Chapter 23: MD Anderson Growth as an Impact on Institutional Culture and on Radiology
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Description
Dr. Podoloff talks about the need for growth at MD Anderson and sketches expansion has had an impact on how radiology is conceptualized as a practice.
He first talks about the need for regional care centers to better serve patients, then sketches changes to the institution as it has grown, with particular attention to the increases in regulation.
Dr. Podoloff then notes that the field of radiology is addressing a question: Is radiology a legitimate field of medical study or a technology? He gives background on why radiology can be seen as superflouous, and notes that other specialties have their methods of reading films. He talks about strategies for integrating radiologists into multi-disciplinary teams.
Dr. Podoloff praises MD Anderson’s method of paying physicians to take the profit motive out of care deliver. He addresses the period of turbulence at the institution since Dr. DePinho became president, noting the he is satisfied with his leadership with one exception.
Identifier
PodoloffD_03_20150604_C23
Publication Date
6-4-2015
City
Houston, Texas
Interview Session
Tacey A. Rosolowski, PhD, Oral History Interview, June 04, 2015
Topics Covered
The University of Texas MD Anderson Cancer Center - Institutional Change; Institutional Mission and Values; MD Anderson Culture; Institutional Processes; Growth and/or Change; Overview; Definitions, Explanations, Translations
Transcript
Tacey A. Rosolowski, PhD:
It sounds like we’re switching subjects but I think we’re going to come back to some of these issues again. I wondered about your view of MD Anderson growth, particularly affiliation with other institutions. And the reason I’m aligning it is—yeah, you got it.
Donald A. Podoloff, MD:
OK, yeah, no, I see where you are. I was at a cocktail party the other night. It was a fundraiser actually for research. And Jim Cox was there. Have you interviewed Jim?
Tacey A. Rosolowski, PhD:
I have.
Donald A. Podoloff, MD:
OK. I made the point to Jim that he had a lot of vision, because he recognized very early that if his intent with radiotherapy was palliation only, he needed to go to the patients. Because to have them come in here five days a week when they were in pain wasn’t going to work. It’s from that seed that we developed these Regional Care Centers. It’s absolutely imperative that that effort continues because we’ll die if it doesn’t. The traffic in the Medical Center is getting so bad, and there’s so many other opportunities in the periphery, and plus Houston is growing, that we absolutely need to bring our work to our patients. So from an economic and from an educational point of view, because we’re also obliged to teach, and part of the teaching that we do is to go out into the periphery and educate, that’s one of our major missions, we’re obliged to do that. How we do it, the particulars, who’s in charge of it, that’ll change over time. But I think we’ve done a very very good job so far. There are bumps in the road. There are differences. This is not the same institution that I came to twenty-nine years ago when I knew everybody in the institution on a first-name basis, when I had 15 people in a Radiology Department that now has close to 200. So it’s different and much bigger. And there are problems with growth, but they’re manageable.
Tacey A. Rosolowski, PhD:
What are some of the problems you see?
Donald A. Podoloff, MD:
The same thing that happens to any large group, any company, any entity that grows immediately needs more regulation. And the regulatory environment is stifling to some degree but it absolutely is a requirement. You can’t have everybody doing what they want to when you’ve got 18,000 people allegedly working together. But our core is good. Discovery, integrity, those are good goals and good behaviors. I think I told you this before also. The mission of MD Anderson is to eliminate cancer as a public health problem in the state of Texas, the United States, and the world through programs in education, research, and clinical care, and prevention now. When I was in private practice my mission was to practice high quality medicine and make a profit. Very different missions. Both good missions, there’s nothing wrong with them. The MD Anderson model is a little bit more ennobling. But maybe some people would say that’s self-serving.
Tacey A. Rosolowski, PhD:
What’s the place of the radiologist in the teams that are established as MD Anderson moves out into regional care?
Donald A. Podoloff, MD:
That’s a great question. There’s a much more fundamental question. And that is is radiology a legitimate medical specialty, or is it a technology. And radiology is groping with that question right now.
Tacey A. Rosolowski, PhD:
Really.
Donald A. Podoloff, MD:
There are forces that say, “Well, anybody can do that.” And my answer to anybody can do that, reading a film, is there’s a difference between reading a film and looking at it. Because I’ve been trained. But when I was an internist, that’s what I thought.
Tacey A. Rosolowski, PhD:
Well, I was recalling one of our conversations where you were talking about how the ease with which you can now digitally provide copies of films, you send them to a treating physician who believes they’ve taken a class, they can read this, and interpret it.
Donald A. Podoloff, MD:
The orthopedics still believe that they can read films better than radiologists. Neurosurgeons believe that they can read most brain studies better than most radiologists, even neuroradiologists.
