Chapter 06: A Commitment to Training and Education: A Failed Battle For an MD Anderson Medical School
this chapter begins with Dr. Freireich's reflections on the circuitous path that took him to hematology. He describes the unique clinical oncology program he helped set up at MD Anderson, and the "best and brightest" fellows who came to train. He traces the creation of graduate education at MD Anderson. He weaves in discussion of how growth at MD Anderson was tied to debates over bringing a medical school to Houston.
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
The Interview Subject's Story - Professional Path; Personal Background; Professional Path; The Educator; Education; MD Anderson History; Building/Transforming the Institution; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; Portraits; Leadership; Obstacles, Challenges; Controversies
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History of Science, Technology, and Medicine | Oncology | Oral History
Tacey Ann Rosolowski, PhD:
So I wanted to ask you just a couple of followup questions, after the conversation yesterday about your research. Part of it is just my own curiosity. You said in the interview that you did in 2001 that it was kind of unexpected that you ended up going into hematology. It was kind of really a circuitous path. I’m wondering if you felt that coming as you did—from the side, in an unusual path—helped you be innovative in that field.
Emil J Freireich, MD:
Well, sure. As I’ve told you, you’ve read my background. Ever since I was a young man I always wanted to be a family doctor, like my idol, the family doctor. But as my training went along, I kept getting fired from every job for the same reason—I always did more than I was supposed to do. So I had an internship at Cook County Hospital. I got fired because I got into a controversy over patient care with a nurse. Then I went to internal medicine because I figured that I had learned all the surgical techniques andOBand all that, and I didn’t know much about medicine. It was very complicated. So I took a year of medicine. My professor, who I adored, got fired and asked me what I didn’t know a lot about, and I said hematology. We had a terrible hematology professor. So he said, “Go to Boston.” So that was the beginning of a transition from a practice-oriented career to a research-oriented career. The new academic research environment was created in Boston in the ‘60s and ‘50s.
So when I got there, I was offered jobs in hematology, but the one that I was forced to take was the only one that paid. In those days, trainees all came from well-to-do families and didn’t need money, so they worked for free. But Dr. [Merrick] Ross at Massachusetts Memorial had a grant to study iron deficiency, so instead of learning hematology as a general discipline, I was thrown into an academic situation where I had to do research, so that was the beginning of my research career. Then, as I’ve emphasized in previous interviews, just because the dean at Boston University was the first assistant secretary of health in the country, and just because the NIH opened in ’64 and I got drafted in ’64, Dr. [Chester Scott] Keefer recruited me to go to the NIH in ’65. So there I was in a research job, taking care of children with leukemia. Remind me of the question again.
Tacey Ann Rosolowski, PhD:
I was just curious about the way that—I mean—oftentimes when people are thinking about how an individual’s career has become very successful and why they’ve been so innovative, it turns out that very innovative people often come to a field from outside that field, so they bring a broader perspective or a different way of approaching problems. So I was just curious to what degree you found that the case in your own career.
Emil J Freireich, MD:
Well, my career was a natural flow. I was never in a position to make any decisions; they were all made for me. When I found myself in the Clinical Center of the NIH, there we were with all these dying children. You had to do something about it. It’s important to recall that when I graduated from medical school in 1949, the undergraduate career in medicine included nothing about cancer. In our pathology, we learned a little bit about how the pathology of cancer looked, but there was no such thing as treatment. There was no such thing as natural history or diagnosis, so from a medical point of view, we knew nothing about cancer. We didn’t know it existed.
As you know, the first inkling of treatment for cancer came out of the Second World War with nitrogen mustard in ’44—Dr. Farber—’48—6MP—‘49. When I went to theClinicalCenter, the concept of treating cancer was really a whole new thing. As I pointed out in previous conversations, since Dr. Zubrod inspired us to do formal clinical trials, we began to convert the knowledge about the natural history of leukemia into quantitative data so we knew how many children died and how often, what the complications were. We discovered meningeal leukemia and how to treat it, so we just had to learn quantitatively about the disease. Are we done with that? Because I want to get back to education.
Tacey Ann Rosolowski, PhD:
Yeah, let’s go on to that.
Emil J Freireich, MD:
Well, I think in my career the things I’m famous for are patient care and research, but the third leg of the academic stool is education. Education was always a part of my research career. When we went to theClinicalCenter, under leadership of Dr. Frei and Dr. Zubrod, we had all these young physicians who had no talents in research who were recruited to the Clinical Center largely because of their military obligation. The Clinical Center was staffed with physicians who were drafted but weren’t activated by the Navy, Air Force, and so on. The people who needed them were the Public Health Service, so they recruited all these young, bright physicians usually referred by the chairs of their department as promising, young, intelligent, potentially research oriented doctors.
