Chapter 07: The Radiation Oncology Fellowship Program

Title

Chapter 07: The Radiation Oncology Fellowship Program

Files

Loading...

Media is loading
 

Description

In this chapter, Dr. Buchholz discusses his strategies and philosophy as he assumed directorship of the department's fellowship program (1998 - 2001). He explains that he and the Division head, James Cox, MD [oral history interview] were in agreement about the importance of education for the department and Division of Radiology as a whole. He notes that he wanted to establish a new culture for education.His first task was to involve the department in writing a mission statement, a step that was met with skepticism based the medical community's distrust of ""leadership sciences."" He describes this process as an ""elucidating moment"" where he saw how a group could be transformed. He explains that the mission statement raised productive questions about the program.Next, Dr. Buchholz talks about the process of changing culture in the department.

Identifier

BuchholzT_01_20180110_C07

Publication Date

1-8-2018

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; Building/Transforming the Institution; Professional Path; Education; Military Experience; Research; Mentoring; On Mentoring; Leadership; Character, Values, Beliefs, Talents; Personal Background; Influences from People and Life Experiences; Professional Practice

Transcript

Tacey Ann Rosolowski, PhD:

Let me—and I want to just let you know I forgot my watch today, which is why I’m taking time by looking at the counter [on the recorder]. I’m not... (laughs) My attention’s not wandering from you. So I wanted to ask: obviously, for you, as a leader, there were some really big lessons that came out of this residency program. And you had mentioned last time that when you took over as department chair you began to use your experience with the residency program as a kind of model for what to do next. And we talked a little bit about that, but I wonder if you could go a little bit more deeply into some of—maybe some of the key moments that were really revelatory for you in your role as department chair. I mean, was there something that worked that you really learned from, or something that maybe was a struggle that you equally learned from? (laughs)

Thomas Buchholz, MD:

So, yeah, I had a lot of bravado confidence, I guess, from some of my own MD Anderson experiences to date, that if you approached things, like I said, with self-evident truths, and follow this methodology, that in the end things should work. There might be some rough patches, but things should work. And I had had success in my multidisciplinary breast group of forming these types of relationships, and earning trust of developing great collaborative, that I remember as I was in that position of running the residency program, and running the breast cancer service, and participating in the multidisciplinary group, I remember attending some of these faculty development things where they say, “Navigating through the political nightmare of MD Anderson.” And I’d sit there and I’d go, MD Anderson’s not that political place. It doesn’t seem like overtly challenging political environment in which to work. I’m having the time of my life. I’m not going home stressed about this or that. When I became department chair, you take on a much broader context, and you find true pockets where things aren’t working, and they’re... I wanted... I think the hardest transition to being a department chair is your sincere desire to find the win-wins, you know? Come to a resolution that makes everybody happy. And I think I started to recognize that one type of solution doesn’t always work, and you’re not empowered to make everybody happy. There are some people who are just going to be unhappy no matter what, and that’s their issue. That’s not your issue. And you have to start to really focus on what’s important beyond the individual, important for the group, and important for, again, doing the right thing, and doing the right thing by which, as prioritized for the group or the system, rather than the individual.

Tacey Ann Rosolowski, PhD:

Did you find that some of your professional, personal relationships within the institution changed when you were department chair?

Thomas Buchholz, MD:

Yeah. I mean, obviously they changed within our department quite a bit. I think whenever you—again, back to military training, there was kind of a strict fraternization rule about leadership, and that’s done, again, for some good reasons. So the blurring of, “Oh, I’m Tom’s friend,” we’ll go out to dinner with our wives together, and how come this faculty member’s able to do that versus me, can lead to appearances, even if they’re not of unfair treatment or so. So within our department, I think it took on a new level of responsibilities that said, well, I am the chairman, and we’re going to treat everybody with the same equity, and we’re not going to have, oh, this person likes to golf with Tom on Saturday mornings, or these types of things, unfairly. That service is better... So it’s not just favoritism type of problems, but also perceptions that inevitably will happen in those types of situations. So you have to be mindful and careful of that. That, again, that could be a real problem in MD Anderson where you have so many spouses who work, and that was a problem (laughs) throughout our organization. Fortunately, I think most of my best MD Anderson social colleagues were outside of the department, and so it never became that big an issue, but I was mindful of that, and, I mean, I was still a member of the Breast Cancer section. And I remember the chairs before me saying, “Oh, Head and Neck always is treated the best because the former chair was a Head and Neck person,” right? So there was always kind of that type of tension, but I always tried to mitigate that. I think what struck me, though, sometimes you’d have some really good ideas and elegant solutions, and they just wouldn’t work, and they wouldn’t work because of specific personalities that you just couldn’t... I remember once there was some obvious dysfunction in one of our sections, and it was a dysfunction in part because of personality, of some very senior faculty members. And they were in need of a change in their structure, to increase their efficiency, and they were in need of some sort of objective say of how to—the best path forward. And I thought, well, this is a way to use a consultant, right? Because it depersonalizes it. And sometimes consultants can bring new insights that you don’t recognize, but sometimes they could just act as an arbitrator to... Because, again, some of the processes that I wanted to do, if you and I were to discuss them over coffee, you would find it in that self-evident, just equity of distributions. Like, do you think one attending should have three residents working with them when two attendings don’t have any? Or should we maybe have an equal distribution, right? So that all faculty feel like they’re treated fairly, and actually the residents get a better training experience. So some things like that. Well, no, I’ve always worked with three residents. I’m the senior member of the group. And so sometimes those types of things, you could be heavy-handed and say that, or you could try to find more elegant solutions to this. And so there were—we were having process problems, where people were seemingly doing what they felt was the best thing in radiation, for instance. We want to get patients started on treatment right away. And so you could say, “Oh, I saw a patient,” throw him on the simulator, get him on the treatment unit, start him right away. That sounds like a good thing, but our attendings know that there’s much more complexity to that, that there’s a series of steps and measures that have to be done, and they have to be done very safely, and if we just throw someone on a machine we could have a major quality and safety error. And there’s a lot of back work that involves physicists and phantom measurements, and all these things that intellectually we know, but why can’t they just do that quicker? Doesn’t always work. So that’s where you try to explain processes, but then to have a consultant come and set up a system, and say, “Okay, are we all in agreement? Do we all understand? Do we need to educate, and...?” So some of those agreements I would ask a consultant to come in and say, “Okay, we’re going to pilot this, right? We’re not going to do it with the whole group, and we’re going to pilot it with two groups: one, group A, which is completely dysfunctional; and group B, which is the group I came from, the Breast Cancer group,” right? And not saying one’s dysfunctional and one works well, just to say, “Well, we’re all in this together.” In fact, even the section I work in is going to go through the same arduous thing, and... (Break in recording)

Tacey Ann Rosolowski, PhD:

Okay, we are recording again after about a half-hour interlude for a technical issue, and, I’m sorry, the time is...? Just...

Thomas Buchholz, MD:

10:27.

Tacey Ann Rosolowski, PhD:

10:27, okay, great.

Thomas Buchholz, MD:

So I was mentioning that sometimes it’s helpful to have a consultant tell you what already you know to be true, but it depersonalizes the... And going into consultantship with an open mind, certainly they might have some alternative strategies.

Tacey Ann Rosolowski, PhD:

Well, and it helps to have an outsider come in and tell these truths and then leave. (laughter)

Thomas Buchholz, MD:

Yeah, right. Then leave, right. (laughter) And, again, so one of the strategies I thought would work would be to depersonalize it, not say that your section of our entire group is the dysfunctional one, but say that we’re going to do this as a departmental initiative, and look for two pilots, two groups that would pilot this, that then we could disseminate to the rest of the department. In a very altruistic fashion, I volunteered the section that I was in that was functionally doing quite well and bringing in the most dysfunctional section. And, not surprisingly, the consultant reinforced what I knew to be apparent going into this, and was able to articulate a best practice that was consistent for both groups. I thought that was a brilliant, non-personalized, non-heavy-handed strategy, where you would have buy-in from one component of the faculty organization, and it would just seem to be able to then be translated to the rest of the group. But, unfortunately, it didn’t work, because of personalities that, in the end, weren’t accepting of the outcome.

Tacey Ann Rosolowski, PhD:

Can you sketch—and I realize that you want to kind of be sensitive about providing detail, but could you kind of sketch what the dysfunction was, so that—and why the individuals involved were so attached to sticking to that practice?

Thomas Buchholz, MD:

Well, change is difficult. I think change, and your ability to change, is multifactorial. It’s not just all emotional. People have— (loud background noise)

Tacey Ann Rosolowski, PhD:

Do we have something happening here?