Tacey A. Rosolowski, PhD:
So that’s again one of those pressures to say that radiology is actually a technology and not a craft, an art, a specialty.
Donald A. Podoloff, MD:
Exactly. We just faced that right here in our own division. PET/CT is read by nuclear medicine doctors, it’s read by the abdominal imagers, some of them, it’s read by the chest radiologists, and it’s read by the orthopedic radiologists. So there’s about thirty or thirty-five people that read. Not too long ago the chest radiologist leadership said, “We want to read all the chest and esophagus. It’s ours. We go to the conferences. We deal with the docs.” So I went out because it was curious to me, and I asked the end user, the thoracic surgeons and the medical thoracic oncologists, who should read their films. And the thoracic surgeons said to a person it should be the chest radiologists. And the medical oncologists didn’t care. Well, the difference is that the medical oncologist has a need to know is this better, worse, the same. The surgical oncologist needs to know the anatomy of the situation, which lymph nodes are involved, all that kind of stuff. And somebody who does chest probably—although I can’t prove it, because we tried and failed—somebody who read chest all the time probably knows more about that anatomy than somebody who reads it along with 50,000 other things that they’re reading. So we ended up developing an answer for this problem. We now have a separate section of PET/CT with a section leader. And we’re working through how to solve that. I’m not sure I want you to put that in this article.
Tacey A. Rosolowski, PhD:
OK. Well, actually this’ll be part of a transcript. So if you want to seal it or redact it then we can talk and do that.
Donald A. Podoloff, MD:
Yeah, because it was a very painful discussion.
Tacey A. Rosolowski, PhD:
Was it? Huh.
Donald A. Podoloff, MD:
But I think it got solved as best it could, although everybody’s still not happy.
Tacey A. Rosolowski, PhD:
And it was a painful discussion because?
Donald A. Podoloff, MD:
Of ownership.
Tacey A. Rosolowski, PhD:
Ownership, yeah, those territory issues.
Donald A. Podoloff, MD:
Right. It was painful for me to hear it because nobody ever told me what’s best for the patient. They only told me what was best for them.
Tacey A. Rosolowski, PhD:
Well, that’s why I think it’s such an interesting question. As MD Anderson’s services are spread out globally now, what is the fate of radiology? Are radiologists part of the multidisciplinary teams?
Donald A. Podoloff, MD:
Well, we’ve encouraged that. I started doing that when I was division head. The price that you pay for that is a tremendous decrease in efficiency, because if the radiologist is not sitting in a darkened room reading one case after the other rapidly, and they’re out talking to people, they’re not reading the volume that they read. And the question is what’s the balance between those. So now our radiology schedule makes room for conference attendance, like Tumor Boards. So they’re part of that multidisciplinary, just like the pathologist, just like the radiation oncologist, just like the surgeon. And that’s the way for them to survive. Because if I can digitize it, then I can send it anywhere I want to get it read. You don’t necessarily have to be here. This all started, in my opinion, when some people who weren’t thinking very clearly and didn’t fully appreciate the implications I think of what they were recommending decided to get nighthawks. And this became a burgeoning industry of people. They read films when the docs didn’t want to. So from 5:00 p.m. until 5:00 a.m. the nighthawks took over. And then the dayhawks, the regular radiologists, read from 5:00 a.m. to 5:00 p.m. And the first time I heard about that, I said, “Well, if they don’t need you from 5:00 p.m. to 5:00 a.m., why do they need you the other twelve hours?” Some people—
Tacey A. Rosolowski, PhD:
So I’m confused. When did this happen and who started it?
Donald A. Podoloff, MD:
It was radiologists. First nighthawks were owned by a group of radiologists from out in California.
Tacey A. Rosolowski, PhD:
Huh. So this was an industrywide thing or a fieldwide thing.
Donald A. Podoloff, MD:
Well, it started very locally. But it spread very quickly.
Tacey A. Rosolowski, PhD:
Wow.
Donald A. Podoloff, MD:
And now you can get your studies read in India if you want. We can’t, because you have to be a credentialed member of the MD Anderson staff to read, and you have to be credentialed in radiology. And with very limited exceptions, if you’re not a radiologist you can’t interpret stuff. You can look at it but you can’t write a report, send it out, and bill for it.
Tacey A. Rosolowski, PhD:
Interesting.