In my lectures—you mentioned the things I do now—in the lectures I do now, I give a lecture on the origin of science in the United States. As you know, our medicine was based largely on European medicine. In the ‘40s and ‘50s, the physicians who were academic were all trained inEurope. The American science began, really, during my lifetime. It’s a new thing for this country. Really, the turn of the century is when the Flexner Report and all that stuff—
When we were at theClinicalCenterand we had all these young, intelligent physicians, Dr. Zubrod and Dr. Frei and I recognized that there needed to be a formal training program in oncology. There was no oncology discipline. We were just thrown into the Cancer Institute with all these cancer patients, so the young physician scientists who came to spend their two-year military service at the Clinical Center—ninety-plus percent of them ended up in academia because the environment was so academic. That is, the backbone of what we did was create a teaching program for these trainees so that after two years they were oncologists, although the word didn’t exist at the time. So really the first formal training program in cancer began at theClinicalCenter. The other academic institutions in the country all recognized the power of what had happened in Bethesda.
Tacey Ann Rosolowski, PhD:
Can you tell me what was involved in that first program? What were the courses offered?
Emil J Freireich, MD:
Well, we didn’t have courses, they learned by doing. They rotated through my service and learned about who came in and how to treat it and how to classify it and natural history and how to do randomized trials. They rotated through the solid tumor service. They learned how to take care of breast cancer, colon cancer. So we had a complete medical oncology program, and the fact that they rotated became a training program. They had a formal, systematic exposure to all the diseases in a setting where the physicians were scientists and not treating but observing and recording and studying the natural history of these diseases.
I’ll come back to that—when I came to MD Anderson—because the environment we created was totally unique, and where it was going at the moment was the rest of the academic medical centers in the country were all created on the basis that academics had three legs of the stool—patient care, research, and education. When theClinicalCenteropened, there were no students—there were no medical students—there were no interns, there were no residents. And I recall, in my first year there, my job was to recruit patients, so I traveled to the academic medical centers in the D.C. area. I went to Hopkins and G.W. and Georgetown and all those places to tell them that we were doing research. We were treating children with leukemia. We were trying to figure out how to cure them. The comments I got from the senior—in 1965, I was thirty-eight years old. The professors were sixty-five, and they all came from the old school.
I remember, particularly at Hopkins, Dr.—I forgot his name. He was a very famous physician, one of the founders of the Association of American Physicians. But he got up and he said, “It’s ridiculous to have an institution where the physicians do patient care and research and no teaching.” The stool is broken. But having a full-time research career was so productive. Then in the period from ’65 to ’75, academic medicine in the United States was totally transformed. All the medical schools developed academic clinical research programs, and they realized we had something with this teaching. So by 1964, the universities created a board exam in medical oncology patterned after this program that began at the NCI. So the point I’m making is that although we didn’t teach undergraduates, graduated medical education was a component of my career from day one.
Tacey Ann Rosolowski, PhD:
I was curious about how long it took you to recruit a critical mass of students from these other institutions.
Emil J Freireich, MD:
Oh, they came automatically. They were all in the Army, Navy—they all had commissions in the military, and their professors, like my professor, were contacted by Zubrod, Frei, or me. We went around and we told them there was an opportunity for these people to serve their—we called them Green Berets, because they could serve their military time in a peaceful situation rather than go fight in Korea, so it attracted the best and the brightest. The clinical associates that came to our hospital were the backbone of our research program. These guys were—they all became giants—[Dr. Vincent] DeVita; [Dr. George] Canellos; David Nathan, who won a Nobel Prize for his work at Hopkins; the guy at Children’s Hospital who just got the AAP Kober Medal. All these people became the scientific leaders in the academic medical centers around the world. Two years the NCI converted them not only into oncologists but academic oncologists. So all the universities were populated with the graduates, and all the universities began to mimic that. They had their own training programs, and then finally they realized that, like gastroenterology and cardiology, oncology was a specialty, and the specialty exam was created in ’64.
Tacey Ann Rosolowski, PhD:
I’m starting to see why you said that that period between 1955 and 1965 transformed—
Emil J Freireich, MD:
It was the golden age of medicine. It transformed all the specialties. What happened in oncology happened in cardiology. All the open heart surgery began at the Cancer Institute. It happened in neurosciences. All the studies of senile dementia—these were all people working around me. They were all like me—forty-year-old guys, fresh out of school, eager beavers in a candy shop. They had everything. They had patients, they had time, they had no responsibility. They did the research. They controlled their practice. They didn’t have a service obligation, that’s the main thing. I didn’t have to see people dying with sickle cell anemia. I just saw leukemia patients. The guys who did neuroscience only saw multiple sclerosis patients.
