Chapter 19: A Return to MD Anderson in 2016 and Reflections on a Career

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Chapter 19: A Return to MD Anderson in 2016 and Reflections on a Career

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Dr. Balch begins this chapter by explaining why he returned to Texas and then to MD Anderson in 2016, retiring from clinical practice and devoting energy to mentoring young faculty's careers. Dr. Balch next reflects on his contributions to MD Anderson then on the changes to the healthcare environment he has seen over the course of his career. He explains that he had an impact on the field through his efforts to shift the practice of surgery from a reactive intervention to surgical oncology and a treatment development mindset implemented in a collaborative team environment. Dr. Balch then talks about changes to how surgeons develop their careers as researchers and as leaders. He explains that they need special support to develop research careers and this has an impact on how fellows are trained and how surgeons manage their working environments to encompass research. In the final minutes of the interview, Dr. Balch reflects on his legacy and what his long career has done for him.

Identifier

BalchC_04_20190326_C19

Publication Date

3-26-2019

Publisher

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

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Contributions; Personal Background; Professional Values, Ethics, Purpose; Leadership; Mentoring; Contributions; Activities Outside Institution; Career and Accomplishments; Professional Path; The History of Health Care, Patient Care; Understanding Cancer, the History of Science, Cancer Research

Transcript

Charles Balch, MD:

Finally, at age 70, as my children were finishing their training, I wanted to follow them. My oldest son Glen had come on to the faculty at the University of Texas Southwestern, in surgical oncology. So I retired, quote-unquote, from Johns Hopkins. They had a very nice Festschrift for me, and we actually had people from all over the world who came to that to celebrate my retirement from Johns Hopkins. I said at the time I'm not really retiring; I'm going to stop my clinical practice, but I'm still going to do teaching and research. So I came back to the University of Texas Southwestern for five years on the faculty there, across the hallway from my son, and provided mentoring and career development for the young faculty there in surgical oncology. Did my own areas of teaching and research. Glen Balch then was appointed as the Chief of Colorectal Surgery at Emory University, and moved to Atlanta. I did not want to start out in a new location once again, and Jeff Lee, who is the Chair of Surgical Oncology here at MD Anderson, who was one of my fellows, and I had a conversation about my coming back to MD Anderson. And as you know, part of what we had done, even in my Anderson days, was to talk about burnout and career development among surgeons, and the need for mentoring. So Jeff Lee hired me part-time for mentoring, career development, and job placement for the fellows and the young faculty, and I was delighted to come back 20 years to the week of being gone, of coming back onto the faculty at MD Anderson.

T.A. Rosolowski, PhD:

And the date of that was? Or the year?

Charles Balch, MD:

That was in 2016. So the other motive for coming here is my daughter Laura Balch Sloan was a physician assistant here at MD Anderson. My two grandsons are here in Houston. So a major motive for moving here was also to follow my family. Just as another part of the story that's interesting is I hired the first physician assistant at MD Anderson, a lady named Carol Lacey who worked with me in the Melanoma area, who is still an employee now in the Division of Medicine. At a Christmas party, Carol Lacey saw my daughter, who was in pre-nursing at Texas Christian, and convinced her she should be a PA instead of a nurse, so she switched. She ended up going to UTMB as a physician assistant, and her first and only job was to come to MD Anderson, and she's now the senior physician assistant in the Department of Medical GI in the Division of Medicine. So part of that story is not only MD Anderson, but a personal story of my family being here, as well.

T.A. Rosolowski, PhD:

Yeah, and having a real impact on people's growth patterns into the professions.

Charles Balch, MD:

Yes, and what a privilege for me at this point in time with the experience of almost 45 years in medicine, and a real networking capability of helping fellows and faculty get connected in terms of research collaboration, educational opportunities, mentoring, and job placement for the fellows as they finish their programs.

T.A. Rosolowski, PhD:

What do you see? Well, maybe I should ask it differently. What are some of the differences in career challenges, comparing early in your career with what's been going on now? Because the whole environment for work and research is so different.

Charles Balch, MD:

Yeah. Well, the practice has changedcould you turn that off?

T.A. Rosolowski, PhD:

Oh, certainly.

Charles Balch, MD:

I need to get [break in audio]

T.A. Rosolowski, PhD:

All right, we're back on.

