Chapter 16: A New Department of General Medical Oncology
Dr. Fisch notes that the Community Clinical Oncology Program (CCOP) offered a platform to create a new Department of General Medical Oncology. He tells the history of how the department was formed. He explains how the program at LBJ Hospital was involved as well as Dr. James Cox’s [Oral History Interview] mandate to expand radiation oncology services beyond MD Anderson proper.
Given this complexity, Dr. Fisch notes, it made sense to put all generalists together in a new department. He lists the functions included and talks about the challenges of creating cohesion in the diverse department.
Building the Institution; MD Anderson History; Beyond the Institution; On the Nature of Institutions; Building/Transforming the Institution; Multi-disciplinary Approaches; Growth and/or Change
Tacey Ann Rosolowski, PhD:
So can I ask how did the development of these studies—what was happening that made it clear that a Department of General Medical Oncology needed to be created from this?
Michael Fisch, MD:
Right. So I would say that that became sort of the linchpin of the department. You have a grant-funded program that’s taking advantage of a perspective of general oncology to connect community oncologists to experts of various types, but that by itself wasn’t enough to departmentalize, because that’s just a research program. It can stand alone. You have to say, where’s this research program sit in the institution, and how’s it piped in? But really, the department came about because at that time that I was getting going there. By 2004 I moved out of Palliative Care as my sort of departmental home to the Department of GI Medical Oncology, and that’s because they had, amongst the specific GI illnesses, disease-specific realms, they were the ones who saw cancer of unknown primary site, like cancers where we don’t know where it came from, could be from anywhere, and that was sort of the closest thing to general oncology, like what if the cancer could come from anywhere, then it’s nonspecific oncology in a sense. It’s really sort of a given kind of chapter in textbook. Cancer of unknown primary site is like a site, it’s just a certain way of looking at it. But anyway, that seemed to be the most generic sort of place to put somebody who is functioning in an unusually broad fashion. But then we had other things that were happening at the same time in the sort of general oncology realm. The LBJ program, which had started in the mid-nineties with Vicente Valero’s leadership and just a few people, was beginning to grow, where MD Anderson faculty were working with MD Anderson fellows in another health system with a broad case mix in both inpatient and outpatient setting, and as the number of patients there grew and a few more faculty had to get involved and more and more fellows were seeing patients out there, that became a bigger thing, and it was being managed like an executive-sponsored project within the Division of Cancer Medicine, so it didn’t sort of belong to any of the department chairs. It then belongs to the division head and the fellowship program, and it’s sort of a one-off thing that you manage right from the top office, from the corner office. But things that are managed as executive-sponsored projects tend to have trouble getting bigger in scope and having a big vision. They have their ups and downs because you’re borrowing time from everybody. There’s nobody in charge. It’s a small part of their job. It’s a project that won’t go away, but it’s not really what they do. And as it gets more complicated, it just becomes a bit hard to deal with, right? So there is that happening. Then at the same time in the institution, the radiation oncology world, under the leadership of Jim Cox, the division head at the time, had started to fulfill demand that people had for getting their radiation closer to home. So people didn’t want to come to the solution shop for radiation if they could get it closer, and MD Anderson was not able to influence care for patients who wouldn’t come here for their radiation. So under Dr. Cox’s leadership, they started to build some radiation satellites and then they had some success with that and they were starting to think, as oncology became more and more interested in combining chemotherapy with radiation, then it was a bit of a hassle to have pure radiation satellites where there’s only radiation oncologists in the satellites. So they said, “We would like to hire an oncologist to give chemo-radiotherapy at our radiation satellite.” Then the question to the division was, “Who would do that? I mean, why would you hire one oncologist just to give chemo and radiation? Why don’t you hire—?” First of all, you can’t hire one. You always have to have more than one, because they’re not going to work every second. So you need more than one. You need at least two. And, sure, they’ll give chemotherapy with radiation, but how about giving chemotherapy by itself? So how can we just start to have a more robust version of a satellite that had two medical oncologists and one radiation oncologist with some other rotating radiation oncologists backing him up. Why don’t we try doing that? Then the division was asked, “Should we do this and can we try this? We’ll do this in the Bay Area as our first place.” So then you started to say, well, that’s another sort of executive-sponsored project that gets complexity, hire them and who’s going to supervise them? How are we going to run this clinic? We have no experience running community outlying clinics. We’ve never functioned that way. This wasn’t an invention of the Division of Cancer Medicine. This was an executive idea, and Cancer Medicine was sort of asked to fulfill the cancer medicine part of this idea. So then you started to have multiple things that were beginning to sort of build up the complexity surrounding the division office, and it made sense to just departmentalize these things, put them together, say, well, who’s going to run the satellites and hire them and start thinking about all that, and that same general oncology department can tackle this LBJ program. So then you have generalists in the Bay Area and you have a generalist in LBJ, and then you have the CCOP program, which is a bunch of generalists thinking across disease. And for that matter, we have our International Cancer Assessment Center, so people from all over the world who come with cancers where many times they haven’t yet sorted out what cancer it is, so there’s a portion of their experience that needs to start in a very general mode. So why don’t we just sort of take these general oncology things and put them into a department, and then we can have a bigger vision and grow over time, and it will run more efficiently and effectively. That was, I think, Dr. Hong’s idea that didn’t all come one fell swoop as Marty Raber, who was a special adviser, a beloved GI medical oncologist, senior person but very much known for his wisdom and his perspective, and Marty would say there was a lot of time planting seeds around some of these ideas, and sometimes