Thomas Buchholz, MD:

That’s my printer.

Tacey Ann Rosolowski, PhD:

Oh, okay. Should we pause while it does its thing, or...? Because it’s going to read on the...

Thomas Buchholz, MD:

Okay. [The recorder is paused.]

Tacey Ann Rosolowski, PhD:

Yeah. All right, we’re good to go again. So you were saying change is hard, and...

Thomas Buchholz, MD:

Change is hard, and change isn’t all just a psychological issue. It’s an issue that sometimes people have different competencies with respect to skills needed for that change. A great example of that would be implementation of Epic. The ability of a younger generation to quickly adapt to a changing environment—I think in one of my Friday notes I wrote about the plasticity of one’s brain, the ability to learn new work methods, and to implement them, are dependent on a variety of cognitive and physical factors, in addition to psychological factors. And so I think you have to be somewhat respectful of that. That, again, is somewhat of the art of leadership, in addition to holding principles. You can’t be overly rigid. You have to allow for some flexibility for the human condition. And I was starting to mention it—I don’t know if it was cut off or not—that comes then into the art of prioritizing decisions based on the cost benefits. The cost benefits are complex, because we live in a four-dimensional world, and you might say that we’re making a decision about an individual circumstance that seems to be two-dimensional, without an appreciation that the decision that you make with this individual or this circumstance also has ramifications of what’s going on next door, because they’re going to be interpreting that in their own context. And it also has implications of how these things translate over time, because everybody’s looking for consistency rather than inconsistency. Everybody’s looking for fairness that is not about an individual.  

Tacey Ann Rosolowski, PhD:

Okay, we are recording, and it’s about 90:30 on the 31st of January, 2018, and I’m here in the Department of Radiation Oncology for my second session with Dr. Tom Buchholz. Thanks very much for making time.

Thomas Buchholz, MD:

Thank you.

Tacey Ann Rosolowski, PhD:

Beautiful day.

Thomas Buchholz, MD:

It is.

Tacey Ann Rosolowski, PhD:

You have a beautiful window behind you.

Thomas Buchholz, MD:

Thank you.  

Tacey Ann Rosolowski, PhD:

And we were strategizing a little bit before the recorder went on, and I realized that you had not spoken about your role as Director of the Radiation Oncology Residency Program. That was from 1998 to 2001. So tell me how you were the person who came to step into that role, and what you were able to accomplish.

Thomas Buchholz, MD:

Well, I’ve always been interested in education. My mom—I don’t know if I said this last time—was a public school educator, and one of the enjoyments I had with academic medicine was residency training programs and medical students, etc., who are going to be the next generation of leaders in your given profession. They bring with them a lot of enthusiasm, a great degree of intelligence, and just really make—the educational environment is a really fun environment in which to work. So I came to MD Anderson 1997 with an interest in participating in education. Education, from a residency program, was one of the most important components of our department. It was, in part, because our division head at the time, Jim Cox [oral history interview], really prioritized development of outstanding residency training in our group. So it was a highly sought after role to play. Usually, in radiation oncology departments, the number of residents and attendings are somewhat equal, but in our department, because we’re so big, not everybody could be as actively participated in the residency program. So Jim thought I’d be a contributor to the program. Again, I was one of the only junior faculty when I joined. We were kind of more weighted to senior faculty. He thought I would be kind of a role model that was more in their generation, and he thought I’d be a good personal fit. So even my first day, I started as the Director of the Medical Student Rotation, and a component—then the Assistant Residency Program Director to a much more senior faculty member, a professor at that time, and I was an assistant professor.

Tacey Ann Rosolowski, PhD:

Who was the professor you worked with?

Thomas Buchholz, MD:

