Chapter 14: Head of the Department and Division of Radiation Oncology
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Description
Dr. Cox explains his dual role as Head of the Department and Division of Radiation Oncology, first discussion his Departmental goals of expanding the faculty and creating a strong and highly specialized department. He also notes that the department was technologically out of date when he took over, and he explains the upgrades he introduced: a modern system for treatment planning, a CT simulator, and the transition from 2-D to 3-D treatments. The department next combined 3-D treatment planning with computer assisted treatment planning to refine patient protocols. Dr. Cox explains how the Department established a dosimetry school as the program grew. The Department next developed intensity modulated radiation therapy.
Identifier
CoxJ_03_20130423_C14
Publication Date
4-23-2013
City
Houston, Texas
Interview Session
Topics Covered
The Interview Subject's Story - The Administrator; The Administrator; Professional Practice; The Professional at Work; Building/Transforming the Institution; Definitions, Explanations, Translations; Technology and R&D
Transcript
Tacey Ann Rosolowski, PhD:
And this was—this was after you were department chair (both speaking at once)—this is when you were division head?
James D. Cox, MD:
Yeah. Now a department chair and division head were one and the same when I took over in—
Tacey Ann Rosolowski, PhD:
’95?
James D. Cox, MD:
’95. And they stayed linked until, I believe, 2007.
Tacey Ann Rosolowski, PhD:
That is what I have down here, and then the title changed.
James D. Cox, MD:
And then there was a separate department chair and a separate division head.
Tacey Ann Rosolowski, PhD:
So there was a restructuring of the department at that time? Was there?
James D. Cox, MD:
No. There was a dividing up of work.
Tacey Ann Rosolowski, PhD:
Oh—okay. So how did that all work? What was the change?
James D. Cox, MD:
I mean a lot of—the heavy load that falls upon the department chair and the person who shared both titles was evaluation of faculty, and that—you know—there is a requirement that the faculty are evaluated annually, and that forms are filled out, and questions are answered about have they done this and what—what contributions have they made and so on. And then that evaluation is supposed to match up with any recommendations for merit increases. In a more complicated way it is supposed to match up with how people use their time. In other words, are they spending only twenty percent of their time doing academic activities or are they more heavily involved in research that they are doing maybe in a laboratory in which case it may be a fifty/fifty designation. There are a very small number of individuals who spend twenty percent of their time clinical and eighty percent of their time in the lab, but those are specifically designated within the institution as physician-scientists. So there are only a few of those in radiation oncology, I think maybe four or five.
Tacey Ann Rosolowski, PhD:
So what was the scope of your—well—tell me how you came to become department chair in ’95.
James D. Cox, MD:
They were linked together. They were just—it was one job—department chair and division head (both speaking at once).
Tacey Ann Rosolowski, PhD:
Okay. So it was simply just a more limited title at that point. So what was the scope of your responsibilities?
James D. Cox, MD:
Well—you know—in that position you did everything.
Tacey Ann Rosolowski, PhD:
Yeah. How big was the department in ’95?
James D. Cox, MD:
In 1995 there were seventeen faculty. I think there were probably fifteen full-time physicists. There was only a pretty small symmetry group. The symmetrists are sort of a bridge between the physicists and the physicians. So—well, there were things that we did and not necessarily in chronological order, but in an order of some importance we expanded the faculty as we expanded the number of patients that we were treating. And we expanded the number of patients we were treating in part to keep up with the expansion and other disciplines in surgery and medical oncology throughout the institution. In doing that and recruiting the right people and having them in the right place and governing all that because we are so highly specialized that people who take care of patients with cancer of the prostate never treat a patient with cancer of the breast. And people who take care of patients with cancer in the head and neck do not treat patients with cancer of the lung even though it is a few centimeters away. So we are super specialized, and getting the right people into those right specialization areas is a challenge both for recruitment and retention.
Tacey Ann Rosolowski, PhD:
When you say the right people—what were you looking for?
James D. Cox, MD:
Well you are looking for people who are interested in that area who will make a contribution who have expressed some strategies or goals that would make them contribute in a favorable way to the group. And rarely—I don’t know if I should say rarely—infrequently has the role of one entirely of taking care of patients. The goal is to have academic interests, academic accomplishments and to evaluate faculty on the basis of those accomplishments as well as the patient care.
Tacey Ann Rosolowski, PhD:
What did you envision for the department and division when you took over in ’95?
James D. Cox, MD:
Well, the other thing that was lacking was that it was technologically pretty much out of date. And so approaches to equipment—new equipment, new—
Tacey Ann Rosolowski, PhD:
Why was there—why was it out of date? Why hadn’t there been a commitment to keeping up?
James D. Cox, MD:
Well, I’m not sure I can answer that for certain. I believe it was the interest of my predecessor as department chair and division head that his interest was primarily in the laboratory, and I think he took pretty good care of what went on in the laboratory, but I think he was less interested in the breadth of activities in a clinical domain. And so—and at the same time the same was true—I guess—in physics. So it was a—there needed to be some changes in those areas. I mean—Dr. [Lester] Peters left and went back to Australia. Dr. [Ken] Hogstrum and I were together for a while. He was not as open to that movement of technology as I was hoping to see.
Tacey Ann Rosolowski, PhD:
What was going on in technology that you wanted to grab hold of?
James D. Cox, MD:
Well—for example—we didn’t have modern computer systems for treatment planning. They had a home-grown system that they were sort of married to, but there were commercial systems now becoming available that were much more sophisticated, and that other people in the community and private practice in the community had these systems and were able to do things that we were not able to do.
Tacey Ann Rosolowski, PhD:
What does a system like that do?