over time you plant the seeds and the little water and sunshine and time, and some of them will sprout. So between 2004 and 2006 or so, some of those seeds sprouted, and then it kind of became like a General Oncology Program between roughly 2006 and 2008. I mean sort of have a label where I would start coming to the Division of Cancer Medicine Executive Council meetings as the head of the General Oncology Program, and I would be speaking towards that particular collection of things and what was bubbling up in that realm. And then around 2008, the plan for departmentalizing it came forth, and I was the ad interim chair in 2008, and then I was named chair of the department by 2009. So this was a process of putting these things together, and as the department came together, that’s when the Integrative Medicine Program, which had been in Behavioral Science and then a little bit in Palliative Care, I think—exactly where it was, sometimes I’m finding the history of where it literally was a little puzzling, but it wasn’t in General Oncology. It was somewhere else. And the patient care piece was being done in one room of the Palliative Care Clinic at the time, and a decision was made to move that program into General Oncology, and instead of having a sort of integrative medical specialist who wasn’t a cancer specialist doing integrative medicine, to hire oncologists trained in palliative care to be the backbone of an Integrative Medicine Clinical Program. So that was the vision for Integrative Medicine coming into General Oncology, and then we executed on that vision, hiring, first, Richard Lee from Northwestern, who finished his medical oncology fellowship and did a palliative care fellowship and then got recruited because he was highly interested in integrative medicine and had done some work in acupuncture and had an ASCO YIA grant about attitudes, about integrative medicine and practice. So he was sort of like the perfect person to come and fulfill this vision of an integrative medicine specialist with an intellectual home in general oncology to see that program. Then, subsequently, we hired a Gabe Lopez, who’s similarly trained, that is, medical oncology and palliative care, interested enough to come from, I think, the Medical University of South Carolina to join Richard and be the second similarly trained person working full-time in Integrative Medicine. And then pairing them up, the clinicians, with Lorenzo Cohen, who had a longstanding successful research program that was continuing to build momentum on the research side, a PhD researcher, and then a clinical program built around that. And we were sort of the home base for that. Then the question was, how are you getting all these pieces of the puzzle together into some kind of cohesive department? Because Integrative Medicine is happening, International Center is a little different thing, some of the people are offsite at LBJ in the Bay Area, so how are they going to feel like they’re part of the same family? So that wasn’t always easy, and in the early years we were a band of a new department with a certain energy and we could get people together periodically at the main campus and also tune them in by teleconference. Then we also could cross-cover, so our Integrative Medicine guys would see some patients at LBJ, and sometimes I would cover weekends in the Bay Area, and sometimes any of us would help in the International Center. So we were flexible and versatile and doing all that. So that’s how it got started, and it worked well. Then as time went on, each of these things grew enormously in their own right, so the regional program blossomed so there were then sort of satellites in Katy and Sugarland and in The Woodlands, and then a regional administration came, so it wasn’t sort of run and administered through the Division of Cancer Medicine. We became the academic home and the sort of content advisors, but it became more multidisciplinary, so they started to add surgery, got lab-path involved, and they became more like multidisciplinary centers and started to think of it more like a regionalized care of MD Anderson more so than satellite care. And that’s a whole other story. But the punch line, I guess, is that each segment of General Oncology began to grow in its own right, and then the possibility of cross-coverage became less and less, right? So as the Integrative Medicine is really growing rapidly, then getting those oncologists to come to the International Center would not seem like an especially great idea to them. Or the LBJ Program was also growing significantly, and so each of them grew in their own rights and, over time, creating a challenge for the department to not feel like you have just separate silos that got big enough to where they could even cover themselves, but then they’re resourced from one department, so what would be the incentive to share resources from one department when each of them are sort of self-sustained things and then try to make them feel like a family, that became the challenge. But the starting point is they were able to cross-cover each other and share the same sort of flexible and versatile attributes and had the fundamental attribute of having interest across disease, both clinically and then research areas that cut across disease, neuropathy, fatigue, chemotherapy, side effects, distress, you know, all kinds of things that cut across disease were kind of what we were into, and that’s very hard. You’d say, well, everybody’s interested in these things, but it’s hard to make progress in other areas because if you—let’s say you were interested in fatigue in breast cancer patients or even breast cancer survivorship. If you go into the breast department, the mission of breast medical oncology is to eliminate breast cancer in Texas, the nation, and the world. So what does fatigue have to do with that? I mean, it’s not like we don’t care about that, but it’s not really what we’re built to do. It’s not really who we are. And we only have a certain number of dollars to spend and positions to hire to, so getting people to use a position to have somebody basically focus on something that isn’t eliminating that cancer is not so easy to do. And if a faculty member took that on, if they got permission to do it in the first place, they may have trouble, you know, sort of holding serve in their group. They’d be a little bit marginal to that group. So it’s a little bit easier to have a department where things that cut across disease are safe and appropriate, are consistent with—you know, the mission of the Department of General Oncology wouldn’t be to eliminate such-and-such cancer in Texas, the nation, and the world. We’d have to have a different story that would allow the development of broader interests and basically throwing a block so that patients could get upfield and other kinds of cancer treatments could get upfield and score the touchdown.
Fisch, Michael J. MD, MPH and Rosolowski, Tacey A. PhD, "Chapter 16: A New Department of General Medical Oncology" (2015). Interview Chapters. 839.
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