The secret to clinical research is to be able to control your service work, to manage your research as part of your service. That’s what MD Anderson—you hear Dr. [John] Mendelsohn [Oral History Interview] say, “Our patient care is research driven.” That’s what was discovered in the Clinical Center of the NIH. They discovered that the best patient care is research. The patients in research had the best chance of getting the best care.
Training was a part of my career from day one. One of the reasons I came to MD Anderson—when Dr. Clark tried to recruit me, I had a job offer to go to University of Toronto, I had a job offer to go to Children’s Hospital, Harvard, in Boston. I could have gone anywhere, but the thing that Clark said that impressed me—I loved Dr. Clark. I hated him because he tortured me and fired me, but I loved him because of his vision of the future. He was a person—you know—when he took the job as director of MD Anderson, Houston was a backwater. The population was 200,000. They still had malaria. It was a very primitive community. But he saw the potential. He saw the oil industry. He felt immediately that Houston was going to be the biggest city in Texas, and when he recruited people, that’s what he told you. He said, “Houstonis nothing, but it’s going to be the best, because we have everything. We have money, we have industry, we have culture, we have the water, and we have the climate.Houstonis going to be the town.”
When I was thinking about coming here, he met with me and he said—you know—he was very impressed, as was everybody in the world, in what was going on at theClinicalCenter. He said, “You know, the one thing theClinicalCenterlacked was undergraduate education.” We had graduate medical education, but no undergraduate education. Dr. Clark, when he got a cancer center, he didn’t want it to be a cancer hospital, like Mayo Clinic. The first thing he did was negotiate with the University of Texas. The university—this is an academic institution. It’s not going to be like a TB hospital where people come to die. That was what the legislators wanted. The legislators conceived this place as a place like a TB hospital where you send dying cancer patients, get them off the street, get them out of their homes, put them in this place where they die. Not Dr. Clark. He was a surgeon. “We’re going to treat them.” And to do that, the very first thing he did, when he recruited colleagues from the military—you know—Dr. White to do surgery, Dr. Howe to do medicine—he recruited the backbone. The very first thing he did was recruit a basic scientist. He wanted to have research.
MD Anderson started off as a place with practitioners, not academic. They were all just doing their job, but he recruited basic scientists. He recruited Felix Haas from Galveston. They had three or four PhDs who began the research backbone of the hospital. And he insisted throughout that we be an academic—not a patient care—but an academic institution.
The very first idea he had was the basic scientists had to have post docs and undergraduates, but there’s no university. So they recruited post docs from other graduate programs around the country who came here to learn with the PhD’s working in the cancer hospital. But the post docs didn’t have any undergraduates who wanted to come, so Dr. Clark went to the university and said, “We have to have a graduate school.” Our graduate students had to drive to Austin to take their orals and their final exams. He said, “No. We have to have graduate school.” So the very first thing he did—we’re going to come to that when we talk about the PSTP—is it wasn’t just MD Anderson; it was MD Anderson’s Graduate School of Biomedical Science. And, God bless them, Dr. Grant Taylor, the head of Pediatrics was the first dean of the graduate school.
When I came here in 1965, they recruited Alfred Leon Knudson, who is an absolute genius. He’s a Nobel Laureate class scientist—physician-scientist. He was the dean of the graduate school. I am the longest serving full member of the graduate school. I don’t have a graduate degree, but Dr. Clark felt I was qualified, and Dr. Taylor, and I became—I am still the longest-serving member of our graduate school—full member—and I don’t have a PhD. But I’m better than all the PhDs.
After he got the graduate school, he convinced the regents that we had to have a health science center like there was in Galveston, like there was in Dallas, because he knew Houston was going to be the biggest city in Texas, and they had to have a medical school. So he convinced them to have the public health school. It’s still there.
So when he was recruiting us—Frei and Freireich—he was chair of a committee of deans. There was the dean of MD Anderson—that was him—the dean of the graduate school—one of his employees—the dean of the public health school that he had recruited. Oh, and he also created a School of Allied Health, which is Ahearn [Michael Ahearn, MD ophp]. What was lacking was a medical school. So when he recruited us, I remember him telling me, “Freireich, we need to have a medical school,” and it still doesn’t exist today. Now you’re talking 1965, so that’s forty-six years ago. We need to have a medical school where the faculty is physician-scientists, where the first-year students who learn anatomy, physiology, and biochemistry learn it from working physician-scientists, so that all their knowledge is scientific. And when they get to the clinic, they’re not going to go to Kelsey-Seybold and follow a doctor around; they’re going to learn from professors who really know what they’re doing—Freireichs who teach leukemia and DeVitas who teach Hodgkin’s.
