Chapter 18: As Head of the Division of Cancer Medicine: Building MD Anderson's Academic Programs and Research Focus
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Description
Dr. Bast begins this chapter by reviewing his reasons for leaving his role as head of the cancer center at Duke University in 1994 to take over as Head of the Division of Cancer Medicine at MD Anderson. He sketches the restructuring of divisions at the time he arrived and explains why this helped bring good leadership to departments. Dr. Bast then talks about his work building MD Anderson's educational programs, focusing in particular on preparing physicians to get involved in research throughout their careers, even if they are in community practice. He talks about the types of research that can be conducted in community settings and explains why MDs may leave academic medicine and avoid conducting research. He lists specific indicators that show a stronger research focus among fellows.
Identifier
BastRC_03_20141218_C18
Publication Date
12-18-2014
Publisher
The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center
City
Houston, Texas
Interview Session
Topics Covered
The University of Texas MD Anderson Cancer Center - Building the Institution; The Administrator; Institutional Mission and Values; Building/Transforming the Institution; Education; Understanding the Institution; MD Anderson History; Growth and/or Change; MD Anderson Culture; Institutional Mission and Values
Transcript
Tacey A. Rosolowski, PhD:
Now, as I mentioned before we started the recorder, we did not talk in our previous sessions about the time that you spent between 1994 and 2000 as head of the Division of Cancer Medicine, and also as chief of the Division of Medical Oncology. So I was—
Robert Bast, MD:
Actually, Experimental Therapeutics.
Tacey A. Rosolowski, PhD:
Oh, I’m sorry.
Robert Bast, MD:
Chair of Experimental Therapeutics.
Tacey A. Rosolowski, PhD:
Oh, okay, wow. I’m sorry. I don’t know where I got that. (laughter) Thank you.
Robert Bast, MD:
There is a very small Division of Medical Oncology at UT Health’s [University of Texas Health] Science Center.
Tacey A. Rosolowski, PhD:
Oh, okay.
Robert Bast, MD:
At that time, they did not have a competing activity with MD Anderson. The position and title at UT Health went along with being head of the Division of Medicine at MD Anderson.
Tacey A. Rosolowski, PhD:
Okay, so that’s where that came from.
Robert Bast, MD:
Yeah.
Tacey A. Rosolowski, PhD:
It wasn’t pure fantasy on my part. (laughter)
Robert Bast, MD:
No, no. That’s—it—
Tacey A. Rosolowski, PhD:
Thank you.
Robert Bast, MD:
[inaudible]
Tacey A. Rosolowski, PhD:
I was worried. All right. Well, we didn’t have an opportunity to talk about that particular period of time.
Robert Bast, MD:
Okay.
Tacey A. Rosolowski, PhD:
So I was wondering if you could maybe tell me some of the highlights of what you felt you accomplished during the time when you were head of the Division of Cancer Medicine.
Robert Bast, MD:
Surely. Well, we talked before about being at Duke and heading up the Cancer Center there.
Robert Bast, MD:
And I’d been co-chair of their division of hematology and oncology and headed the Cancer Center there for about seven years. And it was a matrix center, unlike MD Anderson, which is a free-standing cancer center. There we had done a lot of the things that you can do with a matrix center. We’d increased the philanthropy several-fold, although it was very modest by MD Anderson standards. We had put up new buildings, increased the membership, and increased peer--reviewed funding. We’d also built a section for experimental oncology that my colleague, Bob [Robert M.] Bell, had headed, so that we could actually recruit individuals directly to Duke for cancer-related activities, which is not the case at many centers that are matrix centers. Having accomplished about as much as I knew how to in that context, when there was an opportunity to lead a division at arguably the world’s leading cancer center, that was a very good reason to move to Houston, and decision that I’ve never regretted. At that time there was just one Division of Medicine. Subsequently, in 2000 or 2001, the Division of Medicine was split into a Division of Internal Medicine Specialties and a Division of Cancer Medicine. Over the previous six years, the Division of Medicine had grown substantially. At one time, the whole of Internal Medicine Specialties was just one department in the Division of Medicine. Obviously, it had much more room to grow, and reorganizing that was exactly the right thing to do.
Tacey A. Rosolowski, PhD:
Why was that? I mean, it’s always a question of why these big reorganizations are undertaken.
Robert Bast, MD:
The Division of Medicine had just grown substantially and Internal Medicine Specialties had a distinct role of providing general medical and supportive care for cancer patients, whereas the Division of Cancer Medicine provided chemotherapy and developed new treatments for different forms of cancer. I don’t have the exact numbers of faculty members, but the Division of Medicine had grown by more than a third. The unit of organization within MD Anderson is the department and the Department of Internal Medicine had sections of cardiology, pulmonary, infectious disease and others. If you want to get a real leader to head those sections it’s really tough, because sections don’t have any formal status. By creating a Division of Internal Medicine Specialties, you could appoint department chairs for each of these sub-specialties and each department would include a reasonable number of faculty. For example, we must have more than a dozen infectious-disease people and that is within the range of at least some other departments at MD Anderson. As the faculty grew institutionally, it made a lot of sense to split off a new division. Bob [Robert F.] Gagel became the first division head of Internal Medicine Specialties. The new Cancer Medicine still had at least ten departments, which I think have grown to sixteen. So we’ve had a general increase in all of our clinical divisions, but it’s been particularly true for those two. As we had discussed earlier, one of the things that we accomplished over the six years with the division was to build their educational programs, particularly the medical oncology fellowship program. When I first moved here, we had some really fine young people in training, but very few of them had actually gone to medical school in the United States. Many had come from South America or from Europe or from Asia, and had been twice trained in medicine, and then came here for their oncology fellowships. Almost none of our fellows had published a paper before they got here. I don’t think we had had any MD PhDs apply to the program. We tried to change that. Marty [Martin N.] Raber [Oral History Interview] and then Rick [Richard] Pazdur had worked directly in leading the fellowship program. After my arrival, as we discussed previously, we had written to all the chairs of medicine at all of the medical schools and explained that life was different, and that our medical oncology fellowship program was a major priority at MD Anderson. We asked that they counsel their most promising graduates of their medical residency programs to consider MD Anderson as the place to get their oncology training.