Alan Pollock. And so within a short—or within a year, anyway, then Alan became a chair at an outside institution, and Jim asked me to take over as the Residency Program Director. And it was a new opportunity for me, then, to be really in charge of something, again, with the support of the division head. Because it was such a priority placed by the division head and department chair, it was pretty easy for me to make some significant changes and establish kind of a new culture for education, because I knew I had the backing. And sometimes when... So one of the first things we did, based on my military training, was to really identify a mission statement. And so I worked collectively with our residency program leadership, and the residents themselves, to define why do we have a residency program? What do we really want to achieve? Residency program’s a great thing in which to do that, because, not surprisingly, we focused our mission on training, because that’s what residency programs are all about, but by articulating our residency program mission statement, which still exists today, it’s really about training the next generation of leaders of radiation oncology. We were fortunate to have many, many more qualified applicants than we do training slots. And we wanted to decide, what is our program about? Is it about just training great practitioners, or is there something more? There’s a uniqueness to MD Anderson in terms of the portfolio of resources we have for a young trainee to come in here. We have incredible opportunities for research, and incredible opportunities for leadership development. We have many of the leaders of our profession here. Obviously, we have incredible opportunities for great clinical training, as well. We have the whole gamut of—anything that you’d want to learn about radiation, we have at our disposal. So we focused on identifying this mission statement, and it really permeated then into how we ran the residency program, because we could turn back to that mission statement, and we could say to our faculty, “This isn’t about the residents making your life easier by doing the scutwork, or doing this. There are going to be some concerted—if we’re serious about this mission, we’re going to have to take time for leadership training. We’re going to have to take time for the ability to formulate an effective scientific presentation. We’re going to go beyond just clinical training, because we’re really here to train the next generation of leaders.”

Tacey Ann Rosolowski, PhD:

What was the level of participation of the department in creating that mission statement?

Thomas Buchholz, MD:

We had a Residency Program Committee, that consisted of a variety of faculty representatives from various sections, whether they be disease site sections, but also then representatives from our biology group and our physics group. So I think that core element helped collectively define the mission statement, and then we brought it to the trainees for feedback, and then we’d bring it to the entire faculty during staff meetings. And so it was an iterative process, where we got a lot of give and take, but it started with kind of the core leadership community of the residency program.

Tacey Ann Rosolowski, PhD:

Could you see kind of an impact of that process as it was going on? Were people enthusiastic? Were they skeptical? How did that all work?

Thomas Buchholz, MD:

I think they were... I think... For me, I was a little bit skeptical about... I’m a very typical doctor, trained, who always kind of feels a little bit skeptical about soft sciences, and the social sciences aren’t necessarily—I guess we’re biased to proof and certainty, and oftentimes the social sciences aren’t as rigorously conducted in terms of statistical certainty as some of the hard biological and physics sciences. So there’s a degree of skepticism—and this is MD Anderson culture, too—

Tacey Ann Rosolowski, PhD:

True.

Thomas Buchholz, MD:

—about underplaying the importance of some of these leadership sciences, for instance. That would be kind of a social sciences that there’s a degree of skepticism within the medical community about the importance of these types of things. And I, too, had such biases as I started my own leadership: Well, I get why would you write a mission statement, or where is the proof that something like that really benefits organizations, and when you read about it in Harvard Business Review there are all these so-called case reports, like, wow, here’s an example of how a CEO turned a company around. In the medical literature, when you read a case report, it’s kind of considered the lowest level of evidence, and most times now journals don’t even accept a case report, because they’re just a story without really credible science. And yet, I think for me this was an elucidating moment. I went from Air Force kind of rigorous, textbook, “Here’s how you are a leader; let’s all turn to binder three and paragraph six, section things; write a mission statement.” Well, why do you write a mission statement? Well, because we have all these anecdotes that it might be. But then when you actually implemented it, for me, the first time in a leadership role during residency, I saw the power, that it was really transformative for our group. Because for the first year when I was on faculty you could see these tensions arise. The residents would sometimes go to the attending and say, “Oh, I have a noon lecture,” and the attending would say, “We’re not done with clinic yet. Your responsibility is to be here with me in clinic. Why should I have to be here in clinic if you’re not here? You’re a trainee. I’m an attending. Don’t tell me you’re going to go hear a lecture about leadership, because this is your priority.” When I was at Harvard, during my training, I never left my attending. And so without an articulation of what we’re doing as a group, and why we’re doing it, there was always this kind of tension and our program couldn’t really be elevated to the next level. And so for me it was a great learning opportunity about the power of these social sciences being truly transformative. Now, again, I couldn’t have done that without the engagement of the faculty. And sometimes just having this conversation of why is it that we have a residency program. Is it really so that you don’t have to learn how to use Epic and order lab tests, because you could have someone else do it? Why don’t we just hire a scribe for that, if that’s what we really need? Or is it something more? Are we in a different generation of education than we were when you were a resident, right? And if not, why not? Why can’t we do this? Are we serious about our commitment to train the next leaders? And if we are, then let’s adhere to our mission statement, and let’s make choices that are consistent with what we articulated as our reason. So I think it was a powerful elucidation in my own mind, and I think probably for many, too, that what is this all about. And then as I became a department chair, one of the—I think I may have mentioned this previously, but it struck me that during my period as Residency Program Director, we were able to really change the program quite significantly from one that a lot of our residents went into practice and not leadership, but after three or four years most everybody was graduating and pursuing real leadership journeys. And the quality of our program went up quite considerably, and, not surprisingly, the positive reinforcement among—do you choose to come to MD Anderson? Well, you come to MD Anderson, you talk to the other trainees, and they’re saying, “This is what we’re all about.” You actually—when I was running the interviews, we’d have a mission statement, say, “This is how we’re going to guide you. And if you want to be a great practitioner of radiation oncology in your small town of Iowa, as a solo practitioner for your life, we applaud you for that, but you might not get a position, because we’re aiming to... And I’m not passing judgment this position is better than that position, but we feel we have not only great clinical training to provide you, but we have a whole bunch of resources, and we do have a number of people in our profession who want to take advantage of those resources. So maybe a different residency program would be better for you.”

