. Meaning that someone like myself who is actually involved in designing the written exam will never be allowed to sit for it because I am not a graduate of an ACGME approved fellowship. But this is one way of keeping the total number of trainees limited such that they can perform the function that they American Board of Surgery would like them to which is in some ways much more of a consultative, facilitating function rather than a group of specialists who will supplant general surgeons who are going to continue to perform the majority of cancer surgical care in the United States. So as you can well imagine, there is a tremendous amount of politics that have had to be navigated over the past thirty years to make this development possible.
Tacey Ann Rosolowski, PhD:
I can see that. And also, I’m recognizing as you are describing that facilitative role—that was one of the first things you mentioned when we first spoke, and I asked you for an overview definition of surgical oncology. So that really has been purified and purified, and that really is the role that is going to define this discipline. So it’s a very—I mean—that must be very gratifying to see.
Raphael Pollock, MD:
It is very gratifying, because I’ve worked on the national level through the Surgical Oncology Advisory Council of the American Board of Surgery for the past twelve years, and to finally see this come to fruition is very gratifying.
Tacey Ann Rosolowski, PhD:
So you’ve been very actively engaged in defining this.
Raphael Pollock, MD:
Yeah, working with colleagues elsewhere who also serve on this committee.
Tacey Ann Rosolowski, PhD:
Who are some of the other people that you’ve worked with on this?
Raphael Pollock, MD:
Oh, Carlos Pellegrini chaired the committee for quite a long time. He’s a surgeon at the University of Washington in Seattle who was my chief resident when I was an intern at the University of Chicago, so we go back that far. Fabrizio Michelassi, who is a surgeon at Cornell—chairman of their surgery group. John Daly, a former faculty member here, most recently dean of the Temple University medical school has been another very active individual. Tim Eberlein, who is chair of surgery at Washington University in St Louis, another friend and colleague who has been very involved. There have been a number of very prominent national leaders who have worked cohesively and selflessly as a unit to try to move this forward.
Tacey Ann Rosolowski, PhD:
I’m trying to kind of visualize or get a sense of what the commitment was twelve years ago or when these conversations first began about what this discipline should be. What was the philosophical theme that brought all of you together and said, yes, we know what direction we need to move in?
Raphael Pollock, MD:
Well, this effort actually goes much further back than twelve years. This really was begun in the early 1980s. And our predecessor committee—and I don’t know what the name of that committee actually was, but it was, again, a committee sponsored by the American Board of Surgery—spent five or six years trying to push this forward, and it was ultimately voted down by the parent board. So this is something that we’ve always thought about, and it’s been there in our consciousness for a long, long time. But it’s a recognition that patients will get better care for their solid tumor problems if there’s a small cadre of experts who can assist the larger surgical community by providing input, consultative advice, even intraoperative assistance to help our colleagues in the general surgery arena so that the patients will get that much better care. And if it could be done and ultimately was done in a way that did not pose a threat to the general surgery community, then we’re that much more certain that we would receive acceptance, and it’s taken a long time, and that’s where we finally landed, so we’re very gratified about that.
Tacey Ann Rosolowski, PhD:
I mean, I’m just kind of putting together a number of things that I’ve heard from other interview subjects and the things I’ve read about—you know—you have this evolution of the understanding of cancer and of becoming much more complex addressing the cancer, and then there becomes this need for this mediator kind of role—this facilitator kind of role—that’s born out of that. And I suppose nobody quite understood what that would look like. But then you have these surgical oncologists moving forward to say, okay, we’re going to be defining and refining this role. It’s very interesting.
Raphael Pollock, MD:
Well, like we talked about in our first interview session, Kirby Bland, who was the chairman of surgery—still is actually—at the University of Alabama and a former faculty member here, used to always quip that the difference between a general surgeon and a surgical oncologist is a general surgeon knows how to do a mastectomy and a surgical oncologists knows when to do a mastectomy, implying the knowledge about how to do the procedure, but also the knowledge of how that procedure insets into the natural history of the disease and the impact of other nonsurgical treatments so that you can orchestrate a multidisciplinary care program. That, in capsular form, is what board-certified surgical oncologists should be able to provide in their local practice environment. But they certainly don’t want to be doing all the mastectomies at a given hospital. It would be an overwhelming workload.
Tacey Ann Rosolowski, PhD:
It seems like a— Well, it’s a completely different cognitive approach as well.
Raphael Pollock, MD:
Exactly. It’s a cognitive as well as technical specialty, and it takes a while for people to understand that. But we’ve reached that goal, so we’re very elated.
Tacey Ann Rosolowski, PhD:
Congratulations. That’s huge.
Raphael Pollock, MD:
It’s huge, and it’s been the work of more than 100 committed individuals over the course of a thirty-year period of time.
Recommended Citation
Pollock, Raphael E. MD and Rosolowski, Tacey A. PhD, "Chapter 18: Surgical Oncology, Board Certification, and Working to Define the Field" (2012). Interview Chapters. 1330.
https://openworks.mdanderson.org/mchv_interviewchapters/1330
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