Chapter 09: Creating a New Way of Conducting Research and Caring for Patients in a Changing Environment

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Chapter 09: Creating a New Way of Conducting Research and Caring for Patients in a Changing Environment

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In this chapter, Dr. Dmitrovsky provides an overview of how MD Anderson must operate in the new environment of research and healthcare economics. He begins by explaining that scientific endeavors traditionally rely on decisive discoveries by individual investigators that also reveal opportunities to development treatments. Today, he says, this process moves ahead via team- and interdisciplinary science, and the institution must educate the next generations of researchers in this way of conducting research. At the same time, MD Anderson must operate in a context of a flat NIH budget while responding to the new economics of the Affordable Care Act. Next, he notes that MD Anderson is supporting the education of the next generation by making investments in junior faculty with the R. Lee Clark Fellowship Program. He explains the award (juried by experts outside of MD Anderson). Next Dr. Dmitrovsky notes that reductions are being made to the length and complexity of informed consent forms so faculty can spend less time on paperwork and more time for their primary activities. He then speaks briefly about faculty recruitment and retention efforts. Then Dr. Dmitrovsky talks about strategies used to encourage interdisciplinary investigation. He speaks in detail about finding ways to provide team members with proper recognition for their contributions (when contribution is traditionally measured by first or last author status) and linking credit to faculty promotion. He also talks about empowering team members to initiate investigations and provides some examples.

Identifier

DmitrovskyE_01_20150303_C09

Publication Date

3-3-2015

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - Building the Institution; On Research and Researchers; Understanding Cancer, the History of Science, Cancer Research; Building/Transforming the Institution; Research, Care, and Education; Multi-disciplinary Approaches; The History of Health Care, Patient Care; On the Nature of Institutions; Business of Research; Fiscal Realities in Healthcare; Institutional Processes; MD Anderson Culture; Growth and/or Change; Understanding the Institution; The Institution and Finances; The Administrator

Transcript

Ethan Dmitrovsky, MD:

So one of the observations that I would suggest has value to consider is the nature of the scientific endeavors, today, build on extraordinarily important, decisive, discovery science that is finding fundamental pathways that control the growth or differentiation or immunologic state of human cancers has taken many decades of work, ever since the National Cancer Act was signed by President Nixon. So we are the beneficiaries of decades of discovery science, and yet, there's so much we still need to discover. But those discoveries have begun to reveal tractable potentially tractable targets for cancer therapeutics. And as we must surely have discovery science continue, this opens up another way of conducting science, and that would be using interdisciplinary teams, so bringing people together from different disciplines, working on common problems. At the same time, I would submit that we're at an era not only of team science, but where discoveries will be made in a very interesting area, and that will be in the area between disciplines, where the distinction between fields becomes blurred. So when you ask the question about, strategically, what kind of scholarship, what kind of educational model we would want, I think there has to be a broad understanding that the nature of science may actually be changing.

Tacey A. Rosolowski, PhD:

And the challenges of transforming an institution to be aligned with that larger environment, too, seems like the challenge.

Ethan Dmitrovsky, MD:

Yes, and then if I could just continue this line

Tacey A. Rosolowski, PhD:

Sure.

Ethan Dmitrovsky, MD:

