Chapter 09: Transforming the Division of Surgery, an Overview

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Chapter 09: Transforming the Division of Surgery, an Overview

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In this chapter, Dr. Balch provides an overview of how he went about transforming the Division of Surgery when he arrived at MD Anderson in 1985. He explains the scope of his responsibility, which included the entire Division, its core resources, its clinical trials office, and the database management. Next Dr. Balch explains the rationale for the division system that had been set in place by then president Dr. Charles LeMaistre [oral history interview]. He notes that his mandate was to unify disparate surgical departments into a single division with strong academic grounding and a research purpose. He acknowledges the challenges in demonstrating the value of this administrative restructuring. He notes the role of Donna Sollenberger [oral history interview], his administrative assistant, in helping him achieve this goal. Dr. Balch explains how the current administrative state was preventing the institution from recruiting quality individuals. He discusses his key recruits (Jack Roth and Elizabeth Grimm) in his attempt to build both surgical excellence as well as research. Next Dr. Balch discusses how the Division developed a training program in support of a new Department of Thoracic Surgery, with the assistance of Dr. Denton Cooley of The Texas Heart Institute, and chief of Cardiovascular Surgery at clinical partner Baylor St. Luke's Medical Center. He mentions some other new departments created as well as his role in creating the first ambulatory surgery space.

Identifier

BalchC_02_20181112_C09

Publication Date

11-18-2018

Publisher

The Making Cancer History® Voices Oral History Collection, The University of Texas MD Anderson Cancer Center

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; Leadership; Building/Transforming the Institution; Multi-disciplinary Approaches; Working Environment; Growth and/or Change; Obstacles, Challenges; MD Anderson Culture; Professional Practice; Understanding the Institution; Education at MD Anderson; Education; MD Anderson Impact

Transcript

T.A. Rosolowski, PhD:

And we strategized a little bit beforehand, and I wanted to make sure that you felt you had adequately covered your years as Division Head. Because you came in 1985, and then transitioned away from that role in 1993. We talked about the training programs, the way you developed a new surgical perspective focused more on surgical oncology than on the traditional MD Anderson way of doing surgery. So was there? You may not have perfect memory of everything we talked about, but was there something that you really wanted to make sure that we did talk about today?

Charles Balch, MD:

Remember, at that time I actually had two levels of responsibilities. One was as the Division Head, and at the time that was for all of the surgery departments and Anesthesia and Dental Oncology. And at that level, one of the things we really tried to do was to create some core resources that would be available to the faculty in all of those departments, and that included a clinical trials office, editorial office, a database management system, a library, because at those times everybody used print manuscripts and textbooks.

T.A. Rosolowski, PhD:

So was this a library research withinresource within the Division?

Charles Balch, MD:

Within the Division of Surgery. Part of my story, too, is that when I was finally accepted for the position in March of 1983, the Lee Clark Clinic Building was being constructed. And they were going up one floor a week. So this was in March [1985]. I didn't start until July. And I was given the entire tenth floor. So I had to, within eight weeks, even before I showed up, have the finished architectural plans for the entire tenth floor, which was supposed to house the Division of Surgery Office [ ].

T.A. Rosolowski, PhD:

So what were some of the kind of physical issues you were thinking about for that design?

Charles Balch, MD:

So what we wanted to have was a division office with a conference room, and with the space for some of these resources. We had to recruit a division administrator. Remember, the Division of Surgery, Anesthesia, and Dental Oncology existed in name only. Bob Hickey was the head of that on an interim basis, and chaired the recruitment committee [ ]. So we had to put in place an entire concept of division administration that also included the capacity for doing clinical research, protocol office, conference rooms. At the time, a core resource was an information systems platform that would be available to all the faculty, which at the time was not consistently available. We didn't have things like laptops. We didn't even have mobile telephones. [ ] The architect for the building had to fly over to Birmingham on a number of occasions, and I had to come over here and meet in the hotel, in order to plan this tenth floor, because they had to have the concrete inserts and have the architectural plans finished in [the next] eight weeks. That was really a challenge for me and for the architects, but we did that.

T.A. Rosolowski, PhD:

Now, let me ask you

Charles Balch, MD:

And was not completed, of course, until later in the year, after I arrived.

T.A. Rosolowski, PhD:

Now, this was part of a huge transformation in the institution when Charles LeMaistre put in the division system.

Charles Balch, MD:

Yes.

T.A. Rosolowski, PhD:

And so what, in yourand it's kind of an interesting conversation, about how that administrative decision was having a direct impact on the physical layout of things. Now, what is your view of the value of the division system to kind of take MD Anderson into the next phase of its institutional life?