James D. Cox, MD:
It stores the characteristics of the beams that you have. You know—if you have an accelerator and it has got two photon beams and 6 electron beams—those beam characteristics are measured and stored in the computer. And then you capture—and that was the other thing that was missing—we did not have a CT simulator, so we were using old fashioned simulation. And so we needed to get CT simulators to use which then that information could be put into the computer, and it could be planned in three dimensions. So we went from doing two-dimensional treatment to three-dimensional treatment at virtually every site—some earlier than others. And then as time went on and the field moved forward, we went from the three-dimensional planning which was based on CT and MR—those two major approaches, and then that combined with the computer-assisted treatment planning systems or the computerized treatment planning systems, and with that was the development of a much more sophisticated dosimetry program. We developed a dosimetry school, and for the first couple of years we could train the dosimetrists, but they did not want to stay and work here.
Tacey Ann Rosolowski, PhD:
Why didn’t they?
James D. Cox, MD:
Well—I don’t know. I guess the work environment was not as comfortable as they would like, but—so that changed over time.
Tacey Ann Rosolowski, PhD:
Now is the dosimetry school still in existence?
James D. Cox, MD:
Oh yeah.
Tacey Ann Rosolowski, PhD:
I had no idea.
James D. Cox, MD:
It is very vigorous.
Tacey Ann Rosolowski, PhD:
Wow.
James D. Cox, MD:
I’ve forgotten how many students there are—probably fifteen maybe. We have a therapy school and a dosimetry school, and they are both excellent, and the people who are trained are in very high demand.
Tacey Ann Rosolowski, PhD:
And these are all things that were started when you were division head?
James D. Cox, MD:
The therapy school was already there, but the dosimetry school was not. And so it was started—I recruited—actually Robin Famiglietti, who is now the division administrator who came and started the therapy school, started the therapy program, expanded it greatly, did a wonderful job in developing it, and now it is a gem of the department or division.
Tacey Ann Rosolowski, PhD:
Were there other technological initiatives—technologies available that you brought to MD Anderson?
James D. Cox, MD:
Well—I mean—those—I think those were the major ones. There were similar kinds of technological developments in the area of brachytherapy—that is where you put sources in the body—but probably the major ones were computerized dosimetries so that we could go from 2-D to 3-D, and then the imaging that fit into that kind of dosimetry. And then as time went on we went on to intensity-modulated radiation therapy, which was another more sophisticated way of planning and delivery, and it was dependent upon getting new accelerators that had the capability of delivering IMRT.
Tacey Ann Rosolowski, PhD:
What does that mean—intensity-modulated?
James D. Cox, MD:
It means that you can target a tumor and deliver unequal doses with the beams that come in from various different directions, often five to nine different directions, and they sum in a way so that it gives a high-dose to the tumor, but it avoids the nearby normal tissues. And it is now our preferred way of treating—I would say the majority of patients that we treat with curative intent in any site—maybe not every site. But like in head and neck it is the only way we do it now.
Tacey Ann Rosolowski, PhD:
It sounds like it has a similar function to the proton therapy in that it can target and not (both speaking at once)—
James D. Cox, MD:
Yeah. It does. It does.
Tacey Ann Rosolowski, PhD:
Yeah—go into healthy tissues.
James D. Cox, MD:
Yes. It does. And, in fact, it was a challenge on the part of some of the people who were doing so well with IMRT—especially our head and neck team—were doing so well with IMRT that they didn’t have any interest in protons. Now that has changed or at least is in the process of changing so that now some of the areas that are treated under the title or rubric of head and neck are now being treated only—well not only but preferentially with protons.
Tacey Ann Rosolowski, PhD:
Tell me about some of the kind of key moments of change or growth in the division when you were head.
James D. Cox, MD:
I’m not sure there were moments so much as it was a continuum. I probably—I think that probably the first thing that changed was an approach to buying equipment. There were those who felt that it was good to have different kinds of equipment from different vendors because there were research opportunities. This was among the physicists. I didn’t agree with that, and I had some problems with the physicists on that because if we had equipment that replicated each other—if one piece of equipment went down and we could change over and patients would never lose a treatment, and we evolved in that direction. So there was a change there. And then the equipment itself evolved, and we sort of kept up with what were the latest capabilities that the equipment itself provided like these multi-leaf collimators where you could shape the beam with devices inside the head of the linear accelerator, and that is especially important for IMRT. And so you got accelerators that had that. And then there were others that had imaging devices attached to the accelerators. We used to call it OBI—on-board imaging, but now pretty much every accelerator has on-board imaging, so we don’t talk about it anymore. It’s just part of what an accelerator does because we set up the patients with imaging before we treat them. So all of this was in evolution, but I think changing the approach to buying accelerators was a big change early on, changing the approach to dosimetry systems was a pretty big change, and some of the physicists bought into that, and some didn’t at the beginning because they were interested in their own research area that involved that. A lesson there that the institution is learning now is that you can develop something within your department or within your institution, and it is not only state of the art it is ahead of state of the art. But then companies come along, and they can devote absolutely everything that they do to developing the same thing, and it can quickly go beyond what our department can do or what the institution can do. And so now that’s coming up with the electronic medical record. They are going to change the electronic medical record from what we have now to a commercial system sooner or later. I am not sure exactly when that is going to take place. So that was very much true for the treatment planning systems also.
Recommended Citation
Cox, James D. MD and Rosolowski, Tacey A. PhD, "Chapter 14: Head of the Department and Division of Radiation Oncology" (2013). Interview Chapters. 796.
https://openworks.mdanderson.org/mchv_interviewchapters/796
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