Tacey Ann Rosolowski, PhD:

Absolutely. I mean, it’s very interesting, because that shift in perspective about let’s take the time to talk about our basic values, professional values, and what we want to do with those. Those are often conversations that get put on the back burner because of all kinds of immediate fires that need to be put out, and so that this was really an interesting process. I mean, how long did it take, do you feel, before you began to see the impact of that mission statement on how people were actually behaving, specifically the faculty?

Thomas Buchholz, MD:

Well, there’s an acute phase and then a culture change. And so the acute phase happened pretty quickly, because to change the culture you’re going to have to adhere to your mission statement. You’re going to have to make choices that are consistent with your mission statement; otherwise, your mission statement doesn’t have much value. So I think the first process isn’t to write a mission statement and implement it. The first process is to work collectively as a group, and get everybody to buy in that this is a mission statement that they’re happy or consistent with. And once you have people kind of signing off—and these things aren’t so controversial. If you say, “Here we are at MD Anderson. You’re all academic physicians. You’re all proud to be here. You’re a leader in your respective field, and this is why you’re a faculty member in the best radiation oncology department in the world. And you realize that our trainees come here, and you’re proud that they’re coming here, and they’re coming here because they have the opportunity to be the next generation of leaders, right? Is everybody onboard with that? Do we have a responsibility? Can we really do something different?” It doesn’t sound so controversial. These are types of truths that are self-evident, almost. And in doing so, then, it’s not that big a jump to gain a consensus. There are other situations, obviously, where you’re going to find tensions, right? But this was something that there might be some people who would—but they would be a minority. So you have a vast majority who are saying, “Yeah, this is exciting.” And then you start to put the resources in, and come up with, “What are we going to do?” And, again, it sounds kind of exciting. But then the implementation phase, that’s where [plainly?], well, what does that mean? Hmm, they snuck that one in.

Tacey Ann Rosolowski, PhD:

It means behavior change.

Thomas Buchholz, MD:

Behavior change.

Tacey Ann Rosolowski, PhD:

I mean, I was thinking about that scenario you gave earlier of the attending and the resident, and suddenly the resident wants to leave, and that’s when the rubber hits the road. (laughs)

Thomas Buchholz, MD:

It does. But that’s, again—I had the good fortune of being a hundred percent backed by the department chair and the division heads, right, who ultimately was... I’m a Midwesterner, where there’s always a boss at the end of the day, right? And then, after a while, it’s not that big of an issue. After a while, it’s just the norm. And so I think to have that consensus and get everybody’s buy-in, and then have the courage to say, “Okay, we’re going to adhere by that, and there’s going to be some ramifications about it, and not all of them are going to be fun,” and then moving to that to... And what that enabled—I guess, what the insight from a lot of our faculty was like, wow, we could benefit from this, as well. And then it became an issue of how come our residents are treated so well, but I’m a new faculty, and I didn’t train in this program, and I never got this type of opportunity as a resident? I need this type of training, and wouldn’t it be more important for me as a junior faculty that you’re really invested in, to...? How am I going to become a leader in the profession? And so that was a natural evolution, then, for me to start developing very similar focused programs in mentorship for junior faculty.

Conditions Governing Access

Open

Chapter 07: The Radiation Oncology Fellowship Program

Share

COinS