Tacey A. Rosolowski, PhD:
So this was kind of part of that period when MD Anderson was really trying to build up its reputation as having a strong research component. Because I know many people have said, over and over, that there was this—this was considered to be a real gap.
Robert Bast, MD:
Yes, I think that’s true. And also, many fine young people came here to train, but the majority of graduates at that time wanted to go into community practice. We’ve really missed an opportunity, not only here but at most academic institutions, to encourage people who do want to practice in the community to maintain a commitment to research lifelong. Probably ninety-eight percent of the oncologists are in the community rather than at medical centers like this. All have been through academic training programs both in internal medicine and medical oncology. Many of them have felt that they weren’t respected by academe, because they wanted to go into practice in the community. That’s a huge mistake, for starters. But we’ve missed the opportunity to really convince them that it’s—that it’s not just enough to go out and earn a living and care for people, but you’ve got to have a commitment to research, in clinical research, in the community, and that important—by supporting—by participating in trials that you can do in the community, and by referring patients to centers, at least for a portion of their care, so that they can participate in clinical trials. For whatever reason, we’ve not succeeded in getting that kind of commitment. And there certainly are some people in the community who do clinical research, but it’s a minority. And it should be the majority.
Tacey A. Rosolowski, PhD:
What is the obstacle there? Is it ignorance? What is going on?
Robert Bast, MD:
I’m sure it’s multi-factorial. I don’t have a comprehensive list of factors and I’m sure that it also hasn’t been studied very thoroughly.
Robert Bast, MD:
It is difficult to find interviews and data regarding why physicians go into practice as opposed to stick with academic pursuits. On the positive side, some physicians really just enjoy taking care of patients, and, conversely, don’t enjoy writing papers or applying for grants. Very often these days—it’s been true for a long time—physicians take out huge loans for undergraduate school or for medical school. And as a resident or intern you don’t get a salary that’s adequate to pay those back. By the time many oncologists finish a fellowship program, they have not only a spouse but kids. Being able to support your family has become a real priority, understandably enough. Salaries in the community are at least twice what we can pay in academe. MD Anderson is something like seventy-fifth percentile in academic institutions, so we pay people pretty well by academic standards. But that is not nearly what a busy oncologist can make in the community. In terms of having time for research in community practice, often medical oncologists will join practices where there’s already a large patient base and where they need to see twenty or twenty-five patients every day with one afternoon off a week, in order to be able to earn the salary that they’ve been promised or they have a contract where their ultimate compensation really depends upon how many patients they see. With a busy practice, the amount of time left for research is limited. In academic institutions like MD Anderson, we subsidize research quite heavily. Almost all of the people who are investigators on clinical trials have their institutional salary paid, and not paid by the contracts for the trials that they’re conducting. Also, we often don’t have enough support for research nurses and data managers. That does largely come from contracts and rarely—and at least occasionally from grants. A substantial chunk of the true costs of doing clinical trials are subsidized either directly or indirectly by the institution. And in many practices in the community, there’s not the same level of financial commitment for infrastructure support to conduct clinical trials. In community practice there’s not a lot of time to sit and talk with patients about their alternatives for clinical trials, let alone write a clinical trial. And—but also that there isn’t the research nurses and the data managers paid by the practice to actually do interact with patients. There are some practices and groups like US Oncology, which do some research for sure.
Tacey A. Rosolowski, PhD:
I’m sorry, what was the name of that?
Robert Bast, MD:
US Oncology. It’s a group of about 1,000 oncologists, mostly medical spread across the nation. Texas Oncology is the local branch of US Oncology. From the numbers I have heard, they enter no more than five or six thousand patients on clinical trials nationally. Last year, MD Anderson put at least 12,000 to 14,000 patients on trial with a much smaller number of medical oncologists on the faculty. So, by and large, it’s been difficult to do research in the community. The other thing is, increasingly, the kind of research that you can do in the community has really been late-stage phase II trials and phase III trials. If you need intensive monitoring or if you need biopsies, or any kind of monitoring of heart function or other thing on an ongoing basis, that’s been really difficult to accommodate in the community. We’re really the only kind of organization that could do that. Over the six years when I led the Division of Medicine, the medical fellowship program evolved. In the final year, the majority of the thirteen graduates took academic jobs. Most had published papers before they arrived at MD Anderson for training. A third to one-half were MD PhDs. Importantly, we were beginning to compete for the best fellows with the Dana Farber Cancer Institute, Memorial Sloan Kettering, Johns Hopkins and other major institutions. Like Ki [Waun Ki] Hong [Oral History Interview], of course, who became head of the Division of Cancer Medicine after that, built on the start that we had made and took it a couple of levels higher, doing a wonderful job with the fellowship program.
Recommended Citation
Bast, Robert C. Jr., MD and Rosolowski, Tacey A. PhD, "Chapter 18: As Head of the Division of Cancer Medicine: Building MD Anderson's Academic Programs and Research Focus" (2014). Interview Chapters. 455.
https://openworks.mdanderson.org/mchv_interviewchapters/455
Conditions Governing Access
Open