His vision was never realized, and one of the greatest frustrations in Dr. Clark’s life was that when it came to the medical school, when he recruited us, he had already convinced the governing board of the Texas university system—I don’t know what it’s called, the Texas governing council for the university—that a medical school had to be in Houston. That was already approved. The medical school was coming. It was going to be staffed with outstanding physicians, and it’s going to have not only cancer institute and heart institute and blood, everything was going to be research oriented in our academic medical center. Great triumph. I signed on immediately. That appealed to me enormously.
What happened, between the time I resigned my commission and I came here, Dr. Frei was fired, my department was eliminated, and he lost the medical school. It’s complicated how it happened, but part of it was the war—Vietnam. That froze all construction. So although he had the money to build the Lutheran Pavilion, he couldn’t do it. So although we were promised a whole ward with protected environment and beds, we had nothing but this little teeny lab because we didn’t have a hospital. The research institute wasn’t finished. We had no lab space. A big part of it was, as I mentioned before, political. That is, once the ball stopped rolling, at the same time the Supreme Court passed the one-man-one-vote thing—because all of west Texas was all Hispanic people and they didn’t vote—but when the Supreme Court judged, then they got the vote, and the regents overruled the governing board of the medical center and moved our medical school to San Antonio.San Antoniogot our medical school.
So our first year was no labs, no building, no money, no medical school. And then as we came out of the war and we began to get more money and we built our program, it was time for the medical school. Clark put his career on the line for that. He wanted a health science center in Houston. But the presidents in Galveston, particularly— See, what was happening is Galveston was the flagship health science center because of the Sealy money. Even though it was totally destroyed in a hurricane, they were still rebuilding it. They can’t give it up because the Sealy money is put there and it can’t be used for anything else, so you have to haveGalveston. But Galveston was the flagship, and when Southwestern became University of Texas and grew in academic stature, that was a threat to Galveston, but they’re 300 miles away. But Houston, that’s fifty miles upstream, and the flow of patients and academics and grants and everything was flowing into Houston. The major opponent we had was Truman Blocker, who was the president atGalveston. The presidents at Southwestern and in San Antonio—all the university presidents—feared a medical school in Houston. And under Clark—they knew a medical school was coming, but not under Clark, because it was Clark—this would have been the greatest medical center in the country in a decade.
Dr. Clark’s right-hand man was named Dr. Morton. Do you know Dr. Morton—Robert Morton? He was a radiotherapist, and he was Dr. Clark’s political arm. He dealt with the regents. He made sure that we got all the money. When the medical school was denied to Clark, they not only gave him the medical school, they took the graduate school, the public health school, and the school of nursing away from MD Anderson and made a health science center—which is what they wanted—but they wouldn’t give it to Clark. So what they did, because of his seniority, is they carved MD Anderson out of the health science center, and it didn’t take very long for them to fire Dr. Clark. He totally lost his political capital in that battle—the battle with the other regents. As Clark was fired, Truman Blocker had retired as chancellor of the Galveston Health Science Center. They appointed him acting head of our health science center in Houston until they recruited a real one. At the first speech he made where I was present in the room, Dr. [Truman] Blocker said, “We’re going to incorporate MD Anderson into the health science center.”
You see, there are only two institutions that own their hospital—Galveston, which is hopeless and will never be a major center because of geography, and MD Anderson. The other health science centers all have to use community hospitals. San Antonio has a county hospital, and Dallas has a county hospital. Tragically, our medical school doesn’t have a county hospital. It has Hermann Hospital, a private hospital. What’s going to happen to our medical school is what happened to Baylor. They’re never going to make that an academic medical center. If you don’t control your hospital, the financial pressures make it impossible to run the medical school. Ninety percent of your income comes from patient care, so if Hermann Hospital controls ninety percent of the budget, what does the president of the medical school control? Nothing, a few grants. So what happened to Baylor will happen to our medical school. It’s never going to succeed. Hermann Hospital’s interests are totally contravening to the medical school’s interest. So Clark lost the battle. It was within a year that he was fired and they brought in Mickey [Dr. Charles A. LeMaistre [Oral History Interview]] with a search committee and all that stuff.
Freireich, Emil J. MD and Rosolowski, Tacey A. PhD, "Chapter 06: A Commitment to Training and Education: A Failed Battle For an MD Anderson Medical School" (2011). Interview Chapters. 26.
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