Donald A. Podoloff, MD:
So our problems are different from the rest of the world, because of the way we split up our money. We’re like communists. Everybody makes the same more or less. There are differences per department and stuff like that. Surgeons make more money than medical oncologists usually. But we’re much more collegial and cooperative, and we’re not very territorial. One of the experiences that illustrated that in an interesting way for me. They recruited somebody here maybe twenty years ago now. And he came from the medical school here in town. And he wanted a gamma camera so he could do cardiology. And they put it in his package that he would get one. But we ended up staffing it, and after a year, he decided that he really didn’t want to bother with that anymore, now that he had us, because he wasn’t collecting the dollars for it, the technical fees were higher than the professional fees. And so we have a very nice cooperative effort with cardiology now where two days a week I think it is we read the cardiac stuff and then three days a week they read it, or something like that. That would not happen in a fee-for-service free enterprise system, because money would be the driver.
Tacey A. Rosolowski, PhD:
Yeah. Interesting.
Donald A. Podoloff, MD:
Yeah. So I like our financial model. And I actually believe that it’s the right financial model for all of medicine. I think we should have a single provider and that all doctors should be on salary. But that’s me. And I’m at the end of my career, not at the beginning of it. Although I think I’ve always felt that way. I often tell people, “If you’re going into medicine to make a good living, you won’t be disappointed, but if that’s the major reason you’re doing it, you’re going to be very unhappy. Whereas if you’re going to be a stockbroker, that’s what you want to do. You want to make a lot of money.”
Tacey A. Rosolowski, PhD:
I had just one more question about the institution.
Donald A. Podoloff, MD:
You don’t have much more time for—
Tacey A. Rosolowski, PhD:
I know. I don’t. But—
Donald A. Podoloff, MD:
I changed my schedule around so I can do some other things.
Tacey A. Rosolowski, PhD:
OK. Can we stop at though? That’s when I have.
Donald A. Podoloff, MD:
That’s a little longer than I wanted to go.
Tacey A. Rosolowski, PhD:
OK. When would you like to stop today?
Donald A. Podoloff, MD:
I’d like to stop by .
Tacey A. Rosolowski, PhD:
OK, OK. Well, I’m glad we checked on that. Well, I guess I do want to ask this next question. Since Dr. DePinho arrived at the institution in 2011 there’s been a lot of turbulence at the institution. And I wondered if you could comment on what you feel—temperature-take. What’s been the source of dissatisfaction or upsetment with changes in the institution? And then the next phase. What do you think is going to coalesce and move out of it?
Donald A. Podoloff, MD:
Well, I think the next phase is already happening. And that is things are settling down. People who come to an institution and are brought here to change it often get criticized by the people who are here for doing what they were brought here to do. The Board of Regents hired Dr. DePinho. The faculty didn’t. I’m sure they made it very clear to him what they wanted done and why. And he’s doing it. So I would say it’s fairly unfair to criticize him for doing what the people he really works for want him to do. I think the faculty through the Faculty Senate is confused. They think that DePinho works for them. He doesn’t. He works for the Board of Regents. That’s who hired him. That’s who hires every leader in the UT System. Case closed.
Tacey A. Rosolowski, PhD:
Case closed. (laughter) What do you think MD Anderson is going to look like in five years, ten years, with the changes that Dr. DePinho is bringing?
Donald A. Podoloff, MD:
So your question assumes some things.
Tacey A. Rosolowski, PhD:
It does.
Donald A. Podoloff, MD:
It assumes that what his changes are will be here five or ten years from now. And that is not a given. But if they are, and he’s successful, what you’ll see is an institution that’s bigger, an institution that’s more global and local, and an institution that has significantly reduced the death rate from five or seven cancers that are in the moon shot programs. If the Moon Shots are successful, that’s what’ll happen. That’s the goal of the Moon Shots. The obvious criticism is that it’s an allegory. And going to the moon was an engineering problem that could be solved with mathematics and science. Curing cancer is a bit more complicated than that. But I don’t think he ever envisioned curing cancer. I think he envisions setting the tone for getting people to think about how we could do it if it was possible. I’m very satisfied with his leadership. He’s been personally very kind to me, I never had any issues with him. I don’t think that’s true of all of my colleagues. I have had no direct experience that says that he’s doing something that he shouldn’t have done. Probably the closest I would come to that is if it is true that he reversed unanimous decisions of the Promotion and Tenure Committee, unanimous positive decisions, and if he reversed them, if he didn’t explain why he did that, that’s probably a mistake. And I suspect he recognizes that, if that’s all true. I mean I only know what Todd Ackerman tells me.
Recommended Citation
Podoloff, Donald A. PhD and Rosolowski, Tacey A. PhD, "Chapter 23: MD Anderson Growth as an Impact on Institutional Culture and on Radiology" (2015). Interview Chapters. 751.
https://openworks.mdanderson.org/mchv_interviewchapters/751
Conditions Governing Access
Open