Charles Balch, MD:

So the practice of oncology, both surgery and all of the disciplines, has changed remarkably over the last 20 years. First of all, it's all digital. All the medical records, instead of paper, are electronic. That is both good and bad. The information systems that we use today, the so-called Epic system, capture a lot of information, but in doing so it captures a lot of information that may not be relevant to each patient, but it slows down entering all the data in the record. But nevertheless, I think the net effect is a good thing that we have electronic and digital records that can be transported between institutions, and are much easier to have the documentation that's legible by the physicians and the staff. The second is the revenue, and the billing and the billing codes has become much more sophisticated and difficult and complicated than it was before, and the documentation that goes along with it. So the business practices of medicine have changed dramatically. It used to be fairly straightforward and simple; now it's very complicated. It takes, I think, time away from the personal time that we've had with the patients. A very important part of this that I mentioned earlier is the midlevel providers. We've gone from being a doctor taking care of a patient with a nurse occasionally around him to team practice, in that we really now are the head of a team for which the midlevel providers, the nursing staff, social workers, physical therapy, the financial people, all are focused in specialty areas, become very expert in that, and that the team collectively, I think, allows the physicians to be more efficient in their time, to see more patients, but the routine management of the patient can be handled by the team under their direction.

T.A. Rosolowski, PhD:

Not many people are trained in that, either. [laughs]

Charles Balch, MD:

No. The other thing that's changed dramatically here that I had a major role in is the development of surgical oncology as a Board-certified discipline. So this was something that actually we started when I was President of the Society of Surgical Oncology, and those that were presidents before me, to have a specialty recognition of surgical oncology. There was a lot of resistance about this from the general surgeons, especially those who did gastrointestinal surgery, worried about the fragmentation of general surgery. We actually set up the training programs in the SSO. We did it in a way that could be transferred to the American Board of Surgery and the Residency and Review Committee, and it took 20 years of debate and discussion until the American Board of Surgery, the RRC, and all of the other governing bodies finally approved surgical oncology as actually complex general surgical oncology; we had to add those words so that the general surgery community and others wouldn't be concerned that all cancer patients had to be treated by a surgical oncologist. It had to be general surgical oncology so that the specialty surgeons, such as urology and gynecology, wouldn't feel like their specialty was threatened. But finally, through all these negotiations it finally was approved, and I think it has now had an impact in the world because once the American Board of Surgery had approved this as a specialty, the specialty of surgical oncology is being recognized in training programs, implemented around this model, in many places around the world. And this was something that I led in both the Society of Surgical Oncology and the American Board of Surgery in the early years to set the foundation for that.

T.A. Rosolowski, PhD:

I was curious in how some of these changes

Charles Balch, MD:

Oh, one other thing. When I started practice, we were trained to operate in all body components, to take care of multiple cancers. And, in fact, a lot of my practice early on was abdominal cancers, not breast cancer and melanoma, for which I'm well-known. Today, the practice of surgical oncology for most people is limited to one organ system. You either operate on the liver or the pancreas, the colorectal area, the breast, but not multiple areas. And that's a major change. Remember, I mentioned the concerns about the fragmentation of general surgery. Well, now there's the fragmentation of surgical oncology, where there are not many people, even at the community practice, that care for multiple disease sites, but they super-specialize based upon their excellence in one organ system. Now, in one way that is not so good because we tend to focus on the organ and not on the whole patient, but on the other hand you get super skilled at doing the same thing in one organ, and the quality and the outcome improves dramatically by that focus in one area, doing it repetitively, and selecting patients so that you can get them through it safely. So it's just reality now that we are surgical oncologists in a broad sense but, in fact, everybody specializes within that to only one or two organ systems, in order to take on complex cancer care, the whole management, not just the surgery but the oncology management, and to do that with good outcomes.

T.A. Rosolowski, PhD:

How has this transformation of the environment for practice influenced how people are mentored, or the kind of mentoring that individuals who are more advanced in their careers will offer to newcomers?