Charles Balch, MD:

So what Dr. LeMaistre had already done before I arrived, it had a Division of Radiation Oncology, it had a Division of Radiology, and then had a Division of Medicine. And Irv Krakoff, who was the Chief of Medicine, I think had come one or two years before I arrived, and he'd already started in place of looking at core resources at the division level for all of the departments, especially around clinical research. So a lot of what I did was coming in to place those kind of things at a division level which didn't exist in surgery, but had already been in place in the Division of Medicine under Dr. Krakoff.

T.A. Rosolowski, PhD:

Did that help the acceptance? Because I knowI mean, I've talked to people who have told stories about the resistance to the division system.

Charles Balch, MD:

Yes. Well, remember, you had some very strong personalities in the department who liked the idea of reporting directly to Dr. LeMaistre, so having an intermediary between the departments and Dr. LeMaistre was something that, for some, really was difficult because of the history that they were formed a decade or two beforehand. Urology, Head/Neck, and Gynecology all had a direct reporting relationship, so taking on a new reporting relationship to some guy from Alabama was a new thing for them, and certainly not something you would expect that people would accept willingly. From Dr. LeMaistre's perspective, it made the administration easier to have something in Surgery and Anesthesia and Dentistry that paralleled what was going on in Medicine, especially if there was enough need for core resources that spanned those faculties, and that was part of my challenge was, one, to incorporate all of the department chairs into an Executive Committee, so they felt an ownership in the Division, and so we strictly kept the Division administration and authority and resources to those things that were common to multiple departments.

T.A. Rosolowski, PhD:

What were some of the bumps and knocks along the way of that? I mean, again, strong personalities in a Division of Surgery. Setting up this Executive Committee, how did you go about doing that?

Charles Balch, MD:

Well, so there several things we had to do besides the facilities and the core resources. We also had to hire a division administrator, which also was just another layer of administration, but one that could make the division components more influential at the senior administration level.

T.A. Rosolowski, PhD:

And this person was?

Charles Balch, MD:

So we hired a division administrator whose name I can't remember, but I'll get it for you, who lasted for, I think, three years, and then he moved on, and then we hired Donna Sollenberger [oral history interview] from the University of Southern Illinois, who became the Division Administrator, then the Hospital Director, and is probably one of the most influential hospital administrators in the country. So the value we had to demonstrate was could we really develop the programs, the resources, and then execute in a way that the departments, however unwillingly politically, would still feel like their issues and their needs were being met. The other part of this, Tacey, that I think was very important, was brilliant on Dr. LeMaistre's part, is at that time you could not recruit people in the specialties to be in a division underneath some department chair, and so flipping the division and department titles I think really was critical. That was part of Dr. LeMaistre's brilliance, to say if we're going to really recruit top people, we want to continue to recruit them at a department chair level, and those people who were currently department chair were not going to be demoted by having another divisional title, so that having a department reporting to a head of a division was really a very important move, and allowed us then to recruit, besides those that were here in Urology, Gynecology, and Head/Neck, to recruit new chairs of thoracic surgery, neurosurgery, plastic and reconstructive surgery, and so forth, which would not have been possible if they were being recruited into a division level. So one of the other parts early on, the first recruitment was Jack Roth [Division of Surgery interview] and Elizabeth Grimm. I don't think I covered that before, did I?

T.A. Rosolowski, PhD:

No.

Charles Balch, MD:

So these were leading people from the NIH who were actually going elsewhere, and I was able to convince them, as a husband and wife team, and their academic and research experience, to come to MD Anderson.

T.A. Rosolowski, PhD:

Why were they so desirable?

Charles Balch, MD:

Well, because they brought two things: one is Jack Roth was Board-certified in cardiothoracic surgery. No one at MD Anderson was Board-certified [in cardio-thoracic surgery]. Also, Jack Roth and Elizabeth Grimm both had very significant research programs and research funding. So it was, for me personally, a statement to make that, one, we were going to develop a full-fledged research program, including laboratory research that would be fundable by the NIH, but also we wanted to create a new Department of Thoracic Surgery. To do that, you had to have Board-certified thoracic surgeons. The other component of that that I thought was important from a training perspective was to partner with Dr. Denton Cooley to have the first ever Board-certified cardiothoracic program that specialized in thoracic surgery, because at that time the training everywhere else in the country was 18 months of cardiac surgery, six months of thoracic, and most of the thoracic surgery for lung cancer and esophageal cancer was done by general surgeons or cardiac surgeons who did this part-time. So part of our original vision was to have thoracic surgery specialists who specialized in lung cancer, but to be Board-certified they had to have at least six months of cardiac surgery. So we did create and had approved the first ever cardiothoracic Board approval for a program that was 18 months thoracic and six months cardiac. Denton Cooley wasn't going to do that with anyone else who wasn't Board-certified, so it was critically important to have a Board-certified person come in.

T.A. Rosolowski, PhD:

Now, what was Denton Cooley's role within all of this? Planning, and?