of reasoning, you also need to educate the next generation of contributors, who are able to act decisively in this changing environment, where having skills of being able to communicate effectively with other investigators from different tradit areas of scholarship will become increasingly important skills. And having the ability to take full advantage of what's called "big data,all the information that we have acquired means that we perhaps need to create new disciplines. So all of this opportunity is occurring at the time of uncertainty regarding the Affordable Care Act so-called Obamacare. We are still learning firsthand what an American medicine delivery system will look like, and in particular, what role academic medical centers will play, and especially quaternary cancer centers like MD Anderson. There's an uncertainty about what it will look like, and at the same time, we have a flat NIH budget, which means the purchasing power is actually going down considerably, when you consider that there has been no accommodation of cost of living increases for faculty, inflationary costs for equipment all that has been going on. And it is even said that perhaps we have lost the purchasing power of the doubling of the NIH budget in the years since the doubling ended, because a flat budget means that you're falling behind. So we need to recognize these truths, and at the same time, we need to consider how we can respond to this changing biomedical environment. So with all that said, and I wanted to say is that one of the areas that is particularly important for us to consider is the next generation. We have made substantial investments in supporting our junior faculty. One is, we created the R. Lee Clark Fellowship Program R. Lee Clark Program, which provides $100,000 of resources to, in the inaugural year, sixteen new Clark fellows, for them to use as they see fit in one of three areas. This was a competitive peer review process that included a review committee of outside experts, so no one at MD Anderson chose the candidates. And these were distinguished colleagues, members of the Institute of Medicine or National Academy [of Science] or people who will likely become members in the future. So we've invested in junior faculty. We've also sustained our support for institutional research grants, IRGs, for junior faculty. We have created a new Clinical Innovator award for faculty in the three areas for the R. Lee Clark Program. One was for a science panel. Another was a physician-science panel, and a third was Clinical Innovator. These are individuals who the majority of their time and effort is in scholarship on the faculty of these different areas. We also want to support people who are largely involved in the management of patients as the major thrust of their work, so we created a Clinical Innovator Program. These are $50,000 awards that can be renewed, competitively, again with this model of outside experts choosing or identifying the most meritorious candidates. And we've decided to begin an effort a substantial effort, a good faith effort to reduce administrative burdens, so we invested I made a large investment, on a pilot basis, to make CLIA-approved genetic testing available to patients on trials without cost. And we have made an even larger investment to offset the costs of diagnostic services for patients on trials, so that that wouldn't be a barrier to patients going on trials. We have made a concerted effort to reduce the complexity and the length of informed consents. We put them online, so that patients can electronically sign these, and we've also reduced a number of administrative steps that we involved in what's called material transfer agreements. So we're trying very hard to have faculty spend their time doing what they do best, which is their scholarship, their clinical care, their service, their teaching, rather than in the administrative services that are needed. We've also recruited and retained a number of remarkable colleagues at the division head level, at the department chair level, and at the frontline faculty level. So we've recruited leaders who are really excited about joining us, and we've retained our faculty who are attractive obviously nationally to other institutions, and our office makes a lot of time making sure that we retain the very best faculty here. We're pleased with the record that we have in that area. So how do we encourage these interdisciplinary collaborations? We've also made investments in multi-investigator grants, both internally and through the CPRIT mechanism. One of the initiatives that we have is we've as an example, the last cycle for multi-investigator grants to CPRIT were eighteen applications. And even though our faculty are very competitive, we certainly don't expect all eighteen to be funded. But what we've decided to do is to take the four closest CPRIT applications that weren't funded and have a panel review those, and then support two or three of them to allow these multidisciplinary, interdisciplinary collaborations, because the changing science environment is, as I said, between disciplines. So we have individual investigator grants from the NIH that are called the R01 mechanism, and we have multi-investigator grants that are called the P01 or SPORE mechanism. So we have ways to support faculty in both areas for instance, the R01 mechanism we have supported we created a new program called the INTEREST program that allows us to directly provide mentorship to faculty writing grants, R01 grants. Seasoned reviewers on the faculty will review their grants, provide them guidance we have science writers who help them with their grant applications. We have a robust bridge funding program, and so we're adding more resources. So if people are close to making payline which is the code word for getting a grant that's in the fundable range "paylineis the word that's used. For those who are very close, we're providing bridge funding to them, and our Institutional Research Grants, which have, as their focus, junior faculty. We recognize that senior faculty moving in new directions are particularly challenging for them to get grants in this stable or this flat NIH budget, and [inaudible] we broadened our institutional research grants to welcome senior faculty for this first time, moving in new directions. So all of those are substantial investments that we've made.

Tacey A. Rosolowski, PhD:

Can I ask and I'm not even quite sure how to ask this question, but how I remember reading someplace in my background research that you felt one of your challenges was to create a balance between individually-conducted science and team science.

Ethan Dmitrovsky, MD:

Right, that's what I'm talking about, yeah.

Tacey A. Rosolowski, PhD:

Right, and so

Ethan Dmitrovsky, MD:

But not to to find the balance, but not to deemphasize either.

Tacey A. Rosolowski, PhD:

Right.

Ethan Dmitrovsky, MD:

So that's the challenge, is to find the right balance, but not to support one type of science over the others, because they're both meritorious.

Tacey A. Rosolowski, PhD:

Right, and it seems like they could feed each other, obviously.

Ethan Dmitrovsky, MD:

And they are connected, yeah.

Tacey A. Rosolowski, PhD:

Absolutely. So my question is sort of an aligned question. I mean, clearly, interdisciplinary science, team science has been involving through the desires of individuals and also out of the necessity of making these kinds of complicated discoveries in what are basically new fields. How what are some of the challenges that are when trying

Ethan Dmitrovsky, MD:

Yeah.

Tacey A. Rosolowski, PhD:

to encourage that at an institutional level?

Ethan Dmitrovsky, MD:

So that's a very important question that I'd like to address, and so there are many levels of response. One is at the level of the individual faculty members. What they ask us is, "How will I receive recognition or credit, for want of a better word?So I've actually met with the promotion committees at the beginning of every year, and we talk about what we hope to foster, and one of the areas we hope to foster is this area of team science. So we want the people to be recognized for their contributions to discoveries, whether or not they're the first or last author, which are viewed as the most visible positions on paper. But let me say to you if you have a clinical investigator who is the instrumental individual in the team that can move the discovery from the bench into the clinic, that discovery, as a whole, wouldn't have occurred without that person. So we have to articulate, in promotion packages, how does that individual receive appropriate recognition and credit. So it starts at the level of communicating the need for us to find ways to promotion committees. The other is to make sure our guidelines for promotion accommodate the value of team science, and when there is recognition to be garnered at the time of awards or at the time of visible publications, to give credit to the entire team. Oftentimes, there are a large number of individuals who are essential in making a discovery, because science has become so interdisciplinary. To highlight, spotlight the team approach is really important. And this is a national trend that we're seeing, this recognition that teams are important in science and that the team members, obviously, are so important, and they each bring content expertise. What becomes a bit challenging at the moment of promotion is to articulate the role someone played, because there hasn't been that tradition in the academy, because the focus is always on the first and last author, so we need to develop a cultural tradition to recognize, to spotlight, to showcase the members of the team who, in particular, were instrumental in making the entire project happen. I think the Moon Shots Initiative is a good example of when things can go in a positive direction in assembling interdisciplinary collaborations, because they are these niches, by their very nature, are team oriented. So I'm pretty confident that that's going to be possible to move forward, and then the next is how can we take full advantage of the scholarship that has been done? So when you make a discovery that might be in some of the most visible journals and in the scientific literature, there are oftentimes follow-up observations, discoveries that can be made, and so we need to find a way to empower those team members, so that each one can have an area of scholarship that's meaningful to them and meaningful to the people we serve. That's why this Clinical Innovator Award was created, is actually for fashioned to support those faculty members who are seventy percent of their time or more spent in clinical activity, to give them funds so that they can make some of these very relevant translational discoveries that their particular expertise lends itself to. So we're trying to support the team members independently of the other mechanisms that we've put in place.

Tacey A. Rosolowski, PhD:

OK, that clarifies that a little bit.

Ethan Dmitrovsky, MD:

Hopefully that helped, but I wanted to emphasize we are not diminishing discovery science. What we want to do is add upon that strong foundation without diminishing discovery science.

Tacey A. Rosolowski, PhD:

Yeah.

Ethan Dmitrovsky, MD:

It served us well for decades.

Tacey A. Rosolowski, PhD:

Because it seems as though I mean, there are so many areas in which you can exert a pressure point to make any discovery, in the sense of taking a particular possibility for a targeted approach to the bedside when it's just a glimmer of an idea at the bench. So just to follow up so I was thinking about that Clinical Investigator Award. So the idea behind that would be if a clinical individual is

Ethan Dmitrovsky, MD:

Clinical Innovator Award.

Tacey A. Rosolowski, PhD:

Innovator Award.

Ethan Dmitrovsky, MD:

Yeah, and so the Clinical Innovator Award was meant to be of the broadest scope, so that wouldn't necessarily be any particular area of clinical innovation. They're people who are experts in safety systems and experts in population science, and so we were not trying to direct these funds in a particular direction. But we were able to we wrote a grant to support this program to the first foundation that was funded, so we've been able to gain peer review support for this initiative.

Tacey A. Rosolowski, PhD:

I guess I was just trying to link the conversation about that award to the conversation about team science, and the idea of taking advantage of the scholarship that had been done. So when I was assuming that, perhaps as a clinician who's part of a team, an award of this kind would enable them to perhaps make an additional from bench to bedside approach.

Ethan Dmitrovsky, MD:

Oh, absolutely, that oh, absolutely. And it could be bench to bedside. It could be bedside to bench. It could be bench to bench. I mean, so I wanted to say there's so much, when you make a team science discovery, that can be built upon, and we don't want to be prescriptive about how that has to occur, whether it's from the bench to the bedside or back again. I think that's open to the faculty to decide.

Tacey A. Rosolowski, PhD:

It seems like this is a very

Ethan Dmitrovsky, MD:

And the first ten awardees, actually, were quite broad in what they were doing, yeah.

Tacey A. Rosolowski, PhD:

Interesting. I mean, it seems like it's a very new environment for conducting research. Is that

Ethan Dmitrovsky, MD:

Yes, and you need to adapt to this

Tacey A. Rosolowski, PhD:

Right.

Ethan Dmitrovsky, MD:

So it's a time of constraint, though dollars for research. It's a time of somewhat uncertainty of how the Affordable Care Act is going to be implemented, and a time of exceptional opportunity, because of the decades of discovery science. So all those things are active at the same time.

Tacey A. Rosolowski, PhD:

Right, right, very complex. I'm wondering if this is a good place to stop.

Ethan Dmitrovsky, MD:

Sounds that way to me, yeah. Thanks, great.

Tacey A. Rosolowski, PhD:

OK. All right, great, and I look forward to continuing our conversation.

Ethan Dmitrovsky, MD:

Good, good. I hope this has been helpful.

Tacey A. Rosolowski, PhD:

Absolutely. Well, let me just for the record say that I'm turning off the recorder at about 10:55 a.m., and I want to thank you for your time this [inaudible].

Ethan Dmitrovsky, MD:

And thank you so much, good. END OF AUDIO FILE

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Chapter 09: Creating a New Way of Conducting Research and Caring for Patients in a Changing Environment

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