Charles Balch, MD:

Actually, one other thing related to this. When I was growing up, the object of an academic surgeon was to be the triple threat person: you did excellent patient care; you did teaching; and you did research, including laboratory research that was funded by the NIH or other national organizations. The ability for surgeons now, because of the sophistication of translational research, to do high-end translational research is much more difficult today, and fewer and fewer surgeons are trained or do all of those things at the same time. The good news is that I think our ability to do clinical research, clinical trials, outcomes research, health services research, even global surgical research, has increased to a point that you can develop an academic program and a scholarly activity around those things, without doing molecular biology in the laboratory, and still have a contribution and an academic record to become promoted. So this is also a major change, and it goes to how we train our fellows. There are some who always had a desire to be involved in translational research, and come with that record. In order for them to do that they're going to have to spend 50 or 60 percent of their time in the lab. You can't do it on a small, part-time basis and keep up with a rapidly moving area. But many of them have MPH degrees, or master's in clinical research, advanced degrees in statistics, and other things that I think prepare them for contributing to evidence-based medicine by doing prospective databases, prospective clinical trials. And I think that's a very important thing that has emerged in the field of surgery and in the field of oncology, of documenting what we do in a prospective way, and building on that evidence as all of these major changes occur with new agents, new technology, new instruments. The major changes in our operating room, where we're now bringing in imaging equipment, ultrasound, CT, MRI, navigation instrumentsthe technology in our operating room has just been a remarkable advance, so the surgical trainees have to understand that, capture the essence of what makes excellent care at MD Anderson, and be able to export that to wherever they go at other institutions.

T.A. Rosolowski, PhD:

What about mentoring people for leadership, and the leadership pipeline?

Charles Balch, MD:

Well, part of the program in Surgical Oncology, and I think for most of the programs here, is to train people not only to be excellent surgeons, to be academic, trained in teaching and some type of research, to be oncologists. Now, an oncology perspective is disease management across the long-term continuum, whereas surgery is more about the episode of surgery and the immediate time before and after surgery. So the surgical oncologist has to be both a surgeon and an oncologist, and be a full partner in multidisciplinary care. And then the fourth area that we teach and try to entrain our fellows is in leadership, and that is about characteristics of leadership. It has to do with personnel issues, hiring and firing. It has to do with budgeting. It has to do with practicing wellness, and ensuring that part of leadership is having an environment that promotes wellness within their people in charge of them, both physicians and staff. So those are things that we teach as part of the program to prepare people for not just getting leadership roles but succeeding in them.

T.A. Rosolowski, PhD:

What have all these years of your career at all these different organizations done for you?

Charles Balch, MD:

Hmm. I've had almost 900 publications. I've contributed in research. My publications have been cited almost 28,000 times, even today. But my biggest legacy are two things: my children, all of whom have done well, 53 years of marriage; and the second is the people that I've trained. My legacy, the long-term legacy that I'll leave behind, is not the patient care or the research that comes and goes and is temporary, but the durable legacy of the people you trained and the outcomes of the next generation of my family. And that, to me, is the greatest part of the success is watching people that you recruited as undifferentiated young people, but had the enthusiasm and the skills to rise to leadership in MD Anderson, all over the world in various leadership roles. And that's something that I couldn't be more proud of.

T.A. Rosolowski, PhD:

Is that something you went through yourself? Did you know you had it in you when you started?

Charles Balch, MD:

When you live through the times, you don't really think through that way. Those are recognition events that occur after the fact. If you're ambitious for the sake of being ambitious and having titles, I think people see through that and you don't succeed. I really believe, and I talked to people about servant leadership. This, again, is something I learned from John Durant, my mentor in Alabama, and Mickey LeMaistre. It's the servant leadership, what can I do for you, not what can you do for me. And I think as one embodies that and practices it, you can have people around you who will work with you, who are loyal to you, and when you tell them we're going to take the risk of making changes, they will trust that you're leading in the right direction and follow that.

T.A. Rosolowski, PhD:

Is there anything else you would like to add?

Charles Balch, MD:

No. Thank you for the opportunity to have this time together, to document my own history, both at MD Anderson and elsewhere.

T.A. Rosolowski, PhD:

Well, I want to thank you for the time. It's been a really interesting conversation.

Charles Balch, MD:

Thank you, Tacey.

T.A. Rosolowski, PhD:

And I want to say for the record I'm turning off the recorder at ten minutes after . Interview Session: 01 Interview Date: October 22, 2018 1 Interview Session: 02 Interview Date: November 12, 2018 Interview Session: 03 Interview Date: December 18, 2018 Interview Session: 04 Interview Date: March 26, 2019

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Chapter 19: A Return to MD Anderson in 2016 and Reflections on a Career

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