Charles Balch, MD:

Yes. Well, I introduced him to Jack Roth, and he agreed that he would provide the six months cardiac experience, which, as you know, their volume was such that it equaled most other programs in 12-18 months, so the American Board of Cardiothoracic Surgery saw the wisdom of doing this as a pilot because of the partnering of the largest cancer center and one of the largest cardiac programs in the country. And that, as you can see now, was the beginning of a whole group of thoracic surgeons around the country who really provide a level of expertise for patients with lung and esophageal cancer that didn't exist before. So that was the first department, and that was the first recruitment. We also had to have lab space for Jack Roth and Elizabeth Grimm. Elizabeth Grimm worked with Steve Rosenberg at the NIH, and she brought both experience and, as you know, funding, and worked in the Division of Surgery, first in melanoma, and she's still here 30 years later, now in the Division of Medicine. But that made a very important statement, that we were going to bring a bona fide, established laboratory research program to MD Anderson, through Jack Roth and Elizabeth Grimm, which, as you know historically, they went on and had not only R01 grants but program project grants, and have one of the leading thoracic surgery programs in the United States, if not in the world. I knew also that the other surgical specialties were scattered. They were either in the Department of General Surgery or in the Department of Head and Neck Surgery. So Milan Levins was the neurosurgeon who was in the Department of Head and Neck Surgery. We knew if we were going to have a broad level of expertise we had to create a new Department of Neurosurgery, and we were very fortunate to be able to get Ray Sawaya [oral history interview; Division of Surgery interview] to come and be the first Chair. As you know, that's now grown to be the premier neurosurgery program in the country through his leadership, which was started from scratch. It had to be a vision and a support of the resources, including training and laboratory research and so forth, and the technology in the operating room in order to do sophisticated brain surgery.

T.A. Rosolowski, PhD:

And, again, the very comprehensive vision that he had for all the facets that go into that kind of care.

Charles Balch, MD:

And we were one of the first to have these navigation devices [in the operating room], to be able to understand in three dimensions where you are within the brain, when you're operating through a small hole, trying to take out a tumor in places that previously were not resectable. So he brought some very innovative programs, both at the clinical level and at the laboratory research level. The other major area as a departmentthis is in my role as Division Headwas to create a Department of Plastic and Reconstructive Surgery, which, again, the only person at the time was Steve Kroll, who was an ENT-based plastic surgeon in the Department of Head & Neck Surgery. And that wasn't enough to build a broad program. We also wanted to have a major program in breast reconstructive surgery. Because people were not going to be referred to MD Anderson for us to do mastectomies, we had to offer something that wasn't readily available, and that became skin-sparing mastectomies, for which we were one of the first, and also breast reconstructive surgery with autologous, microvascular tissue flaps, to reconstruct the breast. And we recruited Mark Schusterman, again, from the University of Pittsburgh, who brought microvascular surgery for the first time here. And because of that expertise at breast cancer, we became the leading place for autologous flap reconstructive surgery, which, of course, brought a lot of breast cancer patients to the institution with early disease who ordinarily would not have come here in the first place for doing standard mastectomies, whether it's total mastectomies or partial mastectomies. Now, what's also important here is this meant we needed to have very sophisticated operating room facilities. We inherited some operating rooms that were not very well utilized. We did not have any day surgery, and we didn't have much space [in the ORs]. So one of the things I did as a division head early on was create the first outpatient or ambulatory surgery space. We were able to take a biopsy room that wasn't being used, add another room next to it for so-called ambulatory surgery. That freed up the other operating rooms that were being used for minor or small procedures, so that they could be equipped and be used the entire day for major cases.

T.A. Rosolowski, PhD:

When did you accomplish this?

Charles Balch, MD:

This was around 1988 or '89. This was a major advance of the concept of day surgery, and we were one of the first in the country. In fact, we wrote an entire paper about being able to reduce the length of hospital stay by having day surgery facilities. But the other part of that, it enabled us to make better use of the operating rooms that existed. We also moved towards extended hours, so we had two shifts of nurses, so that we could work into the evening time, which wasn't being done before. And then we had to have specialized operating equipment for both neurosurgery and for microvascular surgery. [ ] The strengths, when I came, were largely in the specialty surgeryUrology, GYN, and Head & Neckbut there weren't that many distinguishing features of services provided in the Department of General Surgery, because they were doing general surgery, which meant they were doing GI, breast, and other things, but not that much differentit was excellent surgerythat isn't the pointbut were they really different from what was in the community, or elsewhere in the Texas Medical Center, which was also vying for patients? So, for example, we drove the whole breast surgery program, because we had breast reconstructive surgery as a primary reason that patients were being referred to the institution.

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Chapter 09: Transforming the Division of Surgery, an Overview

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